ENHANCING YOUR SKILLS IN STROKE

QUALITY IMPROVEMENT
AND DATA ANALYSIS
Sherry Mosier, BSN, RN, CNRN, SCRN
Lynn Wilton, MS RN, CRRN, CNRN
DISCLOSURES
• Sherry Mosier has no actual or potential conflict of interest in relation
to this presentation
• Lynn Wilton has no actual or potential conflict of interest in relation
to this presentation
Methodist Hospitals, Gary/Merrillvillle
• Two campus hospital system
• Methodist Hospital Northlake
• Methodist Hospital Southlake
• Inpatient Beds
• Total beds 634, split between the
2 campuses
• Total Adult Beds 504
• Physicians
• 581 Active / Associate 389
 Stroke Care at Methodist Hospitals
• Each campus has been Primary Stroke Certified (PSC) by
Healthcare Facilities Accreditation Program (HFAP) since 2010
• Two full time neurologists
• One neurointerventional radiologist
• One stroke coordinator
• Stroke coordinator consults per month, 70 – 80
• Stroke discharges per year
• 350 – 400
Parkview Regional Medical Center Parkview Randallia

451 bed Level II Trauma Center 154 bed Community Hospital

Parkview Health System: Allen County Campuses

Joint Commission Primary Stroke Center under
a single license: Over 900 stroke discharges in
2014
 LaGrange
Huntington

Whitley

Noble

Parkview Health System:

Community Hospitals
152 beds
Discussion Points:
Quality
Guidelines
The data itself
Target stroke
Reporting
Core Measures
Quality
• According to the Institute of Medicine it is defined as “the extent to
which health services provided to individuals and patient populations
improve desired 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
• Key word is improvement
• Analysis of performance
• Systematic ways to improve it
• Goal is for best outcome CHECK
Guidelines
• Clinical practice guidelines are recommendations about patient care
with special conditions based on the best available research evidence
and practice experience
• Stroke care quality protocols are based on:
• Brain Attack Coalition
• American Heart Association
• GWTG-Stroke helps facilities ensure continuous improvement of
stroke treatment by aligning clinical care with evidence based
guidelines
 Data
“The appropriate source of data for quality assessment depends on the purpose
for which the information will be used.” (NIH)
Utilize stroke database or registry (ie, GWTG or Coverdell)
• Each measure needs to be evaluated • Analyzed according to standardized
and analyzed performance measures
• Questions to ask: • Review on a regular basis
• Where does the information come from?
• How is it coordinated? • Benchmark externally
• Who is responsible?
• What is done with the data?
Enhancing Quality Processes
• Stroke Inservice/Education
• Physician and nursing educational opportunities
• Peer review
• Stroke champions
• Chart review
• Committees
Internal and External Reporting
• Internal Reporting • External Reporting
• Integration with hospital PI process • Quarterly submissions
• Leadership performance improvement • Joint Commission
• Physician performance improvement • HFAP
• Nursing performance improvement • DNV
• State
• Stroke Committee
• CMS
• Other stroke care providers (ED, units,
EMS, non-stroke units, radiology, IR,
cardiopulmonary)
Core Measures
• Evidence-based, scientifically-researched standard of care which has
been shown to result in improved clinical outcomes
• Utilizes results of evidence based medicine research
• Basic core measure principles imply that it is reasonable to expect
that every patient with a given diagnosis will receive the baseline
(core) care established through research
Importance
• Appropriate Core Measure care is:
• Right care every time
• Reduced morbidity, mortality, complications and readmissions
• It is evidence-based best care for your patients!
Quality is more than just numbers, it is people working
together:
Data base specialist: Diana Rupley – Activate data base, GWTG
Quality specialists: Tanya Freon and Amber Schiebel
Midas Quality Manager: Petra Smith
SCNN coordinator: Brandy Fey
Nursing
Neurologists/Neuro-interventionalist
ED physicians
HFAP SM Measure/Indicator
JC PM Measure/Indicator
SM-1 Stroke Team Arrival (minutes)
SM-2 Laboratory Studies (minutes) STK - 1 Venous Thromboembolism (VTE) Prophylaxis
SM-3 Neuroimaging Studies (minutes) STK - 2 Discharged on Antithrombotic Therapy
SM-4 Neuro-Surgical Services (minutes)
Anticoagulation Therapy for Atrial
SM-5 tPA Administration (0 - 3 hrs) STK - 3 Fibrillation/Flutter
SM-6 Antithrombotic Therapy (%)
STK - 4 Thrombolytic Therapy
SM-7 Antithrombotic at Discharge (%)
SM-8 Anticoagulant at Discharge (%)
STK - 5 Antithrombotic Therapy By End of Hospital Day 2
SM-9 DVT Prophylaxis (%)
SM-10 Statin at Discharge (%) STK - 6 Discharged on Statin Medication

