QUality Enhancement for Speedy Thrombolysis in Stroke

Transcription

1 QUality Enhancement for Speedy Thrombolysis in Stroke Improving Door-To-Needle Times for Stroke Thrombolysis QUESTS 2.0 Meeting March 11, :00 2:30pm

2 Welcome and Agenda Introductions Handouts Updates Funding Letters of Agreement/Criteria for Participation Door-to-Needle baseline survey results Best Practices/Discussion GWTG EMS Special Initiatives tab EMS workgroup Target Stroke Honor Roll Criteria Agree on next meeting date Year 1 QUESTS photo with poster 6/20/ , American Heart Association 2

3 Handouts Year 1 QUESTS Poster tpa talking points pocket cards Target Stroke Criteria Target Stroke Best Practices Target Stroke Patient Time Tracker New tpa Recommendations table EMS Stroke Assessment booklet should have received already FAST Blood Pressure Wallet Cards to be shipped in April 6/20/ , American Heart Association 3

4 Learning Collaboratives All Teach, All Learn Philosophy Institute of Healthcare Improvement 2005

5 Learning Collaboratives Learning Collaboratives have 5 key components 1. A consensus-driven goal for the program DTN < 60 minutes in > 75% of patients treated with tpa DTN goal of 45 minutes 2. A quality improvement leader Kathleen O Neill 3. Content expert Shyam Prabhakaran 4. Multidisciplinary teams from each site Stroke program coordinators, nurses, pharmacists, radiology technologists, physicians from Neurology and Emergency Medicine 5. Face-to-face collaboration On-site visits to each PSC and quarterly group meetings with data and best practice sharing and experiential learning

6 QUESTS 2.0 Site Visits Completed: Advocate Christ Medical Center Scheduled: Rush Oak Park, Swedish Covenant Hospital and MetroSouth Please contact Renee Sednew if interested in scheduling a visit renee.sednew@heart.org 6/20/ , American Heart Association 6

7 AHA Letter of Agreement-Funding Criteria $1500 for participation in Chicago QUESTS initiative. Company participation includes: Execute an AMENDMENT TO PARTICIPATING HOSPITAL AGREEMENT ( APHA ) with Qunitiles, Inc. Execution of the agreement will allow AHA to access COMPANY S Limited Data Set data for the GWTG- Stroke program and EMS data. COMPANY agrees to have APHA executed within 30 days of signing the grant agreement. Collect EMS data elements using GWTG-S EMS special initiatives tab data. The COMPANY s acute ischemic stroke data will be entered for the period of January 1, 2016 through December 31, Must enter 100% of acute ischemic stroke patients, both self presented and transported by EMS arriving within 12 hours of symptom onset. Provide a representative to attend quarterly Chicago QUESTS 2.0 initiative in person meetings, designate a stroke team key contact and provide a contact list of hospital stroke team members to receive project updates. 6/20/ , American Heart Association 7

8 Door-to-Needle baseline survey results 1. Do you enter 100% of acute ischemic stroke patients into Get With The Guidelines? 2. Which of the following best practices are currently in place at your hospital? (mark all that apply) 3. If suspected stroke, when do you activate the stroke team? (All of the above) 6/20/ , American Heart Association 8

9 Door-to-Needle baseline survey results 4. What is required or standard process for stat CT imaging? 5. Who is activated in stroke team page? Which of the following criteria do you use to activate stroke team? < 3, 4.5, 6, 8, 9, 12, 24, all /20/ , American Heart Association 9

10 Door-to-Needle baseline survey results 7. Who decides to give tpa to eligible patients in the ED? SKIP 8. Who is responsible for determining eligibility for tpa? Do you require waiting for lab results before giving tpa? Do you have tpa in your ED 24/7? 61% 6/20/ , American Heart Association 10

11 Door-to-Needle baseline survey results 11. Who re-constitutes, prepares and doses tpa? 12. When do you start pre-mixing tpa? 13. Do you have a direct-to-ct protocol in place? 6/20/ , American Heart Association 11

12 Door-to-Needle baseline survey results 14. What percentage of the time do you use the AHA QUESTS standardized consent template card? 15. Which healthcare providers participate in the informed consent conversation for IV tpa? How often do the following situations delay or prevent administration of IV tpa? % cases 17. Do you provide real-time (within 1 week) feedback to your team (for example, using a DTN scorecard)? 79% 6/20/ , American Heart Association % median 25% 0%

13 Baseline Data at 15 PSCs in Chicago DTN < 45 minutes DTN median is 57.5 minutes DTN for QUESTS 2.0 is 28.4% 77% are within 25 mins 6/20/ , American Heart Association 13

14 Baseline Data at 15 PSCs in Chicago 60% of patients arriving within 4.5 hours of onset are treated with tpa 6/20/ , American Heart Association 14

