Stroke CertificationThrombectomy-Capable Stroke and Comprehensive Stroke: Where Should You Go Next?

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Today’s Presenters

Mary Kelly, MBA, RN, CNRN, FAHA

Disease-Specific Care Reviewer

mkelly@jointcommission.org

David Eickemeyer, MBA,

Associate Director, Business Development

deickemeyer@jointcommission.org

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Neurointerventionists who perform mechanical thrombectomy at the organization applying for certification must perform 15 mechanical thrombectomies over the past 12 months (or 30 over past 24 months) (procedures performed at hospitals other than the one applying for TSC certification can be included)

Eligibility - TSC

Organization must have performed mechanical thrombectomy and post-procedure care for at least 15 patients with ischemic stroke over the past 12 months (or 30 over past 24 months).

• Treatment of 20 SAH caused by aneurysm annually (40 over 2 years)

• Capable of treating aneurysms by per-forming 15 endovascular coiling or microsurgical clipping procedures annually (30 over 2 years)

• Administering IV thrombolytic therapy 25 times annually (50 times over 2 years)

• Organization must have performed mechanical thrombectomy and post-procedure care for at least 15 patients with ischemic stroke over the past 12 months (or 30 over past 24 months).

• Neurointerventionists who perform mechanical thrombectomy at the organization applying for certification must perform 15 mechanical thrombectomies over the past 12 months (or 30 over past 24 months) (procedures performed at hospitals other than the one applying for TSC certification can be included)

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Eligibility - CSC

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• Thrombectomy volume and Interventionalist requirement is the same for both CSC & TSC

• Thrombectomy performed at other institutions COUNTS

• SAH Volume is for CSC ONLY

• IV Alteplase Volume is for CSC ONLY

How we review for Eligibility

• Call schedule for Endovascular

• List of cases performed (billed) by provider

• List of billed cases from other institutions

• List of patients

• Received IV Alteplase at CSC & Transferred in

• Aneurismal SAH

Document Review

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Has extensive expertise; available 24/7

Program Medical Director

Neurology background with ability to provide clinical and administrative guidance to program

TSC CSC

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• Medical Director CV

• Medical Director Call Schedule

How we review for Program Medical Director

Document Review

• Medical Director CV

• Board Certifications

• 8 hours annually of continuing education in stroke care – If not Board Certified in Neurology

TSC CSC

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Available 24/7, at bedside within 15 minutes

Available 24/7, at bedside within 15 minutes

TSC CSC15 min

Acute Stroke Team

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− Policies

− Protocols

− Algorithms

− Call Schedules

Document Review

How we review for Acute Stroke Team

Tracers

Medical record documentation of Acute Stroke Team response time

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Access to protocols used by EMS, routing plans; records from transfer

Emergency Medical Services Collaboration

TSC CSC

Access to protocols used by EMS, routing plans; records from transfer

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− EMS protocols for Ischemic and Hemorrhagic Stroke

− Interfacility transfer protocols for Ischemic and Hemorrhagic Stroke

How we review for Medical Services Collaboration

Document Review

− EMS transfer documents

• To ED

• From outside hospital

Tracers

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Has a neurointensive care unit or designated intensive care beds for complex stroke patients available 24/7; on-site critical care coverage 24/7

Stroke Unit

TSC CSC

Has a neurointensive care unit or designated intensive care beds for complex stroke patients available 24/7; on-site neurointensivist coverage 24/7

24/7

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− Call Schedules• Attendings• NP/PA• Residents/Fellows

How we review for Stroke Unit

Document Review

− Education

− Orientation

− TSC: Additional education or experience in critical care

− CSC: Additional education or experience in neurocritical care and cerebrovascular care

− Conversations with staff

CredentialingTracers Credentialing

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Emergency Department physician

Initial Assessment of Patient

TSC CSC

Emergency Department physician

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− Conversation with staff about Stroke Alert Process

− Documentation of time of initial assessment

How we review for Initial Assessment of Patient

Tracers

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CT, MRI, labs, CTA, MRA, catheter angiography 24/7; other cranial and carotid duplex ultrasound, TEE as indicated

Diagnostic Testing Capability

TSC CSC

CT, MRI, labs, CTA, MRA, catheter angiography 24/7; other cranial and carotid duplex ultrasound, TEE, TTE as indicated

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− Daily schedules

− Call schedules

How we review for Diagnostic Testing Capability

Document Review Tracers

− Conversation with staff

− Documentation of time of testing and test results availability

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24/7 via in person or telemedicine; written call schedule for attending physicians providing availability 24/7

Neurologist Accessibility

TSC CSC

Meets concurrently emergent needs of multiple complex stroke patients; Written call schedule for attending physicians providing availability 24/7

