Quality Improvement and Performance Indicators for Primary ...



Quality Improvement and Performance Indicators for Primary Stroke Center Certification at St. Francis Health Center

Jill Collins

Washburn University

NU 670

Dr. Monica Scheibmeir

December 5th, 2012

Quality Improvement and Performance Indicators for Primary Stroke Center Certification at St. Francis Health Center

Introduction

Cerebrovascular accident (CVA), also referred to as a “stroke” in the lay literature, is the third-leading cause of death and the leading cause of disability annually in the United States (Leifer, et al., 2011). An estimated 795,000 people in the United States are diagnosed with a CVA each year. For more than 600,000 of these Americans, this will be their first CVA but almost 200,000 of the yearly CVAs are recurrences (George, Tong, & Yoon, 2011). Approximately 140,000 CVA deaths occur annually and in addition, it is listed as a contributing factor in another 100,000 deaths (Katz, 2010). With the steady incline in medical conditions putting people at risk for a CVA including obesity, hypertension, dyslipidemia and diabetes, these numbers will likely continue to rise. The resulting effects will cost consumers millions of dollars in both direct healthcare costs as well as loss of productivity and income secondary to the profound and devistating disabilities resulting from a CVA. In 2010, an estimated $73.7 billion was spent on CVA-related medical costs and disability alone (Otwell, Phillippe, & Dixon, 2010). This project will assist St. Francis Health Center in collecting data on their current management of stroke care. The data can then be used to improve the care provided by St. Francis Health Center to victims of cerebrovascular accidents.

Pathophysiology

Before discussing the evaluation of stroke care, it is important to review and understand the anatomy and pathophysiology of the underlying disease. This makes it easier to understand why certain criteria are chosen to evaluate appropriate care. The brain is a relatively small part in the human body occupying only 2% of the body’s mass. However, it receives 17% of the heart’s output and consumes 20% of the body’s oxygen supply. The brain receives it’s vital blood supply through four arteries. The two largest arteries are the right and left internal carotids which branch off the left and right common carotids respectively and travel up the anterior portion of the neck. The common carotids arise from the aorta. These internal carotids give rise to the middle and anterior cerebral arteries which supply blood to the anterior portion of the brain including most of the frontal, parietal and temporal hemispheres as well as the basal ganglia. There are also two smaller arteries that travel up the posterior portion of the neck and are the right and left vertebral arteries. These arteries arise from a single basilar artery. The basilar artery arises from a branch off the subclavian artery which in turn branches off the aorta. These arteries supply blood to the posterior portion of the brain including the brainstem, cerebellum and most of the posterior cerebral hemispheres. The anterior and posterior circulations connect through a circular anastamosis of arteries called the Circle of Willis. The brain receives about 80% of it’s blood supply from the carotid arteries and the remaining 20% from the vertebral arteries (Katz, 2010).

One characteristic of the brain is many of it’s functions are not diffusely spread meaning specific neurologic functions are dependent on certain brain regions. In the cerebral vasculature, each artery supplies a particular brain region. Because most of these regions are associated with a characteristic neurological function, damage to a particular cerebral artery tends to cause characteristic losses of neurological functions which are often referred to as “focal neurological deficits” (Appendix A) (Katz, 2010).

Cerebrovascular accidents can be broadly defined as an interruption in blood supply to the cells which compose brain tissue and are classified as either ischemic or hemorrhagic. This can sometimes be confusing though because both actually cause ischemic damage. In the case of an ischemic stroke, resulting injury to brain tissue is caused by a reduced blood flow to a specific region without initially causing significant cerebral bleeding. This reduction in blood flow is most often secondary to a blocked artery but can also occur as a result of hypoprofusion as in the case of sustained cardiac arrest. Hemorrhagic strokes result from injuries that cause bleeding into the brain or cerebral spinal fluid from the outset. This bleeding is generally due to a tear in an artery or the rupture of an aneurysm. These conditions are often secondary complications from conditions such as hypertension, tumors or drugs. They can also be the result of trauma or physical activity. The majority of strokes (87%) are ischemic from the outset and as mentioned above, are primarily caused by the blockage of an artery. This blockage is predominantly due to a thrombus or blood clot (Katz, 2010).

