Implementation of a Screening Tool to Determine Eligibility for Thrombolytic

Therapy for Acute Ischemic Stroke Management in the Emergency Department

Darene Hall MSN, CCRN, GNP-BC, DNP (c)Scholarly Project

Stroke Program Manager•Adult/Geriatric NP

•Neurovascular

•Critical Care

•Mother

•Wife

•Grandmother of 3

Committee Members• Faculty Chair:

Kathleen A. Ennen PhD, RN, CNE• Has over 42 years of nursing experience which includes

work in cardiovascular intensive care units, teaching, and research in area of stroke recognition and prevention

• Clinical Mentor: Anne W. Alexandrov PhD, RN, CCRN, FAAN• Asst. Dean, DNP Program Director, and Professor at

University Alabama. Neurovascular Management Professor & NET SMART (Neurovascular Education and Training in Stroke Acute Reperfusion Therapy) Program Director. Health Outcomes Institute

What is your Stroke Risk Score?

Introduction and Background

• Stroke is the fourth leading cause of death in the U.S.

• Leading cause of long-term adult disability

• One of the leading hospital admitting diagnosis

(American Heart Association, 2013)

Global Significance

• 795, 000 people in the United States (U.S.) had a new or recurrent stroke

• Stroke killed more than 137,000 people a year

• 2010 - Americans paid about $74 billion in stroke-related medical costs and disability

(American Heart Association, 2013)

Institute of Medicine Summary Report

TO ERR IS HUMAN CROSSING THE QUALITY CHASM

ENVISIONING A NATIONAL HEALTH

CARE QUALITY REPORT

LEADERSHIP BY EXAMPLE

PRIORITY AREAS FOR NATIONAL

ACTION

http://www.acmq.org/education/iomsummary.pdf

Foreground: Local Significance• Heart disease and stroke are

first and third leading cause of death and disabilities

• 2004 -Heart disease and stroke killed over 73,000 Californians

• 2006 – the reported annual cost exceeded $48 billion

(California Heart Disease and Stroke Prevention and Treatment Task Force, 2007)

Stroke Care Advancements

Primary Stroke Center

Provide initial acute stroke care / Stroke Units Ability to administer t-PA in a safe efficient manner

Emergency Medical Services:

Diverting suspected stroke patients to hospital with stroke specialization. Development of Stroke Protocols

The Joint Commission: Greater than 800 PSC in the Nation

American Heart Association / American Stroke Association

Developed AIS Clinical Practice Guidelines Quality improvement program Get With the Guidelines (GWTG-Stroke)

Stroke Care Advancements Continues

Tissue-Type Plasminogen Activator (t-PA)

Proven intervention for acute ischemic

stroke

Class 1, evidence-based

recommendation for the AHA/ASA

The benefits of intravenous t-PA in acute ischemic stroke is strongly time-dependent

Studies have shown, greater

neurological improvement at

90 days with early t-PA treatment

Fonarow et al. (2011b)

Problem• Despite proven benefits, CPG,

explicit goals for timely administration of t-PA

• Recent evidence: GWTG-Stroke– National U.S. registry database

and other studies

• Only one-third of AIS patients treated within recommended door-to-needle time guideline

(Fonarow et al., 2011b)

Proposed Change

•In emergency department providers (MD, NP, PA, RNs)P

•How does integrating the National Institute of Neurological Disorders and Stroke (NINDS) screening tool in the initial evaluation and treatment for acute stroke patients

I•Compared to no NINDS screening tool used for acute

stroke patientsC

•Improve sixty-minute door-to-needle thrombolytic treatment ratesO

•Over a three month timeframeT

Purpose and Scope of Proposed Change•To evaluate effectiveness of the NINDS thrombolytic screening tool on 60 minute TTRs

•Elevate clinicians’ performance in acute stroke management

NINDS Screening Tool

NHMC TPA Screening Tool (2008)

Iowa Model of Evidence-Based Practice to Promote Quality Care

Iowa Model of Evidence-Based Practice to Promote Quality Care (Cullen et al., 2011

Implementation Framework and Change Model

Problem Focused Triggers

TJC Stroke Quality Measures t-PA administration

below 85 percent

Door-to-needle time of 60 minutes met less than 20%

Thrombolytic therapy treatment rate below five

percent (3-5%)

Knowledge Focused Triggers

Lack of adherence to CPG

Inconsistency amongst ED providers in acute stroke evaluation and treatment.

