JCAHO EXPECTATIONS FOR PRIMARY STROKE CENTER Angela M. Williams, MS RN Stroke Care Coordinator St. Anthony Hospital

Primary Stroke Center Certification Based on recommendations from the Brain Attack Coalition and ASA statements Onsite review team will include a medical professional experienced in treating stroke and implementation of stroke centers Programs seeking certification must use a standardized method of delivering clinical care based on these recommendations and guidelines

Requirements for Certification Programs will be evaluated using the standards listed in the Disease Specific Care Certification Manual To evaluate compliance will include evaluating conformity with the recommendations from Brain Attack Coalition Expected to demonstrate application and compliance with the guidelines from ASA ASA and JCAHO standardized set of performance measures for stroke and programs are required to collect data on the first four measures but will be looking at other measures also

Major Elements Hospital and Administrative Support Written documentation showing support by administration Stroke Center Medical Director Stroke team members have expertise in cerebrovascular disease Acute Stroke Team Documentation showing team composition, staffing level and requirements, and notification system and response expectations Log that documents response times, diagnosis, treatments, actions and outcomes

Major Elements cont… Written Care Protocols Include care of ischemic/hemorrhagic stroke patients in the ER, acute care and stroke unit Use of protocol is reflected in order sets and pathways Time parameters for stroke work up are included in ER protocol Emergency Medical Systems Plan should be provided that demonstrates an initiative by the hospital to provide education to EMS

Major Elements cont… Emergency Department ER care providers show familiarity with pathology, presentation, assessment, diagnostics, and treatment of stroke patients; location and application of stroke related protocols, activation of the stroke team, and communications with inbound EMS; recognition, assessment and management of acute stroke complications 80% of ER providers can provide evidence of review of the institution’s acute stroke protocol

Major Elements cont… Stroke Unit Specified unit to which most stroke patients are admitted Care providers demonstrate evidence of initial and ongoing training in the care of acute stroke patients At least 8 hours of annual CE or equivalent educational activity Monitoring systems to include continuous data on heart rate/rhythm with automatic arrhythmia detection; BP and oximetry

Major Elements cont… Neurosurgical Services Documentation shows evidence of neurosurgical coverage or protocol for transfer to appropriate facility If do not transfer – has fully functional OR facility and staff within two hours of the recognized need for such services Neuroimaging Documentation indicates on 24/7 basis, 80% of acute stroke patients have a diagnostic brain imagine completed within 45 minutes of it being ordered when clinically indicated (resuscitation candidates)

Major Elements cont… Laboratory Services Documentation indicates ability to complete initial lab tests and availability on site 24/7 Documentation indicates ability to complete and report lab tests in less than 45 minutes of it being ordered Documentation indicates the ability to perform ECG and chest x-ray within same time frame as laboratory testing Educational programs Documentation shows at least one stroke public education activity per year

Major Elements cont… Outcomes/Quality Improvement Evidence of specific stroke performance measurement and review by quality improvement department and stroke team exists Documentation exists to reflect the following: performance measures and indicators tracked Specific interventions to improve selected measure Specific outcomes to determine success Implementation period and re-evaluation point

Performance Measures DVT Prophylaxis (Required) Patients with ischemic stroke and who are non-ambulatory should start receiving DVT prophylaxis by the end of hospital day two Discharged on Anti-thrombotics (Required) Patients with TIA or ischemic stroke should be prescribed anti-thrombotic therapy at discharge unless contraindicated

Performance Measures cont… Patients with A-Fib receive anticoagulation therapy (Required) Patients with ischemic stroke with atrial fibrillation discharged on anticoagulation therapy unless it is contraindicated Tissue Plasminogen Activator Considered (Required) All patients who present at a hospital with symptoms of an ischemic stroke with symptom onset of 3 hours or less should be considered to receive intravenous tPA

Performance Measures cont… Anti-thrombotic medication within 48 hours of hospitalization Patients with ischemic stroke or TIA who receive anti-thrombotic medication within 48 hours of hospitalization Lipid Profile Patients with ischemic/TIA who had a lipid profile performed during hospitalization or within 30 days prior to hospitalization

Performance Measures cont… Screen for Dysphagia A screen for dysphagia should be performed on all ischemic and hemorrhagic stroke patients before being given food, fluids or medications by mouth This means absolutely NOTHING by mouth, including ALL medications prior to a dysphagia screen

Performance Measures cont… Stroke Education Stroke education and/or resources received by patient and/or caregivers for patients with ischemic stroke, hemorrhagic stroke, or TIA Smoking Cessation Adult smoking cessation advice and/or counseling for patients with ischemic, hemorrhagic stroke or TIA Plan for Rehabilitation considered Patients with ischemic/hemorrhagic stroke who were assessed for or received rehabilitation services

Guidelines for Care NIH Stroke Scale Evidence shows that the “standard neuro check” is inadequate for the acute stroke population. Overlooks large areas of brain function Reveals subtle changes and/or improvements which guides further treatment Reliable and user friendly Provides a common language between caregivers AHA ACLS Provider Manual (2001) indicates that NIHSS is the standard assessment tool within the hospital setting and has been shown to predict cost of hospitalization, length of stay and disposition Required under our stroke protocol that at minimum must be performed in ER on admission See data sheet for compliance percentage

Guidelines for Care Continuous cardiac monitoring All stroke patients are placed on telemetry. Pulse oximetry Q shift Documentation of oxygen saturation every shift. Clinical Pathway outlines standard of care for stroke patient based on ASA guidelines

What we are doing well ASA within 48 hours Discharged on anti-thrombotics A-Fib discharged on anticoagulation therapy Smoking cessation Lipid profile Plan for rehabilitation

Where we need work Stroke Education DVT prophylaxis Dysphagia screen NIHSS in ER Documenting order times on brain imaging, labs and chest x-ray Clinical pathway on chart at admission Patients being placed on stroke unit Care providers with evidence of initial training in care of the stroke patient Stroke orders on chart with stroke consult Not tracking admission placement and compliance with standards of care (guidelines)

Where do we go from here? Brainstorm ideas Develop plan to improve areas that need work Put time parameters for departments to institute change Evaluation and tracking of compliance Education Review and re-evaluate