Main Issue October 2013

Comprehensive Stroke Certification What Does Does it Take?

The Ochsner Medical Center Experience

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The numbers bear out the need: According to recent statistics from the US Centers for Disease Control and Prevention, more than 140,000 people die each year from strokes in the United States. Yearly, almost 800,000 Americans have a stroke. Someone in the United States has a stroke every 40 seconds.

Risk increases with age, but over one-third of all strokes occur to people under the age of 65. Over the course of a lifetime, four out of every five American families will be touched by stroke.

Stroke is a devastating and costly disease. It is estimated that the direct and indirect cost of stroke is around $38.6 billion each year. It has been estimated that 33 percent of stroke survivors need help caring for themselves.

  • 20 percent need help walking
  • 70 percent cannot return to previous jobs
  • 51 percent are unable to return to any type of work after a stroke.

Because stroke continues to be the leading cause of long-term disability in our country, there is a clear need for specialized and focused care. Here, we will talk about our decision to gain comprehensive stroke certification for our medical center, and what your center could expect from the process.

Evolution of Ischemic Stroke Care

Over the last two decades, the acute treatment of stroke has changed dramatically. Prior to 1996, there was no Food and Drug Administration (FDA) approved therapy for the early management of acute ischemic stroke, with the goal of reversing the symptoms. As we all learned in residency, stroke used to be a back of the Emergency Room (ER) diagnosis, and ER physicians called neurologists to come to the bedside “whenever they had time.” In the present day, acute ischemic stroke is a high priority emergency, and hospitals nationwide have developed protocols to manage such patients promptly.

In December of 1995, the New England Journal of Medicine published “Tissue Plasminogen Activator for Acute Ischemic Stroke.” This was the paper that began to change how we treat acute ischemic strokes. It showed that when appropriate patients were treated with IV t-PA, they were approximately 30 percent more likely to have a better outcome from their stroke. The next year, the FDA approved the first and only drug for use for acute ischemic stroke within the first three hours of symptoms onset.

Over the next few years, different groups began studying the use of this drug—Activase (alteplase)—and the time window for which it was effective. In 2008, two different articles were published: the first also in the New England Journal of Medicine, “Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke”; and the second in Lancet, “Thrombolysis with alteplase 3-4.5h after acute ischaemic stroke (SITS-ISTR): an observational study.” Both of the studies’ conclusions confirmed the benefit of the drug for up to 4.5 hours from symptom onset in selected patients. This is now a recommendation by the American Stroke Association for the management of acute ischemic stroke.

Endovascular Therapies

As we began to understand the limitations of intravenous therapies for acute stroke, endovascular therapies were developed to manage patients outside of treatment windows or who were refractory to those therapies. The endovascular treatment of stroke has evolved rapidly over the past decade. Different technologies have come and gone, and the neurointerventionalist has multiple tools at his/her disposal to treat large vessel strokes.

Although these therapies have not been proven in a class I clinical trial, it is widely considered by most experts in the field that they are beneficial to a select group of patients. Multiple trials are underway to improve the benefit of these therapies. Despite the lack of class I data, these therapies are an integral part of a comprehensive stroke center.

Intracerebral Hemorrhage and Subarachnoid Hemorrhage

Just like with ischemic stroke, the management of intracerebral hemorrhage and subarachnoid hemorrhage has evolved over the last few decades. New advancements in the diagnosis and management of these processes have revolutionized the way we treat patients with these diseases.

Aggressive blood pressure control and monitoring of intra-cranial pressure is the foundation in the management of intraparenchymal hemorrhage. In terms of subarachnoid hemorrhage, identification and securing the source of the bleed is of paramount importance, along with monitoring of intracranial pressure and vasospasm. The development of neurointensive care units across the country has helped improve the care of these patients. It has also improved the outcomes for patients who present with such devastating diseases. Neurointensive care units have become a mainstay and a requirement for comprehensive stroke centers.

