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Improving the care of stroke patients


Each year, about 700,000 new or recurrent strokes occur in the United States, killing about 150,000 people. This averages out to one stroke every 45 seconds and one stroke death every 3 to 4 minutes.

Perhaps even more alarming, the incidence of transient ischemic attack (TIA)—a warning sign of impending stroke—exceeds that of stroke. About 15% of strokes occur within 90 days of a TIA.

Improving treatment and outcomes for stroke patients is imperative. Fortunately, evidence-based guidelines are available to help healthcare providers do just that. Our facility has enhanced stroke care by taking part in Get With The Guidelines—Stroke (GWTG—Stroke). Launched in 2004 to improve acute stroke treatment and prevent ischemic strokes, this initiative is part of the American Stroke Treatment Program, created by the American Stroke Association (ASA) and the multidisciplinary Brain Attack Coalition (BAC).

Understanding GWTG
GWTG—Stroke helps healthcare facilities ensure continuous quality improvement of stroke treatment by aligning clinical care with evidence-based practice guidelines. It focuses on quick diagnosis and treatment using protocols to ensure appropriate care and discharge of stroke patients. GWTG is available for implementation at acute-care hospitals, and thousands of healthcare facilities now participate.

Many facilities become familiar with GWTG when pursuing Joint Commission certification as a primary stroke center—a hospital-based center that stabilizes and provides emergent care to acute stroke patients, transfers patients to a comprehensive stroke center, or admits them and provides further care as appropriate.

However, a facility doesn’t have to be a primary stroke center to use GWTG. Even if your facility doesn’t plan to become a primary stroke center or implement GWTG, our hospital’s experience with the program can help you and your colleagues learn how to use evidence-based practice guidelines to improve the quality of stroke care.

Recommendations for primary stroke centers
BAC recommendations for facilities pursuing designation as a primary stroke center include:

  • establishing criteria for emergency response
  • availability of neuroimaging 24 hours a day, 7 days a week
  • laboratory, neurology, and neurosurgery support
  • administrative support
  • appropriate staff education
  • outcomes tracking.

Improving the infrastructure, evaluating treatment
Having a primary stroke center improves the infrastructure through which a facility delivers care, promotes quick diagnosis and treatment, and emphasizes proven treatments. At many primary stroke centers, treatment is measured and evaluated using GWTG electronic tools that offer patient-specific guideline information. These interactive tools allow each facility to track its adherence to the guidelines—both individually and against national benchmarks over time. They also generate automated patient education materials and, with permission, send data to the Joint Commission or other third parties.

Certification criteria
In 2003, ASA and the Joint Commission collaborated to develop the voluntary primary stroke center certification program, which allows consumers and emergency medical service professionals to identify healthcare facilities equipped to treat acute stroke according to nationally recognized standards. Certification criteria were developed by ASA, BAC, and the Joint Commission.

To become certified as a primary stroke center, a facility takes these steps:

  • identifies internal program champions to develop, lead, and mobilize teams
  • builds a team to implement treatment
  • assesses current treatment and identifies areas for improvement
  • refines processes
  • implements needed changes
  • continues to pursue excellence.

Our journey to certification
In March 2004, the Neuroscience Service Line at our 590-bed facility decided we were ready to pursue certification as a primary stroke center. A program coordinator was designated, and a stroke subcommittee was formed from our multidisciplinary Neuroscience Care Management Team to prepare the application for certification.

To gain an overview of the certification process, stroke subcommittee members attended an ASA-sponsored conference, “Improving Stroke Care at Your Hospital,” which featured a workshop on GWTG. Also, GWTG staff came to our hospital and presented the program to our nursing and clinical systems administrators.

Performance measure review
The stroke subcommittee conducted a review of the performance measures affecting outcomes in stroke patients, listed in the Joint Commission’s Disease-Specific Care Certification Manual (second edition). These measures include:

  • initiating deep-vein thrombosis prophylaxis
  • giving antithrombotics within 48 hours of hospitalization
  • prescribing antithrombotics at discharge
  • providing anticoagulant therapy to patients with atrial fibrillation
  • considering tissue plasminogen activator (tPA) therapy
  • evaluating the patient’s lipid profile
  • screening the patient for dysphagia
  • providing stroke education to the patient and family
  • providing smoking cessation materials to the patient and family
  • considering a rehabilitation plan.

For this review, a spreadsheet was created that covered all 450 stroke patients treated from July 2003 through June 2004; it was organized according to each performance measure. Although the initial database was time-consuming to develop, the effort paid off by providing a crucial overall picture of the stroke patient population.

