Services de réadaptation des victimes d AVC en milieu hospitalier. Optional Performance Indicator Protocols

Transcription

1 Services de réadaptation des victimes d AVC en milieu hospitalier Optional Performance Indicator Protocols 1

2 2 Services de réadaptation des victimes d AVC en milieu hospitalier

3 Stroke Distinction Optional Performance Indicator Protocols 1. Percentage of patients who receive acute ASA therapy within the first 48 hours of hospital arrival. Purpose and Rationale Acute aspirin therapy reduces the risk of early recurrent ischemic stroke. It also reduces the risk of venous thromboembolism. Definition Numerator: Number of ischemic stroke patients who receive acute aspirin therapy within the first 48 hours of arrival to hospital. Include as an event for the numerator: All ischemic stroke and TIA patients who receive aspirin within the first 48 hours Patients who receive Clopidigrel (Plavix) or Aggrenox in the first 48 hours instead of aspirin Exclude as an event for the numerator: Stroke patients with no documentation that aspirin was given in the first 48 hours Denominator: Total number of ischemic stroke/tia patients seen in the emergency department or admitted to inpatient. Include as an event for the denominator: All ischemic stroke and TIA patients Exclude as an event for the denominator: All subarachnoid and intracerebral hemorrhage patients Collecting Data Start time should be the triage time as a national standard. Stop time should be the time documented on the patient medication record as the time first dose of ASA given. This can be given orally or through an NG tube. Performance Indicator Threshold 90% of all ischemic stroke and TIA patients should receive acute aspirin within 48 hours of triage in the ED 1

4 Analysis and Reporting Report proportion of all ischemic stroke/tia patients who receive acute aspirin therapy within 48 hours Limitations and Considerations May also calculate and be aware of median door to acute aspirin administration time in an effort to improve the quality of this performance measure Patients who receive acute thrombolysis (tpa) may not be given an acute aspirin dose until 24 hours after tpa administration. Patients who receive tpa should not be excluded from the denominator, and should be included in the numerator if they receive aspirin in the first 48 hours. 2

5 2. Proportion of stroke /TIA patients who receive brain CT / MRI within 24 hours Purpose and Rationale All patients with suspected stroke or TIA should undergo brain imaging immediately upon presentation to hospital. It is not possible to differentiate an ischemic stroke from a hemorrhagic stroke based on clinical presentation alone, and therefore brain imaging is required to guide management decisions. Definition Numerator: Number of stroke patients who arrive in an ED and receive their first CT or MRI scan within 24 hours of arrival in ED. Include as an event for the numerator: All ischemic, hemorrhagic and TIA stroke patients who receive either CT or MRI within the first 24 hours of hospital arrival Includes patients admitted to hospital and those discharged directly from the ED Exclude as an event for the numerator: Patients with no documentation of a CT or MRI performed in the first 24 hours form hospital arrival (triage time) Denominator: Total number of stroke patients admitted to ED and/or inpatient care. Include as an event for the denominator: All ischemic, hemorrhagic and TIA stroke patients who present to an acute care hospital and receive a diagnosis of stroke Includes patients admitted to hospital and those discharged directly from the ED Exclude as an event for the denominator: There should be no exclusions from this denominator Collecting Data Time should be calculated from hospital ED triage time to the time the scan is started. Start time of the CT or MRI scan is documented on the scan report. This performance measure is included in CIHI Stroke Special Project 340 to enable standardized and consistent data collection. Performance Indicator Threshold 90% of all stroke/tia patients have a CT or MRI completed within 24 hours of hospital arrival 3

6 Analysis and Reporting Calculate and report count of stroke and TIAs receiving a CT or MRI within the first 24 hours; and as a proportion of all stroke and TIA patients (n, %) Limitations and Considerations Some patients may receive a CT or MRI scan at one hospital and then be transferred to a second hospital, usually with more advanced stroke care capability, for management. These patients should be included in the numerator and denominator of this measure. In some cases, patients may be first seen in a hospital with more advanced stroke services then repatriated to a community hospital. If the community hospital is reporting on this indicator they should also include these patients in the numerator and denominator. All stroke patients should be included in the numerator and denominator if they were further managed at your hospital. 4

