C E R T I FI C AT I O N. Benchmarking Performance in HFAP-certified Primary Stroke Centers

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1 PRIMARY STROKE C E R T I FI C AT I O N Benchmarking Performance in HFAP-certified Primary Stroke Centers

2 HFAP s mission is to advance high quality patient care and safety through objective application of recognized standards. AAHHS manages accreditation, certification, and education programs under the HFAP name. Our mission is to help healthcare better serve the community through accreditation, education and research. The datasets within this publication were assembled and analyzed by Marci Ramahi, CAE, Director, Accreditation and Certification Operations. Additional thanks to Carol Roesch, MBA, RN, FACHE for her support and advocacy of the HFAP Stroke Certification programs. HFAP 142 East Ontario Street 10 th Floor Chicago, IL certification@hfap.org 2018 AAHHS/HFAP. All rights reserved.

3 Introduction HFAP certification for stroke programs requires data collection for a defined set of clinical performance measures. Most of the measures are used consistently across all program options, but some are relevant only to a specific certification (Stroke Ready, Primary Stroke, Thrombectomy Stroke, Comprehensive Stroke). Certified centers use these measures for internal benchmarking to improve their care and processes in addition to submitting their results to HFAP on a quarterly basis. Centers that have been awarded Primary Stroke certification were invited to participate in a pilot program to elevate the data analysis by comparing results achieved across a range of peer programs. This publication, the product of that pilot, is an external benchmarking resource that identifies target goals and reports the specific results achieved by individual centers. Participating hospitals have been de-identified, but each organization has been notified of their unique identifier to facilitate an understanding of where they fit in the continuum of results. Data from July to December 2017 were used to determine whether benchmarks identified for each performance measure were achieved. The data represent patients 18 years and older who arrived in the emergency department or who experienced onset of symptoms while in the hospital for another diagnosis. As shown throughout the report, HFAP-certified centers met or exceeded benchmarks identified for the majority of the measures. Most centers regularly exceed those thresholds set by the American Heart Association. Stroke coordinators in organizations that participated in this study can share the information in this report with their governing body and community to demonstrate the quality of their stroke care program. Other stroke programs can use this information for education and training and to create realistic external benchmarks. In either case, if you find that your performance on any measure is below that of other centers, this report will help you focus on areas for improvement. Thank you to the HFAP Primary Stroke Centers that agreed to participate in this benchmarking exercise and special thanks to the stroke coordinators who diligently collect and analyze data while working tirelessly to provide and improve patient care. HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

4 SM-1: Stroke Team Arrival Percentage of patients for whom the stroke team responded to the patient s bedside within 15 minutes of arrival in ED or, for inpatients, of onset of symptoms. Benchmark 85% Average 96% HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

5 SM-2: Laboratory Studies Percentage of patients for whom blood was drawn for laboratory testing and results received within 45 minutes of the patient s arrival in the Emergency Department or, for inpatients, the onset of symptoms. Benchmark 85% Average 93% 1 SM-3: Neuroimaging Studies Percentage of patients for whom the neuro-imaging (CT scan or MRI) was completed within 45 minutes of the patient s arrival in ED or, for inpatients, the onset of symptoms. Benchmark 85% Average 91% 1 HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

6 SM-4: Neurosurgical Services Percentage of patients for whom neuro-surgical services were available within 2 hours when identified by a CT as experiencing a hemorrhagic stroke. Benchmark 85% Average 82% 1 NA NA NA NA NA SM-5: Thrombolytic Therapy within 0 3 hr. Percentage of acute ischemic stroke patients who arrived at hospital within 2 hours (120 minutes) of time last known well and for whom IV tpa was initiated within 3 hours of time last known well. Benchmark 85% Average 96% 1 HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

7 SM-6: Antithrombotic Therapy Percentage of all eligible ischemic stroke patients who received the first dose of antithrombotic therapy by the end of hospital day two. Benchmark 85% Average 97% 1 SM-7: Discharged on Antithrombotic Therapy Percentage of eligible ischemic stroke patients who received prescription for antithrombotic at the time of discharge. Benchmark 85% Average 98% 1 HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

8 SM-8: Anticoagulation Therapy for AF/Flutter Percentage of eligible ischemic stroke patients who received prescription for anticoagulant at the time of discharge. Benchmark 85% Average 99% 1 NA SM-9: Venous thromboembolism (VTE) Prophylaxis Percentage of eligible ischemic or hemorrhagic stroke patients who either received VTE prophylaxis the day of or the day after being admitted as an inpatient, or who have a documented reason why no VTE prophylaxis was given within that timeframe. Benchmark 85% Average 95% 1 HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

9 SM-10: Discharged on Statin Medication Percentage of eligible ischemic stroke patients who received prescription for statin at the time of discharge. Benchmark 85% Average 96% 1 HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

10 SM-11: Stroke Education Percentage of ischemic or hemorrhagic stroke patients with documentation that they or their caregivers were given educational material on stoke care during their stay. Benchmark 85% Average 96% 1 SM-12: Dysphagia Screening Percentage of eligible patients who received a dysphagia screen prior to receiving something by mouth. Benchmark 85% Average 91% 1 NA HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

11 SM-13: Assessed for Rehabilitation Percentage of eligible patients who received a physical rehabilitation evaluation. Benchmark 85% Average 98% 1 SM-14: Door-to-Needle Time Percentage of acute ischemic stroke patients receiving intravenous tissue plasminogen activator (tpa) therapy during the hospital stay and the time of their hospital arrival to initiation of tpa (door-to-needle time) was 60 minutes or less. Benchmark Average 64% 1 HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT

12 2018 AAHHS/HFAP. All rights reserved. Chicago, IL HFAP PRIMARY STROKE CENTER BENCHMARKING PROJECT