Ready-or-Not? Acute Stroke Ready Here We Come! Acute Stroke Ready Hospital Certification Program Kenny Barajas DNP, RN, CEN Disease Specific Care Reviewer-The Joint Commission April 28, 2017
Presenter Disclosure Statement ASRH, PSC and CSC Reviewer for The Joint Commission No Financial Disclosure
Mission The mission of The Joint Commission is to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
Objectives Understand the rationale for developing an acute stroke ready (ASRH) certification for the disease-specific care program Describe key features of the ASRH standards that might fit your organization Build a case for supporting this certification at your institution Lead the charge for incorporating the ASRH team with your collaborating PSC or CSC
History of Acute Stroke-Ready Hospitals (ASRH) On July 1, 2015, The Joint Commission in collaboration with the American Heart Association/American Stroke Association developed the Disease Specific Care Advanced Certification program for Acute Stroke Ready Hospitals (ASRH). Over the past ten years in the United States, using stroke centers to provide care for patients with an acute stroke has become a more frequent practice.
History of Acute Stroke-Ready Hospitals (ASRH) The Joint Commission provided two levels of stroke center certification primary stroke and comprehensive stroke. The literature indicated that many patients who have an acute stroke live in areas without ready access to a primary or comprehensive stroke center. In fact, at least 50% of the population in the United States lives more than 60 minutes away from a primary stroke center.
History of Acute Stroke-Ready Hospitals (ASRH) It is estimated that 1200-1500 rural facilities have the capability to give t-pa, complete a CT scan and have Neuro expertise (maybe telemedicine) Less than 5% of patients receive t-pa Based on the literature it was identified that if a patient is greater than 15-20 minutes away from PSC/CSC patients should go to the closest ASRH
History of Acute Stroke-Ready Hospitals (ASRH) Designed for the acute care and critical access hospital Should be rural and less than 100 beds No designated stroke beds Transfer agreements Telemedicine- how do you assess their competency? t-pa on formulary
Facts Acute Stroke Ready- 26 Primary Stroke Centers 1107 Comprehensive Stroke Centers 123
Disease-Specific Care Programs for Stroke
Why Acute Stroke Ready? The history of stroke center certification Serve the need of small and/or rural communities Suitable for small facilities to include free standing ED s Getting patients to the nearest stroke-ready facility in a timely manner Limited staffing and resources Capitalizing on EMS expertise and collaborative with PSCs and CSCs
Requirements Assessed at Application A relationship with local emergency management systems (EMS) that encourages training in field assessment tools and communication with the hospital prior to bringing a patient with a stroke to the emergency department Stroke protocols along with an acute stroke team, in order to expedite the assessment and treatment of a patient presenting with acute stroke symptoms
Requirements Assessed at Application The ability to perform diagnostic imaging and laboratory tests 24 hours a day, 7 days a week with results within 45 minutes of testing. Access to stroke expertise 24 hours a day, 7 days a week (in person or via telemedicine) and transfer agreements with facilities that provide primary or comprehensive stroke services. The ability to administer intravenous thrombolytics, if needed, prior to transferring the patient to a facility that provides primary or comprehensive stroke services.
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Clinical Practice Guidelines Purpose: To describe appropriate care based on the best available scientific evidence and broad consensus; To reduce inappropriate variation in practice Where to locate Clinical Practice Guidelines:
ASRH Review Schedule 1 Reviewer 0800-0900 Opening session 0900-0930 Planning session 0930-1230 Tracers 1230-1300 Lunch 1300-1400 Data Management 1400-1500 Competency 1500-1600 Credentialing and Privileges 1600-1630 Issue resolution and report preparation 1630 Closing Note times are flexible based upon the necessary time to complete activities
Preparing for Your Site Visit Request assistance from your accreditation/quality department Utilize your resources Mirror tracer experience Increases staff comfort level in presenting patient case Inter-professional team discussion Individual role and communication as a team
Checklist for Day of Review List of all patients that are and were treated for a stroke (inpatients, hemorrhagic stroke, ischemic stroke, TIA, IV thrombolytics) currently and in the past 4-12 months. - List should include primary diagnosis, presentation date, transfer disposition, location in your facility, patient age, gender and ethnic origin Letter of support, charter or line item on a budget to demonstrate leadership support of the program. A copy of the stroke program s mission and scope of services. List of core stroke team members and their disciplines, roles, responsibilities.
