Protected stent retriever thrombectomy prevents iatrogenic ...
Thrombectomy-Capable Stroke and Comprehensive …...• Treatment of 20 SAH caused by aneurysm...
Transcript of Thrombectomy-Capable Stroke and Comprehensive …...• Treatment of 20 SAH caused by aneurysm...
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Stroke CertificationThrombectomy-Capable Stroke and Comprehensive Stroke: Where Should You Go Next?
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Today’s Presenters
Mary Kelly, MBA, RN, CNRN, FAHA
Disease-Specific Care Reviewer
David Eickemeyer, MBA,
Associate Director, Business Development
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Neurointerventionists who perform mechanical thrombectomy at the organization applying for certification must perform 15 mechanical thrombectomies over the past 12 months (or 30 over past 24 months) (procedures performed at hospitals other than the one applying for TSC certification can be included)
Eligibility - TSC
Organization must have performed mechanical thrombectomy and post-procedure care for at least 15 patients with ischemic stroke over the past 12 months (or 30 over past 24 months).
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• Treatment of 20 SAH caused by aneurysm annually (40 over 2 years)
• Capable of treating aneurysms by per-forming 15 endovascular coiling or microsurgical clipping procedures annually (30 over 2 years)
• Administering IV thrombolytic therapy 25 times annually (50 times over 2 years)
• Organization must have performed mechanical thrombectomy and post-procedure care for at least 15 patients with ischemic stroke over the past 12 months (or 30 over past 24 months).
• Neurointerventionists who perform mechanical thrombectomy at the organization applying for certification must perform 15 mechanical thrombectomies over the past 12 months (or 30 over past 24 months) (procedures performed at hospitals other than the one applying for TSC certification can be included)
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Eligibility - CSC
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• Thrombectomy volume and Interventionalist requirement is the same for both CSC & TSC
• Thrombectomy performed at other institutions COUNTS
• SAH Volume is for CSC ONLY
• IV Alteplase Volume is for CSC ONLY
How we review for Eligibility
• Call schedule for Endovascular
• List of cases performed (billed) by provider
• List of billed cases from other institutions
• List of patients
• Received IV Alteplase at CSC & Transferred in
• Aneurismal SAH
Document Review
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Has extensive expertise; available 24/7
Program Medical Director
Neurology background with ability to provide clinical and administrative guidance to program
TSC CSC
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• Medical Director CV
• Medical Director Call Schedule
How we review for Program Medical Director
Document Review
• Medical Director CV
• Board Certifications
• 8 hours annually of continuing education in stroke care – If not Board Certified in Neurology
TSC CSC
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Available 24/7, at bedside within 15 minutes
Available 24/7, at bedside within 15 minutes
TSC CSC15 min
Acute Stroke Team
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− Policies
− Protocols
− Algorithms
− Call Schedules
Document Review
How we review for Acute Stroke Team
Tracers
Medical record documentation of Acute Stroke Team response time
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Access to protocols used by EMS, routing plans; records from transfer
Emergency Medical Services Collaboration
TSC CSC
Access to protocols used by EMS, routing plans; records from transfer
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− EMS protocols for Ischemic and Hemorrhagic Stroke
− Interfacility transfer protocols for Ischemic and Hemorrhagic Stroke
How we review for Medical Services Collaboration
Document Review
− EMS transfer documents
• To ED
• From outside hospital
Tracers
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Has a neurointensive care unit or designated intensive care beds for complex stroke patients available 24/7; on-site critical care coverage 24/7
Stroke Unit
TSC CSC
Has a neurointensive care unit or designated intensive care beds for complex stroke patients available 24/7; on-site neurointensivist coverage 24/7
24/7
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− Call Schedules• Attendings• NP/PA• Residents/Fellows
How we review for Stroke Unit
Document Review
− Education
− Orientation
− TSC: Additional education or experience in critical care
− CSC: Additional education or experience in neurocritical care and cerebrovascular care
− Conversations with staff
CredentialingTracers Credentialing
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Emergency Department physician
Initial Assessment of Patient
TSC CSC
Emergency Department physician
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− Conversation with staff about Stroke Alert Process
− Documentation of time of initial assessment
How we review for Initial Assessment of Patient
Tracers
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CT, MRI, labs, CTA, MRA, catheter angiography 24/7; other cranial and carotid duplex ultrasound, TEE as indicated
Diagnostic Testing Capability
TSC CSC
CT, MRI, labs, CTA, MRA, catheter angiography 24/7; other cranial and carotid duplex ultrasound, TEE, TTE as indicated
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− Daily schedules
− Call schedules
How we review for Diagnostic Testing Capability
Document Review Tracers
− Conversation with staff
− Documentation of time of testing and test results availability
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24/7 via in person or telemedicine; written call schedule for attending physicians providing availability 24/7
Neurologist Accessibility
TSC CSC