Ischemic strokes, as the name implies, cause ischemic damage which is either complete or incomplete. If the blood supply to the brain is cut off completely, as is the case with cardiac arrest, there is widespread cell damage and neurons begin to die quickly. The brain uses energy quickly but only has a small back-up supply. When complete ischemia occurs, there is an immediate decrease in available oxygen and glucose that brain cells need to survive. Local neurons will begin to run short on their internal ATP (the back-up intracelluar energy stores) within a matter of seconds. As ATP is depleted, the cell membranes depolarize and extracellular ions rush in. This leads in water accumulation in the cells and eventually causes the cell to self-destruct, burst and die. This process is also known as apoptosis. As cells die in this manner, the toxic substances released from them can have a detrimental domino effect on surrounding cells which will continue until the blood supply is re-established (Katz, 2010).

Most ischemic strokes are not a result of complete ischemia. They are primarily caused by incomplete ischemia as a result of a partially or completely blocked artery. These blockages are generally caused by a blood clot or thrombus. The thrombus itself is usually the result of other conditions including but not limited to coagulopathies, atrial fibrillation and atherosclerosis. Even when an artery is competely occluded, the cerebral circulation has many overlaps and interconnections. Some blood will usually reach the affected brain regions via collateral circulation. The remaining perfusion will vary throughout the affected region. A common pattern is severely reduced perfusion in the center with gradually increasing profusion toward the edges. The area of minimally profused cells is referred to as the pneumbra. Neurons will become functionally silent when arterial profusion drops by even a small amount. In the case of a stroke, as soon as the cerebral blood flow is reduced, electrical activity in the region will stop and neurological deficits begin to appear. For a short time, silent neurons remain alive but no longer have the energy to generate membrane potentials sufficient enough to respond to stimuli or transmit signals. To remain alive, these neurons need some arterial profusion and if cerebral blood flow falls below 13% of normal in the affected region, silent neurons begin to die in the same fashion as complete ischemia.

The amount of irreversible damage increases steadily as long as regions are without sufficient blood supply. If the affected areas have no blood flow, neurons begin to die in less than 10 minutes. In areas with 85 years: 16%

Average age: 72 years

c. Race:

White: 87%

Black or African American: 10%

Hispanic: 2%

American Indian: 1%

2. Stroke Core Measure Set Performance Indicators

Stroke core measure set performance indicators are those items reviewed by The Joint Commission as part of the credentialing process as well as determining reimbursement rates for stroke care. The specific performance indicators are as follows:

a. 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). Results of compliance for St. Francis Health Center are as follows:

Baseline Data: 83% of qualifying patients received VTE prophylaxis

2011 Data: 100% of qualifying patients received VTE prophylaxis.

Current Data: 82% of qualifying patients received VTE prophylaxis

All Hospitals: 92% of qualifying patients received VTE prophylaxis

b. 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). Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 100% of stroke patients were discharged on antithrombotic

2011 Data: 98.5% of stroke patients were discharged on antithrombotic

Current Data: 98.6% of stroke patients were discharged on antithrombotic

All Hospitals: 98% of stroke patients were discharged on antithrombotics

c. 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 treatement 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%. Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 100% of patients with afib/aflutter were discharged on antithrombotics

2011 Data: 82% of patients with afib/aflutter were discharged on antithrombotics

Current Data: 67% of patients with afib/afutter were discharged on antithrombotics

All Hospitals: 93% of patients with afib/aflutter were discharged on antithrombotics

d. 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 (Appendix E). 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 U.S. all recommend the use of IV tPA for eligible patients (Outcome Sciences Inc., 2011). Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 57% of eligible patients received IV tPA within the 3 hour time window

2011 Data: 70% of eligible patients received IV tPA within the 3 hour time window

Current Data: 78% of eligible patients received IV tPA within the 3 hour time window

All Hospitals: 79% of elegible patients received IV tPA within the 3 hour time limit

e. Early antithrombotics. Patients with ischemic stroke or transient ischemic attack should receive anithrombotic 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 (Outcome Sciences Inc., 2011). Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 100% of qualifying patients received early antithrombotic therapy

2011 Data: 97% of qualifying patients received early antithrombotic therapy

Current Data: 98% of qualifying patients received early antithrombotic therapy

All Hospitals: 97% of qualifying patients received early antithrombotic therapy

f. 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 (Outcome Sciences Inc., 2011). Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 81% of qualifying patients were discharged on a statin or had a documented reason for why this was not done.

2011 Data: 89% of qualifying patients were discharged on a statin or had a documented reason for why this was not done

Current Data: 93% of qualifying patients were discharged on a statin or had a documented reason for why this was not done.