SM-11 Stroke Education STK - 8 Stroke Education

SM-12 Dysphagia Screening (%)
STK - 10 Assessed for Rehabilitation
SM-13 Physical Rehab Evaluation (%)
SM-14 Door-to-Needle Time (minutes)
Target Stroke Launched 2010
• A national quality
improvement initiative
focused on improving acute
ischemic stroke care by
reducing door-to-needle
times for eligible patients
being treated with tPA
Target Stroke Phase II 2014:
Improvement Strategies
• EMS pre-notification • Mix t-PA ahead of time
• Rapid triage protocol and Stroke Team • Rapid access and administration of IV
notification t-PA
• Direct transfer to CT/MRI • Stroke tools:
• Stroke order set
• Single call activation system • Guidelines
• Rapid acquisition and interpretation • Algorithms
of brain imaging • Pathways
• NIHSS
• Rapid laboratory testing • Inclusion/Exclusion
Value Based Purchasing
It Should All Start with EMS…
Role of EMS in Stroke
• Primary Stroke Centers
• Primary Stroke Center recommendations by the Brain Attack Coalition in 2000
and updated in 2011 address the vital role the EMS have in the chain of
survival for patients with stroke
• Primary Stroke Centers must cooperate and communicate with inbound EMS
• Primary Stroke Centers are required to meet standards for EMS pre-hospital
stroke care
JAMA, Volume 283, Number 23, June 21 2000
Stroke 2013, Stroke, 2011, and Stroke 2007
Notification and Response of Emergency Medical
Services (EMS) for Stroke
• The notification and response of EMS to a stroke patient is an important part of
our process
• It involves the public, the EMS systems, and the hospital EDs
• Treatment for stroke is most effective if tPA is administered within three hours of
symptom onset showing decreased disability
• EMS transport of stroke patients to a hospital equipped to treat strokes generally
results in better outcomes and reduced disability and death compared to patients
who arrive by car or other forms of personal transport
Process Improvement for EMS
• Goals
• Limit stroke disability
• Improve relationship with EMS and Emergency Departments
• Utilize same language for acute stroke patient throughout region
Implementation
• Stroke Task Force Implemented for District 1 EMS
• Committee members
• Area EMS providers
• Area Stroke Coordinators
• Stroke Checklist form developed
• Beta Test completed
 District 1 Stroke Alert Checklist

DATE AND TIMES

RUN NUMBER: DATE: EMS ARRIVAL TIME: HOSPITAL ARRIVAL TIME:

PATIENT DATA
PATIENT NAME: ED CONTACT TIME: SYMPTOM ONSET TIME:

AGE: GENDER: BLOOD SUGAR: ALLERGIES:

HISTORY OF EVENT YES N0 MEDICAL HISTORY YES NO

Sudden headache Stroke/Tia (“Mini-Stroke”)
Did patient fall @ onset of
symptoms ”Bleeding in the Brain”
Sudden change in vision in one
or both eyes: Previous MI
Sudden unilateral weakness Seizures
Sudden onset of
Vertigo/Dizziness Recent Surgery
Current Use of Blood Thinners

Initial V.S.: Pulse: ______ B/P: ______ Resp: _____ Hypertension

Diabetes
History Drug/Alcohol Abuse
Final V.S.: Pulse: ______ B/P: ______ Resp: ______
Medications and/or list of Meds with
patient
FAST EXAMINATION (√ if Abnormal)
PREHOSPITAL F – Facial Droop (Show teeth or smile)
A – Arm Drift (Close Eyes hold both out arms)
STROKE S – Speech (You can’t teach an old dog new tricks)
SCREEN T- Time (Last time patient was seen normal) ___:___ AM/PM
STROKE ALERT CRITERIA YES NO
Time of Onset Less than 6 hours
Any Abnormal Findings on FAST Examination
Barriers Found
• Crews were slow to catch on/unsure of the purpose
• Initially, concerns with more paperwork to complete
• Where to place the completed forms
• ALS vs BLS with compliance/participation
Benefits Observed
• Reminders of important assessment details
• Condensed form of information for radio report
• Consistent reporting of “stroke” symptoms from the field
• Ability to hand hospital staff information immediately
Changes Suggested
• Signatures of crew members

• FAST – check boxes – either “Normal” or “Not Normal”

