Quality of Care for Stroke Patients - Trinity Health

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28 Οκτ 2013 (πριν από 3 χρόνια και 5 μήνες)

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Quality of Care for Stroke
Patients

Jerilyn Alexander, RN

Stroke Coordinator

Trinity Health

Quality


Everyone wants it whether it is for your house,
your car, or healthcare!


Quality healthcare is a measurement of the
healthcare received at your Dr.’s office, the ER,
or during a hospital stay


It goes beyond the manners and attitude of
health care providers


Definition


According to the Institute of Medicine it is
defined as “the extent to which health
services provided to individuals and patient
populations improve desired health outcomes.
The care should be based on the strongest
clinical evidence and provided in a technically
and culturally competent manner with good
communication and shared decision making.”

Quality Improvement


A formal approach to the analysis of
performance and systematic efforts to
improve it.


Key word is Improvement


Always strive for the best outcome!

Stroke Care


How do we get a sense of the quality?



What’s the best way to care for stroke
patients?



Are there guidelines for care of a stroke
patients?

Stroke Care


Guidelines
:

o
2007 AHA/ASA Guidelines for the Early
Management of Adults with Ischemic Stroke

o
2011 Revised and Updated Recommendations for
the Establishment of Primary Stroke Centers

o
2009 Comprehensive Overview of Nursing and
Interdisciplinary Care of the Acute Stroke patient:
A Scientific Statement from the American Heart
Association

Stroke Care


The guidelines are the basis for protocols for
treating the Acute Stroke Patient


Drive the Quality care of stroke patients


GWTG
-
Stroke helps healthcare facilities ensure
continuous quality improvement of stroke
treatment by aligning clinical care with evidence
-
based guidelines.


AHA/ASA have partnered with Joint Commission
for certification of Primary Stroke Centers.


Began the Certification Program in 2003.

Primary Stroke Center Certification


BAC Recommendations


Establishing Criteria for emergency response


Availability of neuroimaging 24/7


Laboratory, Neurology, and Neurosurgery support


Administrative Support


Appropriate Staff Education


Outcomes tracking.

State of North Dakota


Developing Statewide Stroke System of Care


Similar to State Trauma System


Encouraging all Tertiary Centers to become
Primary Stroke Centers


Sanford
-
Fargo and St. Alexius Bismarck are
currently only 2 certified but all centers are
pursuing it.

Certification Requirements


Use standardized method of delivering care based on BAC
recommendations for establishment of primary stroke
centers


Support a patient’s self management activities


Tailor treatment and intervention to individual needs


Promote the flow of patient information across settings and
provides while protecting patient rights, security and
privacy


Analyze and use standardized performance measure data
to continually improve treatment plans


Demonstrate their application of and compliance with the
clinical guidelines published by AHA/ASA or equivalent
evidence
-
based guidelines.

Joint Commission Standardized
Performance Measures for Stroke


Venous Thromboembolism(VTE) Prophylaxis by
Day 2 (Ischemic and Hemorrhagic)


Discharged on Antithrombotic Therapy


Anticoagulation Therapy for At Fib/Flutter


Thrombolytic Therapy


Antithrombotic Therapy by end of Hospital Day 2


Discharged on Statin Medication


Stroke Education (Ischemic and Hemorrhagic)


Assessed for Rehab (Ischemic and Hemorrhagic)

Data


Each measure needs to be analyzed and
evaluated.



Where does the information come from?


What is done with it?


Who is responsible for what?


How is it coordinated?


Data


Each stroke patients care is reviewed on an
ongoing basis


Analyzed according to the standardized
performance measures


Improve upon care ongoing rather than
retrospectively.


Outcome Sciences database can benchmark to
other facilities.

Stroke Quality


8 indicators for ischemic stroke patients and 3 of
these same indicators are looked at for
hemorrhagic stroke patients.


GWTG looks at 9 indicators primarily looking at
timeliness in the emergency phase of
presentation.


CMS looks at 3 different areas (Stroke, VTE, ED),
with some overlap of the Joint Commission
Indicators. For stroke they will look at 7
indicators.