Before the database was created, our facility could track stroke patients only through an annual retrospective chart review of a representative sampling of stroke cases. Now that we’re using GWTG, we have concurrent data on each stroke and TIA patient as he or she is admitted, which allows more timely documentation of areas that need improvement. Largely because of this performance measure reporting, our 2-year recertification visit by the Joint Commission was a breeze.

Our primary stroke center coordinator saw every patient with suspected stroke or TIA who was admitted to the hospital, gathering data for the new database and mentoring the nursing staff in performance measures and standards.

Implementation and site visits
Our target date for implementing GWTG was July 2004. In November 2004, the Joint Commission conducted its site visit of our primary stroke center—and we were awarded certification. In October 2006, the Commission made its unannounced 2-year site visit. During both visits, surveyors created a collaborative rather than investigative atmosphere, and supported our efforts by making suggestions and sharing ideas gained from other successful primary stroke centers.

Pinpointing areas for improvement
Before we implemented GWTG, our facility complied with only six of the 10 performance measures for stroke patients; now it complies with nine. (We continue to be challenged in documenting that patient and family education has been completed.) Using the GWTG database, we can produce reports that compare our performance against that of other facilities. We’ve found this is a powerful way to pinpoint areas that need improvement and motivate staff to implement required changes.

We’re also using the database to track door-to-computed tomography (CT) time—the interval from the patient’s arrival in the emergency department (ED) to completion of the CT scan. (Previously, we’d used a smaller database that lacked benchmarking capabilities.) While we’ve always had good door-to-CT times for acute stroke patients (22 minutes in 2004, compared to the national benchmark of 25 minutes), our ED nurses saw room for improvement. To boost motivation, they devised a quarterly contest in which the nurse with the shortest door-to-CT time got a gift certificate to the hospital gift shop. Using this strategy shaved another 4 minutes off our door-to-CT time over the next year. Between July 2005 and June 2006, we shaved off another 2 minutes by changing the procedure so that stroke patients are taken straight from the EMS vehicle to the CT area. Our current door-to-CT time is 16 minutes. Of course, time saved means patients get the treatment they need faster, which helps save lives and reduce disability.

Our ED staff also recognized the need to shorten door-to-needle time—the interval from the patient’s arrival in the ED to the beginning of tPA administration. We developed a performance improvement initiative to track this time and presented the tracking data to the pharmacy. Having this data gave us much greater credibility than if we’d simply told the pharmacy we thought it was taking too long to start administering tPA. In response, the pharmacy staff reviewed—and improved—their own process, which has enabled us to cut a few more minutes off door-to-needle time. From July 2005 through June 2006, we dropped below the benchmark of 60 minutes for the first time.

Developing a dysphagia screening tool
The GWTG database also helped us develop and improve a dysphagia screening tool. Before we had this tool, our speech therapists were screening only about 50% of stroke patients for dysphagia (a risk factor for aspiration pneumonia). With guidance from our monthly GWTG teleconferences, we were able to conduct a literature search that helped us develop a customized dysphagia screening tool identifying patients at risk for aspiration. We put at-risk patients on a controlled diet and instructed them on safe swallowing methods or, if needed, we used an alternative feeding method.

As a result, our dysphagia screening compliance rose to 88% and the incidence of aspiration pneumonia fell by about 50% from July 2005 through June 2006. Being able to report this statistic to the staff and administration gave us the chance to dramatically demonstrate the extent to which process improvement affects patient outcomes.

Improving risk factor identification
Thanks to our database, we can now report on risk factors specific to our stroke patients. For instance, we know what percentage are diabetic, and we’re managing their care partly by tracking their hemoglobin A1C values (which reflect long-term blood glucose control). Multidisciplinary team meetings and physician department meetings brought these values to the attention of physicians, and we’re now seeing tighter blood glucose control. We’re also able to track management of patients with hypertension, the leading cause of stroke. Because we can share these data with physicians and other staff, we’re seeing more consistent management. Before we implemented GWTG, these quality measures were impossible to track and trend.

Eliminating outdated practices
Using GWTG has led us to eliminate some outdated practices. ASA’s scientific statement “Guidelines for the early management of patients with ischemic stroke” provides treatment recommendations, along with clinical evidence to back each recommendation. These guidelines state that:

  • anti-embolism support stockings have no proven value to stroke patients
  • routine anticoagulation in patients with acute ischemic stroke isn’t recommended
  • the patient’s swallowing reflex must be assessed before he or she can receive anything by mouth.

