Comprehensive Stroke Systems: The Saint Luke’s …wcm/@maa/documents/... · Comprehensive Stroke Systems: The Saint Luke’s Experience • Debbie Summers, MSN, APRN-BC – Speakers

9/13/2012

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Comprehensive Stroke Systems: The Saint Luke’s

Experience

Debbie Summers MSN, ACNS-BC, CNRN, CCRN, FAHA

Disclosures

Comprehensive Stroke Systems: The Saint Luke’s Experience

• Debbie Summers, MSN, APRN-BC– Speakers Bureau

• Genentech, Inc

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Kansas City

Saint Luke’s Hospital System Non Profit

• 10 Hospitals– 4 Metro

• SLH – 590 (PSC –CSC)

• SLH East – 174 (PSC)

• SLH South – 125 (PSC)

• SLH North – 150

– 2 Community – 2 Critical Access – 1 Free standing

rehabilitation – 1 Behavioral Health

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Objective

• At the conclusion of your presentation, participants should be able to understand the stroke systems of care framework.

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St. Luke’s Neuroscience Institute

2004 – Joint Commission

Primary Stroke Certified

2011 Population• 678

Ischemic• 108 ICH• 80 SAH• 96 TIA

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St. Luke’s Neuroscience Institute

1992-03 Stroke program organize

2001 formally branded MABSI

2007 Re-branded as SLBSI

2012 Re-branded as SLNI

Organized around Centers of Excellence

Who We AreMission

To improve the health of the people of Kansas City and the surrounding region by advancing neuroscience research and education, pioneering emerging technology and therapy while sustaining cost effective clinical excellence in the treatment, prevention and rehabilitation of the nervous system and spine.

Vision

To be the regional leader in providing comprehensive integrated care and services for people with conditions of the nervous system and spine and to be nationally recognized as a “Best Place to Get and Give Neurological Care.”

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Media Recognition

The New York Times

48 Hours

Discovery Channel

Newsweek

Business Week

ABC World News

Progression from PSC - CSC

Clinical Trials

1994 IV tPANINDS Clinical

Trials

2002 IMS IV to IA

2002 MERCIMechanical

Process Structure

Flow of Patient care

Evaluation & management

Ease of Access

Capacity – No Diversion

Professional outreach

Clinical Tools

Science Based Evidence

Guidelines

Transport Protocols

Equipment

Point of Care

Radiology

Future -Institute

Data

Access Data Base

Tracking Treatment

90 day

Reporting Data

People

No Neurology or

Neurosurgery Residents

APN’s

CNN

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Progression to CSC • EMS and Regional Hospital OutreachSpoke and hub

networking

• Flow of Patient Care • Practice Changes Process Structure

• Clinical Orders• Severity Scoring

Evaluation and Management

• One Call Number (DOC One)Ease of Access to Stroke Program

• ED Initiatives • People - CNNNever on Diversion

• EMS Education• Shadowing Professional Outreach

Regional Networking 02-11

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Clinical Tools

• Neuro Evidenced Practice Team – System Orders

• Pre-Checked Orders -Guiding Care

• PSC/CSC Core Measure Integrated– NIH Stroke Scale

– CT time and results

– IV inclusion/Exclusions

– Hunt and Hess

– INR reversal

– mRS – 90 day

– TIA – ABCD Sco

• Transport Protocols

Clinical Tools • Ischemic

• ICH

• SAH

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Example of Capturing Measures: Severity Scoring in ICH, SAH, TIA

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Risk Factor Point Score

Age >60 years – 1 point 1BP Systolic BP > 140 or Diastolic > 90

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Clinical FeaturesUnilateral weakness with or without speech impairment Speech impairment without unilateral weakness

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Duration of TIA > 60 minutes 2Diabetes history 1

Total Score

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Transport Protocols

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Additional Clinical Tools • Clinical Path

• Dysphagia Screening Tool

• Patient Education Book

• Discharge Tools

… an Extremely short amount of time to achieve the best outcome for stroke

Stroke

0 hour3 hours

National Stroke Reversal Treatment Rate = 2%

Clinton Mo.

Emergency Department

Doc One

Transfer

Team

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Equipment

Patient Unit

Dedicated neurosciences med/surg unit

(East-1)

Medical and Neurosurgical

ICU

18-bed inpatient rehab unit (East-

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ED

Point of Care Testing

Lab

Radiology

2 64 CT scanner adjacent to ED –

perfusion capability

1.5 T inpatient MR

Ceretomportable CT

scanner

2 Neuro-interventional

radiology suites(3)

Dedicated Neuro OR suite (main OR #3)

Major Asset – Consolidated Outpatient

Neurology Neurosurgery Outpatient Rehabilitation

Neuro-Oncology

Shaped Beam Surgery Center

(Novalis)CT

3T MRI Brain Fitness Center

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Data Revolution

GWTG – PSC2003

Lumedex – Growth to CSC (home grown out of cardiac data base)

Medicare Reporting3rd QTR 2012

Comprehensive –2011 - ??????

