200810 HAPSHSAA PAO Indicators: Stroke Care

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• 2008-10 HAPS/H-SAA PAO Indicators Stroke Care

August 2007
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Overview

• This session covers Patient Access Outcomes
  stroke indicators in 2008-10 Hospital Annual
  Planning Submission (HAPS) Guidelines and
  Web-Enabled Reporting System (WERS)
• Aimed at hospital and LHIN staff involved in the
  preparation and review of HAPS
• Updated and expanded as needed

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2008-10 HAPS/HSAA Indicators Domains
Training Development
Financial Health
Organizational Health
Capital Health IT/Med Equipment
Turnover Rate
Paid Sick Time (Full-time)
Operational Efficiency
Vacancy Rate
Paid Overtime (Full-time Part-Time)
Capital Health Facility Condition Index
Nursing FTE
Current Ratio Consolidated
Staff Satisfaction
Total Margin Sector Code 1
Workplace Safety Indicators
Total Margin Consolidated
Readmissions to Own Facility
Readmissions (All Facilities CHF Only)
CCC Skin Ulcers
Mental Health
CCC Care Index Indicators
ALC Indicators
Volumes
Rehab Indicators
ED Indicators
Stroke Care Index Indicators
Patient Safety
Hospital-CCAC Integration Indicators
System Integration
Patient Access Outcomes
HSMR
Adult IP Sat Indicators
ED Sat Indicators
Paediatric Sat Indicators
Patient Experience
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2008/10 HAPS/H-SAA Patient Access Outcomes
(PAO) Stroke Care Indicators

• Monitoring Indicators
• CT/MRI within 24 hours
• Discharge ASA/antithrombotic
• Discharge Anticoagulation for Atrial Fibrillation
  
• Developmental Indicator
• Stroke Quality of Care Index (new, based on
  thrombolysis and stroke unit care)
• No Performance or Explanatory Indicators

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Context
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Impact of Stroke in Canada
40,000 50,000 strokes/year
300,000 Canadians living with stroke
16,000 Canadians die from Stroke each year
Someone strokes every 10 minutes
20 chance of Second stroke Within 2 years
Price Tag 2.7 Billion annually
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Alignment Leads to Great Things
HSFO
Public Health Agency of Canada
LTC
EBRSR
Ontario Stroke System
Canadian Stroke Consortium
CHEP
Community Care
Rehabilitation all disciplines
Accreditation
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What is Optimal Stroke Care?

• Extensive process to develop a core set of
  performance indicators that crosses the continuum
  of stroke and addresses system issues and patient
  impact CSQCS, SCORE

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Stroke Best Practices

• 24 Recommendations
• Public Awareness (1)
• Patient and Caregiver Education (1)
• Stroke Prevention (7)
• Acute Stroke Management (8)
• Stroke Rehabilitation (6)
• Follow-up and Community Re-engagement (1)

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Indicator Development Process

• Extensive review of research literature, CPGs,
  protocols, and ongoing trials determine levels
  of evidence
• Extract currently reported indicators
• Consensus panel
• survey-type review of potential indicators
  (includes summary of evidence), opportunity to
  add additional candidates
• Panel meetings for discussion and refinement
• Final voting
• External review of panel decisions by key
  stakeholders for validity and relevance check
• Feasibility testing, including development of
  data dictionary
• Dissemination and implementation support

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Stroke Evaluation Advisory Committee (SEAC)

• Mandate
• To provide guidance and expertise in developing a
  system to monitor and evaluate the progress of
  the Ontario Stroke System at the provincial,
  regional, organizational and patient care levels.
  SEAC will form and support partnerships with key
  stakeholders.
• Chair Mr. Nizar Ladak, CE LHIN
• OSS Staff Lead Dr. Patrice Lindsay

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Registry of the Canadian Stroke Network
Every 2 Years
Ongoing Quarterly
Quarterly, Annual
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SPIRIT Structure
Protected PHI
Demographics
Risk Factors
Acute Care
Telestroke
Secondary Prevention
Monitoring and Reporting System
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Administrative Data Sources (future use)

