Stroke Certification Options

Jenny Edwards, MSN, RN, CNRN, SCRN

Martha Power FNP, SCRN

Every year 795,000 people in the United States have a stroke

1 of 4 die 87% of the strokes are ischemic, 13% are hemorrhagic

Over 1000 Certified Stroke Centers in the US Half of the population of the United States lives more than 60 minutes from a Primary or Comprehensive Stroke Center

Stroke Facts

Improves quality of care by reducing variation in clinical processes.

Provides a framework for program structure and management.

Objective assessment of clinical excellence Facilitates marketing, contracting and reimbursement

Strengthens community confidence in your carehttp://www.jointcommission.org/certification/certification_main.aspx

Why do we need stroke certification?

Certifying Bodies for Stroke Certification

Stroke Ready 0 PSC >1000 CSC 93

Stroke Ready 0 PSC 90 CSC 25

Stroke Ready 0 PSC 41 CSC 0

Stroke Ready 0 PSC 3

Stroke Certification Programs – Program Concept Comparison

Program Concept ASRH PSC CSC Program Medical Director Sufficient knowledge of cerebrovascular disease Sufficient knowledge of cerebrovascular disease Has extensive expertise; available 24/7; 8 hours of

stroke education annually Acute Stroke Team Available 24/7, at bedside within 15 minutes; at

least 4 hours of stroke education annually Available 24/7, at bedside within 15 minutes; at least 8 hours of stroke education annually

Available 24/7, at bedside within 15 minutes; at least 8 hours of stroke education annually

Emergency Medical Services Collaboration Access to protocols used by EMS Access to protocols used by EMS Access to protocols used by EMS, routing plans; records from transfer

Stroke Unit No designated beds for acute care of stroke patients

Stroke unit or designated beds for the acute care of stroke patients

Dedicated neuro intensive care beds for complex stroke patients available 24/7

Initial Assessment of Patient Emergency Department physician, nurse practitioner, or physician assistant

Emergency Department physician Emergency Department physician

Diagnostic Testing Capability CT, MRI, labs 24/7 CT, MRI, labs, CTA, MRA 24/7, and cardiac imaging when necessary

CT, MRI, labs, CTA, MRA, other cranial and carotid duplex ultrasound, TEE, TTE, catheter angiography 24/7 and cardiac imaging when necessary

Neurologist Accessibility 24/7 via in person or telemedicine 24/7 via in person or telemedicine Meets concurrently emergent needs of multiple complex stroke patients; Written call schedule for attending physicians providing availability 24/7

Neurosurgical Services Within 3 hours (provided through transferring the patient)

Within 2 hours; OR is available 24/7 in PSCs providing neurosurgical services

24/7 availability: Neurointerventionalist; Neuroradiologist; Neurologist; Neurosurgeon

Telemedicine Within 20 minutes of it being necessary Available if necessary Available if necessary Treatment Capabilities IV thrombolytics; Anticipate transfer of patients

who have received IV thrombolytics IV thrombolytics; May have the ability to perform the following: Neurovascular interventions for aneurysms, Stenting of carotid arteries, Carotid endarterectomy, and Endovascular therapy

IV thrombolytics; Microsurgical neurovascular clipping of aneurysms; Neuroendovascular coiling of aneurysms; Stenting of extracranial carotid arteries; Carotid endarterectomy; Endovascular therapy

Transfer protocols With one PSC or CSC For neurosurgical emergencies Receiving transfers and circumstances for not accepting transferred patients

Staff Education Requirements ED staff – a minimum of twice a year ED staff – a minimum of twice a year Nurses and other ED staff - 2 hours annually; Stroke nurses - 8 hours annually

Provision of Educational Opportunities Provides educational opportunities to prehospital personnel

Provides educational opportunities to prehospital personnel; Provides at least 2 stroke education activities per year to public

Sponsors at least 2 public educational opportunities annually; LIPs and staff present 2 or more educational courses annually for internal staff or individuals external to the comprehensive stroke center (e.g., referring hospitals)

Clinical Performance Measures Non-Standardized Measures: Organization chooses 4 measures, at least 2 are clinical measures related to clinical practice guidelines

Standardized Measures: 8 core stroke measures Standardized Measures: 8 core stroke measures and 8 comprehensive stroke measures for a total of 16

Research N/A

N/A

Participates in patient-centered research that is approved by the IRB

Guidelines Recommendations from Brain Attack Coalition for Acute Stroke Ready Hospitals, 2013

Recommendations from Brain Attack Coalition for Primary Stroke Centers, 2011

Recommendations from Brain Attack Coalition for Comprehensive Stroke Centers, 2005

