JCAHO EXPECTATIONS FOR PRIMARY STROKE CENTER
Angela M. Williams, MS RNStroke Care CoordinatorSt. Anthony Hospital
Primary Stroke Center Certification
Based on recommendations from the Brain Attack Coalition and ASA statements
Onsite review team will include a medical professional experienced in treating stroke and implementation of stroke centers
Programs seeking certification must use a standardized method of delivering clinical care based on these recommendations and guidelines
Requirements for Certification
Programs will be evaluated using the standards listed in the Disease Specific Care Certification Manual
To evaluate compliance will include evaluating conformity with the recommendations from Brain Attack Coalition
Expected to demonstrate application and compliance with the guidelines from ASA
ASA and JCAHO standardized set of performance measures for stroke and programs are required to collect data on the first four measures but will be looking at other measures also
Major Elements
Hospital and Administrative SupportWritten documentation showing support by administrationStroke Center Medical DirectorStroke team members have expertise in cerebrovascular disease
Acute Stroke TeamDocumentation showing team composition, staffing level and requirements, and notification system and response expectationsLog that documents response times, diagnosis, treatments, actions and outcomes
Major Elements cont…
Written Care ProtocolsInclude care of ischemic/hemorrhagic stroke patients in the ER, acute care and stroke unitUse of protocol is reflected in order sets and pathwaysTime parameters for stroke work up are included in ER protocol
Emergency Medical SystemsPlan should be provided that demonstrates an initiative by the hospital to provide education to EMS
Major Elements cont…
Emergency DepartmentER care providers show familiarity with pathology, presentation, assessment, diagnostics, and treatment of stroke patients; location and application of stroke related protocols, activation of the stroke team, and communications with inbound EMS; recognition, assessment and management of acute stroke complications80% of ER providers can provide evidence of review of the institution’s acute stroke protocol
Major Elements cont…
Stroke UnitSpecified unit to which most stroke patients are admittedCare providers demonstrate evidence of initial and ongoing training in the care of acute stroke patientsAt least 8 hours of annual CE or equivalent educational activityMonitoring systems to include continuous data on heart rate/rhythm with automatic arrhythmia detection; BP and oximetry
Major Elements cont…
Neurosurgical ServicesDocumentation shows evidence of neurosurgical coverage or protocol for transfer to appropriate facilityIf do not transfer – has fully functional OR facility and staff within two hours of the recognized need for such services
NeuroimagingDocumentation indicates on 24/7 basis, 80% of acute stroke patients have a diagnostic brain imagine completed within 45 minutes of it being ordered when clinically indicated (resuscitation candidates)
Major Elements cont…
Laboratory ServicesDocumentation indicates ability to complete initial lab tests and availability on site 24/7Documentation indicates ability to complete and report lab tests in less than 45 minutes of it being orderedDocumentation indicates the ability to perform ECG and chest x-ray within same time frame as laboratory testing
Educational programsDocumentation shows at least one stroke public education activity per year
Major Elements cont…
Outcomes/Quality ImprovementEvidence of specific stroke performance measurement and review by quality improvement department and stroke team existsDocumentation exists to reflect the following:performance measures and indicators trackedSpecific interventions to improve selected measureSpecific outcomes to determine successImplementation period and re-evaluation point
Performance Measures
DVT Prophylaxis (Required)Patients with ischemic stroke and who are non-ambulatory should start receiving DVT prophylaxis by the end of hospital day two
Discharged on Anti-thrombotics (Required)Patients with TIA or ischemic stroke should be prescribed anti-thrombotic therapy at discharge unless contraindicated
Performance Measures cont…
Patients with A-Fib receive anticoagulation therapy (Required)Patients with ischemic stroke with atrial fibrillation discharged on anticoagulation therapy unless it is contraindicated
Tissue Plasminogen Activator Considered (Required)All patients who present at a hospital with symptoms of an ischemic stroke with symptom onset of 3 hours or less should be considered to receive intravenous tPA
Performance Measures cont…
Anti-thrombotic medication within 48 hours of hospitalizationPatients with ischemic stroke or TIA who receive anti-thrombotic medication within 48 hours of hospitalization
Lipid ProfilePatients with ischemic/TIA who had a lipid profile performed during hospitalization or within 30 days prior to hospitalization
Performance Measures cont…
Screen for DysphagiaA screen for dysphagia should be performed on all ischemic and hemorrhagic stroke patients before being given food, fluids or medications by mouthThis means absolutely NOTHING by mouth, including ALL medications prior to a dysphagia screen
Performance Measures cont…
Stroke EducationStroke education and/or resources received by patient and/or caregivers for patients with ischemic stroke, hemorrhagic stroke, or TIA
Smoking CessationAdult smoking cessation advice and/or counseling for patients with ischemic, hemorrhagic stroke or TIA
Plan for Rehabilitation consideredPatients with ischemic/hemorrhagic stroke who were assessed for or received rehabilitation services
Guidelines for Care
NIH Stroke ScaleEvidence shows that the “standard neuro check” is inadequate for the acute stroke population.Overlooks large areas of brain functionReveals subtle changes and/or improvements which guides further treatmentReliable and user friendlyProvides a common language between caregiversAHA ACLS Provider Manual (2001) indicates that NIHSS is the standard assessment tool within the hospital setting and has been shown to predict cost of hospitalization, length of stay and dispositionRequired under our stroke protocol that at minimum must be performed in ER on admissionSee data sheet for compliance percentage
Guidelines for Care
Continuous cardiac monitoringAll stroke patients are placed on telemetry.
Pulse oximetry Q shiftDocumentation of oxygen saturation every shift.
Clinical Pathway outlines standard of care for stroke patient based on ASA guidelines
What we are doing well
ASA within 48 hoursDischarged on anti-thromboticsA-Fib discharged on anticoagulation
therapySmoking cessationLipid profilePlan for rehabilitation
Where we need work
Stroke Education DVT prophylaxis Dysphagia screen NIHSS in ER Documenting order times on brain imaging, labs and
chest x-ray Clinical pathway on chart at admission Patients being placed on stroke unit Care providers with evidence of initial training in care of
the stroke patient Stroke orders on chart with stroke consult Not tracking admission placement and compliance with
standards of care (guidelines)
Where do we go from here?
Brainstorm ideas Develop plan to improve areas that need
work Put time parameters for departments to
institute change Evaluation and tracking of compliance Education Review and re-evaluate
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