Meets concurrently emergent needs of multiple complex stroke patients; Written call schedule for attending physicians providing availability 24/7
24/7
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− Daily schedule
− Call schedule
− CSC: Policy/Protocols for 2 concurrent patients
How we review for Neurologist Accessibility
Document Review Tracers
− Conversation with staff
− Medical record documentation of Neurologist consultation
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Within 2 hours; OR is available 24/7 in TSCs providing neurosurgical services
Neurosurgical Services
TSC CSC
24/7 availability: Neurointerventionist; Neuroradiologist; Neurologist; Neurosurgeon
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How we review for Neurosurgical Services
Document ReviewOpening
− Trauma level designation by outside organization
− OR daily schedule
− OR call schedule
− Physician call schedules
− Documented time to OR
Tracers
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IV thrombolytics; Mechanical thrombectomy; Microsurgical neurovascular clipping of aneurysms; Neuroendovascular coiling of aneurysms; Stenting of extracranial carotid arteries; Carotid endarterectomy
Treatment Capabilities
TSC CSC
IV thrombolytics; Mechanical thrombectomy, IA thrombolytics
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− Patient lists
How we review for Treatment Capabilities
Document Review Tracers
− Patient tracers of varying patients
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For neurosurgical emergencies
Transfer Protocols
TSC CSC
For receiving transfers and circumstances for not accepting transferred patients
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− Written Protocols for transferring and receiving patients
• Include time parameters
• Transfer procedures
How we review for Transfer Protocols
Document Review System Tracers
• TSC: Door to transfer out data
• CSC: How do you evaluate CSC transfers in
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Nurses and other ED staff – 2 hours annually; Stroke nurses and core stroke team – 8 hours annually
Staff Stroke Education Requirements
TSC CSC
Nurses and other ED staff - 2 hours annually; Stroke nurses and core stroke team - 8 hours annually
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− Department Educators should be present for this session
− Written or electronic list of education with hours indicated
− Education in cerebrovascular and stroke
− Read note in standards as to which nurses need 8 hours of education
− Best Practice
• Organizational schedule with department and STROKE educational requirements
How we review for Staff Stroke Education Requirements
Credentialing and Competency
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Provides educational opportunities to prehospital personnel; Provides at least 2 stroke education activities per year to public
Provision of Educational Opportunities
TSC CSC
Sponsors at least 2 public educational opportunities annually; LIPs and staff present 2 or more educational courses annually for internal staff or individuals external to the comprehensive stroke center (e.g., referring hospitals)
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− Usually a list of education activities in opening session
− Often with photos of the events
How we review for Provision of Educational Opportunities
Opening Session
Tracers
Document Review
− List of education events
− List of participants
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Standardized Measures: 8 inpatient STK measures and 5 ischemic comprehensive stroke measures for a total of 13 measures.
Clinical Performance Measures
TSC CSC
Standardized Measures: 8 inpatient STK measures and 10 comprehensive stroke measures (ischemic and hemorrhagic) for a total of 18 measures.
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How we review for Clinical Performance Measures
Data Session
− TSC: 90 minutes− Additional Data to be presented (Please review DSPM standards for up to date
requirements):− Process Improvement activities− Stroke log
− Door to Needle times− All cause death within 72 hours of mechanical thrombectomy and symptomatic ICH− IV thrombolytic complications− Follow up phone call− Patient satisfaction
Have a Power Point Presentation
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− CSC: 2 hours− Additional data to be presented (Please review
DSPM standards for up to date requirements) :− Process Improvement activities− Stroke log
− Door to needle times− Research − Process for Peer Review− Follow up phone call− Patient satisfaction
How we review for Clinical Performance Measures
− Additional DSPM requirements
− Complications
− CEA/CAS data
− Diagnostic Angiography
− CSF infection rate
Data Session
Have a Power Point Presentation
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Participates in patient-centered research that is approved by the IRB
Research
TSC CSC
N/A
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− Patient centered
− IRB Approved
− Registry or Laboratory based research DOES NOT meet this standard
− List of current stroke research
• Reviewer may ask for current IRB letters for enrolling studies
− Remember: nursing and rehab patient centered IRB approved research counts
How we review for Research
CSC ONLY
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Recommendations from Brain Attack Coalition for Comprehensive Stroke Centers, 20052018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association
Guidelines
TSC CSC
AHA/ASA Focused Update for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment, 20152018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association
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− List of organizations current CPG for the care of the stoke patient population
• OK to have online
• Reviewer may ask staff to find CPG
How we review for Guidelines
Document Review
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One Reviewer, Two Days
Review Length
TSC CSC
Two Reviewers, Two Days