Stroke Quality & Outcomes/media/Files/Providence OR... · 2019-02-26 · Case Scenario Pt “A”...
Transcript of Stroke Quality & Outcomes/media/Files/Providence OR... · 2019-02-26 · Case Scenario Pt “A”...
Objectives:•Stroke Program: Quality and Outcomes
•Modified Rankin Scale (mRS)
•Portland Stroke Standardized feedback Tool
(PSST) EMS feedback
•Providence Oregon Stroke Data
Case ScenarioPt “A” 94y.o. female sitting down to eat dinner suddenly develops left side
hemiplegia, right gaze preference, and left side inattention at 1705. Dtr witnessed
the sudden onset of stroke symptoms and called 9-1-1, initial NIHSS 21.
Treatment summary:
IV alteplase + thrombectomy
Door to needle time: 43min
Pre TICI= 1
Door to groin= 93min
1 pass with stent retriever
Right M1
occlusion
Case Scenario
Right M1
occlusion
Right MCA
openPost procedure TICI= 3
24hrs post procedure
NIHSS= 3 (left face
droop, left upper and
lower extremity drift).
Discharged: SNF
(ambulating with FWW)
90 day mRS=1
(living back at home
with DTR)
Dayshift DTN median= 39min (n=53)
Nightshift DTN median= 50min (n=26)
2017 DTN median=42min (n=67)
2018 DTN median= 42min (n=79)
18% volume increase/ 70% EMS arrivals
EMS DTN median= 35.5min (n=54)
Walk-ins DTN median= 57.5min (n=24)
Median Door to CVL= 10.5min
Transfer median DTG= 24.5min (n=12)
Dayshift median= 25min (n=7)
Nightshift median= 24min (n=5)
New
DTG
Record
Modified Rankin Scale
0
Saver JL, Filip B, Hamilton S, et al. (2010). Improving the reliability of stroke disability grading in clinical trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke
DATA8/1/2016 - 7/31/2018
8/1/2016 - 7/31/2018
PSV mRS 0-2 (n=70)
73% Independent
PPMC mRS 0-2 (n=42)
67% independent
50% independent mRS 0-2
Case Scenario #2“Pt B”- 52 y.o. f with no past medical history, bouncing on trampoline when
husband found her 15min later not speaking or moving her right side. 9-1-1 was
called and a “stroke alert” was called in by EMS. NIHSS on arrival 24.
Treatment Summary:
IV Alteplase + thrombectomy
Door to needle time: 41min
Pre TICI= 0
Post TICI= 2b
Door to groin= 82min
Successful recanalization
with 4 passes of stent
retriever
LMCA clot
Case Scenario #2
Immediately post thrombectomy NIHSS=4 in ICU (aphasia only)!
12hrs post procedure NIHSS= 0, DC’d home day 3 NIHSS=0 no
neuro deficits!
Quality/Data Benefits• Robust database eliminates data lag for real time feedback to all team members
• Validate current process or use to initiate a new quality improvement initiative
– example: parallel process vs working in silos
• Visual data is meaningful
• Encourages rapid cycle evaluations to take action, adjust process, test ideas
• Consistent feedback to all stakeholders for clear communication of goals to improve patient
outcomes
• Reflection on clinical practices from previous years, ability to investigate trends in patient
management over time
• Benchmark with other stroke programs
Treatment
Faster treatment saves lives and reduces disability!
For every 15 minutes saved:
•Fewer patients die
•Fewer patients bleed
•More patients go home
•More patients are independent at discharge
Saver JL, Fonarow GC, Smith EE, et al. (2013). Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA.
References
1) Powers, W., Rabinstein, A., et.al. (2018). AHA/ASA Guidelines for the early management of patients with
acute ischemic stroke. Stroke. 49:e1-e344. doi:10.1161/STR.0000000000000158.
2) Saver JL, Filip B, Hamilton S, et al. (2010). Improving the reliability of stroke disability grading in clinical
trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke 41(5):992–95.
doi:10.1161/STROKEAHA.109.571364.
3) Saver JL, Fonarow GC, Smith EE, et al. (2013). Time to treatment with intravenous tissue plasminogen
activator and outcome from acute ischemic stroke. JAMA. 309(23):2480–2488.
doi:10.1001/jama.2013.6959
4) Summers, D., Leonard, A., Wentworth, D., (2009) AHA Guideline: Comprehensive overview of nursing and
interdisciplinary care of the acute ischemic stroke patient. Stroke. 40:2911-2944.
5) Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. (1988). Interobserver agreement for
the assessment of handicap in stroke patients. Stroke 19(5):604-7