Not familiar with NINDS screening tool

Stroke National Hospital Quality Measures 2011-2012

1 2 3

t-PA Administ

ration 5 6 7 80%

10%20%30%40%50%60%70%80%90%

100%

July - Sept 11Oct - Dec 11Jan - March 12Apr - Jun 12YTD 2011-12

Door-to-Needle Time 2011-2012

July,11

Aug, 11

Sept, 1

1

Oct, 11

Nov, 11

Dec, 11

Jan, 1

2

Feb, 1

2

Mar, 12

Apr, 12

May, 1

2

Jun, 12

0

0.5

1

1.5

2

2.5ED Arrival < 2 hours

Monthly Average

Hour

s

AHA/ASA-GWTG“Target-Stroke”

Target 60 minutesNational Average

78 minutes

Thrombolytic Therapy Treatment Rate Acute Ischemic Stroke

YTD Jul, 10 – Jun, 11 YTD Jul, 11 – Jun, 120%

1%

2%

3%

4%

5%

6%

7%

8%

7%

4%

Thrombolytic Treatment Rate

Thrombolytic Treatment Rate

National Aver-age 3 – 5%

EBP Implementation Framework

Is this Topic a Priority

For the Organization?

Yes

Stroke Core Quality Performance Measures

•Nationally reported

•Required to maintain Stroke Center designation status

•Reported to CMS (reimbursements tied to quality measures in the near future)

•ASA proposed 60 minute DTN as a new core measure (reimbursement tied to quality)

EBP Implementation Framework el•Door-to-Needle Time Committee formed

•Reviewed three studies on improving acute stroke care and DTN times

•Identified EBP and national benchmark targets

Form a TeamStroke Sub-Committee (Stakeholders)

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

STAKEHOLDERS

PatientEMS

Stroke Coordinator

Change Agent

Stroke Call Panel

ED Physicians

ED Nurses and Staff

Radiology Services

Laboratory Services Pharmacy

Pre-Hospital Coordinators

Community at Large

Quality Management

ED Leadership Team

Neuroscience Department

NHMC Stroke-subcommittee, 2012

Chart Review Forms

Developed by Darene Hall

Kotter’s Eight Step Change Model

Step 1 Establish a sense of

urgencyProblem Identification

Step 2Create a guiding

coalitionGetting a vision of the

project

Step 3Develop a vision and

StrategyBuy-in

Step 4Communicate the change

visionUse every vehicle to

communicate new vision

Step 5Empower broad-based

actionGet rid of obstacles,

encourage risk taking

Step 6Generate short-term

winsShow staff improvement,

reward and recognized

Step 7Consolidate gains and produce more change

Restructure system that do not fit, reinvigorate

processes with new projects

Step 8Anchor new

approaches in the culture

Make change stick

Why Transformaton Efforts Fail (Kotter, 2000, p. 61)

Market Analysis: California Legislature• Assembly Bill 1220

(Berg, 2003)

• Governor-appointed Task Force

• California’s Master Plan for Heart Disease and Stroke Prevention and Treatment 2007-2015

(California Heart Disease and Stroke Prevention and Treatment Task Force, 2007)

Statewide Plans

Continuous quality

improvement initiatives

Primordial and primary prevention

Notification and response

of EMS for stroke

Acute treatment for

stroke

Sub-acute stroke care

and secondary prevention for

stroke

Rehabilitation of stroke patients

(The Stroke Systems Work Group, 2009)

Risk and Barriers• Efficiency in acute ischemic stroke management

• Lack of stroke symptom recognition

• Failure to seek urgent help

• Non-urgent triage of stroke patients EMS and ED Staff

• Delayed CT scans

• Inefficiency in-hospital emergency processes of stroke care

(Carter-Jones, 2010)

Risk and Barriers• ED nurses insufficient level of comfort in

assessing acute stroke patient

• Infrequent feedback regarding nurses performance and patient outcome

• Environmental issues – Staffing– Competing priorities– Patient and family needs

Johnson, Cohn, and Bakas (2011)

Kotter’s eight step model: Step-Five

Empower based –action (get rid of obstacles and encourage risk

taking

Literature Review• Alberts et al. (2000) reported Primary Stroke

Centers improve care of patients with stroke (Level I, Grade A)

• Fonarow et al. (2011) reported 60 minutes DTN times were achieved in less than 26.2% of acute ischemic patients (Level III, Grade B)

Literature Review• Jauch et al. (2013) reported hospital should

have an organized protocol for emergency evaluation of patient with suspected strokeMeta-analysis (Level I, Grade A)

• Fonarow et al. (2011) reported t-PA is a proven intervention for AIS patients, Class 1 evidence-based recommendation from the AHA/ASA (Level III, Grade B)

