Headline. Objectives. Baptist Health Mission Stroke Core Measures

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1 Headline 2010 Stroke Core Measures Baptist Medical Center Downtown Baptist Medical Center South Presented by Maria Martinez, RN, BSN May 21, 2010 Objectives 2 Baptist Health Mission To continue the healing ministry of Christ by providing accessible, quality health care services at a reasonable cost in an atmosphere that fosters respect and compassion. 3 1

2 Baptist Stroke Centers Mission Statement Support the community by providing superior care to patients with stroke, while simultaneously adding value to the Baptist healthcare organization. 4 Objectives 5 Florida In 2004, Florida passed the Florida Stroke Act (FSA) (S.B. 1590) Goal: to strengthen the chain of stroke survival in Florida through legislation establishing a statewide Emergency Medical Services (EMS) stroke system and hospitals to properly identify, transport, and treat stroke victims

3 Florida Results The 2005 data indicated that only % ischemic stroke patients received t-pa (Alteplase) After FSA enactment, significantly more ischemic stroke patients (pts) were treated with intravenous t-pa per month rising from 3.8 pts/month to 5.2 pts/month the proportion rose, from % Our findings suggest that the Florida improved access within the community to t-pa treatment of acute stroke, said Scott Silliman, M.D. of University of Florida College of Medicine- Jacksonville 7 Objectives 8 Primary Stroke Center The Joint Commission accredits U.S. hospitals and, since 2004, has certified hospitals as primary stroke centers To qualify, hospitals must provide a range of services: round-the-clock emergency room staffing neurosurgeon availability within two hours perform imaging test within 25 minutes must provide extra professional and community education to improve early recognition of stroke symptoms, monitor quality improvement initiatives and document standardized care protocols 9 3

4 Primary Stroke Centers Baptist Medical Center Baptist Medical Center South Flagler Hospital Memorial Hospital Jacksonville Orange Park Medical Center Comprehensive Stroke Centers Mayo Clinic Shands Jacksonville Medical Center Source: ahca.myflorida.com/mchq/health_facility.../strokecenterslist.pdf Source: 10 Objectives 11 What are Core Measures? Evidenced-based best practice clinical indicators When used in daily nursing practice patient outcomes are improved Compliance with Core Measures is reported to the Joint Commission and the Centers for Medicare and Medicaid Services (CMS). 12 4

5 Stroke Measure History Were developed in collaboration with American Heart Association (AHA) / American Stroke Association (ASA) / Brain Attack Coalition (BAC) for use in certified primary stroke centers Disease-Specific Care Stroke Advisory Panel helped harmonize Stroke measures from data elements contained in the AHA Get With The Guidelines SM (GWTG) and Centers for Disease Control and Prevention (CDC) Paul Coverdell National Acute Stroke Registry (PCNASR) Eight of the ten measures in the stroke set were endorsed by the National Quality Forum (NQF) in July 2008 and aligned with the Centers for Medicare & Medicaid Services (CMS) In October 2009, the eight NQF-endorsed measures have been approved as a core measure set for use in the Joint Commission s ORYX program Source: 13 Which Patients Qualify for Stroke Measures? Ischemic Stroke Hemorrhagic Stroke Transient Ischemic Attack (TIA) Cerebrovascular Accident (CVA) 14 Activate the Code Stroke Protocol REMIND YOUR PHYSICIAN TO IMPLEMENT STROKE/TIA ADMISSION ORDERS! 15 5

6 Objectives 16 Thrombolytic/Fibrinolytic Therapy Ischemic Stroke patients who arrive at this hospital within 2 hours of time last known well (TLKW) must have IV t-pa initiated within 3 hours of TLKW unless the MD/PA/ARNP documents a contraindication Patients must be carefully screened for eligibility using the t-pa (Alteplase) Inclusion/Exclusion Criteria form National Institute of Health (NIH) Stroke Scale score of 4-23 for 0-3 hour window 17 Venous Thromboembolism (VTE) Prophylaxis Ischemic and Hemorrhagic Stroke patients must start treatment by end of hospital day 2, unless the MD/PA/ARNP documents a contraindication All Stroke patients are at increased risk of developing VTE, regardless of ability to ambulate Aspirin alone and TED hose use without SCDs are insufficient therapy to prevent VTE Treatment recommendations: - Heparin - Lovenox - Coumadin 18 6

7 Anticoagulation Therapy for Atrial Fibrillation/Flutter Ischemic Stroke Patients with Atrial fibrillation/flutter must be prescribed anticoagulation therapy at hospital discharge unless the MD/PA/ARNP documents a contraindication 5-7 times more likely to have a stroke than the general population Agents that stop thrombosis - stop blood from clotting inappropriately in the blood vessels Coumadin is the treatment of choice 19 Antithrombotic Therapy Ischemic Stroke Patients must have administered antithrombotic therapy by end of hospital day 2 unless the MD/PA/ARNP documents a contraindication Ischemic Stroke Patients must be prescribed antithrombotic therapy at hospital discharge unless the MD/PA/ARNP documents a contraindication Prescribed at discharge, reduces stroke mortality and morbidity 20 Statin Therapy Ischemic Stroke Patients must be prescribed a statin at discharge unless the MD/PA/ARNP documents a contraindication Obtain a Lipid Profile within 48 hours of admission unless results are available from within the past 30 days Statins are required in those patients: 1. with an LDL > 100 mg/dl 2. whose LDL has not been measured 3. who were on a lipid lowering medication prior to arrival 21 7

8 Intensive Statin Therapy On the basis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial, administration of statin therapy with intensive lipidlowering effects is recommended for patients with atherosclerotic ischemic stroke or TIA and without known Coronary Heart Disease (CHD) to reduce the risk of stroke and cardiovascular events Statin agents and doses which produce a mean LDL reduction of approx 50% or greater: Atorvastatin (Lipitor) 40 mg or 80 mg total daily dose Simvastatin (Zocor or generic) 80 mg total daily dose Rosuvastatin (Crestor) 20 mg or 40 mg total daily dose Simvastatin/Ezetimibe (Vytorin) 10/80 mg dose 22 Assess for Rehabilitation Ischemic or Hemorrhagic Stroke Patients must be assessed for rehabilitation services Stroke is a leading cause of serious, long-term disability 40% are left with moderate functional impairment 15-30% with severe disability Rehab Goals 1. Mobilize the patient 2. Encourage resumption of self-care activities 3. Prevent complications 4. Minimize impairments 5. Maximize function 23 Stroke Education Ischemic or Hemorrhagic Stroke Patients or their caregivers must be given education during the hospital stay on ALL of the following: 1. process for activation of emergency medical system 2. need for follow-up after discharge 3. medications prescribed at discharge 4. risk factors for stroke 5. warning signs and symptoms of stroke Three methods will ensure stroke education is complete from admission through discharge: Neurological Interdisciplinary Plan of Care (BMC-881) Medical-Surgical Discharge Summary (BMC-674) Daily Problem, Intervention, and Evaluation (PIE) notes Provide every patient and/or caregiver with the resource: Stroke: A Patient Guide 24 8

9 Discharge Stroke: A Patient Guide Medication Reconciliation Order Record (BMC-746) for all discharge medications Patient Discharge Summary with Stroke education Follow-up instructions Plan for rehabilitation 25 References ahca.myflorida.com/mchq/health_facility.../strokecenterslist.pdf tpatient/forms/59a3_2085_fac_rule_text.pdf E ter2.htm cemeasurement/current+nhqm+manual.htm cemeasurement/stk+core+measures.htm/ 26 9