Data – access1993

Daily Stroke Admit Report

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EMS & Referring Facility Follow-Up

Purpose: to provide patient outcome follow up on

transferred cases; regional networking

PowerPoint to transporting and transferring facilities

Cases receiving acute intervention: IV & IA tPA, and

mechanical embolectomy

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Expansions of Program Clinician Roles to CSC

Nurse Driven

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Primary Stroke Program Roles

Medical Director

Data Coordinator

Stroke Coordinator/

APN

ACNS-BC; Post Masters

Neurovascular Clinician

Training

Dr. Marilyn

Rymer

Comprehensive Program Growth

Increasing Volume

ED Capacity –

Core measure missing

Physician Burden

Physician Needs

• 1993 – 220 Ischemic• 2011 678 Ischemic

• IV tpa patients in ED• Lack of Intensive

Monitoring

• Primary • Comprehensive

• Intensive Call Schedule

• Recruitment

• Neurologist• INR’s• Neurosurgeon• Intensivist

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SLNI Clinician Roles

APN Stroke –Coordinator

(ED Workups, program process)

Code NeuroNurses – full

time 24/7

APN ‘s Center of Excellance

SLNI APN Role

– Staff education, oversight of patient care, acute patient care, community education, maintenance of paths and orders, quality improvement, involved in discharge planning

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Code Neuro Nurse Role

The CNN Scope of Practice

Key Functions:• Respond to all acute neurological admissions in ED• Assist transfer team as needed• Evaluate ED patients & provide critical info to other

required caregivers (physicians, nurses, technicians, etc.)• Preliminary screen for research studies; notify research

RNs of candidates as appropriate• Accompany patients to procedures or attend to patients in

ED if admit is delayed• Participates in Clinical practice changes - revision and

update of clinical tools (paths, orders, glucose management, and f/u to pre-hospital providers)

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Implementation of CNN

• High level of satisfaction from ED physicians, ED staff all members of the stroke team

• Improved the management of the acute neuro patient

• Provides “just in time” education to nursing staff

• Increased the immediate notification of the stroke team

SLNS Clinical Support Staff

Data - responsible for neurovascular

database and GWTG

Quality Informatics Specialist

RN

2 Research RN’s

Responsible for scope of clinical

trials

Administrative Assistant

Support to APN’s, research coordinator and Medical Director

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Neurologist – Stroke Team – 3 in 1993

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Neuro Interventional Team - 1996

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Neurosurgeons – 3 in 1993

Dr. Lovick – Brain Tumor

Dr. Mollman -Spine

Dr. Milligan Skull base

Dr. Griffith – Tremor

Dr. Hiser – General

Outreach

As early as 1994 – clinical trial

Components…

•Education – EMS/hospitals,

community

•Pre-hospital care, NIHSS

•Follow-up inconsistent – 09 formal

•Team building and Collaboration

•Research

•Social media

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August 18, 2010

Time and Stroke

Just Get Here!

Code Neuro Nurses

Follow-up Reports – sporadic

•Life Flight Eagle

•Miami County, KS EMS

•MO State TCD Initiative

Outreach & Collaboration

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Formalized F/U Report

Follow-upsSporadic����formal

Outreach:Picture here of Template from before.

SLNI

Social Media

Outreach: Examples of blog

And fb site

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Leadership Structure

Medical Director

Stroke Coordinator

Data Coordinator

RN Abstractor

CNN-Clinical Leaders

VP Neuroscience

Institute

Clinical Director

Denise Mogg –SLNI Clinical Director

Kevin Thorpe VP SLNI

Nursing Experts and Leaders19 Certified CNRN’s 2011

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Education Structure - Unstructured

Stroke Coordinator

APNs

CNNs

Unit Education Chair

Neuro ICU specific

• SLH /System • AHA Stroke

Consortium

• In the moment

• In the moment• Formal Outreach

• Shared Gov Clinical Nurse

• Clinical care and education

Outcomes

What Does That Really Mean For Stroke?

