Primary and Comprehensive Stroke Center Designation
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1 Primary and Comprehensive Stroke Center Designation 1
2 Presenter Disclosure Information Michelle Whaley MSN, CNS, CCRN, CCNS, ANVP-BC Primary and Comprehensive Stroke Center Designation FINANCIAL DISCLOSURE: Genentech Speakers Bureau UNLABELED/UNAPPROVED USES DISCLOSURE: None 2
3 Objectives Compare and contrast stroke ready, primary and comprehensive stroke center certifications Explore the core elements of the certification process. Discuss institutional preparation for certification survey visits. 3
4 Benefits of Stroke Center Designation Improved quality of care Demonstrates a culture of excellence Promotes a program locally, regionally, or nationally Strengthens consumer confidence May fulfill regulatory requirements in certain states 4
5 Most Common Certifying Organizations Det Norske Veritas (DNV) Healthcare Facilities Accreditation Program (HFAP) The Joint Commission (JC) 5
6 Det Norske Veritas (DNV) 6
7 Healthcare Facilities Accreditation Program (HFAP) 7
8 The Joint Commission 8
9 Brain Attack Coalition (BAC) Recommendations 9
10 Elements of Stroke Ready Facility Ability to diagnose and treat acute stroke patients with IV tpa Program can be ED physician driven Neurosurgical expertise may be via telemedicine Transfer protocols and agreements in place 10
11 BAC Elements of a PSC Patient Care Areas Acute stroke teams Written care protocols Emergency medical services Emergency department Stroke unit Neurosurgical services Cerebral and Cerebrovascular imaging Cardiac imaging Rehabilitation services Laboratory services 11
12 BAC Elements of a PSC Support and administrative services Commitment and support of the medical organization Outcomes and quality improvement Continuing medical education Nursing education 12
13 Characteristics of a CSC Meet minimum volume requirements IV tpa, SAH clips/coils Availability of neuroscientists 24/7 Written documentation of processes, protocols, etc. Advanced imaging capability Ability to manage multiple, simultaneous complex acute stroke patients Dedicated neuro intensive care unit Physician, nursing, EMS, and community education Peer review process Stroke research Post hospital care coordination 13
14 Texas Stroke Designation Texas stroke legislation requires state designation Texas recognizes JC and DNV certifications Level 1 (CSC) Level 2 (PSC) Level 3 (ASR) 14
15 Texas Stroke Certified Hospitals Comprehensive Stroke Centers 2 JC 11 DNV Primary Stroke Centers 96 JC 17 DNV 15
16 16
17 17
18 18
19 JC PSC/CSC Elements of Performance 19
20 20
21 21
22 JC Hot Topics 2012 Certification Volume requirements Depression screening Cognitive evaluation EMS trip sheets Actual weight vs. stated/estimated weight for tpa dosing calculation Public reporting of stroke program data 2015 Re-Certification INR Documentation SAH/ICH patients in the ED Vital signs Neuro checks Rapid neuro assessment in the ED for IS patients Drip titration documentation Neurocritical Care 22
23 Core Measures 23
24 DNV Stroke Core Measures tpa Considered/Thrombolytic Therapy Administered Screening Patients for Dysphagia Deep Vein Thrombolysis Prophylaxis Lipid Profile During Hospitalization Discharged on Cholesterol Reducing Medication as needed Offering of Patient Education About Stroke Smoking Cessation/Advice/Counseling Plan/Assessed for Rehabilitation Considered Antithrombotic Medications Started in 48 Hours Antithrombotic Medications Prescribed at Discharge Anticoagulants Prescribed for Patients with Atrial Fibrillation 24
25 HFAP Measures Quarterly Data Submission SM-1 Stroke Team Arrival SM-2 Laboratory Studies SM-3 Neuroimaging Studies SM-4 Neurosurgical Services SM-5 Thrombolytic Therapy 0-3 SM-6 Antithrombotic Therapy by End of Hospital Day 2 SM-7 Discharged on Antithrombotic Therapy SM-8 Anticoagulation Therapy for Atrial Fibrillation/Flutter SM-9 Venous Thromboembolism (VTE) Prophylaxis SM-10 Discharged on Statin Medication SM-11 Stroke Education SM-12 Dysphagia Screening SM-13 Assessed for Rehabilitation SM-14 Door to Needle Time 25
26 HFAP Measures Quarterly Data Submission SM-15 NIHSS Scores for Ischemic Stroke or TIA (Required for CSC) SM-16 Initial Severity Measures for SAH, ICH & AVM (Required for CSC) SM-17 Clipping/Coiling Within 48 hours (Required for CSC) SM-18 Nimodipine Treatment Within 24 hours to < 21 days (Optional for CSC) SM-19 INR Reversal with Procoagulant Preparation (Optional for CSC) SM-20 Diagnostic Neuroangiography Within 24 Hours (Optional for CSC) SM-21 Discharge Physical Rehabilitation Referral (Optional for CSC) 26
27 JC PSC Stroke Core Measures Monthly or Quarterly Submission STK-1 Venous Thromboembolism (VTE) Prophylaxis STK-2 Discharged on Antithrombotic Therapy STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-4 Thrombolytic Therapy STK-5 Antithrombotic Therapy by End of Hospital Day STK-6 Discharged on Statin Medication STK-8 Stroke Education STK 10 Assessed for Rehabilitation 27
28 JC CSTK Measures Monthly or Quarterly Submission CSTK 01 NIHSS performed for ischemic stroke patients CSTK 02 mrs at 90 days CSTK 03 Severity measurement performed for SAH and ICH pts CSTK 04 Procoagulant Reversal Agent Initiation for ICH CSTK 05 Hemorrhagic Transformation (Overall Rate) CSTK 06 Nimodipine treatment administered CSTK 07 Median time to revascularization CSTK 08 Thrombolysis in cerebral infarction (TICI Score post IA) 28
29 29
30 National Stroke Databases Get with the Guidelines Paul Coverdale National Acute Stroke Registry Society of NeuroInterventional Surgery NeuroVascular Quality Initiative (NVQI) Cerebral aneurysm Acute ischemic stroke Carotid Artery Disease Cerebral AVM 30