Checklist for Day of Review Job description for Medical Director. Document listing ED staff who participated in stroke education in the past year. List of ED practitioners who are educated in the Acute Stroke Ready Hospital s stroke protocols. A copy of your stroke alert process for inpatients and outpatients (ED). Order sets and Clinical Practice Guidelines (CPG s). A copy of the patient education binder, pamphlet, folder, etc.
Key Focus Areas for Review Emergency Department EMS CT/MRI based on your model of care Pharmacy Laboratory Nursing staff Physical Therapy Occupational Therapy Speech Therapy Palliative Care/Hospice Case Managers Social Workers Data Collection Abstractors Medical Staff/Office Staff Practitioners including Stroke Medical Director and or CMO/VPMA Educators Unit Managers Human Resources Additional staff: leadership, regulatory, quality improvement staff, volunteers, dietary
Opening Session Highlights Attendance: Representatives from all areas that support the program All departments who provide care to stroke patients, EMS Stroke Medical Director and Stroke Coordinator Areas to consider including: Mission Target population (including unusual populations) Volumes for each type of stroke patient Emergency Department annual volume Annual IV thrombolytics volume Identify your core stroke team members Reporting structure for Medical Director Model of care in ED Neurologists who participate via telemedicine Stroke alert processes Rapid response team members, if you utilize such a team Telemedicine 60 minutes
Opening Session Highlights Dashboard metric overview for key areas Door to needle time, practitioner response time, number of times stroke team activated (remember you have a full data session later in the day to share all data) Volume for drip and ship patients transferred to other facilities Beds utilized for stroke patients EMS system overview, relationship, transfer policies out of stroke facility Total number of stroke patients who are delivered to your organization by car versus EMS EMS Structure (regionalized, coalition, municipal, volunteer, paid on call) Your hospital s interface with EMS, including provision of stroke education and input into their protocols Method in which you provide performance improvement data to EMS Education requirements for staff in the ED (hours, type) Multi-disciplinary team planning (rounds, team planning meetings, etc.) Functions of key committees or teams: stroke team, peer review sessions, data management Get With the Guidelines - Stroke Performance Awards, if applicable
Individual Tracers The RN assigned to the patient and someone who can navigate the EMR should be ready to start the tracer when the reviewer arrives All staff should be able to speak to their stroke orientation and on-going stroke education Staff should be prepared to speak to their formal processes for care and multi-disciplinary care practices Assessments and re-assessments will be a focus Patient procedures and hand off communication are reviewed Patients provided IV thrombolytics (neuro checks etc. will be reviewed for compliance with the facilities protocols.)
Indivudual Tracers All staff should be able to speak to: Performance improvement processes Individualized patient goal setting Behavior modification for risk factors Stroke alert process Patient and caregiver education Assessing the patient s ability and willingness to learn Preparing the patient and caregiver for discharge Follow-up care coordination when the patient returns to their own community or to your health care organization for care after discharge
Emergency Department Topics Discussion from the perspective of the walk in patient and the patient delivered via EMS Use of NIHSS (NIH Stroke Scale) Telemedicine practices, as appropriate Decision for IV thrombolytics (rapid response team/acute stroke team, neurologist, ED MD) Inclusion and exclusion criteria for IV thrombolytics IV thrombolytics: weights, mixing, provision, double checks, documentation
Emergency Department Topics Discussion regarding the administration of IV thrombolytics (including risks and benefits) as well as other treatment options with the patient, family/significant others Staff education re: stroke, (NIHSS, Dysphagia screens, administration of IV thrombolytics) Preparation for transfer of patient Use of Clinical Practice Guidelines (CPGs) Use of order sets Accessibility of neurology expertise Current resources available to staff
Emergency Department Topics The reviewer will speak to: Security Registration Nursing ED providers Pharmacy Lab CT tech Radiologist
Emergency Department Topics Transitions of care (CT, ICU, and inpatient beds) EMS provider transporting the patient has the level of expertise to assure that the level of care is not decreasing during transport, especially with patients provided IV thrombolytics or with a hemorrhagic stroke Assure staff can speak about how the ASRH works with the Primary Stroke Center or Comprehensive Stroke Center to coordinate the care of the patient Discuss how the ASRH interacts with these entities to assure the transfer of patients is completed in a well coordinated manner A discussion regarding the health care organization s formulary If your hospital has a stroke alert occurring while the reviewer is on-site, please notify the reviewer for an opportunity to observe
Data Session Powerpoint presentation with ALL data collected as it relates to your stroke program This is the best method for The Joint Commission to view your data Method allows for all team members to see and discuss the same data points at the same time Assure reports have date range and n noted with volumes Tracer will start with a discussion of how you utilize the data you collect in your hospital to improve your program
Data Session Prepare to speak to how you collect, analyze and share data to make improvements in your program on a continuous basis Attendees from across the hospital who are involved in the collection or interpretation of the data should attend the session Include your patient satisfaction data in this session Data on the administration of IV thrombolytics within 60 minutes should be included Share all data collected for your program (this should indicate how you are interested in improving different aspects of your program) Prepare questions for the reviewer on how to improve your data collection methods, changing your measures, areas to focus on, etc. (ask about Best Practices seen in other Acute Stroke Ready Hospitals)
Credentialing and Privileges- Peer Review Plan to have a MD attend (this could be the Stroke Medical Director, CMO, or VPMA) This discussion will include the number and types of patients selected to review via your peer review process Sampling versus 100 percent of cases Criteria should be clear and should not just include outliers.
