DNVGL Healthcare. 2nd Annual Stroke Center Certification Workshop November 6, Comprehensive Stroke Center Certification Program

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1 DNVGL Healthcare Comprehensive Stroke Center Certification Program 2nd Annual Stroke Center Certification Workshop November 6, 2014 Cathie Abrahamsen RN MSN SAFER, SMARTER, GREENER

2 Disclosure Employment Chief Standards and Program Development Officer for DNVGL 2

3 Integrity at the core Independent foundation established in 1864 / In the US since year Anniversary 2014 Third Party Evaluation and Assessment with a focus of managing risk as our core Vision: Global Impact for Sustainable Future Purpose: Safeguarding Life, Property and the Environment Accreditation Organization with deeming authority approved by CMS 23 December 2014 Slide 3

4 DNVHC Comprehensive Stroke Center Certification Primary Stroke Center Certification November 2009 Comprehensive Stroke Center Certification September 2012

5 DNVHC Comprehensive Stroke Center Certification Basic Premises of the DNV GL Certification Program We are partners with the centers to assure the best health care possible. We believe you are the experts in the care you are giving and we are the third eye that will listen, ask questions, discuss and verify. Certification is not accreditation, but a highly evolved, specialty clinical care within an accredited facility so focus on the expertise is key. Be thoughtful and reasonable Be inclusive, not exclusive. Find a reason to say yes. Always keep the patient in mind. 5

6 DNVHC Comprehensive Stroke Center Certification Comprehensive Stroke Center Eligibility Criteria Current Hospital Accreditation, does NOT have to be DNV accredited host hospital must be Medicare Certified Hospital State or Accredited by one of the approved accreditation organizations with deeming authority. does not require non DNV hospitals to be ISO certified if they have a functional equivalent process in place within the host hospital

7 DNVHC Comprehensive Stroke Center Certification Must be able to show compliance with primary as well as Comprehensive Stroke Center standards during the survey process Must be part of a data registry If in a hospital system, may participate in the system data if there is comparative data reports Must be involved in some IRB research 7

8 Comprehensive Stroke Centers Criteria Volume Requirements Greater than or equal to 20 SAH patients per year Greater than or equal to 10 clippings/coilings Greater than or equal to 25 tpa Each neurosurgeon should participate in greater than or equal to 10 surgical intervention cases per year. Lower volume centers can have excellent outcomes High volume centers are not assured of excellent outcomes 8

9 Comprehensive Stroke Center Certification Process Surveys will be planned and announced 30 days notice Notice to give an opportunity to have the stroke team leaders present Survey activity emphasis on stroke services such as: Data review for trending, analysis and use of data Development of protocols based on national guidelines (Brain Attack Coalition, American Heart/ Stroke etc.) Capabilities for diagnostic and treatment of stroke patients Competence and engagement of care providers Timelines for response, turn around for labs and imaging Physical rehabilitation evaluation and therapy Initiation tpa within specified timeframes Areas included in the assessment are those involved with stroke (e.g. ED, ICU, Stroke Unit, Interventional and surgical areas), additional areas related to the PSC/CSC will also reviewed.

10 Comprehensive Stroke Centers CSC survey is every year at this time on site May go with a model of every other year on site survey with the alternate GAP year Proposal is to look at : Previous findings and corrective actions report Review of data Focus Subject which would be a pre determined focus on one subject for either all of CSCs or the individual focus of the stroke center 10

11 DNVHC Comprehensive Stroke Center Certification Surveyor Enhancement Licensed physician or nurse Stroke education every year Add current stroke coordinators as surveyors Current working experts Opportunity to network with other program coordinators Opportunity for inclusion in review of requirements on an on-going basis Potential to see other programs

12 DNVHC Comprehensive Stroke Center Certification Survey is over two days Starts with an overview from the Stroke center leadership Both surveyors usually visit the emergency room Technical advisors tend to focus on the stroke clinical aspects DNV clinical surveyor focus is on supportive services Credentialing Competency Rehab Radiology Both will do chart review and quality sessions 12

13 Scope of the CSC Components Leadership and Management of the Comprehensive Stroke Center Staff (Competency/Qualifications/Evaluation) Staffing Management Policies/Procedures Pre hospital Process Stroke Pathway (Protocol) Emergency Department (Initial Assessment and Treatment) Stroke Unit Visit (ICU or other Respective Unit) Medication Management Quality Management System/Monitoring, Measuring and Analysis Rehabilitative Services Medical Records Physical Environment

14 Staff (Competence / Qualifications) Qualifications for those involved with Stroke Care Job descriptions Licensure, experience, etc. Education (specific for care of stroke patients) Stroke Team Nursing staff not assigned to the Stroke Team need education on accessing the Stroke Team / care of stroke patients Orientation (specific regarding CSC, Stroke Team, Stroke Protocols) Defined the criteria and qualifications required for designation of qualified practitioners, professionals and other personnel as a Stroke Team Neurologist or Neurosurgeon Physician with expertise in cerebrovascular disease Other qualified professionals Emergency department personnel and emergency medical services Nursing Staff Radiology Technologists (MRI/CT) Rehabilitation Therapists Case Manager / Social Worker