Review One Reviewer, One Day One Reviewer, One Day Two Reviewers, Two Days

© Copyright 2015 The Joint Commission. The Stroke Certification Programs – Program Concept Comparison is copyrighted property of The Joint Commission and used by American Heart Association/American Stroke Association with permission. Current as of 1/12/15

Current Joint Commission Certification Options

Developed in Collaboration with AHA/ASA Applications accepted starting 7/1/15 Derived from the BAC Rec 2013 “Formation and Function of

Acute Stroke Ready Hospitals within a Stroke System of Care” in Nov 12, 2013 Stroke journal

Goal: to recognize hospitals equipped to treat stroke patients with timely, evidenced-based care prior to transferring them to a PSC or CSC

2yr certification after an onsite review

Acute Stroke Ready (ASR) Certification

“An Acute Stroke Ready Hospital will be the foundation for acute stroke care in many communities, allowing it to be the first stop on a patient’s acute stroke journey before being transferred to a Primary Stroke Center or Comprehensive Stroke Center. Certification demonstrates a commitment to a higher standard of service, while promoting the best quality care for all patients that present with a stroke.”

Wendi Roberts Executive Director, Certification Programs, TJC

http://www.jointcommission.org/the_joint_commission_american_heart_associationamerican_stroke_association_launch_new_stroke_certification_program/

Why Acute Stroke Ready Certification?

Dedicated Stroke Focused Program Collaboration with EMS – encourage training in assessment

tools and prenotification of arrival 24/7 rapid diagnostic and laboratory tests Availability of telemedicine technology Ability to give IV thrombolytics to eligible patients. Transfer agreements/protocols with facilities that provide

PSC and CSC services

Acute Stroke Ready Requirements

In order for a hospital to be eligible for ASRH certification,an organization should see its role in stroke management asadministering intravenous thrombolytics and then transferring patients to a primary or comprehensive stroke center (or center of comparable capability) for continued treatment. There must be transfer protocols in place indicatingthat transfer after thrombolytics is the planned pathway forthe vast majority of patients (unless the patient is unstableor not a candidate for advanced therapies).

http://www.jointcommission.org/assets/1/18/StrokeProgramGrid_abbr_AHA-TJC_5_1_15.pdf.

Acute Stroke Ready Requirements

Protocols to address the prompt diagnosis and emergency treatment of stroke patients

One Physician, NP or PA onsite to supervise patient care, order medication and manage emergent issues

Educational Requirements Data Collection and Process Improvement Free 90 day access of Standards at

www.jointcommission.org

Acute Stroke Ready Standards

The program maintains a stroke log that includes at a minimum:1. Number of times stroke team was activated2. Practitioner response time to acute stroke patients3. Type(s) of diagnostic tests and acute treatment if used4. Patient diagnosis5. Door-to-IV thrombolytic time6. Patient complications7. Disposition of the patient (for example, upon admission to the organization,

discharge, transfer to another organization)

The program utilizes a stroke registry or similar data collection tool to monitor the data and measure outcomes.

The program monitors its IV thrombolytic complications, which include symptomatic intracerebral hemorrhage

Acute Stroke Ready Standards

Follows recommendations published by the Brain Attack Coalition and the American Stroke Association consensus statements for stroke

Evaluates compliance with national standards, clinical practice guidelines to manage and optimize care, and the institution’s performance improvement

Any hospital (even small, rural) can be designated a PSC Willing and able to give IV tPA Systematic approach to QI and patient education

If a hospital performs intra-arterial (IA) or endovascular procedures for stroke patients, the minimum level of Joint Commission certification for which the hospital is eligible is PSC certification

Primary Stroke Center (PSC) Certification

Administrative support is key! Administrative lines of authority

Organizational chart for Stroke Center

Medical Director appointed Physicians with expertise in cerebrovascular disease

Major Elements of a Primary Stroke Center:Administrative Support

Written protocols◦ Describing/defining the team

Specification of qualifications, education requirements, assignments of duties

◦ Notification process Expected response times Stroke team log Performance Improvement process

Major Elements of a Primary Stroke Center:Acute Stroke Team

• Protocols based on published guidelines and updated regularly

• Acute work up of ischemic/ hemorrhagic stroke available in the ED, patient care areas• Readiness evident no matter how or where individual

enters the system • tPA protocols – stick to the guidelines• Use of protocol reflected in order sets, pathways,

medical records• Time parameters in ED

Major Elements of a Primary Stroke Center:Written Care Protocols

Improved coordination between hospitals and EMS is a cornerstone of a Primary Stroke Center

Effective communications between EMS personnel and the stroke center during rapid transport