31 Get with the Guidelines 31
32 32
33 Preparing for Certification Survival Tips Obtain the most current requirements for certification Become the expert at your institution Perform a gap analysis Meet with hospital administration Discuss program strengths and weaknesses Develop a plan to manage missing elements Schedule Monthly meetings Stakeholders Hospital leaders Stroke team members Share the work 33
34 Preparing for Certification Survival Tips Know your patient population all year long Concurrent review of patient records Understand your numbers Golden hour times Treatment rates IV IA Complication rates 34
35 Preparing for the Big Day Be ready ahead of time Don t cram! Prep the staff Physicians Nurses Techs Housekeepers Valet Hire temporary staff Ensure policies, procedures, guidelines and order sets have been updated to match current guidelines Review employee and physician files Education hours Meet internal standards Use formal presentations to showcase your program 35
36 PSC and CSC Survey Day Start the day well rested Bring a scribe Plan for computerized chart review Have department leaders on standby Incident command structure Text/pager messaging Be prepared for thorough chart reviews Present your stroke program data in a clear and concise manner 36
37 PSC and CSC Survey Day Follow the 1 or 2 day schedule format JC reviewers will want to stay on time when possible Collaborate with the quality department Escort reviewer throughout the facility Experts on regulations and accreditation Keep detailed notes for future reference 37
38 Celebrate! After the Survey Thank everyone involved for their involvement Determine action plans for RFI s Collaborate with the quality department Formulate action plans Schedule formal meetings with department leaders Submit 4 months of data Maintain constant survey readiness 38
39 Thriving in Your Role Form alliances with other tribes Local and regional stroke coordinator groups Sister hospitals National organizations 39
40 Thank You! Michelle. 40
41 References Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the Establishment of Primary Stroke Centers. Jama. 2000;283(23):3102. Kelly MA. Stroke: a modern history. American Journal of Therapeutics. 2011;18(1): Alberts MJ. Stroke centers: proof of concept and the concept of proof. Stroke. 2010;41(6): Douglas VC. Do the brain attack coalition's criteria for stroke centers improve care for ischemic stroke? Neurology. 2005;64: Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36(7): Alberts MJ, Latchaw RE, Jagoda A, et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition. Stroke. 2011;42(9): The Joint Commission. The Joint Commission History. Wykes S. Stanford Hospital is first in nation to earn comprehensive stroke center designation - See more at: Stanford Hospital is first in nation to earn comprehensive stroke center designation - See more at: html#sthash.6pFfEKJD.dpuf. Healthcare Facilities Accreditataion Program. Healthcare Facilities Accreditation Program (HFAP) History, Healthcare Facilities Accreditation Program. Stroke certification guide: certification process handbook v :1-22. Det Norske Veritas. Our history. Accessed October 5,
42 References Methodist Awarded First DNV Comprehensive Stroke Center Certification. HealthNewsDigest.com2012. Schwamm LH, Pancioli A, Acker JE, 3rd, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Stroke. 2005;36(3): Gropen TI, Gagliano PJ, Blake CA, et al. Quality improvement in acute stroke: the New York State Stroke Center Designation Project. Neurology. 2006;67(1): Services TDoSH. Stroke System Development Lichtman JH, Allen NB, Wang Y, Watanabe E, Jones SB, Goldstein LB. Stroke patient outcomes in US hospitals before the start of the Joint Commission Primary Stroke Center certification program. Stroke. 2009;40(11): Smith EE, Dreyer P, Prvu-Bettger J, et al. Stroke center designation can be achieved by small hospitals: the Massachusetts experience. Critical pathways in cardiology. 2008;7(3): Levine SR, Adamowicz, D., Johnston, K.C. Primary stroke center certification. Continuum Lifelong Learning Neurol 2008;14(6): Mohammad YM, Divani, A.A., Jradi, H., Hussein, H.M., Hoonjan, A., Qureshi, A.I. Primary stroke center: basic components and recommendations. Southern Medical Journal. 2006;99(7): American Stroke Association. Target: Stroke Best Practice Strageties Morrison K. The road to JCAHO disease-specific care certification: a step-by-step process log. Dimensons of Critical Care Nursing. 2005;24(5): Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3): The Joint Commission. Advanced disease-specific care certification requirements for comprehensive stroke center (CSC). 2013:CSC 1 - CSC
43 References Det Norske Veritas Healthcare Inc. Comprehensive stroke center certification program requirements CSC :1-31. Pexman JH, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. ANJR Am J Neurolgiol. 2001;22(8): Kohoury RE, Jung R, Nanda A, et al. Overview of key factors in improving access to acute stroke care. Neurology. 2012;79 (Suppl 1):S Sun CH, Nogueira RG, Glenn BA, et al. "Picture to puncture": a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke. Circulation. 2013;127(10): Leifer D, Bravata DM, Connors JJ, 3rd, et al. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(3): Neurocritical Care Society. History. Connolly ES, Jr., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6): Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke. 2009;40(8):
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