Joint Commission Certification Primary Stroke Center Robert

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Joint Commission Certification Primary Stroke
Center

• Robert Smith, MD
• Joel Patterson, MD
• Valerie Brumfield, MSN, RN, CNS, CCRN

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Primary Stroke Center

• JCAHO certification program based on
• Brain Attack Coalition (BAC) Recommendations for
  Primary Stroke Centers
• American Stroke Association (ASA) Statements for
  Stroke
• UTMB Stroke Center
• Emergency Room
• Intensive Care Unit
• 9C general stroke unit
• TDCU 7A and ICU

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Why Certify?

• Allows us to stay competitive with other
  organizations
• Texas Medical Center
• Community Hospitals in Galveston County
• Provides for up to date, evidence based care
  using clinical practice guidelines
• Standardized care for all patients
• Improved quality of care
• Care based on evaluation of performance and
  clinical practice

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Recommendations for Stroke Centers

• Hospital/Administrative support
• Appointment of stroke center medical director
• Dr. Robert Smith
• Physicians and providers with knowledge and
  expertise in treatment of stroke
• Acute Stroke Team
• Comprised of ER physicians and nurses, Neurology
  faculty and residents, radiology, diagnostics,
  lab, etc.
• Responds within 10 minutes on all acute strokes
  that are eligible for thrombolytics

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Recommendations and UTMB Status

• Written Care Protocols
• We have the following order-sets
• Stroke Activation (112)
• Thrombolytic Therapy (376)
• Stroke Floor Admission (300086)
• Stroke Critical Care Admission with tPA
  Order-sets (in development)
• Stroke Critical Care Admission without tPA
  Order-sets (in development)
• Stroke Transfer from Critical Care to Floor
  (300088)
• Stroke Discharge (3004002)

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Recommendations and UTMB Status

• Continued
• Clinical Pathways
• Floor Critical Path for Stroke patients
• Critical Care Critical Path for Stroke patients
• Guidelines of Care (based on AHA/ASA)
• Ischemic Stroke
• Hemorrhagic Stroke
• Transient Ischemic Attack
• Thrombolytic Therapy

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Recommendations and UTMB Status

• Emergency Room
• Providers with additional training in the care of
  the acute stroke patient, Stroke Activation
  process for acute stroke patients and recognition
  and management of acute stroke complications
• Stroke Unit
• Specified unit to which most stroke patients are
  admitted
• ICU
• 9C
• TDCJ 7A and ICU
• Providers with additional training and competence

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Recommendations and UTMB Status

• Neurosurgical services
• Neurology expertise is available 24/7
• Neurosurgeons are available within 2 hours of the
  recognized need for such services
• Neurology notified (Stroke Team Activation
  Process) of stroke patient within 5 minutes of
  patient arrival
• Neurology determines the need for tPA (IV, IA)
• Neurology performs the NIHSS and Dysphagia
  screen.

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• Neuroimaging
• 80 of all acute stroke patients receive
  diagnostic imaging within 25 minutes of order
• Laboratory services
• 80 of all acute stroke patients laboratory, ECG
  and chest x-ray results within 45 minutes of
  order

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Recommendations and UTMB Status

• Outcomes/Quality Improvement
• Evaluates and analyzes performance measures and
  implements process for improvement when necessary
• Stroke QM Committee and
• Stroke QI Committee
• Educational Programs
• Provides educational activities to the public at
  least annually
• Health Fairs done at least twice a year

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Performance Measures

• PM1 DVT Prophylaxis
• PM2 Discharged on anti-thrombotics
• PM3 Anticoagulation therapy for A-fib
• PM4 TPA consideration
• PM Anti-thrombotics within 48 hours

• PM6 Lipid profile
• PM8 Stroke education
• PM10 Plan for rehab considered

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Additional Performance Measures being tracked at
UTMB

• Dysphagia Screen
• Time to CT
• Time to lab resulted
• NIHSS completed daily
• Cerebral Hemisphere NVS completed with VS
• Stroke order-sets initiated for admission,
  transfer and discharge