Literature Review• Adams et al. (2007) reported ED physicians

evaluation of acute stroke patients should be brief and thorough within 60 minutes of arrival in the ED Meta-Analysis (Level 1, Grade A)

• Adams et al. (2007) also reported physicians should review the criteria used in the NINDS trial to determine patient eligibility for thrombolytic therapy Meta-Analysis (Level 1, Grade A)

Literature Review• Fonarow et al (2011) reported time-to-treatment

with t-PA is a good determinant of patient 90-day and 1-year functional outcome (Level III, Grade B)

• Jauch et al. (2013) reported healthcare institution should organize a multidisciplinary QI committee to review and monitor stroke care quality benchmarks, indicators, EBPs, and outcome Meta- Analysis (Level 1, Grade A)

Is There a Sufficient Research

Base?

Base Practice on Other Types of

Evidence

Conduct Research

Yes

Pilot the Chang in PracticeFour outcome measures selected1. Improve DTNT from 144 minutes to <

80 minutes2. Increase TTTRs from < 5% to > 7%3. Thrombolytic Therapy Administration

(STK-4) will be met greater than 85% for eligible candidates

4. ED providers will initiate screening tool in 25% of patients who arrive in the ED within 3 hours of symptom onset

Baseline data already establishedAHA/ASA CPG already in placePilot unit: Emergency DepartmentAcute stroke ED management process

restructuredCPGs were modified to accommodate

available resources

Iowa Model of Evidence-Based Practice to Promote Quality Care (Cullen, 2011)

Methods• System change project (divided in 2 phases)

1. Organizational paradigm shift to an EBP model2. Broader investigation of the effectiveness of the

NINDS screening to on 60-minute TTRs

• National Institute of Health Certification completed March 18, 2012

• CITI Basic Course completed September 16, 2013 (required by Dignity Health Corporation)

Methods• Northridge Hospital Medical Center IRB

approval letter January 27, 2013

• RMUoHP IRB approval letter January 29, 2013

• ED providers trained on the use of the NINDS screening tool – December 2012 /January 2013

Methods• Collaboration:

– Stroke sub-committee of stakeholders– ED staff involved with planning and implementation – (“Go Live” February 1, 2013)– Completion of project: April 30, 2013

• Data abstracted concurrently from patient’s charts – MedHost® (ED EMR)– Nurses and physician notes– Stroke Program had an established QI program

Implementation Strategy

Create Awareness

and Interest

Build Knowledge

and Commitment

Promote Action and Adoption

Pursue Integration

and Sustained Use

Implementation Strategies for Evidence-Based Practice. Figure 8-1 (Cullen et al., 2012, p. 129)

Implementation of a Screening Tool to Determine Eligibility for Thrombolytic Therapy for Acute Ischemic Stroke Management the Emergency Department

Problem-Focused Triggers Knowledge-Focused Triggers

Outcome

Input Constraints Activities Output Short-term Long-term Impact

Stakeholders

Stroke Department Specialist

MedHostEDCDS

Midas Database

T-PA screening tool

Data collection process

TJC/CMS

LA EMS Agency

Financial Resources

High use of contracted staff

Existing culture

Limited Timeframe

Regulatory Requirement

Environmental Issues

Lack of EBP mentors

Meetings and training of staff

Develop processes

Revise documents

Obtain tools from vendor

Volunteer recruitment and

training

Review acute stroke assessment

skills

Train 110 ED providers and 25 ancillary staff on the revised acute

stroke process

Train 110 ED providers on

when and how to use the inclusion

and exclusion screening tool

Increase ED providers use of the t-PA

screening tool by 25% in 3 months

Improve DTNT from 144 minutes to less

than 80 minutes in 3 months

Thrombolytic (STK-4) will be met greater

than 85% for eligible candidates

Organizational paradigm shift to an EBP environment by applying IMEBPPQC

Increase the portion of AIS patient who

receive t-PA

Improve identification of eligible

t-PA candidates

Simply the acute stroke evaluation process for

the ED providers

Improve RN/MD collaboration

Improve RN/MD confidence with

screening tool in the initial evaluation process

(Logic Model for DNP Projects (White & Zaccagnini, 2011, p. 481)

Is Change Appropriate for Adoption in Practice?

