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Our Journey to Stroke Certification

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Dedicated inpatient stroke unit. National Institutes of Health Stroke Scale (NIHSS) certification for all nurses caring for stroke/TIA patients. – PowerPoint PPT presentation

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Title: Our Journey to Stroke Certification


1
Our Journey to Stroke Certification
  • Bobbi-Jo Skurko RN, BSN
  • Stroke Clinician
  • UPMC St. Margaret

2
Objectives
  • Review process to prepare for stroke
    certification in the community hospital
  • Identify experiences and barriers met
  • Valuable information at an emergency department
    perspective
  • Surveyor points of interest
  • Interventions to improve care of the stroke
    patient in the emergency department
  • Preparation for recertification

3
Background
  • UPMC St. Margaret is a Joint Commission Certified
    Primary Stroke Center, 249 bed acute care and
    teaching hospital.
  • Dedicated inpatient stroke unit.
  • National Institutes of Health Stroke Scale
    (NIHSS) certification for all nurses caring for
    stroke/TIA patients.

4
Process for Certification
  • Know and understand stroke care measures
  • VTE Prophylaxis
  • Discharged on an antithrombotic therapy
  • Anticoagulation for a-fib/flutter
  • Thrombolytic therapy in appropriate time
  • Antithrombotic by the end of hospital day two
  • Discharged on a statin medication
  • Stroke education
  • Assessed for rehabilitation early on admission

5
Process for Certification cont.
  • Teamwork!!!
  • Review eligibility requirements of the Joint
    Commission Stroke Certification
  • Maintain organization
  • Binders for easy access

6
Process for Certification Cont.
  • 24/7 access to neurology
  • Initial certification and maintaining NIHSS for
    all providers
  • Continuing education to maintain compliance
  • Timely Interventions
  • Is the patient in the window?
  • Door to CT times
  • Arrival to lab result times
  • Mixing, administration and vitals for t-PA
  • Contraindications, delays in giving t-PA
  • Bedside dysphagia screening
  • Initial NIHSS

7
Surveyor Points of Interest
  • What is the process for a possible stroke
    patient?
  • How do we treat a patient with a hemorrhagic
    stroke?
  • Do we have neurology onsite 24/7?
  • What are the staff education levels regarding
    stroke?
  • Are there any challenges or barriers with EMS and
    getting the patient here in time?
  • What do we do when EMS calls with a potential
    stroke patient?
  • Are the emergency department physicians able to
    make decisions about administering t-PA?
  • Where is the t-PA kept and where does the mixing
    take place?

8
Surveyor Points of Interest Cont.
  • Is there a competency for mixing t-PA?
  • How do we weigh the patient for t-PA?
  • How do you assure all stroke patients receive the
    same care?
  • When labs are sent how does the lab know it is a
    stroke patient?
  • Are there order sets in place? How do we know
    they are being used?
  • How does CT become aware of the potential stroke
    patient?
  • Who reads the CT and how does that information
    get relayed back to the ordering physician?

9
What have we learned?
  • Always be ready for a visit!
  • Perform frequent mock tracers.
  • Maintain staff compliance with certifications
    such as NIHSS.
  • Maintain staff continuing education in stroke
    hours.
  • Be sure all departments of the hospital are well
    educated.
  • Develop process flows for stroke patient codes.
  • Be sure staff is aware of stroke care measures
    and is able to identify resources.
  • Remain organized and up to date.
  • Communication is key.

10
Interventions to Improve Care
  • Developed Brain Attack in ED.
  • Dysphagia Screening completed on all ED patients
    age 65 and older.
  • t-PA in-services to improve documentation
    compliance and education.
  • Developed checklists as well as positive
    reinforcement when vitals are appropriately
    documented.
  • Feedback is provided to staff nurses as well as
    Unit Directors on missed opportunities. One on
    one education is done with the individual nurse
    to improve compliance for future patients.

11
Interventions Cont.
  • Every t-PA case is critiqued a the
    Interdisciplinary Stroke Team Meetings.
  • Attendees of Advanced Cardiovascular Life Support
    (ACLS) certification or recertification classes,
    which are held quarterly, are provided with
    review of urgent stroke care measures.
  • Orientation education.
  • Hospital wide education is done yearly in May.
  • Community education.
  • EMS education.
  • Dissemination of data.

12
ED BRAIN ATTACK
  • Identified goals
  • Decrease time seen by a provider
  • Decreased door to CT time
  • Increase use of telemed
  • Decrease time patient is given initial bolus of
    t-PA

13
EMS Alert
  • EMS provides hospital with incoming patient
    information
  • Last known well time
  • Time of onset of symptoms
  • Neuro deficits

14
Hospital Staff Alert
  • Brain Attack is called
  • Nursing staff calls the hospital operator to send
    out an alert
  • Alert is sent to spectralink phones in ED, CT,
    and Stroke Clinician
  • ED Physician is made aware of the incoming
    possible stroke patient
  • CT and Registration are made aware of incoming
    patient

15
Patient Arrival to Hospital
  • Patient is met at the door by the emergency
    department staff
  • Patient is cleared by the physician to go
    directly to CT on the EMS stretcher
  • Paper Req is complete by the provider and sent
    to CT with patient

16
Consult Neurology
  • Patient is placed in ED exam room where telemed
    is set up
  • The physician is able to speak directly with the
    stroke neurologist at UPMC Presbyterian Hospital
    to coordinate care and appropriate interventions
  • The patients nurse performs a NIHSS as well a
    bedside dysphagia screening

17
Outcomes
  • Door to CT time has decreased by an average of 17
    minutes.
  • Process of use of telemed has changed so that we
    are able to call directly into a joined room with
    Presby Neuro
  • T-PA in-services are done monthly with the staff
    nurses from the ED and ICU to provide continuing
    education in mixing and administering of
    medication

18
Implementation of Process
Average time before patients were taken directly
to CT 30 minutes Average time after process was
initiated 13 minutes Benchmark goal 25 minutes
19
Key Players in the Team
  • When providing urgent patient care, working as a
    team is most important.

20
Preparing for Recertification
  • Review current process and policies to be sure
    maintaining compliance.
  • Keep open lines of communication with the Joint
    Commission.
  • Keep binders up to date with data and process
    improvements.
  • Be sure staff has completed all mandatory
    education and certifications.
  • Alert the Joint Commission with any dates that
    are avoidable.
  • Prepare for the visit!

21
Stroke Initiative
22
Goals that were not met
  • IV t-PA
  • There were a total of 5 patients who received IV
    t-PA. Of those five patients all but one
    received the medication within the 60 minute door
    to drug time. The one patient that did not had
    an elevated blood pressure that needed to be
    controlled before administration.
  • Dysphagia
  • There were a total of 46 patients that were
    included in this measure, of the 46 there were 4
    who were not screened. One of the patients
    presented with vague symptoms, one was a direct
    admit, one was an in-house code and one was
    admitted through the ED.

23
Hospital Awards
24
Conclusion
  • Establishing and maintaining Stroke
    Certification is a great deal of work which takes
    a team to accomplish. UPMC St. Margaret is proud
    of its achievements and is constantly focused on
    evidence to improve patient care.

25
(No Transcript)
26
Questions?More Information?
  • Bobbi Jo Skurko RN, BSN
  • Stroke Clinician
  • 412-784-7889
  • skurkob_at_upmc.edu
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