Ochsner’s Neurosciences Program

In 2008, Ochsner Medical Center in New Orleans made a commitment to develop a comprehensive stroke program. For us, the long process began with the hiring of Kenneth Gaines, MD, as chairman of the neurology department. He assembled a team of energetic people to develop and grow the program to what it is today. Over the years, the team has grown to include not only vascular neurologists, but also a multidisciplinary team that includes all levels of stroke expertise across the continuum of care.

A very important part of our system of success was our tele-stroke network. Initially developed to provide vascular neurology coverage to our other Ochsner institutions, the program grew to include a total of 19 spokes, with plans to expand over the next two years. The tele-stroke network has completed over 2,000 consults and given IV t-PA to close to 300 patients since its development.

Key Elements

There are multiple key elements to developing a successful comprehensive stroke center.

Connection with EMS.A successful stroke program begins with a successful EMS service. Paramedics transport approximately half of the patients that arrive to emergency departments, and appropriate identification of symptoms by EMS allows for faster and better care. A strong relationship between a comprehensive stroke center and EMS is of extreme importance for the program success. EMS and community outreach should focus on recognition of symptoms and onset of symptoms, early notification, and pre-hospital stroke exam.

Aggressive emergency department physicians and nurses. The initial care of patients with neurovascular diseases occurs in the emergency department. A well educated and engaged core group of emergency physicians and nurses allows for early, aggressive care of the stroke patient. The development of guidelines of care in the emergency department helps improve the care received by our patients.

Vascular Neurology/Stroke Service and Unit.

A dedicated service and unit to manage patients improves care, helps reduce the rate of complications, improves outcomes, and reduces length of stay. We operate from a single nursing unit with stroke-specific nursing protocols for neurologic assessment, as well as patient and family education. It is a collaborative approach with a multidisciplinary team including a vascular neurologist, an internal medicine hospitalist, physical/occupational/speech therapist, mid-level providers, a social worker, and a clinical pharmacist.

Neurocritical Care Unit.

As our program has grown, our acuity has increased dramatically. Level of care provided at our neurological intensive care unit has been paramount to our success. Our unit opened in 2010 with six beds, but expanded to 25 beds in 2012 due to our large volume and increasing demand. Four neurointensivists and four advanced nurse practitioners/physician assistants, plus residents and fellows, staff the unit.

Neuro interventional lists. The new techniques in management of acute ischemic stroke and subarachnoid hemorrhages require full-time coverage, often endovascular team. At Ochsner, there is full time coverage for these services between three neuroendovascular-trained physicians.

Neurosurgery. Our group of neurosurgeons has grown from three to five over the last two years. Their engagement in the program and their participation in its development has been one of the most important elements to our growth. A good relationship between all the groups is required for success.

Engaged nursing staff. Nothing happens without our nursing staff. This is quite possibly the most important element for the success of our program. Their involvement in the care of patients with cerebrovascular disease begins in the emergency department and follows through into the intensive care unit and the stroke unit. Proper education of nursing staff in matters that relate to this patient population results in improved care and nursing participation.

Order Sets and Protocols. The creation of order sets and treatment/management protocols provides a standardized approach to the care and treatment of stroke patients. This standardization allows for reduction of variation in the provision of clinical stroke care to patients and improves documentation, while allowing for incorporation of current, scientifically based clinical knowledge.

Hospital Involvement

In order to succeed and excel in the care of patients with neurovascular diseases it is important to have administrative support. Many resources are required to monitor and maintain the quality markers required by accrediting institutions. At Ochsner, we have created a Stroke Committee, comprised of members of different services, all of which interact in some way in the care of these patients. It includes representation from services like vascular surgery, physical medicine and rehabilitation, and cardiology, among others. There is also representation from performance improvement groups.