Credentialing and Privileges The Licensed Independent Practitioners (LIPs) for stroke need to meet on a routine basis to discuss the provision of stroke care (monthly, quarterly, etc.) provided to patients at the health care organization LIPs include Medical Director, neurologists, ED MD, APNs, intensivists, PAs, etc Medical Directors should not be reviewing their own cases The process for resolving identified issues should be clear including the peer review process route and the areas identified for further review (process or practitioner issues) On-boarding of new MDs will be discussed
Credentialing and Privileges Discussion regarding how the facility verifies credentials for new practitioners Credentialing and Privileging documents for LIP files: MD, APN and PA Current DEA Appointment and re-appointment to the medical staff 4 hours of stroke education for all core stroke team members If a journal article, please include in APA format with journal, pages, title, hour verification, date, and any other identifying information. OPPE and FPPE Credentialing and Privileging documents for all LIPs All LIPs should be credentialed and privileged for all procedures they perform
HR and Competency Staff identified through tracers (open and closed records) All core stroke team members RN, technicians, case workers, social workers, pharmacists, OT, PT, speech, and others
HR and Competency Documents: License / certificate per job description Current job description Copies of all education records related to stroke per organization hour/course requirement The reviewer will review education on a rolling annual basis Copies of certificates (BLS, ACLS, PALS, etc.) and degrees per job description Orientation checklist Most recent performance evaluation Education for staff who work in specialty areas ED and ICU (as appropriate) should include documentation of education in NIHSS, dysphagia screening, IV thrombolytics administration per the HCO s requirements.
Closing Session The organization can select who they want to attend the closing conference You will be able to print the preliminary report once it is published The reviewer will discuss the results of the review The reviewer will share if they identified any best practices while at your organization and indicate how you can submit them to The Joint Commission s Leading Practice Library
Tips/Information The Joint Commission will provide a 30 day notice for initial review and a 7 day notice for recertification customers Assure your Certification Measure Information Process (CMIP) data is up to date Assure your CPG s are reviewed annually Assure your organization s website is up to date with staff and services for stroke patients Notify your staff in the areas where patients will be traced so they can prepare for their day Closed records should be ready for our review during the late morning (approximately 11:00 a.m., depending on the number of closed records that need to be reviewed)
Tips/Information The reviewer will need at least two computers on wheels In order to assure an efficient review process, we may ask two staff members to find different information on the same patient at the same time Assure that your team is ready to accompany the reviewer during tracers at the beginning of the day and after lunch Please consider limiting the number of staff who accompany the group Suggested staff you may want to consider to accompany the reviewer: Individual responsible for the program Stroke Medical Director or Stroke team member Scribe
DSC Standards and Elements of Performance Basic Review Program Management Delivering and Facilitating Care Clinical Information Management Supporting Self Management not applicable ASRH 14 standards 26 Elements of Performance
Approach to the Standards and Tips to Success
Program Management (DSPR) DSPR.1 The program defines its leadership roles EP1 -The program identifies members of its leadership team The organization appoints an ASRH medical director (Note: the director must have sufficient knowledge of cerebrovascular disease to provide administrative leadership, clinical guidance and input to the stroke program) What is sufficient knowledge? What (s)he doesn t need to be: Attendance at Regional/Ntl Stroke Mtg Classroom/Online programs Regional/State Affiliations Courtesy appointment in Neurology/Neurosurgery Board-certified in neurology or neurosurgery Board-certified in vascular neurology Published in Stroke Journals A member of the AHA/ASA
Program Management (DSPR) DSPR.1 The program defines the accountability of its leaders EP 2- Written documentation showing support of the ASRH program by the hospital or healthcare administration What this might look like: Letter of Support Part of the Program s charter Organizational chart (listing personnel) What would likely not be acceptable: Name mentioned in staff meeting minutes Newspaper article / staff bulletin
