PARTICIPATING IN A DATA-DRIVEN

QI FOR STROKE AND TIA

Anna Hogen, Abbot Northwestern Hospital

Deb Nyquist, MD, FAAFP, Grand Itasca Clinic &

Hospital

June 27, 2011

Rural Hospital Pilot Project

• Minnesota Stroke Registry

• Minnesota Department of Health

• Paul Coverdell National Acute Stroke Registry (CDC)

• Participating Hospitals

• Grand Itasca Clinic & Hospital, Grand Rapids, MN

• River’s Edge Hospital & Clinic, St. Peter, MN

• Clinical Collaborating Hospital

• Abbott Northwestern Hospital – Neurological Emergency Treatment

(NETwork) program

Purpose

• Improve relevancy of data for rural hospitals

• Assist rural hospitals

• Data collection – more detailed

• Quality improvement

• Define a place in the statewide stroke system for rural

hospitals

Minnesota Department of Health

• Coordinate project

• Provide data monthly

• “Host” monthly check in calls

• Review data

• Discuss process improvement

Abbott Northwestern Hospital

• Comprehensive stroke care

• Access to Neurologic Specialists 24/7:

• Neurologists, Neurosurgeons, Interventional NeuroRadiologists

• Stroke treatment options beyond IV tPA: intra-arterial capabilities

• NETwork program-

• Fulltime, experienced stroke care RN

• Provides feedback/support to referring facilities

• Assist with stroke care resources

• Protocol/order set development

• QI/PI support

• Tele-health for stroke

• Participant in MDH stroke care initiatives

Grand Itasca Hospital: Who are we?

• Integrated hospital & clinic • Merged in 2002

• New facility in Dec of 2005

• 65 beds including our ARU

• 60+ providers -multispecialty

• Rural • Town of 8,000

• Service area of 40,000

• Independent ANDinterdependent

Stroke care at Grand Itasca Hospital

Where we began

• Volume of approx 90/year

• CT capability 24/7

• TPA administration for stokes < 3 hours

• Transfer to larger facility:

• Larger strokes

• Hemorrhagic strokes

Goals

• Softly Defined Strongly Articulated

• Improved care in our ED

• EMS involvement

• Timely use of TPA

• Rapid turn around times for lab/CT

• Improved care of our hospitalized patients

• CDC Stroke guidelines

• Patient and community education

Patient population

N (%)

38 (51)

15 (20)

5 (7)

15 (20)

TIA with symptoms completely

resolved prior to presentation to

the emergency department

5 (7)

1 (1)

1 (1)

75 (100)

Stroke not otherwise specified/ill-

defined stroke

Total

Transient ischemic attack (TIA)

Missing

Total

Hemorrhagic stroke

Ischemic stroke

Stroke type

No stroke

Pre-hospital care goals

• Increase arrival by EMS

• Time “Last Know Well”

• Cincinnati Stroke Scale

• Pre-notification by EMS

EMS arrival

Mode of arrival N (%)

EMS 36 (51)

Private

transportation/taxi/other33 (47)

Transfer from another

hospital0 (0)

Not documented or unable

to determine1 (1)

Total 70 (100)

Total

We have seen

• A gradual increase of EMS arrived patients

• Why?

• State and National patient education

• Future plans for local community education

Documenting time of “last known well”

Improvements by

• EMS education and encouragement

• Hard-wiring the documentation

• Nursing documentation

• Physician order set

Cincinnati Stroke Scale

Source: American Heart Association slide.

Consider a “FAST” scale

• FAST

• Face

• Arm drift

• Speech

• Time of last known well

• Effectiveness

• 1/3 signs as a “new event”

• 72% probability of a stroke

• 3 signs present

• 85% probability of a stroke

Pre-notification by EMS

Actions by EMS personnel.

EMS actionTotal

N (%)

Total arrived by EMS 36

Pre-hospital notification 23 (64)

Documentation

Time last known well 23 (64)

Blood glucose level 15 (42)

Cincinnati Stroke Scale

Score10 (28)

Other neurological

assessment27 (75)

Not documented/unable to

determine14 (39)

Pre-notification

EMS and ED communication

• Modeled after our STEMI and TRAUMA care

• ED physician cell phone

• Direct communication from EMS

Emergency Department

• Door-to-Imaging time

• Door-to-Lab draw/report

• National Institutes of Health Stroke Scale

• Door-to-Needle time

Door-to-imaging time

• Goals

• Door to Image < 25 minutes

• Door to Read < 45 minutes

Door-to-imaging and read times

Minutes

Mean 59 minutes 81 minutes

Median 40 minutes 62 minutes

N (%) N (%)

Missing 12 (17) 16 (23)

0-15 minutes 9 (13) 3 (4)

16-25 9 (13) 2 (3)

26-35 9 (13) 4 (6)

36-45 7 (10) 5 (7)

46-55 9 (13) 7 (10)

56-65 4 (6) 10 (14)

66-75 2 (3) 6 (9)

76-85 0 (0) 2 (3)

More than 85 9 (13) 15 (21)

Total 70 (100) 70 (100)

Door-to-

imaging

performed

time

Door-to-

image read

time

Learnings

• Pre-notification helps!!!

• Need to manually enter time of study

• Developed a “Super Stat” read by teleradiography

• Stroke diagnosis may evolve over time

• Re: is it uro-sepsis or a stroke?

