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What is

?

  • An independent, non-for-profit organization, that accredits and certifies health care organizations and programs in the united states.
  • Mission: Continuously improve health care for the public by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

Benefits of Joint Commission Certification

Objectives

  • Improves the quality of patient care by reducing variation in clinical processes
  • Provides framework for program structure and management
  • Provides an objective assessment of clinical excellence
  • Creates a loyal cohesive clinical team
  • Promotes a culture of excellence across the organization
  • Facilitates marketing, contracting, and reimbursement
  • Strengthens community confidence in the quality and safety of care, treatment, and services
  • Recognized by insurers and other third parties
  • Can fulfill regulatory requirements in select states
  • Discuss what the Joint Commission is, it's major functions, and how it effects Hershey Medical Center
  • Discuss and identify core measures specific to strokes
  • Discuss the HMC stroke program
  • Identify areas of strengths are weaknesses in regard to HMC core measures compliance
  • Review a case study and discuss how it coincides with core measures.

HMC 2014 Patient Population

Stroke Patient Volume:

822

484 (59%)

144 (17%)

Ischemic Stroke:

Intracranial Hemorrhage:

Subarrachnoid Hemorrhage:

TIA:

70 (9%)

125 (15%)

Meet the Team

Dr. Reichwein: Co-director

Dr. Cockroft: Co-director

Kathy Morrison: Program Director

Alicia Richardson: CNS, Program Coordinator

Morgan Boyer: Telestroke/ Lion Net Coordinator

New Core Measures

Stroke Certification and TJC

  • The Stroke Center Certification was launched in December 2003
  • Developed in collaboration with AHA and ASA
  • Currently more than 1000 certified stroke centers in 49 states and Puerto Rico.
  • The certification is only available in Joint Commission accredited acute care hospitals.

Accredidation vs Certification

Hospital wide

Accredidation:

Certification:

Disease Specific

(ie stoke, HF, asthma)

Specialty Services

Procedures:

Diseases Treated:

  • Arteriovenous Malformations
  • Arteriovenous fistula
  • Cerebral Aneurysms
  • Carotid Artery Disease
  • Cavernous Malformations
  • Cerebrovascular Disease
  • Ischemic and Hemorrhagic Stroke
  • Headaches
  • Moyamoya Disease
  • Carotid Endardectomy
  • Carotid Angrioplasty and stenting
  • Clot retreival
  • Endovascular embolization
  • Endovascular coiling
  • Gamma Knife
  • Intracranial Angioplasty
  • Microsurgical Anuerism Clipping
  • Microsurgical Exision of AVM
  • Onyx HD

The HMC Stroke Program

STK-1: VTE Prophylaxis

STK-10: Assessed for Rehabilitation

Stroke patients are at increased risk of developing VTE. One study noted DVT in more than 1/3 of patients with moderate to severe stroke.

More than 60% of stroke patients have never received rehabilitation. Early mobilizationand encouragement of care activities as soon as possible may lead to better outcome. The primary goal of rehab is to prevent complications, minimize impairments, and maximize functions.

  • Occlusive Cerebrovasculature Disease
  • TIA
  • Vasospasms
  • Vascular Dementia

STK-8: Stroke Education

STK-2: Discharge on Antithrombic Therapy

  • Comprehensive Stoke Center Certification
  • May 2013: Current certification received
  • April 2-June 30 2015: Certification window
  • Given 1-week notice
  • 7 CSC's in PA and 77 in the country

Patient education programs for specific chronic conditions such as stroke can lead to increased healthful behaviors, improved health status, and decreased healthcare costs

Antithrombotic therapy should be prescribed at discharge following an acute ischemic stroke to reduce stroke mortality and morbidity provided no complications exist.

Stroke Core Measures

STK-6: Discharge on Statin

STK-5: Anticoag Therapy for A-fib/flutter

A-fib is identified as a risk factor for stroke. A previous TIA is also a risk factor. Emphisis is on prevention so patients should be on prophylactic therapy

Elevation of serum lipid levels are a risk factor that can lead to stroke. All patients with ischemic stroke or TIA should have lipid profile measurement performed within 48 hours of hospital arrival

STK-5: Antithrombic Therapy by end of hospital day 2

STK-4: Thrombolytic Therapy

References

IV-TPA given within 3 hours of stroke onset for acute ischemic stroke has proven to be beneficial

Initiate within 2 days of symptom onset in acute ischemic stroke to reduce stroke mortality and morbidity

Comprehensive vs Primary Stroke Center

How TJC uses core measures

Certification by TJC

  • TJC does not require a specific percentage of compliance with the core measures. They look for a concerted effort to be made in implementing core measures.
  • Requires PI plan for core measures that are not being met.
  • Decision to certify based on the elevation of standards, implementation of clinical practice guidelines, and performance measure activities
  • Certification awarded for 2 years
  • At the year, certified organizations must participate in a conference call to attest to its continued compliance with the standards and review their PI activities

Dysphagia Screening

  • Not a core measure, but a quality measure set forth by the TJC
  • Pt is screened prior to oral intake for any patient admitted with stroke
  • If patient fails the dysphagia screening, a speech consult is ordered.

