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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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