Quality Improvement In Stroke Care For Primary Stroke Center Certification at St. Francis Health Center Washburn University Master’s Project by: Jill Collins, RN BSN December 2012. What Is Primary Stroke Center Certification?.
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Quality Improvement In Stroke Care For Primary Stroke Center Certification at St. Francis Health Center
Master’s Project by:
Jill Collins, RN BSN
are on the rise in the U.S. including obesity, diabetes
stroke-related medical costs and disability
1. Venous thromboembolism prophylaxis (VTE). Documentation should be made of either having an ambulatory status or receiving VTE prophylaxis by the end of hospital day 2. This can be accomplished by administering subcutaneous unfractionated heparin, low-molecular weight heparins or heparinoids in patients with acute ischemic strokes. If there are contraindications to anticoagulants or the patient has had a hemorrhagic stroke, intermittent pneumatic compression devices or elastic stockings are recommended. Rationale: patients who experience a stroke in which a lower extremity is paralyzed or paretic or who are otherwise non-ambulatory have increased risk of developing VTE or pulmonary embolism (PE). PEs account for 10% of deaths after stroke. VTE prophylaxis has been shown to lower the risk of VTE and PE by 70-80% in clinical trials (Outcome Sciences Inc., 2011).
2. Antithrombotics prescribed at discharge if the patient was diagnosed with non-cardioembolic ischemic stroke or transient ischemic attack. Antiplatelets rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular events. Aspirin (50-325mg/day), Aggrenox (25/200 mg BID) or clopidogrel (75 mg/day) are all recommended therapies. Rationale: substantial evidence has been accumulated from many large clinical trials which support the effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity and recurrence rates. If the stroke is due to a cardioembolic source (i.e. atrial fibrillation or mechanical heart valve), warfarin is the preferred choice unless contraindicated (Outcome Sciences Inc., 2011).
3. Anticoagulation prescribed for atrial fib/atrial flutter. Patients with an ischemic stroke or transient ischemic attack who also have atrial fibrillation and/or atrial flutter should be discharged home on anticoagulation. Warfarin is the preferred treatment with dosages given to achieve an international normalized ratio (INR) of 2.0 to 3.0. If patients are unable to take anticoagulants, aspirin alone is recommended. Rationale: non-valvular atrial fibrillation is a common arrhythmia and has been identified as a substantial risk factor for stroke. In several clinical trials done on patients with atrial fibrillation, the use of warfarin has been shown to decrease the relative risk of thromboembolic stroke by 68%.
4. IV tPA arrive by 2 hour, treat by 3 hour. Patients with acute ischemic stroke who arrive within 2 hours of the time they were last known to be well should have IV tPA initiated within 3 hours of the time last known to be well. These patients must meet inclusion criteria as established by the American Heart Association. Rationale: several clinical trials show favorable outcomes (defined as complete or nearly complete neurological recovery 3 months after a stroke) were achieved in 31-50% of patients treated with IV tPA within 3 hours of onset of symptoms . The major society practice guidelines developed in the US all recommend the use of IV tPA for eligible patients (Outcome Sciences Inc., 2011).
5. Early antithrombotics. Patients with ischemic stroke or transient ischemic attack should receive antithrombotic therapy by the end of hospital day 2. The recommended agents are the same as listed above in the “antithrombotics at discharge” section for the same rationale. Data suggests that antithrombotic therapy should be initiated within 48 hours of symptoms onset in order to reduce morbidity and mortality (Core Measure Sets: Stroke, 2011).
6. LDL 100 or not documented discharged on statin. Patients with ischemic stroke or transient ischemic attack with an LDL greater than or equal to 100, not measured or already on a cholesterol reducing agent prior to admission should be discharged on a statin medication unless there is a documented contraindication such as allergy. Rationale: Elevated serum lipid levels are a well-documented risk for coronary artery disease and reflects an organ-specific manifestation of atherosclerosis which is a disease process that can affect the heart as well as major and minor branches of the arterial tree. Symptomatic carotid artery disease is one of the recognized coronary disease risk equivalents. The Stoke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study examined the effects of statins to lower LDL cholesterol in patients with stroke or transient ischemic attack of atherosclerotic origin who had no other reason for taking lipid lowering therapy and had a fasting LDL of greater than or equal to 100 mg/dL. This trial convincingly demonstrated that intensive lipid lowering therapy using statin medication was associated with a dramatic reduction in the rate of recurrent ischemic stroke and major coronary events (Core Measure Sets: Stroke, 2011).