All Hospitals: 92% of qualifying patients were discharged on a statin or had a documented reason for why this was not done.

g. Stroke Education. Patients with stroke or transient ischemic attack or their caregivers should be given 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). Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 57% of patients received recommended stroke education before discharge.

2011 Data: 64.5% of patients received recommended stroke education before discharge.

Current Data: 86% of patients received recommended stroke education before discharge.

All Hospitals: 89% of patients received recommended stroke education before discharge.

h. 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). Results for compliance for St. Francis Health Center are as follows:

Baseline Data: 100% of stroke patients were assessed for rehab needs.

2011 Data: 100% of stroke patients were assessed for rehab needs.

Current Data: 100% of stroke patients were assesed for rehab needs.

All Hospitals: 97% of stroke patients were assessed for rehab needs.

3. Stroke “Golden Hour” Recommendations:

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. Results of key items related to “The Golden Hour” are as follows:

a. Door to CT < 25 minutes:

Baseline Data: 52% of qualifying patients had CT done in less than 25 minutes

2011 Data: 26% of qualifying patients had CT done in less than 25 minutes

Current Data: 39.5% of qualifying patients had CT done in less than 25 minutes

All Hospitals: 27% of qualifying patients had CT done in less than 25 minutes

b. NIHSS reported:

Baseline Data: 64% of stroke patients had an initial stroke scale completed.

2011 Data: 53% of stroke patients had an initial stroke scale completed.

Current Data: 78.5% of stroke patients had an initial stroke scale completed.

All Hospitals: 73% of stroke patients had an initial stroke scale completed

c. Door-to-needle time within 60 minutes

Baseline Data: 0% of qualifying patients received IV tPA within the recommended 60 minute time frame.

2011 Data: 37.5% of qualifying patients received IV tPA within the recommended 60 minute time frame.

Current Data: 50% of qualifying patients received IV tPA within the recommended 60 minute time frame. The average time is 76 minutes.

All Hospitals: 39% of qualifying patients received IV tPA within the recommended 60 minute time frame.

4. Miscellaneous Data

These are items that also play and important role in both the care and knowledge of stroke.

a. 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. Please see Appendix F for a sample dysphagia screening tool used by Shore Health System a part of University of Maryland Medical System. This can also be found at .

Baseline Data: 78% of stroke patients had dysphagia screen prior to taking anything orally.

2011 Data: 54% of stroke patients had dysphagia screen prior to taking anything orally.

Current Data: 79% of stroke patients had dysphagia screen prior to taking anything orally.

All Hospitals: 82% of stroke patients had dysphagia screen prior to taking anything orally.

b. Type of strokes treated. This shows that our patient composition for stroke fits what is typical for stroke data nationwide.

Ischemic stroke: 87%

Hemorrhagic stroke: 13%

c. Pre-existing conditions. This illustrates why these conditions are listed as risk factors for stroke and why the database asks about patients being discharged on antihypertensives and a Hemoglobin A1c is suggested with labwork. This is in addition to the LDL levels and discharge on statin and antithrombotic as mentioned previously.

Hypertension: 80%

Dyslipidemia: 52%

Previous stroke/TIA: 39%

Diabetes: 32%

Coronary Artery Disease: 21%

Atrial fib/flutter: 20%

Smoker: 17%

d. Smoking cessation education. Smoking is a common and modifiable risk factor for stroke. Education and assistance are key to eliminating this risk factor.

Baseline Data: 100% of stroke patients received smoking cessation education.

2011 Data: 100% of stroke patients received smoking cessation education.

Current Data: 100% of stroke patients received smoking cessation education.

All Hospitals: 97% of stroke patients received smoking cessation education.

Conclusion/Recommendations

Overall, St. Francis Health Center is currently performing very well in most aspects of stroke care. Even in the areas that are not ideal, they still compare well to hospitals across the nation. They actually began monitoring core measure data in regard to stroke in 2009 knowing that it would become a requirement of The Joint Commission. In response to their findings with this data, they originally developed a stroke order set in March 2010 for physicians to use to assure they were covering all requirements of The Joint Commission. This has since undergone several revisions. By June 2012, St. Francis had created the position of Stroke Coordinator in order to monitor stroke performance, educate on areas for improvement and to work on completing items for The Joint Commission survey for certification. This was originally established as a position solely for managing stroke as well as chest pain accreditation but has since been added to the many duties the Emergency Department director. Many of the improvements from baseline to current data can be attributed to the initial addition of this position and the function of the original person in it especially in regard to the improvements made during “the golden hour”. These have all been important steps to improving quality stroke care.