7 3. Proportion of all admitted stroke patients who are on a ward where stroke patients are clustered Purpose and Rationale Ideally all stroke patients should be cared for on a designated and geographically defined stroke unit for acute inpatient care and rehabilitation. In hospitals where dedicated stroke units are not available, patients should be clustered or admitted to the same section of the same ward. In this setting, staff members should have specialized knowledge of stroke management and patients should have access to early rehabilitation and other services that are provided in dedicated stroke units. Please refer to the Canadian stroke Strategy guide to the Implementation of Stroke Unit Care for additional information on the activities and components of acute inpatient and rehabilitation stroke care. Definition Numerator: Number of patients admitted to hospital with stroke who are on a ward where stroke patients are intentionally clustered and receive specialized stroke care. Include as an event for the numerator: All TIA, ischemic and hemorrhagic stroke patients admitted to hospital and admitted to a bed on a unit where stroke patients are clustered Exclude as an event for the numerator: Patients admitted to ICU, a surgical ward, general medical or neurology ward or a mixed rehab unit where there is not intentional clustering of stroke patients. Denominator: Total number of stroke patients admitted to hospital. Include as an event for the denominator: All TIA, ischemic and hemorrhagic stroke patients admitted to hospital acute inpatient or inpatient rehabilitation Exclude as an event for the denominator: All stroke and TIA patients discharged directly from the ED Collecting Data This indicator applies in acute care and inpatient rehabilitation. The name of the ward where stroke patients are clustered should be known and communicated. Performance Indicator Threshold 75% of all stroke patients admitted to inpatient rehabilitation are managed on a stroke unit for all or part of their inpatient stay 5

8 Analysis and Reporting Calculate and report count of all stroke patients who spend any part of their in-hospital stay clustered with other stroke patients as a model of care Calculate and report as a proportion of all stroke patients admitted to the inpatient setting (n, %). Limitations and Considerations This performance measure should be applied only in acute care and rehabilitation institutions where designated stroke units are not available and this would replace that indicator. This indicator data can be challenging to interpret. Care must be taken when collecting and reporting this data. There should be an intentional effort and a plan to cluster patients and to manage them using protocols and other components of stroke unit care. This plan will need to be demonstrated to the surveyors. 6

9 4. Proportion of all stroke patients who receive an initial rehabilitation assessment within 48 hours of admission Purpose and Rationale Early consultation with rehabilitation professionals contributes to reductions in complications from immobility such as joint contracture, falls, aspiration pneumonia, and deep vein thrombosis. Another key benefit of early consultation with rehabilitation professionals is early discharge planning for transition from acute care to specialized rehabilitation units or to the community. The first interprofessional assessment after admission must identify the physical, cognitive and communication complications of the stroke to help identify the likely discharge needs. Definition Numerator: Number of patients with initial assessment for stroke rehabilitation within 48 hours documented in their chart. Include as an event for the numerator: All stroke patients admitted to an acute care hospital who have documentation that an assessment was completed by at least one rehabilitation professional within 48 hours of hospital admission. Exclude as an event for the numerator: Patients who do not have documentation on their chart that a rehab assessment was completed in the first 48 hours following hospital admission Denominator: All ischemic, hemorrhagic and TIA stroke patients admitted to acute inpatient care. Include as an event for the denominator: All stroke patients admitted to an acute inpatient hospital Exclude as an event for the denominator: All patients discharged directly from the ED Collecting Data The information for this indicator should be documented on the patients chart in the nurses notes, interprofessional progress notes and in referral or consult notes and requests. A rehabilitation professional conducting an initial assessment should include at least one of: a physiatrist, physiotherapist, occupational therapist, speech language pathologist. Performance Indicator Threshold 80% of all admitted stroke patients should have an initial assessment for rehabilitation within 48 hours of hospital admission 7

10 Analysis and Reporting Calculate and report count of all stroke and TIAs receiving an initial rehab assessment within 48 hours; and as a proportion of all stroke and TIA patients (n, %) Also calculate and report mean, median and percentile (10th, 25th, 50th, 75th, 90th) door-to-first rehab assessment times in hours Limitations and Considerations Applies to assessment in acute care and also re-assessment once admitted to inpatient rehabilitation. May be difficult to obtain. Need to clarify/define what constitutes an initial rehabilitation assessment when reporting and be able to articulate this to surveyors and your colleagues. Also need to encourage better documentation that an assessment has been completed and the nature of the assessment (when, by whom, extent). 8