Stroke is recognized as a priority

Major Elements of a Primary Stroke Center:EMS Integration

Major Elements of a Primary Stroke Center:Stroke Units

◦ Definition: a specific unit where most stroke patients are admitted

◦ Care providers show evidence of initial and ongoing education in care of stroke patients

◦ Receive at least 8 hours annually of continuing education as appropriate to their responsibility

◦ Monitoring systems Telemetry Noninvasive blood pressure Oximetry

Stroke Unit Some hospitals may choose to stabilize

patients and transfer them to another facility

Provides care (ICU or stroke designated area)

Written care protocols (pathways/orders)

Use evidence based guidelines

The Evidence Protocols

◦ Increase use of t-PA 11% – 13% have excellent outcome at 90 days 48% likelihood of being discharged to home compared to 38% not

receiving◦ Utilizing clinical guidelines – organizes care and decreases

complications Stroke Units

◦ 17% reduction in death◦ 7% increase in being able to live at home◦ 8% reduction in LOS

Major Elements of a Primary Stroke Center: Neurosurgical Services

◦Available within two hours of when the services are deemed necessary Fully functioning OR and staff for neurosurgery

available 24/7 Call schedule available to stroke team

◦Written transfer plan and protocol in place if patients are to be transferred to another facility for these services

Major Elements of a Primary Stroke Center:Outcomes/Quality Improvement

◦Specific stroke performance measurement and review by QI department and stroke team PI measures tracked Documentation of interventions to improve Outcomes to determine success Implementation period and re-evaluation point

Major Elements of a Primary Stroke Center: The Rest of the Story

Stroke registry: clinical/financial

Public education

Primary and secondary prevention

Professional education

Clinical research

With guidance of the Brain Attack Coalition, TJC has developed advanced certification for CSCs◦Hospitals with specific abilities to receive and

treat the most complex stroke cases The goal of CSC:

◦To recognize the significant differences in resources, staff and training that are necessary for the treatment of complex stroke cases

Comprehensive Stroke Center (CSC)

Major Elements of Comprehensive Stroke Center

◦Personnel with specific areas of expertise◦Specialized diagnostic and treatment techniques

◦Facility Infrastructure◦Programmatic Areas

CSC: Personnel and Clinical Expertise

Center Director Neurologists; Neurosurgeons; Intensivists Surgeons with expertise in CEA Diagnostic Radiologists Interventional endovascular neuroradiology ED and links to EMS Radiology technologists Nursing staff trained in acute stroke care APNs Physicians and therapists trained in rehab Case managers; social workers

CSC:Diagnostic Imaging

Patients need accurate imaging of brain and cerebrovasculature (same as for PSC, plus):◦ MRI/MRA◦ DSA◦ TCD◦ TTE/TEE

CSC:Facility Infrastructure

EMS, ED, Referral, Triage◦ Rapid, efficient patient assessment and triage◦ Pre-hospital communication with hospital staff ◦ Medical stabilization en route◦ Support education

evidence of cooperative educational activities 2x/year◦ ED protocols

Stroke team notification Door to treatment

◦ CSC should be viewed as community and regional resource

CSC:Facility Infrastructure Stroke Unit and ICU

◦ Dedicated neurointensive care unit ◦ Rehab and post-stroke care

Education◦ Professional

> 2 educational courses per year for health care professionals◦ Public

Sponsor at least 2 educational activities per year that focuses on some aspect of stroke Stroke risk factors, health fairs, etc

CSC:The Rest of the Story Stroke Registry/Database

◦ LOS; treatment rate; discharge destination & status Quality Assurance and improvement

◦ Peer review process to evaluate/monitor care Patient-centered research approved by IRB Coordinate post-hospital care for patients

◦ Stroke clinic

Systems of Stroke Care 1. Patients should be transported rapidly to the closest available certified primary

stroke center or comprehensive stroke center or, if no such centers exist, the most appropriate institution that provides emergency stroke care as described in the 2013 guidelines (Class I; Level of Evidence A). In some instances, this may involve air medical transport and hospital bypass. (Unchanged from the 2013 guideline)

2. Regional systems of stroke care should be developed. These should consist of consisting of:

(a) Healthcare facilities that provide initial emergency care including administration of intravenous r-tPA, including primary stroke centers, comprehensive stroke centers, and other facilities.

(b) Centers capable of performing endovascular stroke treatment with comprehensive periprocedural care, including comprehensive stroke centers and other healthcare facilities, to which rapid transport can be arranged when appropriate (Class I; Level of Evidence A). (Revised from the 2013 guideline)

2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute

Ischemic Stroke Regarding Endovascular TreatmentA Guideline for Healthcare Professionals From

AHA/ASA

Questions?