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Comprehensive Stroke Systems: The Saint Luke’s
Experience
Debbie Summers MSN, ACNS-BC, CNRN, CCRN, FAHA
Disclosures
Comprehensive Stroke Systems
• Debbie Summers, MSN, APRN-BC– Speakers Bureau
• Genentech, Inc
Kansas City Saint Luke’s Hospital System Non Profit
• 10 Hospitals– 4 Metro
• SLH – 590 (PSC –CSC)
• SLH East – 174 (PSC)• SLH South – 125 (PSC)• SLH North – 150
– 2 Community – 2 Critical Access – 1 Free standing
rehabilitation – 1 Behavioral Health
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Objective
• Discuss process changes that improve stroke care and eliminate barriers when treating patients in the acute CSC
• Identify clinician roles, responsibilities, and justify how the enhance the acute stroke care of a CSC.
• Define outcomes and how to disseminate these to EMS to demonstrate the effectiveness of a CSC
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St. Luke’s Neuroscience Institute
2004 – Joint Commission
Primary Stroke Certified
2011 Population• 678
Ischemic• 108 ICH• 80 SAH• 96 TIA
Who We AreMission
To improve the health of the people of Kansas City and the surrounding region by advancing neuroscience research and education, pioneering emerging technology and therapy while sustaining cost effective clinical excellence in the treatment, prevention and rehabilitation of the nervous system and spine.
Vision
To be the regional leader in providing comprehensive integrated care and services for people with conditions of the nervous system and spine and to be nationally recognized as a “Best Place to Get and Give Neurological Care.”
Media Recognition
The New York Times
48 Hours
Discovery Channel
Newsweek
Business Week
ABC World News
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Progression to CSC • EMS and Regional Hospital OutreachSpoke and hub
networking
• Flow of Patient Care • Practice Changes Process Structure
• Clinical Orders• Severity Scoring
Evaluation and Management
• One Call Number (DOC One)Ease of Access to Stroke Program
• ED Initiatives • People - CNNNever on Diversion
• EMS Education• Shadowing
Professional Outreach
Regional Networking 02-11
Clinical Tools
• Neuro Evidenced Practice Team – System Orders
• Pre-Checked Orders -Guiding Care
• PSC/CSC Core Measure Integrated– NIH Stroke Scale
– CT time and results
– IV inclusion/Exclusions
– Hunt and Hess
– INR reversal
– mRS – 90 day
– TIA – ABCD Sco
• Transport Protocols
Clinical Tools • Ischemic
• ICH
• SAH
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Example of Capturing Measures: Severity Scoring in ICH, SAH, TIA
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Risk Factor Point Score
Age >60 years – 1 point 1BP Systolic BP > 140 or Diastolic > 90
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Clinical FeaturesUnilateral weakness with or without speech impairment Speech impairment without unilateral weakness
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Duration of TIA > 60 minutes 2Diabetes history 1
Total Score
Additional Clinical Tools • Clinical Path
• Dysphagia Screening Tool
• Patient Education Book
• Discharge Tools
… an Extremely short amount of time to achieve the best outcome for stroke
Stroke
0 hour3 hours
National Stroke Reversal Treatment Rate = 2%
Clinton Mo.
Emergency Department
Doc One
Transfer
Team
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Transport Protocols
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Equipment
Patient Unit
Dedicated neurosciences med/surg unit
(East-1)
Medical and Neurosurgical
ICU
18-bed inpatient rehab unit (East-
8)
ED
Point of Care Testing
Lab
Radiology
2 64 CT scanner adjacent to ED –
perfusion capability
1.5 T inpatient MR
Ceretomportable CT
scanner
2 Neuro-interventional
radiology suites(3)
Dedicated Neuro OR suite (main OR #3)
Major Asset – Consolidated Outpatient
Neurology Neurosurgery Outpatient Rehabilitation
Neuro-Oncology
Shaped Beam Surgery Center
(Novalis)CT
3T MRI Brain Fitness Center
Data Revolution
GWTG – PSC
2003
Lumedex – Growth to CSC (home grown out of cardiac data base)
Medicare Reporting
3rd QTR 2012Comprehensive –
2011 - ??????