• CIHI
• NACRS emergency department records
• DAD Acute inpatient care
• NRS inpatient rehabilitation
• CCRS continuing care facilities
• RAI-MDS Long Term Care Facilities (pilot)
• RAI-Home Care home care services
• Provincial, National
• CCAC data
• RPDB mortality
• Stats Can income, education, CCHS
• Local data on several aspects of stroke care

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Aligning Reports across Ontario
SEAC
Annual Report
Quarterly Report
Quarterly Report
Quarterly Report
New Indicators implemented
Quarterly and Annual Reports
HAPS
Quarterly and Annual Reports
LHINS
Annual Report
OHQC
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Summary

• Directions
• Use external and evidence-based benchmarks to
  inform targets/corridors
• Customize and evolve indicators during the
  alignment process to adapt to performance
  patterns and increase specificity of improvement
  efforts

• Challenges
• Informative indicators (with drill down detail
  for front-line clinicians and managers)
• No single indicator among this set provides a
  comprehensive overview of hospital stroke care
  processes and outcomes

• Aggregate indicator clusters for hospital
  administrators and system stewards to assess
  overall quality of stroke care

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2008-10 HAPS/H-SAA Indicators
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Monitoring Indicator CT/MRI within 24 Hours

• Description
• Rate of timely CT/MRI for stroke or TIA patients
  admitted to an ED of acute care hospital.
• Definition
• stroke/TIA patients who receive
  their first CT/MRI scan within 24
  hours of ED arrival
• Total of stroke/TIA patients admitted
  to ED and/or inpatient acute
  care setting
• Data Source
• Registry of the Canadian Stroke Network (core
  registry and SPIRIT)

Stroke Patients receiving CT/MRI w/24 hrs

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Monitoring Indicator CT/MRI within 24 Hours

• Inclusion Criteria
• Patients admitted to an ED of an acute care
  setting with final diagnosis of stroke, TIA or
  UTD (unable to determine)
• These patients may be admitted to inpatient care,
  or may be treated in an ED and discharged without
  inpatient admission
• Exclusion Criteria
• Final Diagnosis - non strokes
• In-hospital strokes
• Transfer to another ED or acute care hospital
  within less than 24 hours from ED arrival
• Transfer from another ED or acute inpatient
  setting
• Missing scan times
• Targets Corridors
• None at this time

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CT Rates at 24 Hours
Within 24 hours
Within 25 minutes
RCSN - RSC
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Monitoring Indicator Discharge Antithrombotic
Therapy

• Description
• Proportion of ischemic stroke and TIA patients
  who are discharged on antithrombotic therapy 
• Definition
• of all ischemic stroke and TIA patients
  discharged on antithrombotic therapy
• Total of ischemic stroke/TIA patients
  discharged from ED and/or inpatient
  acute care setting
• Data Source
• Registry of the Canadian Stroke Network (core
  registry and SPIRIT)

Discharged Stroke Patients on
Antithrombotic Therapy

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Monitoring Indicator Discharge Antithrombotic
Therapy

• Antithrombotic therapy
• ASA Dipyridamole (Aspirin, Aggrenox),
• Warfarin (Coumadin),
• Clopidogrel (Plavix),
• Ticlopidine HCl (Ticlid)
• Inclusion Criteria
• All ischemic stroke and TIA patients discharged
  from the ED or acute inpatient setting of an
  acute care hospital
• Exclusion Criteria
• None
• Targets Corridors
• None at this time

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Antithrombotic Agents on Discharge
RCSN - RSC
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Monitoring Indicator Discharge Anticoagulation
for Atrial Fibrillation

• Description
• Proportion of Ischemic stroke and TIA patients
  with Atrial Fibrillation who are discharged on
  appropriate anticoagulant therapy
• Definition
• of all ischemic stroke or TIA patients
  with Atrial Fibrillation who are
  discharged on anticoagulant (warfarin)
  therapy
• Total of ischemic stroke/TIA patients
  with Atrial Fib discharged from ED or
  inpatient acute care setting
• Data Source
• Registry of the Canadian Stroke Network (core
  registry and SPIRIT)

Discharged Stroke Patients on
Anticoagulation for Atrial Fibrillation

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Monitoring Indicator Discharge Anticoagulation
for Atrial Fibrillation