11 5. Percentage of inpatients with stroke that experience complications during inpatient stay: including pneumonia, venous thrombo-embolism, gastrointestinal bleed, secondary cerebral hemorrhage, pressure ulcers, urinary tract infection Purpose and Rationale All stroke patients are at risk of complications during in-hospital stay. Reduced complication rates is a measure of effectiveness of care. Definition Numerator: Total number of admissions that experience at least one complication during inpatient stay. Include as an event for the numerator: Any patient that experiences at least one of the following complications: pneumonia, venousthrombo-embolism (VTE), gastro-intestinal bleed, secondary cerebral hemorrhage, pressure ulcer, or urinary tract infection (UTI) Exclude as an event for the numerator: Patients who experience other complications only Denominator: Total number of stroke inpatient admissions. Include as an event for the denominator: All stroke inpatient admissions ischemic, hemorrhagic and TIA patients All inpatient stroke admissions who are discharged alive and those who may die in hospital Exclude as an event for the denominator: There should be no exclusions to the denominator of this indicator Collecting Data Complications listed above should occur after the patient is admitted to hospital for their stroke, and should not be considered if they are conditions that existed prior to hospital arrival for the index stroke event. There should be documentation in the physician and/or nurses' notes confirming the presence of the complication and a plan for management where appropriate. The complications included in this measure should be noted in the discharge summary. Notes that indicate 'query or 'suspected' complication should not be counted for the presence of this indicator, only confirmed cases should be counted. 9

12 Performance Indicator Threshold Rates per complication type: Pneumonia: 10%; VTE: 2%; GI Bleed: 1%; secondary ICH: 8%*; Pressure skin Ulcers: 3% Analysis and Reporting Risk adjustment is required. Factors to include are age, gender, stroke type, stroke severity, and co morbidities where possible (age and gender at a minimum) Calculate and report count of all stroke patients who have a complication in hospital; and also as a proportion of all stroke patients admitted to an inpatient setting with stroke (n, %) Report as composite and also by each complication type A complication must be a new development while in hospital and not exacerbation of a pre-existing condition or complication Report also by number patients with 1, 2 3 and >3 complications, by complication types Limitations and Considerations This indicator will count number of patients. A patient can have one or more of the complications listed. Secondary intracerebral hemorrhage refers only to cases where the hemorrhage is secondary to the patient receiving tpa, not to conversions from ischemic stroke to hemorrhagic stroke. 10

13 6. Wait time from ischemic stroke or TIA symptom onset to carotid revascularization Purpose and Rationale People with carotid territory disease have a high risk of recurrent stroke. Current strong evidence has shown that undergoing carotid endarterectomy within 2 weeks of initial stroke can significantly reduce the risk of recurrence in patients with severe stenosis. Definition Median time from stroke symptom onset to carotid endarterectomy (CEA) surgery. Numerator: Sum[LSN to CEA time (days) for all CEA stroke patients]. Include as an event for the numerator: All patients who undergo a CEA following stroke Exclude as an event for the numerator: Patients who do not undergo CEA following stroke Denominator: Number of stroke patients who undergo CEA following their stroke. Include as an event for the denominator: Include patients who undergo CEA during same admission as for the index stroke Include patients who are discharged and then readmitted for CEA after index stroke to same institution and where possible, within same region Exclude as an event for the denominator: Stroke patients who do not undergo CEA in same facility or same region** Patients who do not undergo CEA Collecting Data Data should be contained in surgical notes, physician notes and discharge summaries. Performance Indicator Threshold 90% of patients with severe carotid stenosis should undergo CEA within 2 weeks. Analysis and Reporting Should calculate mean, SD, and all percentiles (min, 5, 10, 25, 50, 75, 90, 95, 100). Median is statistic of choice for reporting on this measure. 11

14 Limitations and Considerations ** If reporting by region, then this indictor can be analyzed by the region and look at admissions and CEA across all hospitals in the region. 12

15 7. Percentage of TIA/minor stroke patients discharged directly from the ED who receive a referral for assessment in a stroke prevention clinic or equivalent before leaving hospital Purpose and Rationale Evidence clearly demonstrates that a TIA or minor stroke are unstable conditions that warn of high future risk of stroke, death or other vascular events. The risk of recurrent stroke after a transient ischemic attack is 10 20% within 90 days, and the risk is front-loaded with half of strokes in the first 2 days. Immediate initiation of secondary prevention medical therapy and carotid endarterectomy within two weeks has been shown to drastically reduce the risk of recurrent stroke. Definition Numerator: Total number of admissions to an emergency department for stroke who are discharged directly from the ED and receive a referral for a prevention follow-up. Include as an event for the numerator: All stroke and TIA patients discharged directly from the ED back to the community with a referral appointment for prevention follow-up Exclude as an event for the numerator: Patients admitted to hospital Patients without documentation or evidence that a follow-up appointment has been made for stroke prevention Denominator: Total number of stroke separations directly from the ED without an inpatient admission. Include as an event for the denominator: All stroke patients discharged directly from the ED to the community Include all stroke types ischemic, hemorrhagic and TIA Exclude as an event for the denominator: Patients admitted to an acute care hospital from the ED Patients transferred from the ED to another cute care hospital Collecting Data A copy of the referral should be included on the ED chart. See ED progress notes and physician order sheets for notations regarding a referral for secondary prevention. 13

