Title: Our Journey to Stroke Certification
1Our 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
3Background
- 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.
4Process 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
5Process for Certification cont.
- Teamwork!!!
- Review eligibility requirements of the Joint
Commission Stroke Certification - Maintain organization
- Binders for easy access
6Process 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
7Surveyor 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?
8Surveyor 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?
9What 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.
10Interventions 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.
11Interventions 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.
12ED 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
13EMS Alert
- EMS provides hospital with incoming patient
information - Last known well time
- Time of onset of symptoms
- Neuro deficits
14Hospital 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
15Patient 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
16Consult 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
17Outcomes
- 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
18Implementation 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
19Key Players in the Team
- When providing urgent patient care, working as a
team is most important.
20Preparing 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!
21Stroke Initiative
22Goals 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.
23Hospital Awards
24Conclusion
- 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.
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26Questions?More Information?
- Bobbi Jo Skurko RN, BSN
- Stroke Clinician
- 412-784-7889
- skurkob_at_upmc.edu