It is not enough to do your best, you must know what to do and then do your best

Transcription

1 Creating Effective Regional Stroke Systems of Care Stroke Strategies for Success Workshop October 3, 2012 Rick Foster, MD It is not enough to do your best, you must know what to do and then do your best - W. Edwards Deming IOM Six Aims for Improvement Patient care that is: Safe- avoidance of unintended pt. harm Effective- evidence-based Patient-centered- focused on needs and rights of the individual patient Timely- avoidance of delays & barriers to patient care flow Efficient- elimination of waste Equitable- fair access to comparable health care services for all Quality improvement pearls you need to know your starting point to know where you need to go (reliable baseline metrics) Make the right thing to do clear and then make it easy to do for everyone engage physicians at the blunt end of care before trying to change what they do at the sharp end put a face and voice on the data (power of the story) Take local ownership of evidence-based standards your performance over time on key metrics should be your primary improvement benchmark patient-centered care has to be more than a catch phrase 1

2 Mission: Lifeline Overarching Goal: Improve the mortality and morbidity and quality of care for the AMI population, specifically through the development of STEMI systems of care Guiding principle: Patient centric, addressing the continuum of care for STEMI patients from symptom onset into the point of entry into the healthcare system, touching each aspect of the system, and return the patient back to the local community and physician Door to Balloon Average Time ACTION/Get with the Guidelines Registry ( ) 46% improvement rate Time in minutes 7 2

3 STEMI : Time to Reperfusion in <90 Minutes Key Improvement Measures for SC. 10/2/ /2/ , American Heart Association Built on a strong mission and strategic foundation Collaboration and shared accountability among key stakeholders- seat at the table for everyone Active communication and knowledge sharing Effective use of QI tools and methodologies Education built around active learning model Focus on measurable process and outcomes performance indicators Environment that encourages innovation What Missions Are Next All EMS and referral hospitals actively linked to at least one STEMI receiving center Creating regional stroke systems of care w/ standardized pre-hospital stroke assessment protocol All EMS and referral hospitals actively linked to at least one primary stroke center Standardized, integrated pre-hospital and hospital therapeutic hypothermia SCA protocols statewide Establish a system for ongoing training of EMS and ED staff on STEMI and stroke recognition &stabilization Create a stroke care registry to mirror the ACTION registry used w/ M:L 3

4 South Carolina Heart and Stroke Care Alliance Leadership Team Chair Dr. Powers ORH, AHA, SCHA, DHEC-Trauma and prevention, BC, SCMA, HSSC and Drug Companies- (Practice management), Clinical focus MD Chair, SC ACC, SCCEP Coordinator Heart Failure STEMI Sudden Cardiac Arrest Stroke Common Assumptions (binding all clinical topics) Universal Structural Components (for each clinical topic) - Telemedicine -Leadership Teams - EMS -Receiving Centers (representation and involvement) - Reimbursement incentives -Referral Centers (representation and involvement) - Population health -Outreach Coordinators - Small and rural hospitals -Physician engagement -EMS representation and education -Partnering/Collaboration Data The Need for Developing Stroke Systems of Care Previously disjointed system Primary Stroke Centers becoming more prolific and components of stroke care significantly improving IOM concluded that the fragmentation of the delivery of healthcare services frequently results in suboptimal treatment, safety concerns, and inefficient use of healthcare resources. IOM recommended the establishment of coordinated systems of care that integrate preventive and treatment services and promote patient access to evidence based care Does the need exist? 66% of hospitals surveyed did not have stroke protocols 82% did not have rapid identification for acute stroke patients Many acute care hospitals lacked the necessary staff and equipment to provide optimal, safe and effective emergency care for these patients Patients were waiting an average of 3-6 hours to seek treatment; some urban minority populations show a 22 hour delay in seeking help EMS not consistently trained to recognize stroke Only 3% of eligible patients received the only FDA-approved ischemic stroke treatment CONFIDENTIAL American Heart Association 2009 BUILDING STROKE SYSTEMS OF CARE A stroke system should coordinate and promote patient access to the full range of activities and services associated with stroke prevention, treatment, and rehabilitation, including the following key components: Primordial and primary prevention Community education EMS notification, response, evaluation and treatment Acute stroke treatment, including emergency department phases Sub-acute stroke treatment and secondary prevention Rehabilitation Continuous quality improvement (CQI) activities 16 4

