Stroke Benchmark Presentations

Transcription

1 Stroke Benchmark Presentations Lori Merner, Alexandra Marine & General Hospital Bonita Thompson, Huron Perth Healthcare Alliance Linda Dykes & Angela Small Sekeris, Bluewater Health Denise St. Louis, Windsor Regional Hospital Alexandra Marine and General Hospital Goderich, Ontario 1

2 Location Catchment Area Huron County and some of Bruce County North of Goderich to Kincardine East of Goderich as far as Wingham and Seaforth South of Goderich to Grand Bend area 2

3 What is Telestroke? Telestroke Program Year Assessments Lysis 2011/ / / /

4 AMGH Door to Needle Time Year 2012/13 72 min 2013/14 67 min Door to Needle Time(median) 2014/15 61 min 2015/16 67 min Opportunities to reduce DTN 4

5 Door to Neurologist ( 30 minutes) Month 2016 April May June July August September Median Time 30 minutes 31.5 minutes 31 minutes 31.5 minutes 25 minutes 27 minutes Door to Needle Time April September minutes 5

6 Challenges Next Steps 6

7 Emergency Department to Acute admission Improving Process and Time at Stratford General Hospital Acute Stroke Care Forum Nov 16, 2016 Bonita Thompson Interim District Stroke Coordinator Why make a change Fiscal 14/ hours to head in bed for patients admitted from ED Integrated Stroke Unit Opened Dec Designated Stroke Centre Need to raise the bar with target 1.5 hours 7

8 Process Improvements Stroke specific Internal report card Stroke protocol target form added to meditech for documentation provides visual cue for timelines ISU adjusted processes to free acute beds for admissions Monthly physician flow meetings Process Improvements Daily ED huddles include stroke metrics Daily discharge targets set for inpatient units Telestroke implemented Nov 1 st,2016 CT head report -audits daily Addition of Physician ED hours 8

9 Outcomes Strokes never hold in emerg New target of 1.5 hours head to bed set in May 2016 Oct hours for all patients 1.43 hours for those not held in emerg 9

10 Fiscal Year 15/16 Head to Bed (HIB) HIB with > 10 hour waits excluded Target (in hours) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar HIB with > 10 hour waits excluded Target (in hours) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar HIB with > 10 hour waits excluded Target (in hours)

11 Challenges Difficult to get stroke specific unless manual at this time Three destinations to determine timelines NIHSS sign offs Creating culture within ED department to embed stroke strategies Timely admission orders post decision to admit Lessons Learned Communication is key Roles and responsibilities need to be clearly identified and understood Physician engagement improves flow Setting targets and daily reporting changes behaviour 11

12 Next Steps Educate and communicate updated ED stroke protocol Evaluate effectiveness of stroke protocol target tool Standardize drip and ship from ED to inpatient Pull rather than push from ED to acute bed Creation of report for stroke specific head to bed for stroke patient to improve data Thank you ED team CCU team ISU team Patient Flow Manager Stroke Strategy Nurses Contact 12

13 Acute Stroke Unit - Bluewater Health s Experience Linda Dykes, BScPT Manager, Sarnia Lambton District Stroke Centre Angela Small Sekeris RN, BScN, MN, CRN(C) Clinical Nurse Specialist, Bluewater Health Overview Introduction: Past and Present Acute Stroke Care Evaluation measuring change Enablers to success Challenges and opportunities Questions, comments 13

14 Bluewater Health Sarnia, Ontario 326 bed community hospital with locations in Sarnia and Petrolia, serving the urban and rural needs of Lambton County ( 126,000 residents) Sarnia site provides acute, rehab, palliative and continuing care along with surgical, obstetric, pediatric and mental health services. Sarnia site hosts the District Stroke Centre and stroke services Evidence-based stroke care Stroke Unit Trialists Collaboration 2009 Stroke patients who received organized inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were seen regardless of age, sex, or stroke severity. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay. 14

15 Welcome to the Acute Stroke Unit Acute Stroke Unit Care year 1 In-house acute care stroke data Feb 2011-Jan % of the 231 admissions received ASU care 86% of ASU patients were on stroke protocol New AF diagnoses: 10 in ED, 15 on ASU 10 Endarterectomy consultations (only 3 the previous year) Discharge destination 50% home 36% inpatient rehab 6.3% complex continuing care 3.4% long term care Stroke onset to admission to rehab : 6 days (median)* * from NRS data FY

16 Acute Stroke Unit Care and Sustainability - year 5 In-house acute care stroke data FY % of the 204 admissions received ASU care 98 % of ASU patients were on stroke protocol New AF diagnoses: 10 in ED, 9 on ASU 16 Endarterectomy consultations 2 EVT consultations Discharge destination 41 % home 6 % to tertiary centres for procedures/care (CEA, EVT, Cardiac) 44 % inpatient rehab ~1 % complex continuing care 4.9 % long term care Stroke onset to admission to rehab : 5 days (median)* * from NRS data FY Bluewater Health s Experience Table 1: Risk adjusted stroke/tia mortality rate at 30 days (per 100 patients) Source FY FY FY FY FY Ontario ESC LHIN Bluewater Health N Data source: CIHI-DAD 16