• Identify late presenters from early presenters

Door-to-lab draw

Door-to-lab

drawn time

Mean

Median†

N (%) N (%) N (%) N (%)

Missing 1 (6) 1 (6) 2 (12) 5 (29)

0-15 minutes 6 (35) 6 (35) 6 (35) 6 (35)

16-25 2 (12) 2 (12) 2 (12) 4 (24)

26-35 4 (24) 4 (24) 4 (24) 1 (6)

36-45 2 (12) 2 (12) 2 (12) (0)

46-55 (0) (0) (0) (0)

56-65 (0) (0) (0) (0)

66-75 (0) (0) (0) (0)

76-85 1 (6) 1 (6) (0) (0)

More than 85 1 (6) 1 (6) 1 (6) 1 (6)

Total 17 (100) 17 (100) 17 (100) 17 (100)

22 minutes 22 minutes 17 minutes 13 minutes

Time from patient arrival to time lab was drawn or EKG was ordered (door-to-lab drawn

time) among patients who arrived within 3.5 hours of time last known well.

Complete

blood count

(CBC)

Electrolyte

panel with

creatinine

INRDoor-to-EKG

ordered

39 minutes 39 minutes 36 minutes 136 minutes

Door-to-lab turn-around time

Lab turn-

around time

Mean

Median

N (%) N (%) N (%)

Missing (0) (0) 2 (12)

0-15 minutes (0) (0) (0)

16-25 4 (24) 4 (24) 4 (24)

26-35 5 (29) 5 (29) 4 (24)

36-45 1 (6) 1 (6) 1 (6)

46-55 2 (12) 2 (12) 2 (12)

56-65 1 (6) 1 (6) 1 (6)

66-75 (0) (0) (0)

76-85 1 (6) 1 (6) 1 (6)

More than 85 3 (18) 3 (18) 2 (12)

Total 17 (100) 17 (100) 17 (100)

30 minutes 30 minutes 30 minutes

55 minutes 55 minutes 48 minutes

Arrived within 3.5 hours from time LKW

Complete

blood count

(CBC)

Electrolyte

panel with

creatinine

INR

Time lab was drawn to time lab result was received (lab turn-around

time) among patients who arrived within 3.5 hours of time last

known well.

Learnings

• We can rarely get an INR < 1 hour

• Purchased point-of-care device

• Pre-notification helps!!!

• Patient diagnosis identification is key

• New lab process to expedite lab results

NIHSS documented

Improvements

• New ED Stroke Order Set

• Previously only an in-pt order set

• NIHSS hard-wired into the ED Order Set

• Education of ED docs

• Understanding of the “predictability” of NIHSS

• Helps to talk with patients and families

Door-to-needle time

• STK-4. Thrombolytic therapy administration.

Percentage of acute ischemic stroke patients who arrive

at the hospital within 120 minutes (2 hours) of time last

known well and for whom IV-tPA was initiated at this

hospital within 180 minutes (3 hours) of time last

known well.

Reasons for not giving thrombolytics

Reason N

Contraindications 5

Rapid improvement 4

Mild stroke 2

CT findings 2

Advanced age 1

Warnings 0

Refusal 0

Unable to determine eligibility 0

CMO/illnesses 0

Delay in arrival 0

Others including outside tPA 0

Thrombolytics

• Every minute counts

• Development of a “Stroke Code”

• Telehealth Initiative with ANW neurologists

Inpatient care

• Quality Improvement

• CDC Stroke Performance Measure set

CDC Stroke Measures

NTotal

eligible(%)

STK-1VTE prophylaxis administered by

hospital day two21 24 (88)

STK-2 Discharged on antithrombotic therapy 18 19 (95)

STK-3Discharged on anticoagulant for atrial

fibrillation2 4 (50)

STK-4* Thrombolytic therapy administered* 0 3 (0)

STK-5 Early antithrombotic therapy 14 17 (82)

STK-6 Discharged on statin therapy 4 5 (80)

STK-7 Dysphagia screening 19 30 (63)

STK-8 Stroke education 2 8 (25)

STK-9 Smoking cessation counseling 4 6 (67)

STK-10 Assessed for rehabilitation 25 25 (100)

CDC Stroke Performance Measures for treatment/care of patients with

stroke who were admitted to the hospital.

CDC Stroke Performance Measure set

*STK-4 only applies to patients who arrived at the hospital within two hours

(120 minutes) of time last known well.

STK–1: VTE Prophylaxis

STK–2: Discharged on Antithrombotic

STK–3: A-fib Discharged on Anticoagulant

STK–5: Antithrombotic Therapy by Day 2

STK–6 (LDL): Appropriate LDL Reducer

STK–7: Dysphagia Screening

STK–8: Educational Materials

STK–9: Smoking Cessation

STK–10: Assessed for Rehabilitation

Services

What have we learned?

Grand Itasca Hospital

• Pre-notification

• Greases the skids

• Data drives decisions and process improvement

• Hardwiring

• Order-sets

• Standardized areas of documentation

• Difficult with a “paper” system

• Education and communication – KEY

Barriers

• Our staff wears many hats

• Enlisted our RNs for data collection

• Hiring of a clinical coordinator for Stroke, Trauma, STEMI care

• Data does drive decisions and process improvement

• Hard to obtain in a small hospital on a paper system

• Improvements

• EHR

• Continued participation in the Stroke Registry

Minnesota Department of Health

• Learnings

• Acute care data

• Novel method of data abstraction

• Facilitated networking – rural hospitals and Primary Stroke Center

• What we’ve done

• Added optional acute care data elements

• Reports on MSRT (scheduled for July)

• National attention

Questions?