Venous Thromboembolism
Prophylaxis


Thromboembolism is more common than we
think


PE accounts for
approx

10% of deaths after stroke


DVT and PE are more likely to occur in the first 3
months after stroke


Methods to prevent include early mobilization,
antithrombotic agents, and external compression
devices


If contraindicated may need Filter placement into
the Inferior Vena Cava

Venous Thromboembolism
Prophylaxis



To meet the indicator:


Must be administered the day of admission or by
midnight the 2
nd

day


Lovenox or heparin and/or compression devices
acceptable


If no VTE warranted (ex. Patient ambulatory or low
risk of VTE) it needs to be documented in chart
before midnight on the 2
nd

inpatient day


Any reason for not meeting indicator needs to be
documented in the chart (refusal,
etc
)

STK
-
1

Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis
was given the day of or the day

after hospital admission.

Time Period: Q1 2011
-

Q4 2011; Site: Trinity Hospitals (52674)

Data For:
STK
-
1

Data For: STK
-
1

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
109/125
87.2%

All ND Hospitals Q2 2011
131/149
87.9%

All ND Hospitals Q3 2011
128/156
82.1%

All ND Hospitals Q4 2011
143/171
83.6
%

Discharged on Antithrombotic
Therapy



Imperative for stroke prevention


There needs to be documentation in the chart
that patient was given prescription for
antithrombotic medication at discharge


Acceptable medications include ASA,
Aggrenox, Plavix,
Ticlid
, Lovenox, Coumadin


Low dose anticoagulant to prevent DVT’s are
insufficient as antithrombotic therapy to
prevent recurrent strokes

Discharged on Antithrombotic
Therapy



Antiplatelet or

Anticoagulant are acceptable


If not prescribed, needs to be documented by
the physician.


Acceptable documentation:


Allergic


Refusal


Risk for or actual bleeding


Serious side effects


Terminal illness, comfort measures only

STK
-
2

Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
2

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
109/110
99.1%

All ND Hospitals Q2 2011
131/133
98.5%

All ND Hospitals Q3 2011
153/155
98.7%

All ND Hospitals Q4 2011
154/155
99.4
%

Anticoagulation Therapy for Atrial
Fib/Flutter



A patient that has a documented episode of Atrial Fib
this admission. Remote history doesn’t matter.


If patient has Atrial Fib or Flutter must go home on
anticoagulant if not, needs to be documented.


Acceptable documentation


Allergy


Mental status


Refusal


Risk of or actual bleeding


Risk for falls


Serious side effects to medication


Terminal illness/comfort measures only

STK
-
3

Ischemic stroke patients with atrial fibrillation/flutter who are
prescribed anticoagulation therapy at hospital discharge.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
3

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
12/12
100.0%

All ND Hospitals Q2 2011
21/23
91.3%

All ND Hospitals Q3 2011
21/26
80.8%

All ND Hospitals Q4 2011
32/35
91.4
%

Thrombolytic Therapy



If patient arrives within 2 hours of symptom
onset, they should receive thrombolytics within 3
hours.


If Ischemic Stroke Patient does not receive IV tPA,
a documented reason needs to be included in the
patient chart.


May use exclusion criteria in addition to:


Advanced age


Care team cannot determine eligibility


Left heart thrombus


Life expectancy <1 year


NIHSS>22

STK
-
4

Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known
well and for whom IV t
-
PA was initiated at this hospital within 3

hours of time last known well.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
4

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
6/13
46.2%

All ND Hospitals Q2 2011
7/11
63.6%

All ND Hospitals Q3 2011
3/11
27.3%

All ND Hospitals Q4 2011
1/10
10.0
%

Antithrombotic Therapy by end of
Hospital Day 2



Must be administered by midnight of Day 2


Antiplatelet (ASA, Aggrenox, Plavix,
Ticlid
) or
Anticoagulant (Heparin IV, Lovenox, Coumadin, or
arixtra
)


Acceptable documented reasons for not meeting:


Risk of bleeding


Refusal


Terminal illness


Allergy


Serious side effect of medication

STK
-
5

Ischemic stroke patients administered antithrombotic therapy by the
end of hospital day 2.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
5

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
94/99
94.9%

All ND Hospitals Q2 2011
108/116
93.1%

All ND Hospitals Q3 2011
135/141
95.7%

All ND Hospitals Q4 2011
135/ 40
96.4
%

Discharged on Statin Medication



The patient should be discharged on cholesterol reducing
medication as part of prevention


Acceptable documented reasons for not prescribing a statin
on discharge


Allergy


Refusal


Arrhythmias


Hepatitis


Hypoglycemia


Liver failure


Rectal Hemorrhage


Intracranial Hemorrhage


Rhabdomyolosis

STK
-
6

Ischemic stroke patients with LDL >= 100 mg/
dL
, or LDL not measured, or, who were on a lipid
-
lowering
medication prior to hospital arrival are prescribed

statin medication at hospital discharge.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
6

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
69/84
82.1%

All ND Hospitals Q2 2011
93/102
91.2%

All ND Hospitals Q3 2011
98/117
83.8%

All ND Hospitals Q4 2011
99/117
84.6
%

Stroke Education



Required documentation for education


Personal modifiable risk factors for stroke


Stroke Warning Signs and Symptoms


How to Activate EMS for Stroke


Need for Follow up after Discharge


Medication information


Stroke Coordinator consult at Trinity, that alerts the
need for education to patients with strokes or TIA’s.