Data – access1993
Daily Stroke Admit Report
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EMS & Referring Facility Follow-Up
Purpose: to provide patient outcome follow up on
transferred cases; regional networking
PowerPoint to transporting and transferring facilities
Cases receiving acute intervention: IV & IA tPA, and
mechanical embolectomy
Expansions of Program Clinician Roles to CSC
Nurse Driven
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Primary Stroke Program Roles
Medical Director
Data Coordinator
Stroke Coordinator/
APN
ACNS-BC; Post Masters
Neurovascular Clinician
Training
Dr. Marilyn
Rymer
Comprehensive Program Growth
Increasing Volume
ED Capacity –
Core measure missing
Physician Burden
Physician Needs
• 1993 – 220 Ischemic• 2011 678 Ischemic
• IV tpa patients in ED• Lack of Intensive
Monitoring
• Primary • Comprehensive
• Intensive Call Schedule
• Recruitment
• Neurologist• INR’s• Neurosurgeon• Intensivist
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SLNI Clinician Roles
APN Stroke –Coordinator
(ED Workups, program process)
Code NeuroNurses – full
time 24/7
APN ‘s Center of Excellence
SLNI APN Role
– Staff education, oversight of patient care, acute patient care, community education, maintenance of paths and orders, quality improvement, involved in discharge planning
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Code Neuro Nurse Role The CNN Scope of Practice
Key Functions:• Respond to all acute neurological admissions in ED• Assist transfer team as needed• Evaluate ED patients & provide critical info to other
required caregivers (physicians, nurses, technicians, etc.)• Preliminary screen for research studies; notify research
RNs of candidates as appropriate• Accompany patients to procedures or attend to patients in
ED if admit is delayed• Participates in Clinical practice changes - revision and
update of clinical tools (paths, orders, glucose management, and f/u to pre-hospital providers)
Implementation of CNN
• High level of satisfaction from ED physicians, ED staff all members of the stroke team
• Improved the management of the acute neuro patient
• Provides “just in time” education to nursing staff
• Increased the immediate notification of the stroke team
SLNS Clinical Support Staff
Data - responsible for neurovascular
database and GWTG
Quality Informatics Specialist
RN
2 Research RN’s
Responsible for scope of clinical
trials
Administrative Assistant
Support to APN’s, research coordinator and Medical Director
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Neurologist – Stroke Team – 3 in 1993
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Neuro Interventional Team - 1996
Neurosurgeons – 3 in 1993
Dr. Lovick – Brain Tumor
Dr. Mollman -Spine
Dr. Milligan Skull base
Dr. Griffith – Tremor
Dr. Hiser – General
Outreach
As early as 1994 – clinical trial
Components…
•Education – EMS/hospitals,
community
•Pre-hospital care, NIHSS
•Follow-up inconsistent – 09 formal
•Team building and Collaboration
•Research
•Social media
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August 18, 2010
Time and Stroke
Just Get Here!
Code Neuro Nurses
Follow-up Reports – sporadic
•Life Flight Eagle
•Miami County, KS EMS
•MO State TCD Initiative
Outreach & Collaboration
Formalized F/U Report
Follow-upsSporadic����formal
Outreach:Picture here of Template from before.
SLNI
Social Media
Outreach: Examples of blog
And fb site
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Leadership Structure
Medical Director
Stroke Coordinator
Data Coordinator
RN Abstractor
CNN-Clinical Leaders
VP Neuroscience
Institute
Clinical Director
Denise Mogg –SLNI Clinical Director
Kevin Thorpe VP SLNI
Nursing Experts and Leaders19 Certified CNRN’s 2011
Education Structure - Unstructured
Stroke Coordinator
APNs
CNNs
Unit Education Chair
Neuro ICU specific
• SLH /System • AHA Stroke
Consortium
• In the moment
• In the moment• Formal Outreach
• Shared Gov Clinical Nurse
• Clinical care and education
Outcomes
What Does That Really Mean For Stroke?
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Quality Data in Report Cards
• Stroke Unit; # of beds, # nurses, PSC v CSCStructure
• CT time, DTN, Core Measures, Discharge resources available, case review
Process• NIHSS, mRS, Risk adjusted mortality
rate; 30 day mortality or readmissionOutcomes • Case Volume , Risk Adjusted length of
stay, Average LOSUtilization• Average Charge, Risk adjusted average
charge, Cost Financial
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Kelly et al Public Reporting of Quality Data for Stroke. Stroke
2008;39;3367-3371
Outcomes Analysis getting right brained and global
• Currently, we are measuring PROCESS
• We would like to get to real OUTCOMES– And, we would like to get to outcomes that
matter to patients and families.