24/7

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− Daily schedule

− Call schedule

− CSC: Policy/Protocols for 2 concurrent patients

How we review for Neurologist Accessibility

Document Review Tracers

− Conversation with staff

− Medical record documentation of Neurologist consultation

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Within 2 hours; OR is available 24/7 in TSCs providing neurosurgical services

Neurosurgical Services

TSC CSC

24/7 availability: Neurointerventionist; Neuroradiologist; Neurologist; Neurosurgeon

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How we review for Neurosurgical Services

Document ReviewOpening

− Trauma level designation by outside organization

− OR daily schedule

− OR call schedule

− Physician call schedules

− Documented time to OR

Tracers

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IV thrombolytics; Mechanical thrombectomy; Microsurgical neurovascular clipping of aneurysms; Neuroendovascular coiling of aneurysms; Stenting of extracranial carotid arteries; Carotid endarterectomy

Treatment Capabilities

TSC CSC

IV thrombolytics; Mechanical thrombectomy, IA thrombolytics

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− Patient lists

How we review for Treatment Capabilities

Document Review Tracers

− Patient tracers of varying patients

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For neurosurgical emergencies

Transfer Protocols

TSC CSC

For receiving transfers and circumstances for not accepting transferred patients

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− Written Protocols for transferring and receiving patients

• Include time parameters

• Transfer procedures

How we review for Transfer Protocols

Document Review System Tracers

• TSC: Door to transfer out data

• CSC: How do you evaluate CSC transfers in

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Nurses and other ED staff – 2 hours annually; Stroke nurses and core stroke team – 8 hours annually

Staff Stroke Education Requirements

TSC CSC

Nurses and other ED staff - 2 hours annually; Stroke nurses and core stroke team - 8 hours annually

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− Department Educators should be present for this session

− Written or electronic list of education with hours indicated

− Education in cerebrovascular and stroke

− Read note in standards as to which nurses need 8 hours of education

− Best Practice

• Organizational schedule with department and STROKE educational requirements

How we review for Staff Stroke Education Requirements

Credentialing and Competency

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Provides educational opportunities to prehospital personnel; Provides at least 2 stroke education activities per year to public

Provision of Educational Opportunities

TSC CSC

Sponsors at least 2 public educational opportunities annually; LIPs and staff present 2 or more educational courses annually for internal staff or individuals external to the comprehensive stroke center (e.g., referring hospitals)

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− Usually a list of education activities in opening session

− Often with photos of the events

How we review for Provision of Educational Opportunities

Opening Session

Tracers

Document Review

− List of education events

− List of participants

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Standardized Measures: 8 inpatient STK measures and 5 ischemic comprehensive stroke measures for a total of 13 measures.

Clinical Performance Measures

TSC CSC

Standardized Measures: 8 inpatient STK measures and 10 comprehensive stroke measures (ischemic and hemorrhagic) for a total of 18 measures.

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How we review for Clinical Performance Measures

Data Session

− TSC: 90 minutes− Additional Data to be presented (Please review DSPM standards for up to date

requirements):− Process Improvement activities− Stroke log

− Door to Needle times− All cause death within 72 hours of mechanical thrombectomy and symptomatic ICH− IV thrombolytic complications− Follow up phone call− Patient satisfaction

Have a Power Point Presentation

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− CSC: 2 hours− Additional data to be presented (Please review

DSPM standards for up to date requirements) :− Process Improvement activities− Stroke log

− Door to needle times− Research − Process for Peer Review− Follow up phone call− Patient satisfaction

How we review for Clinical Performance Measures

− Additional DSPM requirements

− Complications

− CEA/CAS data

− Diagnostic Angiography

− CSF infection rate

Data Session

Have a Power Point Presentation

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Participates in patient-centered research that is approved by the IRB

Research

TSC CSC

N/A

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− Patient centered

− IRB Approved

− Registry or Laboratory based research DOES NOT meet this standard

− List of current stroke research

• Reviewer may ask for current IRB letters for enrolling studies

− Remember: nursing and rehab patient centered IRB approved research counts

How we review for Research

CSC ONLY

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Recommendations from Brain Attack Coalition for Comprehensive Stroke Centers, 20052018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

Guidelines

TSC CSC

AHA/ASA Focused Update for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment, 20152018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association

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− List of organizations current CPG for the care of the stoke patient population

• OK to have online

• Reviewer may ask staff to find CPG

How we review for Guidelines

Document Review

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One Reviewer, Two Days

Review Length

TSC CSC

Two Reviewers, Two Days

Thank you!Send Questions to certification@jointcommission.org