STROKE MANAGEMENT - University of Illinois at Chicago

Transcript STROKE MANAGEMENT - University of Illinois at Chicago

Stroke Education Q I Initiative– BroMenn Healthcare

October 2007

BroMenn Healthcare Normal, Illinois

• BroMenn Regional Medical Center (BRMC) – 224 bed, full-service, teaching hospital – Level II trauma center with regional referral – Dedicated neuroscience unit – Inpatient rehabilitation • Eureka Hospital (ECH) – 34 bed, critical access hospital • Home Care & Hospice

Decision to Pursue Stroke Designation at BRMC

• To build on existing program strengths – Neuro, neurosurgical & neuro-residency programs • Patient volume sufficient to support a

dedicated program

– 200 strokes admitted annually – 100 TIAs admitted annually

Designation Objectives

• Promote a culture of interdisciplinary,

patient-focused approach to stroke care across the care continuum

• Promote evidence-based practice • Maximize patient care outcomes • Continuous quality improvement

Collaborative Practice Team Was Formed

Emergency Medical System (EMS) American Heart/ Stroke Association Emergency Department Neuroscience Care Unit Intensive Care Unit Other Nursing Unit Representation Physical Medicine & Rehabilitation Physician Representation Cardiopulmonary Services Pharmacy, Lab & Nutritional Services Case Management Radiology

Practice Team

• Establishes the program’s care delivery

model, goals & improvement priorities

• Researches and implements best practices • Coordinates educational efforts • Monitors quality measure performance • Develops performance improvement plans • Includes interdisciplinary hospital, medical

staff and community representation

• Meets 4-6 times per year

Care Delivery Model Was Established

Patient experiences symptoms of stroke EMS is activated Outside the Hospital Location of the patient?

Within the Hospital Nursing evaluation Delivery of Stroke Care Is FAST Criteria met?

Code Gray - Neurologist evaluation - NIHSS - Labs drawn - Imaging - TPA risk assessment Yes Admission to ICU TPA or Intervention?

No No evidence of hemorrhage Admission to NSCU Type of Stroke?

Ischemic Stroke with Thrombolysis - Assessment guidelines - Bleeding precautions - BP management - Swallow screen - Antithrombotics - Anticoagulation for afib - Lipid profiling - DVT prophylaxis - Patient education Ischemic Stroke/ TIA Care Map - Assessment guidelines - BP management - Swallow screen - Antithrombotics - Anticoagulation for afib - Lipid profiling - DVT prophylaxis - Patient education Evidence of hemorrhage Admission to ICU Neurosurgical evaluation and additional imaging Intra-cerebral or sub-arachnoid hemorrhage orders Rehab evaluation Discharge disposition determined - Rehabilitation - Skilled Care - Intermediate Care (Nursing Home Placement) - Home with Home Care - Home Date: 12/05 Rev: 09/06 Model developed from guidelines published by AHA, ASA and the Mayo Clinic.

Addresses screening performed in the community as well as the hospital Includes diagnosis and care of ischemic and hemorrhagic strokes, and TIAs

The Model Encompasses

• FAST Screening • EMS protocols and education • Clinical practice guidelines to direct patient care • Protocols for rapid diagnosis, BP management,

thrombolysis, education and prevention of complications

• Monitoring for early detection and response to

problems

• Early establishment of rehabilitation plan

Measure DVT Prophylaxis Antithrombotics at Discharge Anticoagulation for A Fib TPA Considered Antithrombotics w/in 48 Hrs Lipid Profile Screen for Dysphagia Stroke Education Smoking Cessation Plan for Rehab

Benchmarking

Q3 ‘04 64% 89% 100% 67% 89% 33% 47% 14% 17% 70% Q1 ’07 (January) 100% 100% 100% 100% 94% 78% 56% 92% 100% 88% Target 100% 100% 100% 100% 100% 90% 100% 90% 90% 90% Illinois Capture 75% 97% 93% 45% 91% 60% 47% 64% 84% 88%

Stroke Education

10 0 % 8 0 % 6 0 % 4 0 % 2 0 % 0 % Q3 - 0 4 Q4 - 0 4 Q1- 0 5 Q2 - 0 5 Q3 - 0 5 Q4 - 0 5 Q1- 0 6 Q2 - 0 6 Q3 - 0 6 Q4 - 0 6 Q1- 0 7

Work Group Meeting

Stroke Units Collaborative Culture Marketing; Community Wellness Leadership (QRM, Clin. ED)

Stroke Binder

Let’s talk about Stroke

Progress

100 80 60 40 Stroke education workgroup 20 0 14% 3Q (2004) 24% 4Q Stroke Education 45% Development of patient education materials 1Q (2005) 2Q 3Q

Standardized Documentation

Measure

Stroke Education 100 80 60 40 20 0 24% 14% 3Q (2004) 4Q More Staff education 50% 1Q (2005) 2Q 3Q 71% 73% Standardized form for documentation 4Q 1Q (2006)

Ongoing Process

Act Measure Plan

CVA - TIA

• We do not use a separate CareMap

for TIA patients.

• CVA patients were over the 90%

mark, but TIA patients were not receiving the education.

Almost there

Stroke Education 100 80 60 40 20 0 24% 14% 3Q (2004) 4Q 50% 1Q (2005) 2Q 3Q 71% 4Q Reinforcement to use with TIA patients 1Q (2006) 2Q 89%

Meditech Documentation

• Over the course of the last year on-line

documentation had come full swing.

• We knew nurses were educating and the

supply of notebooks correlated.

• Documentation needed to occur in the

electronic realm.

Breaking the 90

!!

Stroke Education 100 80 60 40 20 0 3Q ( 20 04 ) 24% 14% 4Q 1Q (20 05 ) 50% 71% 89% EMR documentation developed 2Q 3Q 4Q 1Q ( 20 06 ) 2Q 3Q 4Q 1Q (20 07 ) 92%

Holding the ground