15 Specific requirements for CSC Stroke Team The Stroke Team shall be comprised of personnel that may be employed, contracted or otherwise available in some manner to the CSC to encompass the following areas of expertise: neurologists and neurosurgeons (senior-level resident), board certified or eligible; surgeons with expertise performing carotid endarterectomy (CEA) diagnostic radiologists/ rad techs(including MRI and CT technologists) physicians with expertise in interventional endovascular neuroradiology procedures and techniques physicians with expertise in critical care or neurointensive care Emergency department personnel and emergency medical services (EMS) Nursing staff trained in the care of acute stroke patients Advanced practice nurses (APNs) Rehabilitation therapists with expertise in treatment of acute stroke patients case manager or social worker

16 Stroke Protocol References used to develop the protocol will include those prepared by the Brain Attack Coalition, American Stroke Association, American Heart Association, and others recognized professional organizations for the care of stroke patients Shared this protocol with emergency department practitioners, EMS providers and ICU and/or Stroke Unit Review/Update (as necessary) at least annually The Stroke Protocol defines: Evaluation and management of the acute stroke patient. Physicians (as a part of the Stroke Team) have knowledge and expertise in the diagnosis and treatment of cerebrovascular disease. Written documentation with evidence of neurosurgical coverage or protocol for transfer to an appropriate facility. Ensuring access to neurological expertise when required.

17 Specific requirements for CSC Early implementation of stroke protocol and notification to the Stroke Team upon entry to the ED or prior upon notification from EMS personnel. Evaluation and management of the acute stroke patient; A log documenting call times, response times, patient diagnoses, treatments and outcomes will be kept and used for quality improvement projects. The CSC shall have the facilities and appropriate qualified neurosurgical staff within a minimum of two hours when determined to be immediately needed by the patient. For decision to transfer due to periodic gaps in Neurosurgical or Endovascular coverage that the CSC will promptly make both referring PSC s and EMS aware of the situation.

18 Diagnostic Tests Magnetic Resonance Imaging (MRI) and computed tomography (CT) available OR referral protocol in place to identify a facility nearby Brain imaging studies are interpreted by a physician with expertise in reading CT or MRI studies Documentation indicating that on a 24/7 basis, acute stroke patients have a diagnostic brain image completed within 20 minutes of being ordered and results reported to or reviewed by a member of the stroke team within 45 minutes of it being ordered Initial lab / imaging tests are availability on site 24/7 and: lab tests are reporting in less than 45 minutes from being ordered? perform an ECG and chest x-ray within the same time frame as laboratory testing Blood Glucose essential

19 Specific requirements for CSC - Services Endovascular Services will be provided for the treatment of cerebrovascular diseases. microsurgical clipping and coiling must be available ability to perform intracranial angioplasty or IA infusions of vasodilators is recommended. If therapy cannot be provided, protocols for the rapid transfer of patients is required Surgical interventional services will be available for management of stroke patients. neurosurgical expertise must be available 24/7

20 Emergency Department Effective system in place for communicating with inbound Emergency Medical System for activation of the acute stroke team Emergency Department practitioners clearly demonstrate the recognition, assessment, and management of acute stroke complications CSC collaborate with ED personnel, emergency physicians and nurses, and stroke professionals to identify capabilities to improve facilitation with EMS responders for triage and transport of acute stroke patients CSC offer EMS providers the opportunity to participate in education and training programs offered by the PSC DTN time within 60 min or less for 50% of eligible patients during the first 3 to 4.5 hours of care, including thrombolytic therapy for patients Indications and contraindications for the use of IV thrombolytic therapy Consents need to follow policy of the state or hospital New wording in standards treat consent as like CPR, standard of care

21 Specific requirements for CSC Rehab Services Rehabilitation services should be implemented as soon as possible. Mobilization of the stroke survivor and resumption of self-care activities should occur as soon as medically feasible. Both inpatient and outpatient rehabilitation programs can improve outcomes and prevent deterioration. Stroke rehabilitation shall focus on training for maximum recovery, prevents and treats comorbid conditions, enhance psychosocial coping, promote integration into the community, prevent recurrent strokes and other vascular events, and enhance quality of life.

22 DNV Comprehensive Stroke Program Update Comprehensive Metrics Update Required metrics are 1,2,3,4,5,7,8,9,12,13,15,18,19,23. Metric 18 added for Jan 2015 Will require addition of metric 18, starting Jan 1 Metric 18 Complication rates for aneurysm coiling and clipping Complications will be defined to include death, stroke or bleeds Metric 12 delineated further and there will now be a 12a and 12b which will be requiring a separation of the documentation of the ICH and SAH severity scores rather than the sum, remove the AVM references and delineate the severity scales as the Hunt and Hess scale or the World Federation of Neurological Surgeons Scale for SAH patients and the ICH score for ICH patients. 25 Private and confidential 23 December 2014

23 DNVGL Stroke Program Top Five Findings for CSC 2014 PC.4 Monitoring of vital signs after tpa PC.6 Defining members of stroke team PC.4 Consents PC.7 Plan of care (Patient education) PC.6 Protocols Update issue with EHR/paper 27 Private and confidential 23 December 2014

24

25 Patrick (Pat) Horine, CEO Cathie Abrahamsen RN MSN CEO (847) SAFER, SMARTER, GREENER 30

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