The primary recommendation would be for further education to be provided in regard to what the components of quality stroke care are. I know as a nurse in this particular facitily and soon to be provider, the primary reason I would not be performing up to standards would be because I am not aware of the expectations and current recommendations. In fact, if I would not have completed this project, I would not be aware of many of the current guidelines and recommendations and their importance. I am much more apt to be compliant if I know the reasoning behind what I am asked to do.

The primary areas of low performance have to do with the time that the patient spends in the Emergency Department so I would recommend spending a significant amount of time targeting education toward staff in this area. Posters, checklists and friendly competition are all items that I can say from my many years of experience in this department work well in this area.

I think it would be very helpful to have a stroke coordinator whose sole job is to address issues and educate staff. The stroke coordinator currently is not only in charge of maintaining stroke certification but is also responsible for maintaining chest pain education and certification as well as being the director over two large departments within the hospital. I think this allows little time for the attention that needs to be given to improving stroke care.

I would also recommend holding accountability to all staff members including physicians in regard to making sure appropriate order sets are initiated and policies and procedures are followed. I noticed in chart reviews that St. Francis has already developed a discharge checklist for stroke to assure that all aspects of core measures were addressed during the hospital stay. I rarely saw this used and think it would be very helpful.

Again, St. Francis Health Center is doing an excellent job in working toward perfecting stroke care for it’s patrons. The staff is very dedicated to doing what is best for the patient and with some additional education on what to do to improve and why, the numbers will continue to improve.

References

(2009). Retrieved November 26, 2012, from Stroke Care Now:





(2012). Retrieved July 3rd, 2012, from The Joint Commission:



Alberts, M. J., Latchaw, R. E., Jagoda, A., Wechsler, L. R., Crocco, T., George, M. G., et al.

(2011). Revised and Updated Recommendations for the Establishment of Primary Stroke

Centers: A Summary Statement From the Brain Attack Coalition. Stroke: Journal of the

American Heart Association , 2652-2664.

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

:

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



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.

Shojania, K. G., McDonald, K. M., Wachter, R. M., & Owens, D. K. (2004, August). Closing

The Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1—

Series Overview and Methodology. Retrieved August 2, 2012, from NCBI:



Table of Appendicies

1. Review of Cerebral Arteries…………………………………………….APPENDIX A

2. Elements of Stroke Core Measure Set………………………………..…APPENDIX B

3. Disease-Specific Care Certification Manual Standards………………...APPENDIX C

4. Data Entry Items for “Get With the Guidelines-Stroke” registry………APPENDIX D

5. Inclusion/Exclusion Criteria for IV tPA administration………………..APPENDIX E

6. Sample Dysphagia Screen………………………………………………APPENDIX F

APPENDIX A

|Cerebral Artery |Regions Affected |Possible Neurological Findings |

|Anterior Cerebral Artery |Frontal regions on the medial surface of ½ of |loss of discriminatory sensation and weakness |

| |the brain |or paralysis of the contralateral foot and leg |

| |much of the corpus callosum |possibly deficits in the contralateral shoulder|

| |part of the internal capsule |and arm |

| |regions of the basal ganglia |deviation of the head and eyes toward the side |

| | |of the affected cerebral artery |

| | |central motor problems ranging from expressive |

| | |aphasia to dyskinesias |

|Middle Cerebral Artery |primary and sensory motor cortices on the |full sensory loss and weakness or paralysis of |

| |lateral surface of the cerebral hemisphere |the face, arm and leg on the opposite side of |

| |sections of the internal capsule |the body |

| |parts of the inferior parietal and lateral |blindness in the opposite visual field |

| |temporal lobes |deviation of the head and eyes toward the side |

| | |of the affected artery |

| | |if the dominant (usually left) MCA has been |

| | |occluded, there can be global aphasia |

| | |if the non-dominant MCA is occluded, there can |

| | |be contralateral neglect or unawareness of |

| | |neurological deficits |

|Vertebral Artery |medulla of the brainstem |vertigo |

| | |nystagmus |

| | |ipsilateral ataxia |

| | |hypoglossal nerve dysfunction |

|Basilar Artery |ascending and descending motor and sensory |bilateral sensory and motor deficits |

