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 AND
interdependent
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
Total
Stroke type
Ischemic stroke
Hemorrhagic stroke
Stroke not otherwise specified/illdefined stroke
Transient ischemic attack (TIA)
TIA with symptoms completely
resolved prior to presentation to
the emergency department
No stroke
Missing
Total
N
38
15
(%)
(51)
(20)
5
(7)
15
(20)
5
(7)
1
1
75
(1)
(1)
(100)
Pre-hospital care goals
• Increase arrival by EMS
• Time “Last Know Well”
• Cincinnati Stroke Scale
• Pre-notification by EMS
EMS arrival
Total
Mode of arrival
EMS
Private
transportation/taxi/other
Transfer from another
hospital
Not documented or unable
to determine
Total
N
36
(%)
(51)
33
(47)
0
(0)
1
(1)
70
(100)
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 action
Total
N
(%)
Total arrived by EMS
36
Pre-hospital notification
23
(64)
Time last known well
23
(64)
Blood glucose level
15
(42)
10
(28)
27
(75)
14
(39)
Documentation
Cincinnati Stroke Scale
Score
Other neurological
assessment
Not documented/unable to
determine
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
Median
Missing
0-15 minutes
16-25
26-35
36-45
46-55
56-65
66-75
76-85
More than 85
Total
Door-toimaging
performed
time
59 minutes
40 minutes
N
12
9
9
9
7
9
4
2
0
9
70
(%)
(17)
(13)
(13)
(13)
(10)
(13)
(6)
(3)
(0)
(13)
(100)
Door-toimage read
time
81 minutes
62 minutes
N
16
3
2
4
5
7
10
6
2
15
70
(%)
(23)
(4)
(3)
(6)
(7)
(10)
(14)
(9)
(3)
(21)
(100)
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
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.
Door-to-lab
drawn time
Mean
Median†
Missing
0-15 minutes
16-25
26-35
36-45
46-55
56-65
66-75
76-85
More than 85
Total
Complete
blood count
(CBC)
Electrolyte
panel with
creatinine
INR
Door-to-EKG
ordered
39 minutes
22 minutes
39 minutes
22 minutes
36 minutes
17 minutes
136 minutes
13 minutes
N
1
6
2
4
2
1
1
17
(%)
(6)
(35)
(12)
(24)
(12)
(0)
(0)
(0)
(6)
(6)
(100)
N
1
6
2
4
2
1
1
17
(%)
(6)
(35)
(12)
(24)
(12)
(0)
(0)
(0)
(6)
(6)
(100)
N
2
6
2
4
2
1
17
(%)
(12)
(35)
(12)
(24)
(12)
(0)
(0)
(0)
(0)
(6)
(100)
N
5
6
4
1
1
17
(%)
(29)
(35)
(24)
(6)
(0)
(0)
(0)
(0)
(0)
(6)
(100)
Door-to-lab turn-around time
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.
Arrived within 3.5 hours from time LKW
Lab turnaround time
Mean
Median
Complete
blood count
(CBC)
Electrolyte
panel with
creatinine
INR
55 minutes
30 minutes
55 minutes
30 minutes
48 minutes
30 minutes
N
Missing
0-15 minutes
16-25
26-35
36-45
46-55
56-65
66-75
76-85
More than 85
Total
4
5
1
2
1
1
3
17
(%)
(0)
(0)
(24)
(29)
(6)
(12)
(6)
(0)
(6)
(18)
(100)
N
4
5
1
2
1
1
3
17
(%)
(0)
(0)
(24)
(29)
(6)
(12)
(6)
(0)
(6)
(18)
(100)
N
2
4
4
1
2
1
1
2
17
(%)
(12)
(0)
(24)
(24)
(6)
(12)
(6)
(0)
(6)
(12)
(100)
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
Contraindications
Rapid improvement
Mild stroke
CT findings
Advanced age
Warnings
Refusal
Unable to determine eligibility
CMO/illnesses
Delay in arrival
Others including outside tPA
N
5
4
2
2
1
0
0
0
0
0
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
CDC Stroke Performance Measures for treatment/care of patients with
stroke who were admitted to the hospital.
Total
CDC Stroke Performance Measure set
N
(%)
eligible
VTE prophylaxis administered by
STK-1
21
24
(88)
hospital day two
STK-2
Discharged on antithrombotic therapy
18
19
(95)
STK-3
Discharged on anticoagulant for atrial
fibrillation
2
4
(50)
0
3
(0)
STK-4* Thrombolytic therapy administered*
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)
25
25
(100)
STK-10 Assessed for rehabilitation
*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?