Emergency Department
• Core measure – STK 4, SM 5
• Acute ischemic stroke patients who arrive within 120 minutes of time
last known well and for whom IV tPA was initiated at this hospital
within 180 minutes of time LKW
• If patient arrives within 2 hours of onset of symptom onset, should receive
thrombolytic treatment within 3 hours (FDA approved)
• May go up to 4.5 hours for treatment with consent
• If ischemic stroke patient does not receive tPA within this window,
documented reason must be in the chart
• Utilize tPA inclusion/exclusion criteria
ED Improvement Measures
• ED Doctors and Nurses receive advanced stroke education, certified in NIHSS assessment
• Standardized stroke order sets
• One page notification system
• Lab and CT took ownership of improvement process for TAT
• Future: Possible EMS straight to CT to decrease time to treatment
• Door to Needle time less than 60 minutes
• New target stroke information, less than 45 minutes
• Future: Stroke champion in the ED to review tPA patients
• Feedback on misses within one week
• Feedback on tPA patients within one week
Inpatient Acute Care
JC HFAP
STK - 1 SM - 1 Venous Thromboembolism (VTE) Prophylaxis

STK - 2 SM - 7 Discharged on Antithrombotic Therapy

STK - 3 SM-8 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK - 4 SM-5 Thrombolytic Therapy

STK - 5 SM-6 Antithrombotic Therapy By End of Hospital Day 2

STK - 6 SM-10 Discharged on Statin Medication

STK - 8 SM-11 Stroke Education

STK - 10 SM-13 Assessed for Rehabilitation

VTE Prophylaxis STK – 1, SM – 1
Patients with an ischemic or hemorrhagic stroke who received VTE prophylaxis or
have documentation why no VTE prophylaxis was given the day of or day after
hospital admission
• Improvement strategies
• Organizational policy for VTE
• Meaningful use expectations
• Quality measures and safety goals
• Use of stroke order sets with in the EHR
• Training and education
• Nursing autonomy/implementation (application of SCDS)
• Documentation
Discharged on Anti-thrombotic Therapy STK – 2, SM – 7
Patients with an ischemic stroke prescribed anti-thrombotic
therapy at discharge
Improvement strategies
• Standardized discharge order set specific for stroke
• Nursing education including stroke discharge medications
Use of e-mail tools to remind staff to monitor
measures sent on a daily basis:
Patients with Afib/Flutter Receiving Anti-coagulation Therapy STK
– 3, SM – 8
Patients with an ischemic stroke with afib/flutter
discharged on anticoagulation therapy
Improvement Strategies
• Standardized admission and discharge order set
• Admission assessment to include history of
afib/flutter or present afib/flutter
• EKG monitoring per guidelines
• Cardiology consult
Anti-thrombotic Therapy by End of Hospital Day 2 STK – 5, SM – 6
• Patients with ischemic stroke who receive
antithrombotic therapy by the end of hospital
day two (day after patient arrival)
Improvement Strategies
• Standardized admission order set
• Automatic best practice advisory in EMR
• Education
Discharged on Statin Medication STK – 6, SM – 10
Ischemic stroke patients with LDL > 100 or LDL not measured or who
were on cholesterol reducing therapy prior to hospitalization are
discharged on Statin medication
Improvement Strategies
• Standardized order set and discharge order set
• Patient education
• Contraindications
• Use of hard stop in the EMR if Statin not addressed at discharge
 Stroke Education STK – 8, SM – 11
• Patients with ischemic or hemorrhagic stroke or their caregivers who were given educational materials
during the hospital stay addressing all of the following: risk factors for stroke, warning signs for stroke,
activation of EMS, the need for follow-up after discharge, and medications prescribed at discharge
Improvement Strategies
• Develop a stroke education policy
• Who – When – How
• Documentation daily in the EMR
• Standardize educational materials
• Include patient and family in learning
expectations
 Assessed for Rehabilitation STK – 10, SM – 13
Patients with an ischemic or hemorrhagic stroke who were
assessed for rehabilitation services
Improvement strategies
• Standard order set includes therapy
consultations
• Protocol for therapy service
• Follow up after discharge
References:
Centers for Medicare & Medicaid (2014, August 4) CMS to Improve Quality of Care during Hospital Stays Retrieved from
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-08-04-2.html

Chang, F. (2006, February 11) Advances in Treatment of Stroke and Intracerebral Hemorrhage Power Point presentation

Cleary, P.D. and O’Kane, M.E. (n. d.) Evaluating the Quality of Health Care National Institutes of Health Retrieved from
http://www.esourceresearch.org/tabid/794/Default.aspx

Filho J.O., and Koroshetz, W.J. (2014, November 26). Initial assessment and management of acute stroke retrieved from
www.uptodate.com

Shekelle, P. (2014, June 5) Clinical practice guidelines http://www.uptodate.com/contents/clinical-practice-guidelines

Stroke Statements and Guidelines American Stroke Association (n.d.) Retrieved from
http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsQ-Z/Stroke-Statements-
Guidelines_UCM_320600_Article.jsp