Transcript Quality of Care for Stroke Patients

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 evidencebased 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.
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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 2nd 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 2nd 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
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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:
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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:
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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
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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 inservices 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
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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 <= 25min
Benchmark Group Time Period Numerator Denominator % of Patients
My Hospital Q1 2011 10.0%
My Hospital Q2 2011 22.5%
My Hospital Q3 2011
9.7%
My Hospital Q4 2011 17.1%
All Hospitals Q1 2011 24.7%
All Hospitals Q2 2011 24.8%
All Hospitals Q3 2011 24.8%
All Hospitals 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-GuidelinesStroke-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.