16 Performance Indicator Threshold > 90% of all stroke and TIA patients discharge directly from the ED should have a referral for follow-up prevention services Analysis and Reporting Calculate and report count of all stroke and TIA patients with a referral for secondary prevention clinics; and as a proportion of all stroke and TIA patients discharged from the ED (n, %) Limitations and Considerations Stroke prevention clinics are not available in all jurisdictions. Where they are absent, another equivalent model of care may be in place and this should be clarified before tracking this indicator. Other models may include referrals to a neurologist or internist in their clinics or offices you will need to confirm that these are for stroke prevention services. 14

17 8. Proportion of eligible stroke and transient ischemic attack patients with atrial fibrillation prescribed anticoagulant therapy on discharge from acute care Purpose and Rationale Atrial fibrillation is a significant risk factor for stroke with 1 in 6 patients with atrial fibrillation experiencing a stroke in their lifetime. Stroke caused by atrial fibrillation is highly preventable if patients are treated with anticoagulants and monitored carefully to ensure the patient is compliant and remains within the therapeutic range of anticoagulation. Definition Numerator: Number of all stroke/tia patients with atrial fibrillation who are prescribed anticoagulant therapy on d/c from ED or inpatient acute care. Include as an event for the numerator: All ischemic stroke patients with a diagnosis of atrial fibrillation and are prescribed anticoagulants at discharge from the ED or inpatient care Exclude as an event for the numerator: Patients without atrial fibrillation who are prescribed anticoagulants Patients with atrial fibrillation who are not prescribed anticoagulants Denominator: Total number of ischemic/tia stroke patients discharged from ED or inpatient acute care with a diagnosis of atrial fibrillation as well. Include as an event for the denominator: All TIA and ischemic stroke patients admitted to the ED or inpatient care with a diagnosis of stroke and a diagnosis of atrial fibrillation Exclude as an event for the denominator: Ischemic stroke and TIA patients without a diagnosis of atrial fibrillation Collecting Data A copy of a prescription for all discharge medications should be on the patient s chart. Discharge summary note should indicate both the diagnosis of atrial fibrillation and prescribed medications at discharge. Physician order sheets may list discharge medications. Performance Indicator Threshold Threshold 75% of all stroke patients with atrial fibrillation should be discharged on an anticoagulant 15

18 Analysis and Reporting Calculate and report count of all ischemic stroke patients with atrial fibrillation who are discharged with a prescription for antithrombotic therapy; and also as a proportion of all ischemic stroke patients discharged alive from hospital (ED or inpatient) (n, %). Stratify results by stroke type (TIA and ischemic stroke) as well as reporting aggregated results Limitations and Considerations Difficult to determine eligibility for anticoagulants from administrative databases. Need to define which medication groups will be included for this measure when reporting. Common medications include warfarin (Coumadin), sometimes heparin or low molecular weight heparin. 16

19 9. Number of days from stroke onset to admission to inpatient rehabilitation Purpose and Rationale Over 60% of patients with stroke will require some form of rehabilitation. There is evidence that an interprofessional approach to rehabilitation in inpatient rehabilitation services reduces long term disability after stroke. Early access to inpatient rehabilitation has been found to further improve outcomes. Definition Numerator: Sum {Stroke patient admission date to inpatient rehab facility stroke admission data to acute care ED or inpatient}. Include as an event for the numerator: All stroke patients admitted to inpatient rehabilitation Counts should be number of days Exclude as an event for the numerator: Patients who receive outpatient rehabilitation and are not admitted to an inpatient rehabilitation bed Denominator: Total number of stroke patients admitted to inpatient rehabilitation. Include as an event for the denominator: All patients admitted from acute care to inpatient rehabilitation Exclude as an event for the denominator: Patients discharged to the community or other type of convalescent facility other than inpatient rehabilitation Collecting Data This information is recorded in the NRS for facilities that report to the CIHI National Rehabilitation Reporting System. Admission date to acute care (ED or inpatient) and transfer/admission date to inpatient rehabilitation should be in the discharge note form acute care and in the progress notes. Performance Indicator Threshold 75% of all patients discharged to inpatient rehabilitation are transferred to rehab within 10 days of stroke patient admission to acute care Analysis and Reporting Calculate and report mean, median and percentile (10th, 25th, 50th, 75th, 90th) from stroke admission date (first ED triage time or inpatient admission time) to arrival in inpatient rehab (in days) 17