Institute the Change in Practice

Monitor and Analyze Structure, Process, and Outcome Data

Environment Staff Cost

Patient and Family

Disseminate Results

Iowa Model of Evidence-Based Practice to Promote Quality Care (Cullen, 2011)

Kotter’s Eight-Step ModelStep 7 : Consolidate gains and produce more change

Step 8: Anchor new approaches in the culture (Make change stick)

Yes

Results

Jan, 13 Feb, 13 Mar, 13 Apr, 1305

1015202530354045

22

40

32

21

12

2319

12

52 2 2

5

1511

7

Types of Strokes

Occurences (93) Ischemic (54) Hemorrhagic (6) TIA (33)

Results

44

4940

53

Gender and Method of Arrival

MaleFemaleEMSWalk-in

N = 93Maximum

Minimum

Median

Mean

SD

0 40 80

97

40

87

72

14

Acute Stroke Patients' Age

Acute Stroke Patients' Age

Results: t-PA Screening Tools for Acute Stroke - Forms Used

January February March April0

5

10

15

20

25

30

35

40

45

5

1417

12

1

8

13

7

Total Patients

Pt. Arrived to ED < 3 Hour Sx

# Screening Tool Used

Overall drop in hospital census

Overall increase use of screening

tool 33% N= 93

STK-4: Thrombolytic Therapy Administration Measure Met

Q 1FY 12

Q 2 FY 12

Jan, 13 Feb, 13 Mar, 13 Apri, 1365%

70%

75%

80%

85%

90%

81%

72%

77%79%

85%

82%

Thrombolytic Therapy Administration

Goal

T-PA administered to eligible candidates within 3 hours of symptom onset

↑ 4%

Census

Dropped

Results

YTD 11 -12 YTD 12 -1372%

74%

76%

78%

80%

82%

84%

76%

82%

The Joint Commission’s STK-4 (Met)(t-PA Administered within 3 hours of Stroke Symptom)

Thrombolytic Therapy Administration

N = 22

N = 17

Preliminary: Fiscal Year Ends

June 30, 2013

Results

Sept, 12

Oct, 12

Nov, 12

Dec, 12

Jan, 13

Feb, 13

Mar, 13

April, 13

0:00

0:28

0:57

1:26

1:55

2:24

2:52

2:20 2:26

1:261:39

1:14 1:141:24

DTN Time Monthly Averages

DTN Time Monthly Av-erages

Tim

e

Implementation timeframe

(Patient arrival to the ED to medication administration)Ar

Patient Arrival to ED with onset of stroke symptoms

< 2 hours

Results

YTD Jul, 10 – Jun,

11

YTD Jul, 11 – Jun,

12

Jul - Sep, 12

Oct - Dec, 12

Jan, 13

Feb, 13

Mar, 13

Apr, 13

0%2%4%6%8%

10%12%14%16%18%

7%

4%

8%

17%

7%9%

5%

Thrombolytic Treatment Rate

Thrombolytic Treatment Rate

National Aver-age 3 – 5%

NHMC YTD ↑TTR 12%

Results

In emergency department providers, how does integrating the NINDS screening tool in the initial evaluation and treatment for acute

stroke patients compared to no NINDS screening tool used for acute stroke patients

improve 60-minute DTN TTRs over a three month timeframe?

Outcome MeasuresImprove DTN time from 144 minutes to

< 80 minutes in 3 months (Average 77 minutes)

Met

Increase thrombolytic treatment rates from < 5% to > 7% in three months

(2012-2013 (April, 2013) TTR YTD 12%)

Met

Thrombolytic (STK-4) will be met greater than 85% for eligible candidates

(3 month average: 82%)Not Met

ED providers will initiate the thrombolytic therapy (NINDS) screening tool in 25% of

patients arriving to the ED with stroke symptom onset within 3 hours or less

over a 3 month timeframe( 33% increase use in screening tool)

Met

Conclusion

• Implementation of a complex evidence-based system change project in an environment with multiple internal barriers required:

– Heavy emphasis on relationship building

– Communication networks

– Well-coordinated interfaces between professionals and structures in the workplace

(Malloch and Porter-O'Grady, 2009)

Conclusion

• Project represented a collaborative multidimensional interdisciplinary EBP approach to improving acute stroke management process in a department

• Ideas and suggestion for future work– Need for more EBP mentors and educators– Streamline EMR documentation systems– Acute stroke data management system

Sustainability

• TJC stroke center designation status requires maintaining CQI program

• Continue DTN time meetings (identify further opportunities for improvements)

• Code Stroke Policy updates (in-patient) to include screening tool

• Phase II: Conduct Research on effectiveness of the NINDS tool on 60-minute DTN TTRs in patient with AIS (in process)

NHMC Core Stroke Team and Neuroscience Director

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