| |tracts |combined cerebellar and cranial nerve problems |

| |vestibular and cochlear nerves |stupor or coma |

| |reticular activating system |hemiparesis with contralateral cranial nerve |

| | |dysfunction |

|Posterior Cerebral Artery |thalamus |sensory loss of the entire contralateral body |

| |hippocampus |third nerve palsy with hemiparesis, hemiplegia,|

| |underside of temporal lobe |ataxia or decreased LOC |

| |medial surface of occipital lobe |movement disorders of one side of the body |

| |motor areas of the midbrain |visual loss, specifically homonymous hemianopia|

APPENDIX B

|Stroke Core Measurements |

| Venous thromboembolism (VTE) prophylaxis within 48 hours of admission |

| Discharged home on antithrombotic therapy if no contraindications |

| Anticoagulation therapy provided for patients with atrial fibrillation/flutter unless contraindicated |

| Thrombolytic therapy within appropriate time frame if patient meets criteria |

| Antithrombotic therapy by the end of hospital day 2 if no contraindications |

| Patient receives education about stroke including their personal modifiable risk factors, how to activate EMS for stroke symptoms, prescribed|

|medications, stroke warning signs and symptoms and the need for follow-up after discharge |

| Patient discharged on a statin medication if there are no contraindications |

|Patient is assessed for rehabilitation needs |

APPENDIX C

|Disease-Specific Care Certification Manual Standards |Clinically Specific Requirements and Expectations for Primary Stroke |

| |Center Certification |

|Program management |Use a standardized method of delivering care based on the Brain Attack|

|Delivering or facilitating clinical care |Coalition’s “Recommendations for Establishment of Primary Stroke |

|Supporting self-management |Centers” |

|Clinical information management |Support patient self-management activities |

|Performance improvement and measurement |Tailor treatment and intervention to individual needs |

| |Promote the flow of patient information across settings and providers,|

| |while protecting patient rights, security and privacy |

| |Analyze and use standardized performance measure data to continually |

| |improve treatment plans |

| |Demonstrate their application of and compliance with clinical practice|

| |guidelines published by the AHA/ASA or equivalent evidence-based |

| |guidelines |

APPENDIX D

|Data Entry Items for “Get With the Guidelines-Stroke” database |

|Final clinical diagnosis related to stroke |

|ICD-9 principal diagnosis code |

|Earliest documentation of comfort measures only if applicable |

|Discharge disposition |

|If not discharged home, where was the person discharged |

|Patient location when stroke symptoms started |

|How patient arrived to hospital |

|Where did patient first receive care in the hospital |

|Was there advanced notification by EMS |

|Arrival date and time |

|Admit date |

|If patient was not admitted, reason for not admitting |

|Where was the patient admitted to in the hospital, by who, was there a stroke consult |

|Initial physician seeing the patient |

|Demographics: age, gender, ethnicity, health insurance status |

|Medical history pertaining to stroke risk factors |

|Ambulatory status prior to current event, at admission and at discharge |

|Symptom duration if presenting with TIA |

|Resolution of stroke symptoms at time of presentation? |

|NIH stroke scale: was it done and what was the score |

|Initial exam findings related to stroke symptoms |

|Current medication class if antiplatelet/anticoagulant, antihypertensive, diabetic medication, and cholesterol-reducer |

|Date and time patient last known to be well |

|Date and time of discovery of stroke symptoms |

|Date and time of brain imaging if done for this episode of care with results |

|Date and time IV tPA given if qualified |

|Documentation of contraindications if tPA not given |

|Was tPA given at another facility prior to transfer with date and time |

|Complications of tPA therapy |

|Was dysphagia screen done prior to giving the patient anything by mouth and results |

|Was the patient treated for hospital acquired pneumonia or DVT |

|Was DVT prophylaxis initiated by the end of day 2 and what type and when |

|Was the patient ambulating by the end of day 2 |

|If DVT prophylaxis not initiated, is there proper documentation of the reason |

|Was antithrombotic therapy administered by the end of hospital day 2 |

|Labs including lipid levels, PT/INR, creatinine, Hgb A1c and blood glucose |

|Vitals including admit and discharge BP and pulse, height, weight, waist circumference and BMI |

|Discharge date |

|Discharge medications including antithrombotics, antihypertensives, anticoagulants, diabetic meds and cholesterol reducing medications |

|Lifestyle interventions |

|Stroke education |

|Assessment for rehab services |

APPENDIX E

Inclusion/Exclusion Criteria for IV tPA from

Patient Inclusion Criteria (must be YES to all)