• Inclusion Criteria
• All ischemic stroke and TIA patients
• with non-valvular atrial fibrillation
• discharged from the ED or acute inpatient setting
  of an acute care hospital
• Exclusion Criteria
• None
• Targets Corridors
• None at this time

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Discharge Anticoagulation for Atrial Fibrillation
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Developmental Indicator Stroke Care Quality Index

• Description
• Proportion of patients admitted to acute
  inpatient care with ischemic stroke who are cared
  for in a stroke unit and, if eligible, receive
  thrombolysis
• Definition Sum of indicator scores for all
  ischemic stroke patients who are cared for
  in a designated stroke unit, and if
  eligible, receive thrombolysis
• Total of ischemic stroke patients
  in inpatient acute care setting
• Data Source
• Registry of the Canadian Stroke Network (core
  registry and SPIRIT)

Stroke Care Quality Index

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Developmental Indicator Stroke Care Quality Index

• Numerator
• Sum of indicator scores for all ischemic stroke
  patients who are cared for in a designated stroke
  unit, and if eligible, receive thrombolysis
• Each inpatient receives a score as follows
• Patients not eligible for thrombolysis
• 0 if not cared for in a stroke unit
• 1 if cared for in a stroke unit
• Patients eligible for thrombolysis
• 0 if not cared for in a stroke unit and no
  thrombolysis
• ½ if cared for in a stroke unit or
  thrombolysis (not both)
• 1 if cared for in a stroke unit and
  thrombolysis

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Developmental Indicator Stroke Care Quality Index

• Inclusion Criteria
• All ischemic stroke patients admitted to an
  acute inpatient setting of an acute care
  hospital
• Exclusion Criteria
• Transfers from another ED or another acute
  inpatient setting
• Thrombolysis Ineligibility
• Patient arrived too late
• Targets Corridors
• None at this time

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tPA Rates at RSC (IV, arrival within 2.5 hrs)
RCSN, 2003-04 2004-05 2005-06
RCSN - RSC
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tPA Door-to-Needle Time (IV, arrival within 2.5
hrs)
Median Door-to-Needle time (minutes)
Percentage of Patients Receiving tPA within One
hour
RCSN - RSC
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Stroke Unit Utilization
RCSN - RSC
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Interpretation

• Indicators focus on some of the most important
  evidence-based processes of care which lead to
  improved stroke outcomes
• Ontario analysis that led to the choice of the
  components for the stroke quality index linked
  processes to outcomes. Three factors were most
  highly associated with best outcomes
• thrombolysis
• stroke unit care
• referral to rehabilitation

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Future Indicator Targets

• Options for setting indicator targets
• Ontario rates
• Evidence-based rates
• Consensus/policy thresholds
• Appropriate responses to indicator results
• Drill-down to specific components
• Process mapping

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Future Directions

• Other important stroke indicators
• CT/MRI within 25 minutes
• Inpatient Outpatient Rehabilitation
• In-hospital post-acute outcomes
• LHIN-JPPC Future Indicators Work Group to
  provide direction on indicator development,
  selection and categorization for future
  iterations of HAPS/H-SAA

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More Information

• Integrated Stroke Care in Ontario Stroke
  Evaluation Report 2006 (2007)
• www.canadianstrokenetwork.ca
• The Canadian Stroke Quality of Care Study
  establishing indicators for optimal acute stroke
  care (2006), www.cmaj.ca/cgi/reprint/172/3/363
• Draft Quality Indicators and Literature Review
  (2004) www.canadianstrokenetwork.ca/research/downl
  oads/lindsay.litreview.2005.pdf
• Other e-learning sessions and background
  materials in this series are posted on
  www.oha.com, with links on WERS, FIM, LHIN and
  JPPC websites
• If you have questions, please contact your local
  LHIN www.lhins.on.ca

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We Welcome Your Feedback

• For more information on this e-learning series or
  other initiatives of the LHIN-JPPC Communication
  Education Work Group please contact
• Mimi Lowi-Young, Chair
• c/o Ontario Joint Policy and Planning Committee
  (JPPC)
• 415 Yonge Street, Suite 1200
• Toronto, ON M5B 2E7
• Tel [phone] Fax [phone]
• www.jppc.org