STK
-
8

Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital
stay addressing all of the following:

activation of emergency medical system, need for follow
-
up after discharge, medications prescribed at discharge, risk
factors for stroke, and warning signs and

symptoms of stroke.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
8

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
35/48
72.9%

All ND Hospitals Q2 2011
45/70
64.3%

All ND Hospitals Q3 2011
56/85
65.9%

All ND Hospitals Q4 2011
59/83
71.1
%


Assessed for Rehab



Assessment must be completed by any one
member of the Rehab team including:


Physiatrist


Neuro
-
psychologist


Physical Therapist


Occupational Therapist


Speech Therapist

STK
-
10

Ischemic or hemorrhagic stroke patients who were assessed for
rehabilitation services.

Time Period: Q1 2011
-

Q4
2011

Data For: STK
-
10

Benchmark Group Time Period Numerator Denominator % of Patients

All ND Hospitals Q1 2011
120/123
97.6%

All ND Hospitals Q2 2011
143/148
96.6%

All ND Hospitals Q3 2011
154/163
94.5%

All ND Hospitals Q4 2011
166/173
96.0
%

Data Reports


Once all the data is retrieved, entered into
system, generates a report…now what??


Look at indicators that are not improving, how
can we fix it?


Break it down, piece by piece.

STK
-
1 VTE Prophylaxis

Analysis


Review each case, found that SCD’s were
being ordered since it was a pre
-
checked
order on standard stroke order set. This was
done so that if Lovenox was not ordered they
would at least meet indicator with SCD’s


Nursing was not placing SCD’s on the patient
or not documenting it in the HER.

STK 1
-
Compliance Action Plan


December 2011
-
Worked with Informatics to develop
report that prints at each nurses station every shift,
reporting which patients have orders for SCD’s or Foot
pumps


December 2011
-

Included quality indicators in in
-
services on Ischemic stroke to make nursing staff more
aware


January 2012
-
Worked with Clinical Nurse Educators on
compliance with staff


January 2012
-
Will have the SCD or Foot pump order
fire a task for nursing to complete upon application of
SCD’s or foot pumps. Going to Profession Practice
Committee in February 2012.

Follow up


This continues to be a work in progress


Follow up with staff, physicians with the
corrective plan of action.


Frequent updates to Clinical Educators if
compliance drops off.

GWTG Stroke Measures


Door to MD evaluation
-
10 Minutes


Door to CT Scan
-
25 minutes


Door to CT Scan Interpretation
-
45 minutes


Door to EKG
-
45 minutes


Door to Lab Results
-
45 minutes


Door to IV tPA
-
60 minutes


Door to CXR
-
45 minutes


Door to admission
-
3 hours

Stroke Treatment

Action Plan


Instituted Stroke Alert for patients that
present with symptom onset less than 8
hours.


Mobilizes a team to respond and alerts the
Neurologist of potential stroke patient


Once that was in place for several months
began to break down the process and look at
the data

%Door To CT <= 25min

Percent of patients who receive brain imaging within 25 minutes of arrival

Time Period: Q1 2011
-

Q4
2011

Data For: %Door To CT <= 25mi n

Benchmark Group Ti me Peri od Numerator Denomi nator % of Pati ents

My Hospi tal Q1 2011

10.0
%

My Hospi tal Q2
2011 22.5
%

My Hospi tal Q3
2011 9.7
%

My Hospi tal Q4 2011

17.1
%

Al l Hospi tal s Q1 2011

24.7
%

Al l Hospi tal s Q2 2011

24.8
%

Al l Hospi tal s Q3 2011

24.8
%

Al l Hospi tal s Q4 2011

24.9%

Quality issues


Break down the process, why is it taking so long?


Nursing delay (IV placement, assessment)?


Lab delay (Delay due to drawing blood taking too
long)?


EKG delay


Radiology (Delay in transport, logistics of
transport, delay in staff coming to the ETC)?