• Where are our opportunities to benchmark to evaluate how we are doing?
• All of these are important and inter-related
• And then there is the coding mystery
Coding Struggles
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STROKE MORTALITY IS A
BLACK BOX!!
All Patient Refined DX(APR DRG) key words
PROCESS
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National Hospital Inpatient Quality (“Core”) Measures for Stroke
• Acute Measures– Thrombolytic therapy – arrive in 2 hours and treated by 3 hours– Venous thrombo-embolism prophylaxis by end of day 2– Antithrombotic therapy by end of day 2 of admission
• Discharge Measures– Discharged on antithrombotic therapy– Discharged on statin medication if LDL>100– Anticoagulation therapy for atrial fibrillation/flutter
• Quality Measures– Door to CT time 25 minutes in patients presenting with stroke symptoms
3 hours’ duration (Door to CT 25 Minutes)– DTN Time < 60 minutes– Dysphagia screening– Stroke education– Assessed for rehabilitation
Quality Analysis IV t-PA DTN
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STROKE MORTALITY IS A
BLACK BOX!!
APR DRG key words
SLH Core Measures – Dash Board SLH Secondary Core Measures
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Comprehensive Measures- TBA
• CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score on Arrival
• CSTK-02 Modified Rankin Score (mRS) at 90 Days
• CSTK-03 Severity Measurement on Arrival –NIHSS, ICH Score, Hunt and Hess
• CSTK-04 Median Time to Treatment with a Procoagulant Reversal Agent
• CSTK-04a Median Time to INR Reversal
Comprehensive Measures- TBA
• CSTK-05 Hemorrhagic Complication for Patients Treated with Intra-Venous (IV) Thrombolytic (t-PA) Therapy Without Catheter-Based Reperfusion
• CSTK-05a Hemorrhagic Complication for Patients Treated with Intra-Arterial (IA) Thrombolytic Therapy or Mechanical Endovascular Reperfusion Procedure With or Without Intra-Venous (IV)Thrombolytic (t-PA) Therapy
Comprehensive Measures- TBA
• CSTK-06 Nimodipine Treatment Initiated• CSTK-07 Median Time to Recanalization
Therapy• CSTK-07a Thrombolysis in Cerebral Infarction
(TICI) Post- Treatment Reperfusion Grade
TICI - Thrombolysis in Cerebral Infarction
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• 0 = No perfusion • 1 = Perfusion past the initial obstruction with little
or slow distal perfusion • 2A = Perfusion of < ½ of the occluded artery • 2B = Perfusion of ½ or >of the vascular
distribution of the occluded artery• 3 = Full perfusion with filling of all distal
branches
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Limitations - Documentation!
• The determination of whether a process of care was delivered to an individual patient was based on documentation in the medical record, and such data may be incomplete.
• EMR documentation is a challenge for neuro cases.
• Dawn M. Bravata. Processes of Care Associated With Acute Stroke Outcomes. Arch Intern Med. 2010;170(9):804-810
Standardized Order Sets Based on Current Evidence
The SLHS EPT Teams
OUTCOMES(real ones- what are they?
The truth is-------------we don’t know yet)
Example of Measures
• Outcome measures include: mortality, readmissions, complications, and patient/caregiver satisfaction scores.
• Utilization measures include: data pertaining to the frequency of service use, including length of stay.
• Finance measures include economic data pertaining to the provision of stroke care.
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What Really Matters
• mRS at 90 days
• NIHSS score on admission and discharge
• How many days at home in 90 days after stroke
• FIM scores on admission and discharge from rehab
• Satisfaction and QOL scores
Innovation and Research
•Clinical Research elevates practice–Participation in most major stroke treatment trials since
1994–Presentation/publications ISC–Collaboration with other top stroke centers: UCLA,
Pittsburgh, Massachusetts General, Stanford for reporting data
•Process Innovation improves outcomes–SWAT –Database –Code Neuro–Daily stroke report –Feedback reports to ED and EMS–Outcome measures – phone follow-up 2-3 day….. and at
90 day
Where are the Benchmarks?