Program Management (DSPR) DSPR. 1 The program leaders identify the composition of the interdisciplinary team EP 4- The organization appoints an Acute Stroke Team ACUTE STROKE TEAM What this should include: PERSONNEL A physician, nurse or NP/PA TRAINING Continuing education Attendance at reg/ntl mtgs NICU experience INTERDISCIPLINARY TEAM What this should include: ED Manager PSC/CSC liaison Case manager Rehab Services Lab Palliative Care Radiology EMS liaison
Program Management (DSPR) DSPR.2 The program is collaboratively designed, implemented & evaluated EP1- The interdisciplinary team designs the program. The interdisciplinary team composition reflects the needs of the patient population. Transferred Patients Who should be included: Admitted Patients Who should be included: ED staff EMS liaison Stroke coordinator Case management Quality and Safety ED staff EMS liaison Stroke coordinator Case management Rehab team Palliative Care Discharge Planning Quality and Safety
Program Management (DSPR) DSPR.3 The program meets the needs of the target population EP 4- The services provided by the program are relevant to the target population The hospital collaborates with Emergency Medical Services (EMS) providers to ensure the following: EMS alerts hospital of suspected stroke patient The organization has access to EMS treatment protocols The organization and EMS use at least one field assessment tool There is a written transfers protocol The program has access to a PSC or CSC 24/7
Program Management (DSPR) DSPR.5 The program determines the care, treatment and services it provides EP1 - The program defines in writing the care, treatment and services it provides The organization s formulary or medication list must include an IV thrombolytic therapy medication approved by the USFDA for the treatment of ischemic stroke. Alteplase
Program Management (DSPR) DSPR.5 The program provides care, treatment and services in a planned and timely manner EP 3 24/7 on-call acute stroke team with one member responding the to the patient s bedside within 15 minutes of being called (there must be an NP, PA or MD on-site to supervise patient care, order medication and manage emergent issues 24/7 on-site laboratory testing (CBC, plts, coags, chem 7, troponin 24/7 on-site ability to perform a CT scan of the brain An MRI brain may be performed in lieu of the CT brain There must be a written process to notify the acute stroke team bedside consultation or telemedicine consult
Program Management (DSPR) DSPR.5: The program provides the number and types of practitioners needed to deliver or facilitate the delivery of care, treatment and services EP 7- Neurosurgical coverage is documented in a written plan and approved by neurosurgical services and the stroke team Neurosurgical services area available to patients within three hours of it being deemed necessary There is a written protocol for transfer that includes communication and feedback from the receiving facility
Delivering or Facilitating Clinical Care (DSDF) DSDF.1 Practitioners are qualified and competent EP 1- Practitioners have the education, experience, training and/or certification consistent with the program s scope of services, goals and objectives The organization s clinical staff have knowledge of the process used to notify designated practitioners of the need to respond to patients with an acute stroke ED practitioners demonstrate knowledge of IV thrombolysis therapy protocols for acute stroke including: Treatment during the first three hours after the patient was last known normal Indications / contraindications for thrombolytic therapy Patient/family education regarding the risks and benefits of thrombolytics Symptoms of clinical deterioration after thrombolytics
Delivering or Facilitating Clinical Care (DSDF) DSDF.1 Ongoing training and educational opportunities for staff EP 7- Practitioner competence / orientation / ongoing education EXAMPLES In-services Lunch and Learns Lectures Symposia On-line learning modules Huddles Conferences Walking Rounds Bedside demonstrations Simulation labs Shared lectures Gran rounds Newsletter Skills Fairs
Delivering or Facilitating Clinical Care (DSDF) DSDF.1 EP 7 Ongoing in-service and other training activities are relevant to the program s scope of services The medical director of the program receives at least 4 hours annually related to the care of patients with cerebrovascular disease. Members of the core stroke team, as identified by the organization, receive at least 4 hours annually of continuing education or other equivalent educational activity related to the care of patients with cerebrovascular disease. Emergency Department staff, defined by the organization, participates in educational activities related to stroke diagnosis and treatment a minimum of twice a year. The above requirements do NOT apply to the emergency physicians