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DVT Prophylaxis

• Patients with length of staygt 2 days should
  receive DVT prohylaxis unles there is a
  contraindication
• DVT prophylaxis
• Physician has to check their choice of which type
  of prophylaxis they wish to use or select a
  contraindication
• Paralysis of lower extremity increases risk of
  DVT and PE
• Use of DVT prevention strategies reduce frequency
• SCDS
• Lovenox
• Heparin

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Anti-thrombotics on Discharge

• Ischemic stroke or TIA patient should receive
  anti-thrombotics at discharge unless there is a
  contraindication
• Contraindication must be clearly noted in the
  chart
• High risk of recurrent stroke and long term
  disability because mostly due to embolic and
  thrombotic events
• Drugs commonly used
• ASA 81-325 mg daily (1st line therapy)
• Plavix 75 mg daily
• Aggrenox 25/200 mg 1 tab BID

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Anti-coagulation Therapy for Afib

• Ischemic stroke patients with atrial fibrillation
  should be discharged on anti-coagulation therapy
  unless contraindication noted
• Atrial fibrillation is a common arrhythmia and
  significant risk factor for ischemic stroke
• Drug commonly used
• Coumadin dosage variable depending on INR
• Therapeutic INR range 2.0 to 3.0

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TPA Consideration

• Ischemic stroke patients presenting within 4.5
  hours of onset of symptoms of ischemic stroke
  should be considered for tPA administration
• Documentation must show consideration
• MUST document contraindication to tPA in the
  progress notes or on the EPIC admission
  order-set.
• If documentation does not reflect why TPA was not
  given then this measure is not met

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Anti-thrombotics within 48 hours

• Patients with ischemic stroke or TIA should
  receive anti-thrombotic medications by the end of
  hospital day 2
• ASA found to be effective in reducing risk of
  early recurrent stroke
• Drugs commonly used
• ASA 81-325 mg daily
• Plavix 75 mg daily
• Aggrenox 25/200 mg 1 tab BID

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Lipid Profile

• Patients with ischemic stroke or TIA should
  receive a lipid profile within 48 hours, if none
  posted from within the past 30 days.
• CAD is a significant risk factor for stroke and
  increased lipids are directly related to CAD
• Patients must be discharged on Statin therapy, if
  LDL greater then or equal to 100mg/dL, or LDL not
  measured, or patient on lipid lowering medication
  prior to hospital arrival
• Drugs commonly used
• Zocor
• Lipitor

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Stroke Education

• Education and/or resources should be provided to
  patients and/or caregivers of patients
• Guidelines recommend education during
  hospitalization and include information on
• Warning signs
• Risk factors
• Diagnosis
• Support services available
• Patients should be educated using the EPIC
  McKesson education material
• The chart must reflect the patient received hard
  copies of the education material

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Smoking Cessation

• All stroke patients should receive smoking
  cessation advice and/or counseling if they have
  smoked within the past year
• Smoking is the most alterable risk factor for
  stroke
• Doubles the risk of stroke by itself
• If a patient quits smoking, their risk for stroke
  will return to that of someone who has never
  smoked within 2 to 5 years

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Rehabilitation Plan

• All stroke patient should be assessed for and/or
  receive rehabilitation services
• Approximately 50 of survivors are left with
  moderate to severe disabilities
• 60 of survivors have never received any
  rehabilitation services
• Stroke is the LEADING cause of long term
  disability
• Evaluation is performed by PT/OT/SP

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Dysphagia Screen

• All stroke patients must be screened for
  dysphagia prior to oral intake
• Cannot over-ride orders and start a diet prior to
  screening
• Can not order NPO except medications prior to
  screening
• Meds must be given by other routes
• Must be screened by a specially trained nurses or
  physicians
• Physician or nurse must document results in the
  designated location
• 50 of all patients develop dysphagia
• Of those 40 will aspirate
• 37 of those will go on to develop pneumonia

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Dysphagia Screen

• Pass Dysphagia screen
• Order diet
• Resume oral medications
• Fail Dysphagia screen
• Only the Speech Pathologist (SP) can approve oral
  intake
• Cannot over-ride orders and start a diet prior to
  SP evaluation
• Can not order NPO except medications prior to SP
  evaluation
• Meds must be given by other route until cleared
  by SP
• Consider ordering nutrition vial NG or Dobhoff
  until cleared by SP