15 QUESTS 2.0 Best Practices to Target Direct to CT protocols Consent Pre-mixing tpa 6/20/ , American Heart Association 15

16 Direct to CT protocol Direct to CT Merotjia Neurology 2012

17 Direct to CT protocol Ford Stroke 2012

18 Direct to CT protocol Consider protocol for direct transport to CT from triage Stroke team members including physicians, nurses, techs take patient from paramedics ( hand-off ) EMS pre-notified patients (high probability of stroke) ROSIER screen positive patients in triage Quick registration including for unknowns ( John Doe ) Quick assessment for hemodynamic and neurologic stability Examination on the stretcher by stroke team Consider thrombolysis set-up in CT scanner if possible

19 Consent for IV tpa Up to a third of cases on average in the current QUESTS 2.0 survey may be delayed because of the consent process Physician-reported Stroke Thrombolytic Treatment Failures: perspectives from two urban academic medical centers n %* Eligibility Reasons Determining last known well time 4 Obtaining accurate history regarding tpa contraindications Not specified 5 3 Consent Reasons Patient or proxy delay in providing informed consent 3 Patient or proxy refused tpa 3 Initial refusal by patient or proxy 1 *Values represent percent of cases experiencing described delay. Respondents were allowed to pick multiple reasons for delay. Reasons for delay or not administering tpa in 33 eligible patients

20 Consent for IV tpa Failures N (Total = 509) % Consent Failures Refusals Eligibility Determination Failures Inability to Determine Eligibility Eligibility and Consent Failures Eligibility Alone % Consent Alone Eligibility and Consent Failures 4 0.8

21 Consent for IV tpa National Providers of Acute Stroke Care Survey 25% QUESTS 2.0

22 Consent for IV tpa Current Guideline Statements AHA/ASA guidelines: As with any medical therapy that carries more than minimal risk, explicit informed patient consent for fibrinolytic therapy is indicated. In an emergency, when the patient is not competent and there is no available legally authorized representative to provide proxy consent, it is both ethically and legally permissible to proceed with fibrinolysis. AAN guidelines: if the patient has decision-making capacity or a proxy decision maker is present, a documented discussion regarding risks, benefits, and alternatives to intravenous tpa should take place prior to the administration of the medication. Jauch et al., Stroke AAN policy on consent issues for the administration of IV tpa. 2011

23 Consent for IV tpa Decision Aids and Consent Tools Decision Aids: RESOLVE tool 3-page individualized patient tool 1-page clinician tool with risk prediction models Copyright American Heart Association, Inc. All rights reserved. Decker et al., Circ Cardiovasc Qual Outcomes Gadhia et al., Stroke. 2010

24 Pre-mixing tpa Consider pre-mixing tpa meeting criteria: < 4.5 hours from onset Measurable deficit persisting on initial screen (CT head negative for hemorrhage) Glucose mg/dl Genentech return policy for wasted drug 6/20/ , American Heart Association 24

25 TPA - 5 minute Door to Needle 6/20/ , American Heart Association 25

26 Time Tracker in PMT 1. Open Data tool 2. Click on Hospitalizations tab 3. Find the Additional Time Tracker 4. Scroll to the right, and click on the arrow button to expand the field: 6/20/ , American Heart Association 26

27 EMS Special Initiatives Tab 6/20/ , American Heart Association 27

28 6/20/ , American Heart Association 28

29 6/20/ , American Heart Association 29

30 QUESTS 2.0 EMS Workgroup Call for volunteers Aim # 2: To increase pre-hospital notification by emergency medical services through paramedic education and feedback Description: 2 3 calls to recommend plan for Aim # 2 Current Members: Dr. Chris Richards, Dr. Shyam Prabhakaran, Laura Eggers, Sonia Winandy, Dr. Jim Conners, Kathleen O Neill, Renee Sednew, Adam Greenberg, Diane Bures, Leslee Stein-Spencer, Art Miller If interested, please renee.sednew@heart.org Conference call information will be distributed 6/20/ , American Heart Association 30

31 Target Stroke Honor Roll Criteria Target Stroke Honor Roll = DTN < 60 in 50% eligible patients Honor Roll Elite = DTN < 60 in 75% eligible patients Honor Roll Elite Plus = DTN < 60 in 75% eligible patients and DTN < 45 in 50% of eligible patients 6/20/ , American Heart Association 31

32 Congratulations to Target Stroke QUESTS Year 1 Hospitals Rush University Medical Center Holy Cross Hospital Presence Our Lady of Resurrection Northwestern Memorial Hospital Advocate Illinois Masonic Medical Center 6/20/ , American Heart Association 32

33 Next Meeting Date AHA downtown Chicago office Friday, June 10 th 1:00 2:30pm 6/20/ , American Heart Association 33

34 Thank You! 6/20/ , American Heart Association 34