With this scientific statement in hand, we convinced our physician-leaders and interdisciplinary team to change their admission orders. Consequently, our clinicians stopped ordering anti-embolism stockings for deep-vein thrombosis prophylaxis; instead, we’re using sequential pneumatic compression devices. They also stopped ordering heparin drips for virtually all ischemic stroke patients. And we no longer administer medications orally (or allow any other type of oral intake) to patients with suspected dysphagia; previously, our clinicians ordered that these patients be kept “NPO except meds.”

Predicting patient disposition
At our primary stroke center, discharge planning starts on admission with assessment of the patient’s preadmission functional level. Approximately 50% of our stroke patients are able to return home directly from the acute care department; 20% to 25% are discharged to the acute rehabilitation unit; 8% don’t survive the stroke, and the remaining 17% to 22% require placement in an extended-care facility (ECF). Predicting disposition on the first hospital day can reduce stroke care costs by allowing an early start to the time-consuming process of securing an ECF bed.

For guidance in predicting disposition and planning discharges, we turned to the National Institutes of Health Stroke Scale (NIHSS)—a quantitative measure of stroke-related neurologic deficit. Although initially used to determine a patient’s candidacy for stroke research trials, NIHSS has been found to reliably indicate prognosis and thus can be used as an early predictor of discharge disposition. An initial NIHSS score below 10 is linked to a favorable outcome in 60% to 70% of ischemic stroke patients at 1 year after the stroke; a score above 20 portends a favorable outcome in only 4% to 16% of these patients. One study found that an initial NIHSS score of 5 or lower indicates probable discharge to home, scores between 6 and 13 (moderate stroke) indicate probable discharge to an acute rehabilitation program, and scores above 13 (severe stroke) will likely necessitate placing the patient in an ECF.

Garnering awards and recognition
Our facility has received two levels of GWTG recognition—the Initial Performance Achievement Award and the Annual Performance Achievement Award. When the hospital newsletter published these awards, our stroke program gained an identity within the hospital. Now when the hospital needs examples of performance improvement or evidence-based practice, it includes stroke program data. Our facility’s successful Magnet™ recertification application in 2006 also prominently featured our stroke program.

We’ve gained regional and state recognition, too. Our facility has hosted many on-site visits and countless teleconferences with other hospitals seeking to improve their stroke care.
The GWTG experience has helped our nurses become more engaged in the delivery of high-quality care to stroke patients. They now fully appreciate the extent to which nursing care can give these patients the best chance for recovery. In fact, our nursing staff has become so committed to providing high-quality stroke care that membership in the local chapter of the American Association of Neuroscience Nurses has tripled in the past 2 years, and more of our nurses are seeking certification as neuroscience registered nurses.

Pride, purpose, and benefits for all
Our hospital staff is proud that the facility is a certified primary stroke center providing evidence-based care. What’s more, the process of obtaining certification has improved our teamwork. Using a quality improvement program and a powerful database has given us a deep sense of purpose and accomplishment, and being recognized as a quality-based program has had a dramatic impact within our facility.

Our experience with GWTG shows that patients, staff, and the entire hospital benefit when scientific research and evidence inform the care of stroke patients. Through GWTG, our stroke treatment has gained an outstanding reputation, and our staff take great pride in knowing we’re providing excellent care.

Selected references
Adams H, Adams R, Brott T, del Zoppo G, Furlan A, Goldstein L, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003;34:1056. Available at: http://stroke.ahajournals.org/cgi/content/full/34/4/1056. Accessed February 27, 2007.

American Heart Association. Heart disease and stroke statistics. Available at: http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-111/TBL3//. Accessed February 20, 2007.

American Stroke Association. Get with the guidelines—stroke. Available at: www.strokeassociation.org/presenter.jhtml?identifier=3002728. Accessed February 12, 2007.

Goldstein L, Adams R, Alberts M, et al. American Heart Association/American Stroke Association guideline: primary prevention of ischemic stroke. Stroke. 2006;37:1583-1633.

Pugh S, Mathiesen C, Meighan M, Summers D. Guide to the care of the patient with ischemic stroke; AANN reference series for clinical practice. Available at: www.aann.org/pubs/guidelines.html. Accessed February 12, 2007.

Sacco R, Adams R, Albers G, et al. American Heart Association/American Stroke Association guideline: guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Stroke. 2006;37:577-617.

For a complete list of selected references, visit www.AmericanNurseToday.com.

Kathy Morrison, BSN, RN, CNRN, is Stroke Program Coordinator at Lancaster General Hospital in Lancaster, Penna. The author does not have any financial arrangements or affiliations with any corporations offering financial support or educational grants for continuing nursing education activities.

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