17 Bluewater Health s Experience Table 2: Proportion of acute stroke patients (excluding TIA) discharged from acute care and admitted to inpatient rehabilitation Source FY FY FY FY FY Ontario 30.7% 31.5% 32.6% 34.2% 35.1% ESC LHIN 38.7% 36.3% 39.1% 39.7% 40.4% Lambton County 41.4% 42.1% 50.6%* 55.8%* 41.1% *High Performer, Ontario Stroke Report Card Data source: CIHI-DAD, CIHI-NRS Bluewater Health s Experience Table 3: Median number of days between stroke (excl. TIA) onset and admission to in-patient rehabilitation Source FY FY FY FY FY Ontario ESC LHIN Bluewater Health 7 6 5* 4* 5* *High Performer, Ontario Stroke Report Card Data source: CIHI-DAD, CIHI-NRS 17

18 Bluewater Health s Experience Table 4: Proportion of stroke/tia patients discharged from acute to LTC/CCC (excluding patients originating from LTC/CCC) Source FY FY FY FY FY Ontario 9.8% 9.1% 7.9% 7.8% 7.0% ESC LHIN 7.7% 9.0% 8.0% 4.8% 5.7% Lambton County N 4.9% % % % % 170 Data source: CIHI-DAD Bluewater Health s Experience Table 5: Acute ALC Days Proportion of ALC days to total LOS in acute care Source FY FY FY FY FY Ontario 32.5% 27.3% 27.7% 28.4% 26.0% ESC LHIN 27.3% 23.4% 33.6% 33.9% 30.6% Bluewater Health N 16.3% % % % % 167 Data source: CIHI-DAD 18

19 Enablers to Success Continuous Cardiac Monitoring Evaluation for CEA and EVT Improved thrombolytic processes with Telestroke Stroke Team Stroke Nurse role Leadership support Stroke QBP - enhancing practices Emphasis on documentation, coding, auditing and evaluation of stroke cases partnership with Medical Records Challenges and opportunities Fiscal pressures Healthcare environment ever changing ASU is part of a larger unit that has been changing Implementation of physician attending model April 2014 BWH Bed Management & Full Capacity Protocol 2016 MEDT Quality Renewal Plan 2016 currently in process New administrative team overseeing Telemetry and the ASU 19

20 Bluewater Health Acute Stroke Team ASU Nurse Lead: Nancy Hubbard Occupational Therapist: Carolyn Caicco Physiotherapist: Leslie Geddes Speech Language Pathologist: Doug Tomback Dietician: Julie LeBlanc Stroke Nurse: Angela Small Sekeris Pharmacist: Gayathri Radhakrishnan and team Social Worker: Tracy Byrne Thoughts, questions, comments 20

21 Enhanced District Stroke Centre Windsor Regional Hospital Ouellette Campus(OC) ESC LHIN Stroke Report Card Indicator #6: Median door-to-needle time among patients who received acute thrombolytic therapy (tpa) (minutes). Provincial Benchmark Provincial Median Erie St. Clair LHIN WRH (WRH in house) 21

22 The Change Process mapping future state Improvement of CODE STROKE notification process Updating order set KT plan and tools to support Creation of a dashboard to monitor Process Map 22

23 CODE STROKE ED PROCESS OUELLETTE CAMPUS CODE STROKE STANDARD WORK IN ED 23

24 SWITCHBOARD CODE STROKE DOCUMENTATION tpa Order Set 24

25 Outcomes EMS pre alert Pre alert in ED Overhead page To CT on EMS stretcher Created new CT/CTA order for CODE STROKE CT/CTA on all acute strokes All CODE STROKES redirected to Designated site 25

26 Outcomes CODE STROKE in ED protocol was implemented at the OC on May 2, Report as of October 25, 2016: There have been 99 CODE STROKE activations in the ED. 24% of CODE STROKES that were ischemic strokes have received tpa. Metric Target Achieved Door to ERP < 10 min 12 min Door to neuro notify Neuro notify to neuro arrival < 15 min 13 min < 30 min 29 min DTNT < 60 min 55 min Lessons Learned Buy in at executive level Coordinated approach/formalized protocol Old habits are hard to break EMS expertise Switchboard Ensure ED physicians engaged not removed from process Stress end result-outcomes 26

27 Next Steps New target door-to-needle-time of 30 min EMS bypass protocols Public awareness Team notification in prehospital phase Education Refine/incorporate EVT process Become a 24/7 EVT site 27