• GWTG can provide comparative data for Primary Stroke Centers
• The MERCI Registry collected 1000 cases for analysis of interventional stroke center performance.
• There is no national ischemic stroke registry for benchmarking
SLNI Acute Stroke Intervention2002 - 2011
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Overview comparing St Luke’s patients to the “rest-of-world” (ROW)
Datacut Date: April 19, 2010
Analysis Notes
• Datacut Date: April 19, 2010• Analysis cohort:
– All subjects with valid/complete 90d mRS
St Luke’s (N=84) All Others (N=702)
Age – Mean / Median (years) (N) 68.1 / 70 (84) 66.9 / 69 (702)
Baseline NIHSS – Mean / Median (N) 18.9 / 18.5 (84) 18 .0 / 18 (678)
Pre-Stroke mRS > 1 15.5% (13/84) 7.1% (49/690)
Merci Registry Procedural Data
St Luke’s (n=84) All Others (N=702)
% Receiving IV tPA 43% (36/84) 27% (192/702)
% Receiving IA lytic 50% (42/84) 47% (328/702)
% IIb/IIIa 0% (0/84) 7% (51/702)
Vasodilators 0% (0/84) 12% (82/702)
Time: Mean Onset to Groin Access (hrs)
5.4 7.3
Time: Mean Procedure Length (hrs)
1.5 3.1
Source: masterpatientlist_19APR2010.xls
Revascularization Rates
Recanalization St Luke’s(n=84)
Others (n=702)
TICI 2a or better (self reported) 74% (62 / 84) 79% (549 / 698)
TICI 2b or better (self reported)
46% (39 / 84) 53% ( 371 / 698)
Source: masterpatientlist_19APR2010.xls
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Revascularization and Outcomes at 90 days
Source: masterpatientlist_19APR2010.xls
Stroke Mortality Rates
• Ischemic stroke mortality reported in Circulation 2010 18.4%
• SLBSI ischemic stroke mortality rate– Non intervention cases 10%– Intervention cases 16%– Overall 11.6%
SLH Rehabilitation Stroke OutcomesUDS Comparison of Regional and National Statistics
for Rehabilitation Programs
% of Cases SLH Region National
Discharged Home 80.8 65.5 67.3
CI 1.52 1.44 1.54
LOS 14.5 14.7 14.6
FIM Change 25.1 24.6 24.7
Is Immediate Transport Safe?• Retrospective review of consecutive “drip
and ship” cases 2008-2010.
• Analysis– SICH or BP>180/105 on arrival– Inaccurate stroke diagnosis– Need for intra-arterial (IA) treatment– Mortality rate– Clinical outcome (mRS at 90 days)
• Location and Size of referring hospital
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Results
1626 ischemic strokes
717 (44%) were transferred – 63
Referring Hospitals (29 Critical Access)
145 (20%) of transferred cases
were “drip and ship”25% > 100 miles
63% >50 miles
90% >10 miles Mean age 67.
4Mean Admit NIHSS 10.4
Mean Discharge NIHSS 2
2
Blood Pressure on Arrival
1 SICH
1 Mortality
10/14
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• BP=183/77• Mortality
• BP=232/84• No Hemorrhage
• mRS 0-2 at 90 days
• mRS > 2
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14/145 (9.6%) had BP >180/105
4 Cases with Hemorrhage on Arrival
4 SICH • 2.7 % (3 of these had BP <180/105)
2 Died
• 1 related to SICH• 1 BP>180/105
2 Lived
• Admit NIHSS 25; discharge NIHSS 4• Admit NIHSS 18; discharge NIHSS 10
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Outcomes
mRS 0-2 at 90 days = 72/114 (63%)Note: mRS scores not available for 2008
Mortality = 20/145 (13.7%) Further Endovascular therapy = 35/145 (24%)Inaccurate diagnosis at sending facility = 6/145 (4.1%) ; all had excellent clinical outcomes.
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Conclusions
• Immediate transport of patients with IV tPA infusing is safe with a low incidence of SICH en route
• The 63% good outcomes may, in part, relate to early treatment with IV tPA in referring hospitals
• Hospitals of every size and location can safely treat stroke victims with IV tPA if they have access to consultation and transfer agreements with experienced stroke centers
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NEVER SETTLE
Changing Lives
THE EMS CREW WHO SAVED HER LIFE