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Quality Data in Report Cards

• Stroke Unit; # of beds, # nurses, PSC v CSCStructure

• CT time, DTN, Core Measures, Discharge resources available, case review

Process• NIHSS, mRS, Risk adjusted mortality

rate; 30 day mortality or readmissionOutcomes • Case Volume , Risk Adjusted length of

stay, Average LOSUtilization• Average Charge, Risk adjusted average

charge, Cost Financial

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Kelly et al Public Reporting of Quality Data for Stroke. Stroke

2008;39;3367-3371

Outcomes Analysis getting right brained and global

• Currently, we are measuring PROCESS• We would like to get to real OUTCOMES

– And, we would like to get to outcomes that matter to patients and families.

• Where are our opportunities to benchmark to evaluate how we are doing?

• All of these are important and inter-related• And then there is the coding mystery

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Coding Struggles

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STROKE MORTALITY IS A

BLACK BOX!!

All Patient Refined DX(APR DRG) key words

PROCESS

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National Hospital Inpatient Quality (“Core”) Measures for Stroke

• Acute Measures– Thrombolytic therapy – arrive in 2 hours and treated by 3 hours– Venous thrombo-embolism prophylaxis by end of day 2– Antithrombotic therapy by end of day 2 of admission

• Discharge Measures– Discharged on antithrombotic therapy– Discharged on statin medication if LDL>100– Anticoagulation therapy for atrial fibrillation/flutter

• Quality Measures– Door to CT time 25 minutes in patients presenting with stroke symptoms

3 hours’ duration (Door to CT 25 Minutes)– DTN Time < 60 minutes– Dysphagia screening– Stroke education– Assessed for rehabilitation

Quality Analysis IV t-PA DTN

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STROKE MORTALITY IS A

BLACK BOX!!

APR DRG key words

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SLH Core Measures – Dash Board

SLH Secondary Core Measures

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Comprehensive Measures- TBA

• CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score on Arrival

• CSTK-02 Modified Rankin Score (mRS) at 90 Days

• CSTK-03 Severity Measurement on Arrival –NIHSS, ICH Score, Hunt and Hess

• CSTK-04 Median Time to Treatment with a Procoagulant Reversal Agent

• CSTK-04a Median Time to INR Reversal

Comprehensive Measures- TBA

• CSTK-05 Hemorrhagic Complication for Patients Treated with Intra-Venous (IV) Thrombolytic (t-PA) Therapy Without Catheter-Based Reperfusion

• CSTK-05a Hemorrhagic Complication for Patients Treated with Intra-Arterial (IA) Thrombolytic Therapy or Mechanical Endovascular Reperfusion Procedure With or Without Intra-Venous (IV)Thrombolytic (t-PA) Therapy

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Comprehensive Measures- TBA

• CSTK-06 Nimodipine Treatment Initiated• CSTK-07 Median Time to Recanalization

Therapy• CSTK-07a Thrombolysis in Cerebral Infarction

(TICI) Post- Treatment Reperfusion Grade

TICI - Thrombolysis in Cerebral Infarction

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• 0 = No perfusion • 1 = Perfusion past the initial obstruction with little

or slow distal perfusion • 2A = Perfusion of < ½ of the occluded artery • 2B = Perfusion of ½ or >of the vascular

distribution of the occluded artery• 3 = Full perfusion with filling of all distal

branches

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Limitations - Documentation!

• The determination of whether a process of care was delivered to an individual patient was based on documentation in the medical record, and such data may be incomplete.

• EMR documentation is a challenge for neuro cases.

• Dawn M. Bravata. Processes of Care Associated With Acute Stroke Outcomes. Arch Intern Med. 2010;170(9):804-810

Standardized Order Sets Based on Current Evidence

The SLHS EPT Teams

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OUTCOMES(real ones- what are they?

The truth is-------------we don’t know yet)

Example of Measures

• Outcome measures include: mortality, readmissions, complications, and patient/caregiver satisfaction scores.

• Utilization measures include: data pertaining to the frequency of service use, including length of stay.

• Finance measures include economic data pertaining to the provision of stroke care.

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Mortality – What if you are a regional referral center and everything on Friday afternoon is “stroke like sx”

• All the bad cases are coming to you.• You need to know the code words for

documenting severity: brain edema, brain compression, encephalopathy, cognitive impairment, malnutrition, coma, etc.

• Case Study: Expected mortalility and observed mortality.

What Really Matters

• mRS at 90 days• NIHSS score on admission and discharge• How many days at home in 90 days after

stroke• FIM scores on admission and discharge

from rehab• Satisfaction and QOL scores

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Innovation and Research

•Clinical Research elevates practice–Participation in most major stroke treatment trials since

1994–Presentation/publications ISC–Collaboration with other top stroke centers: UCLA,

Pittsburgh, Massachusetts General, Stanford for reporting data

•Process Innovation improves outcomes–SWAT –Database –Code Neuro–Daily stroke report –Feedback reports to ED and EMS–Outcome measures – phone follow-up 2-3 day….. and at

90 day

Where are the Benchmarks?

