jcaho expectations for primary stroke center angela m. williams, ms rn stroke care coordinator st....

JCAHO EXPECTATIONS FOR PRIMARY STROKE CENTER

Angela M. Williams, MS RNStroke Care CoordinatorSt. Anthony Hospital

Primary Stroke Center Certification

Based on recommendations from the Brain Attack Coalition and ASA statements

Onsite review team will include a medical professional experienced in treating stroke and implementation of stroke centers

Programs seeking certification must use a standardized method of delivering clinical care based on these recommendations and guidelines

Requirements for Certification

Programs will be evaluated using the standards listed in the Disease Specific Care Certification Manual

To evaluate compliance will include evaluating conformity with the recommendations from Brain Attack Coalition

Expected to demonstrate application and compliance with the guidelines from ASA

ASA and JCAHO standardized set of performance measures for stroke and programs are required to collect data on the first four measures but will be looking at other measures also

Major Elements

Hospital and Administrative SupportWritten documentation showing support by administrationStroke Center Medical DirectorStroke team members have expertise in cerebrovascular disease

Acute Stroke TeamDocumentation showing team composition, staffing level and requirements, and notification system and response expectationsLog that documents response times, diagnosis, treatments, actions and outcomes

Major Elements cont…

Written Care ProtocolsInclude care of ischemic/hemorrhagic stroke patients in the ER, acute care and stroke unitUse of protocol is reflected in order sets and pathwaysTime parameters for stroke work up are included in ER protocol

Emergency Medical SystemsPlan should be provided that demonstrates an initiative by the hospital to provide education to EMS


Emergency DepartmentER care providers show familiarity with pathology, presentation, assessment, diagnostics, and treatment of stroke patients; location and application of stroke related protocols, activation of the stroke team, and communications with inbound EMS; recognition, assessment and management of acute stroke complications80% of ER providers can provide evidence of review of the institution’s acute stroke protocol


Stroke UnitSpecified unit to which most stroke patients are admittedCare providers demonstrate evidence of initial and ongoing training in the care of acute stroke patientsAt least 8 hours of annual CE or equivalent educational activityMonitoring systems to include continuous data on heart rate/rhythm with automatic arrhythmia detection; BP and oximetry


Neurosurgical ServicesDocumentation shows evidence of neurosurgical coverage or protocol for transfer to appropriate facilityIf do not transfer – has fully functional OR facility and staff within two hours of the recognized need for such services

NeuroimagingDocumentation indicates on 24/7 basis, 80% of acute stroke patients have a diagnostic brain imagine completed within 45 minutes of it being ordered when clinically indicated (resuscitation candidates)


Laboratory ServicesDocumentation indicates ability to complete initial lab tests and availability on site 24/7Documentation indicates ability to complete and report lab tests in less than 45 minutes of it being orderedDocumentation indicates the ability to perform ECG and chest x-ray within same time frame as laboratory testing

Educational programsDocumentation shows at least one stroke public education activity per year


Outcomes/Quality ImprovementEvidence of specific stroke performance measurement and review by quality improvement department and stroke team existsDocumentation exists to reflect the following:performance measures and indicators trackedSpecific interventions to improve selected measureSpecific outcomes to determine successImplementation period and re-evaluation point

Performance Measures

DVT Prophylaxis (Required)Patients with ischemic stroke and who are non-ambulatory should start receiving DVT prophylaxis by the end of hospital day two

Discharged on Anti-thrombotics (Required)Patients with TIA or ischemic stroke should be prescribed anti-thrombotic therapy at discharge unless contraindicated

Performance Measures cont…

Patients with A-Fib receive anticoagulation therapy (Required)Patients with ischemic stroke with atrial fibrillation discharged on anticoagulation therapy unless it is contraindicated

Tissue Plasminogen Activator Considered (Required)All patients who present at a hospital with symptoms of an ischemic stroke with symptom onset of 3 hours or less should be considered to receive intravenous tPA


Anti-thrombotic medication within 48 hours of hospitalizationPatients with ischemic stroke or TIA who receive anti-thrombotic medication within 48 hours of hospitalization

Lipid ProfilePatients with ischemic/TIA who had a lipid profile performed during hospitalization or within 30 days prior to hospitalization


Screen for DysphagiaA screen for dysphagia should be performed on all ischemic and hemorrhagic stroke patients before being given food, fluids or medications by mouthThis means absolutely NOTHING by mouth, including ALL medications prior to a dysphagia screen


Stroke EducationStroke education and/or resources received by patient and/or caregivers for patients with ischemic stroke, hemorrhagic stroke, or TIA

Smoking CessationAdult smoking cessation advice and/or counseling for patients with ischemic, hemorrhagic stroke or TIA

Plan for Rehabilitation consideredPatients with ischemic/hemorrhagic stroke who were assessed for or received rehabilitation services

Guidelines for Care

NIH Stroke ScaleEvidence shows that the “standard neuro check” is inadequate for the acute stroke population.Overlooks large areas of brain functionReveals subtle changes and/or improvements which guides further treatmentReliable and user friendlyProvides a common language between caregiversAHA ACLS Provider Manual (2001) indicates that NIHSS is the standard assessment tool within the hospital setting and has been shown to predict cost of hospitalization, length of stay and dispositionRequired under our stroke protocol that at minimum must be performed in ER on admissionSee data sheet for compliance percentage

Guidelines for Care

Continuous cardiac monitoringAll stroke patients are placed on telemetry.

Pulse oximetry Q shiftDocumentation of oxygen saturation every shift.

Clinical Pathway outlines standard of care for stroke patient based on ASA guidelines

What we are doing well

ASA within 48 hoursDischarged on anti-thromboticsA-Fib discharged on anticoagulation

therapySmoking cessationLipid profilePlan for rehabilitation

Where we need work

Stroke Education DVT prophylaxis Dysphagia screen NIHSS in ER Documenting order times on brain imaging, labs and

chest x-ray Clinical pathway on chart at admission Patients being placed on stroke unit Care providers with evidence of initial training in care of

the stroke patient Stroke orders on chart with stroke consult Not tracking admission placement and compliance with

standards of care (guidelines)

Where do we go from here?

Brainstorm ideas Develop plan to improve areas that need

work Put time parameters for departments to

institute change Evaluation and tracking of compliance Education Review and re-evaluate

jcaho expectations for primary stroke center angela m. williams, ms rn stroke care coordinator st....

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