57 yo male

PMH: CAD, Coronary artery bypass, MI, fem-pop artery bypass, peripheral vascular disease, recurrent SVT since childhood, Legionnaires disease

While driving his car, lost consciousness, and hit a tree.

He was found at the scene unresponsive. After 3 rounds of defibrillation, ROSC was achieved. Pt was intubated in the field and transported to an outside hospital.

CT performed and patient was found to have subdural hematoma in the left frontal and temporal region as well as diffuse subarachnoid hemorrhage.

EVD, Left subclavian triple lumen, foley, and a-line placed at outside hospital before being transferred to HMC.

HMC Stoke Program Compliance to Core Measures

Initiate Brain Attack Protocol

Depression Assessment

Case Study

VTE Prophylaxis

Discharge Antithrombic Therapy

Anticoagulant Therapy for Atrial Fibrillation/Flutter

Applying Core measures to practice

Applying New Core Measures

Hemorrhagic Transformation

NIHSS

Not applicable. Pt did not receive TPA or MER therapy

Completed within 12 hours of admission and daily thereafter.

mRS at 90 days

Nimodipine

Pt started on nimodipine on day one of hospital stay.

The scale runs from 0-6, running from perfect health without symptoms to death.

0 - No symptoms.

1 - No significant disability. Able to carry out all usual activities, despite some symptoms.

2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

3 - Moderate disability. Requires some help, but able to walk unassisted.

4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

6 - Dead.

Severity Measurement

TICI Post-Treatment Reperfusion Grade

Not applicable. Pt had hemorrhagic stroke.

Severity score documented before any surgical intervention and within 6-hours of arrival for those that do not undergo surgical intervention.

Neuro Assessment:

  • NIHSS: 15
  • Pupils 3/3 equal and reactive
  • 5/5 strengths in all extremities
  • Sedated and intubated
  • Oriented to self
  • Eye opening spontaneously

Sent to Neuro Interventional Radiology to locate aneurism and place coils. Aneurism located in anterior communicating artery (ACA). 5 Coils place. Vitals, Neuro, and groin site monitored per post IR protocol.

Median time to revascularization

Procoagulant Reversal Agent

Not applicable. Pt had hemorrhagic stroke.

Antithrombic Therapy by end of Hospital Day 2

Not applicable. Pt INR must be > 1.4 upon admission. Pt's INR was 1.1

Discharge on Statin Meds

Thrombolytic Therpay

Applying Core Measures to Patient Care

Antithrombotics

TPA

Not applicable. Pt had hemorrhagic stroke. Although he has received antithrombics during stay, it is not indicated for discharge.

Not Applicable. Pt had hemorrhagic stoke.

Early Antithrombotics

LDL

Patient received simvastatin during hospital stay and will be discharged on statin med.

Not eligiable for antithrombotics on day two due to hemorrhagic stroke, however enoxaparin was started on hospital day 4.

Rehab

VTE

Bilateral lower SCD's placed starting day 1 of hospital stay

Standing and Ambulation initiated day 14 of hospital stay

Based on assessment, pt will be discharged to a rehabilitation center

Stroke Education

Patient Education

A-FIB/Flutter

Patient and family educated about warning signs, calling 911, risk factors for stroke, medications, and follow up appointments

Not applicable. Patient has no hx if a-fib/flutter

Assessments:

  • Subarachnoid Protocol
  • ICU q1 hour neuro and vitals
  • Monitoring for increased ICP's
  • Monitoring for seizure like activity
  • Monitoring for neurological changes
  • Systolic goals <140 mmHg
  • Daily NIH scores
  • Daily TCD's

Interventions:

  • Maintain HOB > 25-30 degrees with patient in midline position
  • Perform oral care via VAP kit for intubated patient
  • DVT prophylaxis: SCD's on bilateral lower extremities
  • Ensure Minimal stimulation: Limit visitors, Coordinate tasks, keep room quiet, keep lights dim
  • Pulmonary toileting
  • ROM exercises
  • Keofeed placed
  • EVD @ 10 mmHg

The Joint Commission, Core Measures, and Comprehensive Stroke Certification

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