DSDF.2 The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver of facilitate the delivery of clinical care. EP 2- Current literature approved by the stroke program leadership EP 3- ANNUAL REVIEW OR AS NECESSARY EP 4.- 67% of emergency department practitioners are educated on acute stroke protocols Written protocols for ischemic and hemorrhagic stroke Evidence-based dysphagia screening tool Time parameters outlined for the acute stroke work-up Use of IV thrombolytic therapy built into order-sets / pathways
DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient s needs EP 2- Assessments and reassessments are completed according to the patient s needs and clinical practice guidelines An ED MD, NP (with prescriptive authority) or PA (with prescriptive authority) performs an assessment for a suspected stroke patient within 15 minutes of patient arrival to the ED Ongoing assessment are completed in accordance with the program s stroke protocol The NIHSS is used as an initial assessment (and performed by a qualified team member) of patients with acute stroke A blood glucose level is completed for any patient presenting with stroke symptoms
EP 2- Assessments and reassessments are completed according to the patient s needs and clinical practice guidelines The hospital has the ability to perform and read a non-contrast CT or MRI within 45 and 60 minutes respectively of being ordered Radiology reads may be done off-site but must be read by a boardcertified radiologist or physician with expertise in reading brain CT/MRIs Lab tests, ECG and Chest Xray are completed and resulted within 45 minutes of patient arrival if ordered by the practitioner Patients with stroke symptoms are screened for dysphagia prior to any oral intake
DSDF.2 EP 3- The program implements care, treatment, and services based on the patient s assessed needs (continued) Completion of lab tests, ECG and Chest Xray should NOT delay the administration of IV thromboytics Telemedicine / teleradiology equipment is on site for transmission of information Telemedicine link is initiated within 20 minutes of the ED MD or stroke team determining it is necessary
DSDF.5 The program coordinates care for patients with multiple needs and/or communicates the necessary information to manage these conditions to other practitioners EP 1- The program coordinates care for patients with multiple needs Protocols address policies for patient transfers Protocols geared to meeting patient and family needs i.e. hospice or palliative care Goal to transport patients to a higher level of care within two hours of arrival or when medically stable and track time parameters
Clinical Information Management (DSCT) DSCT.4 EP 2- The program shares information with relevant practitioners and or health organizations to facilitate continuation of care. CT/CTA/MRI/MRA/Labs (turn-around times) DSCT.5 EP 4- The medical record contains sufficient information to justify the care, treatment and services provided. Documentation indicates the reason eligible ischemic stroke patients did not receive IV thrombolytic therapy. DSCT.5 EP 5- The medical record contains sufficient information to document the course and results of care, treatment and services Practitioners document all assessments and interventions provided for stroke patients, including date and time, in accordance with program policies.
Performance Measurement (DSPM) DSPM.1 The program has an organized, comprehensive approach to performance improvement (a written performance improvement plan) EP1- The program leaders identify goals and set priorities: The program monitors its ability to administer IV thrombolytics within 60 minutes to eligible patients presenting for stroke care EP 2- Stroke performance measures are analyzed by the stroke team and the hospital s quality department: There is a specified committee that meets a minimum if twice a year to evaluate protocols and practice patterns
DSPM.3 The program collects measurement data to evaluate processes and outcomes: Data must be trended over time and may be compared to an external data source for comparative purposes. EP 2- The program collects data related to processes and outcome of care Stroke registry Stroke Code Activations Practitioner response times Diagnostic testing Acute treatments Patient diagnosis Door to IV tpa times Patient complications sich and serious life-threatening events Disposition Inter-rater reliability
The program evaluates patient satisfaction with and the perception of quality of care at the program level; patient satisfaction data are utilized for program-specific performance improvement activities
Questions? Thank you for you commitment to each other, communities, families and the patients you serve Without you, stroke would not have dropped to the 5 th leading cause of death in the United States
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