7. Stroke Education. Patients with stroke or transient ischemic attack or their caregivers should be given on education and/or educational materials during the hospital stay addressing all of the following: personal risk factors, warning signs for stroke, activation of emergency medical system, need for follow-up after discharge and medications prescribed. There should be a specific team member identified to provide information to the patient and caregiver. Rationale: many examples of how patient education programs for specific chronic conditions have increased healthy behaviors, improved health status and/or decreased health costs of their participants. Some clinical trials show measurable benefits in patient and caregiver outcomes with the application of education and support strategies (Outcome Sciences Inc., 2011).
8. Rehabilitation considered. All patients diagnosed with stroke should be assessed for rehabilitation services. When the patient is medically stable, a consult should be placed for rehabilitation services to assess patient impairments as well as activity and participation deficiencies to establish the patient’s rehabilitation needs and goals. It is strongly recommended that patients with mild to moderate disability in need of rehab services have access to a setting with coordinated and organized rehabilitation care team which is experienced in providing stroke services. Rationale: of the 795,000 patients who experience a new or recurrent stroke annually, about 2/3 survive and require rehab. A large body of evidence indicates better clinical outcomes when these patients are treated in a setting which provides coordinated, multidisciplinary stroke-related evaluation and services. These treatments can enhance the recovery process and minimize functional disability (Outcome Sciences Inc., 2011).
The benefit of IV thrombolytic therapy in acute brain ischemia is very much time dependent. Therapeutic yield is maximal in the first minutes after the onset of symptoms and decreases during the next 4.5 hours. In a typical ischemic stroke, for each minute reperfusion is delayed, 2 million nerve cells die. In every 100 patients treated with IV thrombolytic therapy, for every 10 minute delay in the start of lytic infusion within the 1 to 3 hour treatment window, 1 fewer patient has an improved disability outcome. Because of the critical importance in rapid treatment, national recommendations for hospitals that accept acute stroke patients in their Emergency Departments are to complete the clinical and imaging evaluation of the patient and initiate lytic therapy within 1 hour (the golden hour) of patient arrival. The Joint Commission target for primary stroke centers is to achieve a door-to-needle time (arrival to start of IV lytic therapy) of within 60 minutes in 80% or more of patients (Saver, et al., 2010). In order for patients to have IV lytics started, a certain sequence of events has to occur including evaluation by the MD, initiation of labwork, NIH stroke scale completed, CT scan of the brain done within 25 minutes and interpreted by a radiologist and review of eligibility for tPA. This also would mean that the goal for NIH stroke scale and door to CT < 25 minutes be 80% or more.
Dysphagia screen: one of the common presentations for stroke patients is difficulty talking and swallowing. The origin of these manifestations also put the patient at risk for aspiration. Because of this, a bedside dysphagia screen should be performed by a nurse and if the patient does not pass this, a formal swallow study should be done by speech therapy before the patient has anything by mouth including medication
Smoking cessation education. Smoking is a common and modifiable risk factor for stroke. Education and assistance are key to eliminating this risk factor.
The following are core measure items that fall below the 90% goal for purposes of the GWTG-Stroke data:
The following items currently fall below the suggested 80% benchmark as per The Joint Commission in regard to the “Golden Hour” of stroke care:
Final item for improvement:
In all, St. Francis Health Center really is doing a great job in providing quality stroke care. There are just a few items needing improvement. Most of these items are showing steady improvement. The items that have the lowest performance are still quite comparable and in some cases even better than hospitals nationwide. With additional and continual education and monitoring, I think these numbers would soon all be at goal.
Core Measure Sets: Stroke. (2011, February 4). Retrieved April 25, 2012, from The Joint Commission:
George, M. G., Tong, X., & Yoon, P. W. (2011, February 25). Morbidity and Mortality Weekly Report (MMWR).
Retrieved January 15, 2012, from Centers for Disease Control:
Katz, M. J. (2010). Stroke: A Comprehensive In-Depth Review. Retrieved July 3, 2012, from NursingCEU.com:
Leifer, D., Bravata, D. M., Connors III, J., Hinchey, J. A., Jauch, E. C., Johnston, S. C., et al. (2011). Metrics for
Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to a Brain Attack Coalition
Comprehensive Stroke Center Recommendations: A Statement for Healthcare Professionals From the American
Heart Association. Stroke: Journal of the American Heart Association (online) , 1-29.
Otwell, J. L., Phillippe, H. M., & Dixon, K. S. (2010). Efficacy and Safety of IV Alteplase Therapy Up to 4.5 Hours After
Acute Ischemic Stroke Onset. American Journal of Health-System Pharmacists , 1070-1074.
Outcome Sciences Inc. (2011). The Outcome System. Retrieved July 10th, 2012, from https://qi.outcome.com
Saver, J. L., Smith, E. E., Fonarow, G. C., Reeves, M. J., Zhao, X., Olson, D. M., et al. (2010). The “Golden Hour” and Acute Brain
Ischemia. Stroke: Journal of The American Heart Association , 1431-1439.