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Blood Pressure Management

• Elevation of blood pressure is common in the
  acute phase
• Increases in an attempt to enhance cerebral blood
  flow following ischemic stroke
• Lack of good blood pressure control within the
  established guidelines results in bad outcomes
• To high increases risk of hemorrhagic
  transformation
• To low worsens neurological injury
• Exception to this is in dissections, CHF, CAD,
  and other special circumstances determined by the
  physician

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Blood Pressure Management

• ASA Guidelines for Ischemic Stroke
• Anti-hypertensives should be withheld unless
  blood pressure is gt220mmHg systolic and/or gt120
  mmHg diastolic
• Exception to this would be special circumstances
• When treatment is indicated, lowering blood
  pressure should be done cautiously
• Recommended goal is to decrease blood pressure
  slowly

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Blood Pressure Management

• ASA Guidelines for Hemorrhagic Stroke
• If systolic BP isgt200mHg or MAP gt150mmHg then
  consider aggressive reduction of BP with
  continuous IV infusion with frequent BP
  monitoring
• If systolic BP gt180mmHg or MAP gt130mmHg and there
  is evidence of or suspicion of elevated ICP, then
  consider monitoring ICP and reducing BP using
  intermittent or continuous IV medications to keep
  CPP gt60 to 80mmHg
• If systolic BP gt180mmHg or MAPgt130mmHg and there
  is not evidence or suspicion of elevated ICP then
  consider modest reduction of BP(ie MAP of 110mmHg
  or target BP of 160/90mmHg) using intermittent or
  continuous IV medications to control BP and
  clinically re-examine the patient every 15 minutes

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Glucose

• Hyperglycemia can worsen neurological injury
• Goal is to maintain glucose in a range of
  100-180.
• FSBS should be obtained frequently (AC/HS)
• Use insulin sliding scale
• Treatment should be initiated for FSBS gt140mg/dL
• Avoid sugar based intravenous solutions such as
  D5W, D5 ½ NS
• If not diabetic and normal blood sugars then can
  DC after 3 days

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Fever

• Fever has been shown to reduce neurological
  outcomes in stroke patients
• Goal is to maintain normothermia
• Aggressively treat any elevations of temperature
  with Tylenol 650 mg Q4hours
• If not managed within normal range with Tylenol
  other measures should be considered
• Temperature should be frequently monitored during
  the first few days following stroke
• Nurses will treat with Tylenol x 1 and if not
  reduced then they are required to contact the
  physician for further orders

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National Institutes of Health Stroke Scale (NIHSS)

• Valid and reliable assessment tool for
  neurological patients
• Scale consists of 11 items
• Identifies the presence and severity of
  neurological symptoms in stroke
• Scoring
• 0 normal patient
• 42 highest possible score, indicating severe
  neurological deficits and poor neurological
  outcome
• Online training offered at
• http//nihss-english.trainingcampus.net

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Stroke Orders

• MUST be used on ALL patients admitted with
  diagnosis of stroke or with suspicion of stroke
  (TIA)
• If stroke is in the differential diagnosis
  should use the stroke orders until it has been
  ruled out and then can remove the patient from
  the stroke orders
• Order-set 's
• Stroke Floor Admission 300086
• Stroke Transfer Critical Care to floor 300088
• Stroke Discharge 3004002
• Stroke Critical Care without tPA 3000000001
  (coming soon)
• Stroke Critical care with tPA 300098 (coming
  soon)

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Conclusions

• UTMB Hospital is actively seeking certification
  as a Primary Stroke Center
• It takes all care providers commitment to quality
  stroke care for certification to become possible
• All items must be in place and be in compliance
  for at least 4 months prior to the JC visit in
  order to become certified as stroke center
• We anticipate out visit to be in February of 2013

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Validation of presentation reviewedJoint
Commission Certification Primary Stroke Center
Part I

• This is to validate I ___________________ read
  and understand the content of the presentation
  titled Joint Commission Primary Stroke Center
  Part 1
• Signature ______________________
• Date___________