• Age 18 years or older

• Clinical diagnosis of Ischemic Stroke

• Measureable neurological deficit

• Clearly defined time of stroke onset (within 180 minutes of stroke onset)

• Informed consent (if possible)

• May extend treatment window to 4.5 hours if patient does not meet additional exclusion criteria (see below)

Patient Exclusion Criteria (all must be NO before treatement)

• Evidence of intracranial hemorrhage on pretreatment CT scan

• Minor or rapidly improving symptoms

• Symptoms of subarachnoid hemorrhage, even with normal head CT

• Active internal bleeding: Gastrointestinal or urinary bleeding within last 21 days or known bleeding risk, including but not limited to:

a. Platelet count less than 100,000/mm3

b. Heparin during the preceding 48 hours associated with elevated

aPTT

g. Currently taking oral anticoagulants (e.g. Warfarin sodium) or

recent use with an elevated prothrombin time (PT) greater than

15 seconds or INR greater than 1.7

d. Major surgery or other serious trauma during preceding 14 days

e. Stroke, serious head trauma or intracranial surgery during

preceding 3 months

f. Recent arterial puncture at a non-compressible site

g. Recent lumbar puncture during preceding 7 days

• Systolic BP greater than 185 mm of Hg or diastolic BP greater than 110 mm of Hg at the time of t-PA infusion and/or patient requires aggressive treatment to reduce blood pressure to within these limits

• History of intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm

• Recent Acute Myocardial Infarction

• Observed seizure at stroke onset

Relative Contraindications

• Early signs of a large cerebral infarction: edema, hypodensity, mass effect, and obliteration of sulci in more than 1/3 of middle cerebral artery territory on CT scan.

• NIHSS greater than 22

• Glucose less than 50 mg/dL or greater than 400 mg/dL.

• Pregnant female

• Difficult to control hypertension

• Age greater than 75

Additional Exclusion Criteria for 4.5 hour window

• Patient older than 80 years of age

• Patient with a history of both diabetes AND stroke

• Coumadin (warfarin) use regardless of INR

• NIHSS greater than 25

APPENDIX F

Diagnosis: _________________ Date of Assessment: _________________ Time: _________

Respiratory status: □ TRACH □ VENT □ Abnormal Lung Sounds □ Abnormal Chest x-ray

Diet Prior to Admission: □ Regular □ Pureed □ Thickened Liquids □ Tube Feeding

Cognitive Status: Alert- □Yes □No Follows Commands: □Yes □No

The following items are important warning signs for patients with possible dysphagia. Please indicate by placing a check mark

bedside the appropriate warning sign if they are observed. The patient should be elevated to a 90 degree hip flexion angle prior to

completing the screen. Ensure the patient can maintain alertness for at least 10 minutes prior to completing this screen.

IF ONE OR MORE WARNING SIGNS ARE OBSERVED THE PATIENT WILL BE MADE NPO. OBTAIN A PHYSICIANS ORDER TO CONSULT SPEECH THERAPY. PAGE SPEECH THERAPIST ON CALL MONDAY THROUGH FRIDAY 0900-1700 SATURDAY 0800-1630, AND SUNDAY 0800-1200

□ Control of Secretions- drooling, difficulty swallowing saliva or coughing, difficulty expelling secretions

□ Facial Symmetry- facial/lip droop on one side of the face, inability to move one side of face/lips, tremor in

muscle when patient asked to smile or pucker lips.

□ Tongue Mobility- tongue deviates to right or left side when protruding, unable to touch corners of mouth

□ Inadequate Oral Hygiene- dried, encrusted secretions on tongue or elsewhere in mouth

□ Lip Seal- decreased lip closure

□ Cough- absent or weak cough

□ Wet Vocal Quality- wet/gurgly voice when saying “AHH”

□ Aspiration- history of aspiration pneumonia

□ Dry Swallow- delayed (5 seconds or more)

IF ANY OF THE FOLLOWING ARE PRESENT, OBTAIN A PHYSICIANS ORDER TO CONSULT SPEECH THERAPY.

THIS DOES NOT WARRANT AN NPO STATUS

□ Slurred Speech

□ Aphasia

□ Disorientation/Confusion (Person, Place and Time)

Date/Time Speech Pathology notified: ________________________

Nurse Completing Screen: ____________________________

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