Primary Versus Comprehensive: What is the Difference?
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1 Primary Versus Comprehensive: What is the Difference? April 26, 2018 Bethann Mercanti, PA-C Director of Clinical Practice Stroke Program Coordinator Cooper Neurological Institute Cooper Bon & Joint Institute
2 I have no disclosures to make Disclosures
3 Objectives 1. Understand the benefits of certification as a Stroke Center 2. Define the Eligibility Criteria for Joint Commission Certification 3. Discuss the requirements for Certification as a Stroke Center
4 Stroke Centers What: To improve patient access to time-sensitive stroke treatment Why: Stroke remains the #5 cause of death and a leading case of disability in the US How: Develop evidenced based stroke programs within hospital systems that offer different levels of care, appropriate to the individual hospitals abilities
5 Stroke Centers Benefits: 1. Improve Clinical Quality 2. Provide Objective methods of assessment for clinical excellence 3. Cultivate Cohesive Clinical Team 4. Promote Culture of Excellence 5. Serve the Community
6 Certifying Organizations State Department of Health DNV GL The Joint Commission
7 Levels of Certification Acute Stroke Ready (ASR) Manage strokes in the acute phase Transfer patients to PSC or CSC TJC Only Primary Stroke (PSC) Manage strokes in all phases Staff, Infrastructure, Resources for Stroke patients May Transfer to CSC Thrombectomy Capable (TSC) PSC+ Outcomes and quality focused on Ischemic Stroke TJC Only Comprehensive Stroke (CSC) Manage multiple complex stroke patients Includes services beyond stroke Outcomes and quality focused on AIS, ICH, SAH, Carotid disease, ICP management, etc.
8 Patient Volumes CSC PSC tpa 25/2-years Or 50/year Aneurysmal SAH 40/2-year Or 20/year Endovascular Coiling OR Microsurgical Clipping 30/2-years Serve a minimum of 10 patients
9 Models of Care Neurology Board Certified and fellowship trained in Stroke Available 24/7 Attends 1 Stroke Conference Annually 8 hours Stroke Education annually NeuroCritical Care Board Certified Neurointensivists Additional Physicians with NeuroCritical Care Expertise Available 24/7 8 hours of Stroke Education annually Neurosurgery Board certified in Neurosurgery Available onsite 24/7 within 30 minutes 8 hours of Stroke Education annually Neurointerventional Surgery Board Certified in either Diagnostic Neuroradiology or Endovascular Neurosurgery Available onsite 24/7 within 30 minutes 8 hours of Stroke Education annually
10 24/7 Advanced Imaging Radiology CT/CTA Ultrasonography TTE/TEE Neurosurgical and Endovascular Transcranial &Extracranial US Catheter Angiography MRI/MRA Carotid Duplex
11 Stroke Beds Stroke Units and Neuro-ICU 24/7 Telemetry monitoring Neuro-Assessments NeuroChecks NIHSS Stroke trained Nurses Annual Competencies Procedural Competencies Transitional Care Services with focus on Stroke
12 Protocols and Policies Clinical Practice Guidelines Evidenced based medicine, outlined by the American Heart/Stroke Association Policies and Protocols Reviewed annually for continual evaluation of current practice
13 Primary Stroke STK-1: VTE Prophylaxis by the End of Day 2 STK-2: Discharged on Antithrombotic Therapy STK-3: Anticoagulation Therapy for A.Fib/Flutter STK-4: Thrombolytic Therapy STK-5: Antithrombotic Therapy by the End of Day 2 STK-6: Discharged on Statin Medication STK-7: Dysphagia Screening STK-8: Stroke Education STK-9: Smoking Cessation Education STK-10: Assessed for Rehabilitation 8
14 Comprehensive Stroke CSTK-1: National Institutes of Health Stroke Scale Score (NIHSS) CSTK-3: Overall Rate/(a) Hunt & Hess Score for SAH/(b) ICH Score for ICH CSTK-4: Procoagulant Reversak Agent Initiation for ICH CSTK-5: Overall Rate/Hemorrhagic Transformation Rate for (a) IV tpa/(b) IA tpa or MER CSTK-6: Nimodipine Treatment Administered for SAH CSTK-8: TICI Post-Treatment Reperfusion Grade CSTK-9: Arrival Time to Skin Puncture CSTK-10: Modified Rankin Score (mrs) at 90 Days: Favorable Outcome CSTK-11: Timeliness to Reperfusion: Arrival Time to TICI 2B or Higher CSTK-12: Timeliness to Reperfusion: Skin Puncture to TICI 2B or Higher
15 CSC: Patient Outcomes 1. Mortality and Readmission Rates Acute Ischemic Stroke Subarachnoid Hemorrhage Intracerebral Hemorrhage 2. Stroke and Death Rates 24 Hours Post-Cerebral Angiogram < 1% 30 Days Post-CEA or Post-CAS in Symptomatic patients < 6% 30 Days Post-CEA or Post-CAS in Asymptomatic patients <3% 3. Ventriculitis Rates 1. Post-Extraventricular Drain placement 7
16 Data Review Concurrent & Peer Review Premier Get with the Guidelines Committees & Case Review 7
17 Performance Improvement & Process Development Board of Trustees Quality Committee of the Board SEVPs Stroke Team Members Department Chiefs Physicians APPs RNs Institute PI Committee Stroke Committee, Board, & PI Peer Review of Cases Admin Leadership Techs Pharmacists Therapists Vascular, Radiology, EM, NSG, Cardiology 3
18 Education Outside Hospitals Community Educate EMS Providers 7
19 Multidisciplinary Team Your Most Valuable Tool! Physicians/APPs Transitional Care Nurses EMS Administration Techs
20 1. The Joint Commission 2. American Heart Association and American Stroke Association 3. DNV GL 4. New Jersey Department of Health Resources & References
21 Thank You Questions
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