• GWTG can provide comparative data for Primary Stroke Centers

• The MERCI Registry collected 1000 cases for analysis of interventional stroke center performance.

• There is no national ischemic stroke registry for benchmarking

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SLNI Acute Stroke Intervention2002 - 2011

Overview comparing St Luke’s patients to the “rest-of-world” (ROW)

Datacut Date: April 19, 2010

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Analysis Notes

• Datacut Date: April 19, 2010• Analysis cohort:

– All subjects with valid/complete 90d mRS

St Luke’s (N=84) All Others (N=702)

Age – Mean / Median (years) (N) 68.1 / 70 (84) 66.9 / 69 (702)

Baseline NIHSS – Mean / Median (N) 18.9 / 18.5 (84) 18 .0 / 18 (678)

Pre-Stroke mRS > 1 15.5% (13/84) 7.1% (49/690)

Merci Registry Procedural Data

St Luke’s (n=84) All Others (N=702)

% Receiving IV tPA 43% (36/84) 27% (192/702)

% Receiving IA lytic 50% (42/84) 47% (328/702)

% IIb/IIIa 0% (0/84) 7% (51/702)

Vasodilators 0% (0/84) 12% (82/702)

Time: Mean Onset to Groin Access (hrs)

5.4 7.3

Time: Mean Procedure Length (hrs)

1.5 3.1

Source: masterpatientlist_19APR2010.xls

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Revascularization Rates

Recanalization St Luke’s(n=84)

Others (n=702)

TICI 2a or better (self reported) 74% (62 / 84) 79% (549 / 698)

TICI 2b or better (self reported)

46% (39 / 84) 53% ( 371 / 698)

Source: masterpatientlist_19APR2010.xls

Revascularization and Outcomes at 90 days

Source: masterpatientlist_19APR2010.xls

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Stroke Mortality Rates

• Ischemic stroke mortality reported in Circulation 2010 18.4%

• SLBSI ischemic stroke mortality rate– Non intervention cases 10%– Intervention cases 16%– Overall 11.6%

SLH Rehabilitation Stroke OutcomesUDS Comparison of Regional and National Statistics

for Rehabilitation Programs

% of Cases SLH Region National

Discharged Home 80.8 65.5 67.3

CI 1.52 1.44 1.54

LOS 14.5 14.7 14.6

FIM Change 25.1 24.6 24.7

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Is Immediate Transport Safe?• Retrospective review of consecutive “drip

and ship” cases 2008-2010.• Analysis

– SICH or BP>180/105 on arrival– Inaccurate stroke diagnosis– Need for intra-arterial (IA) treatment– Mortality rate– Clinical outcome (mRS at 90 days)

• Location and Size of referring hospital

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Results

1626 ischemic strokes

717 (44%) were transferred – 63

Referring Hospitals (29 Critical Access)

145 (20%) of transferred cases

were “drip and ship”25% > 100 miles

63% >50 miles

90% >10 miles Mean age 67.

4Mean Admit NIHSS 10.4

Mean Discharge NIHSS 2

2

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Blood Pressure on Arrival

1 SICH

1 Mortality

10/14

2

• BP=183/77• Mortality

• BP=232/84• No Hemorrhage

• mRS 0-2 at 90 days

• mRS > 2

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14/145 (9.6%) had BP >180/105

4 Cases with Hemorrhage on Arrival

4 SICH • 2.7 % (3 of these had BP <180/105)

2 Died

• 1 related to SICH• 1 BP>180/105

2 Lived

• Admit NIHSS 25; discharge NIHSS 4• Admit NIHSS 18; discharge NIHSS 10

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Outcomes

mRS 0-2 at 90 days = 72/114 (63%)Note: mRS scores not available for 2008

Mortality = 20/145 (13.7%) Further Endovascular therapy = 35/145 (24%)Inaccurate diagnosis at sending facility = 6/145 (4.1%) ; all had excellent clinical outcomes.

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Conclusions

• Immediate transport of patients with IV tPA infusing is safe with a low incidence of SICH en route

• The 63% good outcomes may, in part, relate to early treatment with IV tPA in referring hospitals

• Hospitals of every size and location can safely treat stroke victims with IV tPA if they have access to consultation and transfer agreements with experienced stroke centers

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NEVER SETTLE

Changing Lives

THE EMS CREW WHO SAVED HER LIFE