20 Limitations and Considerations Should break time down to acute inpatient admission time and alternate level of care days as inpatient (or days from ready to discharge to rehab until actual discharge date). Some patients may go to another setting for a short stay before entering inpatient rehab and this should also be accounted for and defined when data presented. This is especially important to note from the perspective of an inpatient rehabilitation facility reporting on this indicator. The admission to an inpatient rehabilitation bed may occur in the same facility that provided acute stroke care or it may be in a separate stand-alone inpatient rehabilitation facility. 18

21 10. Change in functional status using a standardized measurement tool, from time of admission to an inpatient rehabilitation unit for stroke patients, to the time of discharge Purpose and Rationale Inpatient stroke rehabilitation should provide adequate intensity, duration and frequency of therapy for patients to obtain optimal benefits. Intensive rehabilitation care for both acute and sub-acute stroke survivors improves arm and leg motor recovery, walking mobility and functional stats. Definition Numerator: Sum {Discharge total functional score admission total functional score}. Include as an event for the numerator: All stroke patients admitted to inpatient rehabilitation who have both an admission and discharge functional assessment completed using a standardized tool Exclude as an event for the numerator: Patients with only an admission or discharge functional score available Denominator: Total number of stroke patients admitted to inpatient rehabilitation. Include as an event for the denominator: All stroke patients admitted to inpatient rehabilitation who have both an admission and discharge functional assessment completed using a standardized tool Exclude as an event for the denominator: Patients with only an admission or discharge functional score available Collecting Data Data should be collected from a standardized data collection tool. The most commonly used tool in Canada in inpatient rehabilitation facilities is the Functional Independence Measure (FIM). The total functional score should be used of calculations, not the sub scores. Performance Indicator Threshold 90% of patients will have an improvement by at least 20 points on the FIM from admission to discharge in inpatient rehabilitation Analysis and Reporting Based on the FIM, Calculate and report mean and median change in FIM scores. Calculating a percent-change in FIM is not generally considered a valid analysis. 19

22 Limitations and Considerations Need to define a standardized functional scale to use, and set time intervals. NRS uses the FIM scale. *Some centres use other valid tools instead of the FIM (such as the Barthel). The tool can be individualized as long as the tool is a validated assessment tool for functional status and the parameters for a clinically significant difference in scores is clearly stated. 20

23 11. Proportion of stroke patients with documentation to indicate screening for depression was performed either informally or using a formal assessment tool in the acute care or rehabilitation setting following an acute stroke event Purpose and Rationale Post-stroke depression may affect as many as 1 in every 4 individuals with a significant stroke. The stroke survivor is at greatest risk for depression within the first few months after stroke. Depression may affect the patient s ability to participate in therapy and is associated with slower recovery. Definition Numerator: Number of stroke patients with documentation to indicate screening for depression was performed either informally or using a formal assessment tool in a rehabilitation setting following an acute stroke event. Include as an event for the numerator: all stroke patients in acute inpatient care or inpatient rehabilitation with documentation that screening for depression was completed Exclude as an event for the numerator: all stroke patients without documentation that screening for depression was performed Denominator: Total number of stroke patients admitted to acute inpatient care or inpatient rehabilitation. Include as an event for the denominator: All admitted stroke patients Exclude as an event for the denominator: Patients who die in hospital while admitted to acute inpatient care for stroke Collecting Data This should be documented in the interprofessional progress notes, physician notes or on a consult form for psychology, psychiatry or possibly social work. Documentation should clearly indicate that the patient was assessed for possible depression. Performance Indicator Threshold 80% of all patients in inpatient rehabilitation have documentation of a screen for depression 21

24 Analysis and Reporting Calculate and report count of all stroke patients in the emergency department, acute inpatient setting or inpatient rehabilitation who are screened for depression; and also report as a proportion of all stroke patients admitted to each of these settings (n, %) Limitations and Considerations Should also track whether the screening was done using a standardized depression screening tool such as the HAD or Beck Depression Scale, or whether the screening was more of an informal assessment. 22