5 Stroke Systems of Care A Stroke System should. EMS Primary Prevention Acute Rehabilitation Secondary Prevention Care ensure effective interaction and collaboration among agencies, services and key stakeholders promote the use of an organized, standardized approach in each facility and component of the system identify performance measures (both process and outcomes measures) and include a mechanism for evaluating effectiveness through the entire system and its individual components continue to evolve and improve A Stroke System should. provide both patients and providers with the tools necessary to promote effective stroke prevention, treatment and rehabilitation ensure that decisions about protocols and patient care are based on what is in the best interests of stroke patients identify and address potential obstacles to successful implementation be customized for each state, region, or locality Get With The Guidelines-Stroke EVIDENCED-BASED MEASURES (>85%) Thrombolytic therapy arrive by 2 hours, treat by 3 hours Antithrombotic therapy by the end of hospital day two. VTE prophylaxis the day of or the day after hospital admission. Antithrombotic therapy at discharge. Anticoagulation therapy at discharge for patients with atrial fibrillation Statin Medication for patients with LDL>100 Smoking cessation advice or counseling during hospital stay. CONFIDENTIAL American Heart Association

6 THE JOINT COMMISSION (TJC)/PRIMARY STROKE CENTER STROKE CORE MEASURES STK -1: VTE prophylaxis STK-2: Antithrombotic therapy at hospital discharge. STK-3: anticoagulation therapy at hospital discharge for patients with atrial fibrillation STK-4: IV-tPA initiated arrive by 2 hours; treat by 3 hours of last known well Oconee Cherokee Greenville Spartanburg York Pickens Union Chester Lancaster Chesterfield Marlboro Laurens Anderson Fairfield Kershaw Darlington Dillon Newberry Abbeville Lee Marion Greenwood Florence Saluda Lexington McCormick Richland Horry Edgefield Sumter Calhoun Williamsburg Aiken Clarendon Orangeburg Georgetown Bamberg STK-5: Antithrombotic therapy by the end of hospital day 2. STK-7 Statin medication at hospital discharge for LDL>100 STK-8: Educational materials provided during the hospital stay STK-10: Assessment for rehabilitation services. CONFIDENTIAL American Heart Association Primary Stroke Centers South Carolina Barnwell Allendale Hampton Jasper Dorchester Colleton Charleston Beaufort Berkeley Cherokee Greenville Spartanburg Pickens York Oconee Anderson Laurens Union Newberry Chester Fairfield Lancaster Chesterfield Marlboro Kershaw Darlington Dillon Abbeville Greenwood Saluda McCormick Edgefield Aiken Lee Lexington Richland Sumter Calhoun Clarendon Orangeburg Bamberg Marion Florence Horry Williamsburg Georgetown Primary Stroke Centers South Carolina Barnwell Allendale Hampton Jasper Dorchester Colleton Charleston Beaufort Berkeley

7 EMS Improvement Aims Processes in place for rapid access to EMS Dispatch protocols match current treatment recommendations Dispatch at highest level emergency response All EMS personnel can assess/screen for stroke Emergency physicians and EMS providers collaborate on triage, transport and treatment Transport to stroke center is norm CONFIDENTIAL American Heart Association 2009 Hospital- Acute Care Aims All hospital EDs with capability to provide acute stroke care including timely access to tpa Primary stroke centers within 60 min. of initial patient contact statewide Non-PSC hospitals with stroke telemedicine access Comprehensive stroke centers in each DHEC region Regional triage, treatment and transfer protocols in place for different levels of hospital care 7

8 Acute Rehab/Care Transition Aims timely rehab evaluation for all stroke patients comprehensive patient-specific rehab plan established during initial admission clear, concise care transition record provided to each patient/family caregiver support systems identified to ensure patients receive appropriate follow up and care levels of rehab resources periodically evaluated Rather than uncoordinated, episodic care, we need to offer care that is well organized, coordinated, integrated, characterized by effective communication, and based on continuous healing relationships -Eric Larson, MD Group Health Research Institute Creating Effective Regional Stroke Systems of Care Stroke Strategies for Success Workshop October 3, 2012 Rick Foster, MD 8