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9/28/2012 1 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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  • 9/28/2012

    1

    Comprehensive Stroke Systems: The Saint Lukes

    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 Lukes 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

  • 9/28/2012

    2

    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

    1

    St. Lukes 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

  • 9/28/2012

    3

    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

  • 9/28/2012

    4

    Example of Capturing Measures: Severity Scoring in ICH, SAH, TIA

    1

    Risk Factor Point Score

    Age >60 years 1 point 1BP Systolic BP > 140 or Diastolic > 90

    1

    Clinical FeaturesUnilateral weakness with or without speech impairment Speech impairment without unilateral weakness

    21

    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

    1

    Transport Protocols

  • 9/28/2012

    5

    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

  • 9/28/2012

    6

    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

    1

  • 9/28/2012

    7

    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 INRs Neurosurgeon Intensivist

    1

    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

  • 9/28/2012

    8

    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 RNs

    Responsible for scope of clinical

    trials

    Administrative Assistant

    Support to APNs, research coordinator and Medical Director

  • 9/28/2012

    9

    Neurologist Stroke Team 3 in 1993

    2

    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

  • 9/28/2012

    10

    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-upsSporadicformal

    Outreach:Picture here of Template from before.

    SLNI

    Social Media

    Outreach: Examples of blogAnd fb site

  • 9/28/2012

    11

    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 CNRNs 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?

    1

  • 9/28/2012

    12

    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

    45

    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

    1

    STROKE MORTALITY IS A

    BLACK BOX!!

    All Patient Refined DX(APR DRG) key words

    PROCESS

  • 9/28/2012

    13

    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

    1

    STROKE MORTALITY IS A

    BLACK BOX!!

    APR DRG key words

    SLH Core Measures Dash Board SLH Secondary Core Measures

  • 9/28/2012

    14

    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

    56

    0 = No perfusion 1 = Perfusion past the initial obstruction with little

    or slow distal perfusion 2A = Perfusion of < of the occluded artery 2B = Perfusion of or >of the vascular

    distribution of the occluded artery 3 = Full perfusion with filling of all distal

    branches

  • 9/28/2012

    15

    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 dont 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.

  • 9/28/2012

    16

    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 practiceParticipation in most major stroke treatment trials since

    1994Presentation/publications ISCCollaboration with other top stroke centers: UCLA,

    Pittsburgh, Massachusetts General, Stanford for reporting data

    Process Innovation improves outcomesSWAT Database Code NeuroDaily stroke report Feedback reports to ED and EMSOutcome 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

  • 9/28/2012

    17

    Overview comparing St Lukes 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 Lukes (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 Lukes (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 Lukes(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

  • 9/28/2012

    18

    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

    2

  • 9/28/2012

    19

    Results

    1626 ischemic strokes

    717 (44%) were transferred 63

    Referring Hospitals (29 Critical Access)

    145 (20%) of transferred cases

    were drip and ship25% > 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

    2

    BP=183/77 Mortality

    BP=232/84 No Hemorrhage

    mRS 0-2 at 90 days

    mRS > 2

    2

    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 Lived

    Admit NIHSS 25; discharge NIHSS 4 Admit NIHSS 18; discharge NIHSS 10

    2

    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.

    2

  • 9/28/2012

    20

    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

    2 2

    NEVER SETTLE

    Changing Lives

    THE EMS CREW WHO SAVED HER LIFE