Primary Versus Comprehensive: What is the Difference?

April 26, 2018

Bethann Mercanti, PA-C Director of Clinical Practice Stroke Program Coordinator Cooper Neurological Institute Cooper Bon & Joint Institute

Disclosures

I have no disclosures to make

1. Understand the benefits of certification as a Stroke Center

2. Define the Eligibility Criteria for Joint Commission Certification

3. Discuss the requirements for Certification as a Stroke Center

Objectives

Stroke Centers What: To improve patient access to time-sensitive stroke treatment Why: Stroke remains the #5 cause of death and a leading case of disability in the US How: Develop evidenced based stroke programs within hospital systems that offer different levels of care, appropriate to the individual hospitals abilities

Benefits: 1. Improve Clinical Quality 2. Provide Objective methods of assessment for clinical

excellence 3. Cultivate Cohesive Clinical Team 4. Promote Culture of Excellence 5. Serve the Community

Stroke Centers

Certifying Organizations

State Department of Health

DNV GL

The Joint Commission

Levels of Certification

Acute Stroke Ready (ASR)

•Manage strokes in the acute phase

•Transfer patients to PSC or CSC

•TJC Only

Primary Stroke (PSC)

•Manage strokes in all phases

•Staff, Infrastructure, Resources for Stroke patients

•May Transfer to CSC

Thrombectomy Capable (TSC)

•PSC+ •Outcomes and quality

focused on Ischemic Stroke

•TJC Only

Comprehensive Stroke (CSC)

•Manage multiple complex stroke patients

• Includes services beyond stroke

•Outcomes and quality focused on AIS, ICH, SAH, Carotid disease, ICP management, etc.

Patient Volumes

tPA Aneurysmal SAH

Endovascular Coiling OR

Microsurgical Clipping

CSC 25/2-years Or

50/year

40/2-year Or

20/year 30/2-years

PSC “Serve a minimum of 10 patients”

Models of Care

Neurology • Board Certified and fellowship trained in

Stroke • Available 24/7 • Attends 1 Stroke Conference Annually • 8 hours Stroke Education annually

NeuroCritical Care • Board Certified Neurointensivists • Additional Physicians with NeuroCritical

Care Expertise • Available 24/7 • 8 hours of Stroke Education annually

Neurosurgery • Board certified in Neurosurgery • Available onsite 24/7 within 30 minutes • 8 hours of Stroke Education annually

Neurointerventional Surgery • Board Certified in either Diagnostic

Neuroradiology or Endovascular Neurosurgery

• Available onsite 24/7 within 30 minutes • 8 hours of Stroke Education annually

24/7 Advanced Imaging

Radiology

CT/CTA

MRI/MRA

Ultrasonography

TTE/TEE

Transcranial &Extracranial US

Carotid Duplex

Neurosurgical and Endovascular

Catheter Angiography

Stroke Beds

Stroke Units and Neuro-ICU • 24/7 Telemetry monitoring • Neuro-Assessments

• NeuroChecks • NIHSS

• Stroke trained Nurses • Annual Competencies • Procedural Competencies

• Transitional Care Services with focus on Stroke

Protocols and Policies

Clinical Practice Guidelines Evidenced based medicine, outlined by the American Heart/Stroke Association Policies and Protocols Reviewed annually for continual evaluation of current practice

Primary Stroke

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STK-1: VTE Prophylaxis by the End of Day 2 STK-2: Discharged on Antithrombotic Therapy STK-3: Anticoagulation Therapy for A.Fib/Flutter STK-4: Thrombolytic Therapy STK-5: Antithrombotic Therapy by the End of Day 2 STK-6: Discharged on Statin Medication STK-7: Dysphagia Screening STK-8: Stroke Education STK-9: Smoking Cessation Education STK-10: Assessed for Rehabilitation

Comprehensive Stroke

CSTK-1: National Institutes of Health Stroke Scale Score (NIHSS) CSTK-3: Overall Rate/(a) Hunt & Hess Score for SAH/(b) ICH Score for ICH CSTK-4: Procoagulant Reversak Agent Initiation for ICH CSTK-5: Overall Rate/Hemorrhagic Transformation Rate for (a) IV tPA/(b) IA tPA or MER CSTK-6: Nimodipine Treatment Administered for SAH CSTK-8: TICI Post-Treatment Reperfusion Grade CSTK-9: Arrival Time to Skin Puncture CSTK-10: Modified Rankin Score (mRS) at 90 Days: Favorable Outcome CSTK-11: Timeliness to Reperfusion: Arrival Time to TICI 2B or Higher CSTK-12: Timeliness to Reperfusion: Skin Puncture to TICI 2B or Higher

CSC: Patient Outcomes

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1. Mortality and Readmission Rates • Acute Ischemic Stroke • Subarachnoid Hemorrhage • Intracerebral Hemorrhage

2. Stroke and Death Rates • 24 Hours Post-Cerebral Angiogram

• < 1%

• 30 Days Post-CEA or Post-CAS in Symptomatic patients • < 6%

• 30 Days Post-CEA or Post-CAS in Asymptomatic patients • <3%

3. Ventriculitis Rates 1. Post-Extraventricular Drain placement

Data Review

7

Committees & Case Review

Get with the

Guidelines

Concurrent & Peer Review

Premier

Performance Improvement & Process Development

3

Quality Committee of the Board

Institute PI Committee

Stroke Committee, Board, & PI

Peer Review of Cases Techs

PharmacistsTherapists

Physicians APPs RNs

Vascular, Radiology, EM,

NSG, Cardiology

Stroke Team Members

Department Chiefs

Admin Leadership

Board of Trustees

SEVPs

Education

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Outside Hospitals Community

EMS Providers

Educate

Multidisciplinary Team Your Most Valuable Tool!

Physicians/APPs

Nurses

Administration

Techs

EMS

Transitional Care

Resources & References

1. The Joint Commission 2. American Heart Association and American Stroke Association 3. DNV GL 4. New Jersey Department of Health

Questions

Thank You