What % of our patients are getting CT in 25
minutes?

Action Plan


New PI Process form for timing of stroke alerts


Educate staff on new form


Review process of assessment with Nursing
staff in the ETC


Continue to work with Radiology regarding
timeliness of CT scan results.


Continue to follow up with involved
departments

Meaningful Use

Meaningful
Use is using certified EHR technology
to


Improve
quality, safety, efficiency, and reduce
health disparities


Engage patients and families in their health care


Improve care coordination


Improve
public
health


All the while maintaining privacy and security


Meaningful
Use mandated in law to receive
incentives


What are the Three Main Components of
Meaningful Use?


The Recovery Act specifies the following 3
components of Meaningful Use
:

1.
Use
of certified EHR in a meaningful manner
(e.g., e
-
prescribing)

2.
Use of certified EHR technology for electronic
exchange of
health information to improve
quality of health care

3.
Use of certified EHR technology to submit
clinical quality measures(CQM) and other such
measures selected by the Secretary


“Core measures”


Core measure program is completely separate
from the Meaningful Use Quality Reporting
Program


Core measure data elements are captured
manually from patients final bill


E
-
measures are captured electronically


Core measure definitions come from a list that
the abstractor chooses from (ICD
-
9 codes)


Meaningful use measures come from SNOMED

How to comply


Will software be able to pull this data and be
Meaningful Use compatible?


Will elements need to be built into the system
to retrieve this data?

MU: Clinical Quality Measures

Eligible
Hospitals and CAHs must complete all 15
:

1.
Emergency Department Throughput

admitted patients Median time from ED
arrival to ED departure for admitted patients

2. Emergency
Department Throughput

admitted patients

Admission decision

time
to ED departure time for admitted patients

3
. Ischemic
stroke

Discharge on anti
-
thrombotics

4
. Ischemic
stroke

Anticoagulation for A
-
fib/flutter

5
. Ischemic
stroke

Thrombolytic therapy for patients arriving within 2 hours of
symptom onset

6
. Ischemic
or hemorrhagic stroke

Antithrombotic therapy by day 2

7
. Ischemic
stroke

Discharge on statins

8
. Ischemic
or hemorrhagic stroke

Stroke education

9
. Ischemic
or hemorrhagic stroke

Rehabilitation assessment

10. VTE
prophylaxis within 24 hours of arrival

11
. Intensive
Care Unit VTE prophylaxis

12
. Anticoagulation
overlap therapy

13
. Platelet
monitoring on
unfractionated heparin

14
. VTE
discharge instructions

15. Incidence
of potentially preventable VTE


CMS Stroke Indicators


Discharged on Antithrombotic


Anticoagulation Therapy for At Fib/Flutter


Thrombolytic Therapy within 3 hours if patient
arrives within 2 hours


Antithrombotic Therapy by end of Hospital Day 2


Discharged on Statin Medication


Stroke Education (Ischemic and Hemorrhagic)


Assessed for Rehab (Ischemic and Hemorrhagic)







The Challenge


EHR Compliance


Quality
measure specifications and logic must be clearly
defined and unambiguous to support automated analysis and
reporting of quality measurement data. Instructions like these
are difficult to implement in an electronic system due to the
number of potential scenarios and corresponding logic that
need to be
specified


Each
organization should understand how
data
requirements
will be captured in their local EHR system to ensure
exclusionary criteria are applied appropriately and

denominator results are calculated and reported correctly.






Kallem
, Crystal. "Analyzing Clinical Quality Measures for Meaningful Use."
Journal of AHIMA

81, no.11 (November/December
2010): 56
-
59.

Any Questions?

References


http://www.ncbi.nlm.nih.gov/books/NBK2681/


http://www.jointcommission.org/specifications_manual_fo
r_national_hospital_inpatient_quality_measures/


https
://qi.outcome.com
/


http://www.heart.org/HEARTORG/HealthcareResearch/Get
WithTheGuidelinesHFStroke/Get
-
With
-
The
-
Guidelines
-
Stroke
-
Home
-
Page_UCM_306098_SubHomePage.jsp


Activase.com


https
://www.cms.gov/EHRIncentivePrograms/Downloads/
MU_Stage1_ReqOverview.pdf


http
://thomsonreuters.com/content/healthcare/pdf/collat
eral/clin_perform_improvement_0211


Kallem
, Crystal. "Analyzing Clinical Quality Measures for
Meaningful Use."
Journal of AHIMA

81, no.11
(November/December 2010): 56
-
59.