Stroke Certification Programs

In 2000, the members of the Brain Attack Coalition (BAC) published the findings of a literature review focusing on the development of recommendations to improve the medical care of patients with stroke. A few years later, the American Heart Association/American Stroke Association (AHA/ASA) published a scientific statement for stroke care. Based on the findings from both of these publications, the Joint Commission launched the Primary Stroke Center Certification Program in December 2003, making it the first nationwide certification program to evaluate stroke care provided by hospitals. Over the next several years, the Joint Commission developed 10 performance measures to evaluate the quality of stroke care. The measures became a requirement of Primary Certified hospitals on January 1, 2008 (STK-7 Screening for Dysphagia and STK-9 Smoking Cessation were not endorsed by the National Quality Forum and were retired on January 1, 2010).

In September 2012, the Joint Commission and the AHA/ASA launched the Disease-Specific Care Advanced Certification Program for Comprehensive Stroke Centers and on October 20, 2012 the Joint Commission certified the first Comprehensive Stroke Center. Due to the complexity of the requirements, the level of advanced care and specialized therapeutic options for patients has made this certification difficult to obtain for many centers.

Some of the new requirements have proven to be more challenging. One of them is peer review process, which requires the review and monitoring of the care provided to patients with complex acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Also, a minimal volume of patients treated must be maintained:

  • 25 or more patients treated with IV t-PA
  • 20 or more patients with subarachnoid hemorrhage
  • 15 or more endovascular coilings or surgical clippings

Happily, and roughly five years after we set out, and less than a year after the Joint Commission began to evaluate for it, Ochsner Medical Center in New Orleans received Comprehensive Stroke Center certification on May 17, 2013.

Why Comprehensive Certification?

Simply put, it has been our goal to provide excellent stroke care. We have been a Joint Commission Certified Primary Stroke Center since 2005. We wanted to further develop the program and extend our services to improve stroke and cerebrovascular outcomes, while decreasing the stroke and cerebrovascular related mortalities throughout the Gulf Coast region. We wanted to find innovative ways for patients to access acute and preventative stroke services.

We take pride in the consistent application of highest standards of care and continued quality improvement for acute stroke patients. We wanted to provide the Gulf Coast region with the newest advancements in clinical services and technologies, as well as be active participant in research opportunities.

We felt that with our resources, team, and dedication, we would be an excellent candidate to provide the Comprehensive Care as dictated by the Joint Commission standards, and be the primary care provider for this patient population in the Gulf Coast region.

How to prepare? What to expect if applying for certification?

Once you have the support from the institution, the first and most critical step toward attaining certification is to complete a gap analysis of the program based on the Joint Commission standards. The gap analysis allows for a true evaluation of the program and helps prioritize the focus of the stroke workgroup. It must be a group effort and should include a multidisciplinary team, including organizational leadership. Once the gap analysis has been completed, the team can assign ownership of each of the gaps identified. In preparation for Ochsner’s Comprehensive Stroke Certification survey, the multidisciplinary/leadership team met weekly for the three months leading up to the survey. These were working meetings focused on evaluating progress and making needed changes to achieve our set goals.

Certification is not easy, but it certainly is attainable. Expect it to be one of the most challenging opportunities in your careers. The Joint Commission standards can be very broad, and it is each organization’s responsibility to clearly define and describe their program. The organization must create realistic and attainable goals and guidelines and then follow them when providing care. Be cautious when creating your guidelines; too broad will not give the surveyors a clear picture of your program, and guidelines that are too specific will be impossible to maintain, which will lead to gaps in documentation that any surveyor will be sure to find.

On the day of the survey, be as organized and prepared as possible. Have supporting documents readily available when requested. Remember the survey is a chance to really showcase the program. Do not be afraid to brag about the team’s accomplishments. The surveyors want to see a cohesive team focused on providing high quality stroke care.

Resources

Once your institution makes the commitment to this process, you will need the resources provided by the Joint Commission in their website regarding the certification. Remember this is not a required certification to treat strokes, and although strokes are time sensitive and require immediate action, Comprehensive Stroke Certification by the Joint Commission does not. You have time to analyze and prepare yourself for it.

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