ED documentation aids certification

Timing of processes is a key for Joint Commission

A change in documentation procedures in the ED played a significant role in making it possible for Porter Adventist Hospital in Denver to receive certification as an advanced primary stroke center by The Joint Commission.

"I'm not sure the entire process of treating stroke patients changed, but the documentation and a lot of the logistics or flow patterns did," says Adam Wolff, MD, the stroke medical director. "We took good care of stroke patients previously, but once we decided to try to become a certified stroke center, we had to take even greater care in a timely manner and be able to prove it." (Education also was an important part of the process. See the story, p. 45.)

In the Porter Adventist ED, he explains, a stroke alert can be activated via EMS in the field or in the ED via a walk-in patient. "But when it is activated, the nurse in charge and the clerk in the ED have a flow sheet specific to that patient that contains a lot of data points." [A sample copy of the form is available. For assistance, contact customer service at (800) 688-2421 or customerservice@ahcmedia.com.]

Summer Cooper, RN, CCRN, the stroke coordinator, explains the data points. "There are some specific time frames to be seen in the ED recommended by the National Institute of Neurologic Disorders to meet the 'golden hour' for care," Cooper notes. "For example, from door to initial evaluation is 10 minutes, [a total of] 25 minutes until the CT scan is initiated, 45 minutes until it is interpreted, and an additional 15 minutes for the tissue plasminogen activator [tPA] decision." In addition, she notes, The Joint Commission has outlined eight standardized measures with which each stroke patient should be treated. (Editor's note: To see a copy of the measures, go to www.jointcommission.org/PerformanceMeasurement. At the bottom of the page, select "Specification Manual for National Hospital Quality Measures.")

Wolff says, "Our ultimate goal is to treat every stroke patient within one hour of hitting the ED. When we meet in committee to review all cases, if a case 'fell out,' we identify why it did. Perhaps they did not receive the CT scan fast enough or the lab was tardy."

The Joint Commission wants to see that you have a plan in place and quality improvement processes to recognize problem areas within the plan and improve them, he says. "So, for example, we were having problems getting reads from radiologists on time," Wolff recalls. "We came up with a solution by ordering not just a CT, but instead a 'CT stroke alert brain,' which requires the radiologist to call with a 'wet read' immediately."

"Immediately" means within minutes, Wolff says. However, he does not want to require the ED to make sure that happens. "They deal with emergent patients all the time, and the more of an onus you put on them, the more likely they are to fall out," Wolff says. When a stroke alert is called, he adds, several services such as radiology, lab, the ED, pharmacy, and neurology are notified, "and that should get everybody moving in a coordinated way."

On the ED level, the nurse is responsible for two IV access lines, Wolff says, "and they do a really good job." The ED physician is responsible for doing a National Institutes of Health Stroke Scale screening. "We do fall out a lot on documentation because the docs are too busy, but we have a program in place to contact the doctors and remind them to do that," says Wolff.

Education key part of certification

Education was an important part of Porter Adventist Hospital in Denver earning certification as an advanced primary stroke center from The Joint Commission, says Summer Cooper, RN, CCRN, the stroke coordinator.

"We worked a lot with EMS to educate them. They know that they can call ahead with a stroke alert, so we prepared them and got everyone else to be ready to hit the time frames," Cooper says. "If they call an alert, we can prepare and have the doctor waiting. The radiology department knows a stroke patient is coming, so they clear a table, and the on-call neurologist is paged to be present or available to talk with the ED physician on the phone."

Physician education was handled by the ED medical director, adds Adam Wolff, MD, the stroke medical director. "Basically it was a primer on the use of tPA. One of the main points of the program is appropriately treating people who are candidates with tPA," he says.

Topics include a description of the drug, its indications and contraindications, side effects, the National Institutes of Health Stroke Scale, and documentation.

"A couple of Colorado facilities in our system are certified, so we worked with their coordinators to help build the program," Cooper says. Then, in preparation for the deciding site visit by The Joint Commission, they performed a mock survey in May 2009. The mock survey was conducted by two stroke coordinators and a neurosciences director from sister Centura hospitals that already were certified primary stroke centers. "They essentially re-enacted an actual TJC on-site review," she says.

Following the mock survey, a number of changes were made, including revision of the ED and in-house stroke patient process flows, so that they were more streamlined. Also, a computerized slide presentation was created with an overview of the processes to create a clearer portrait of the program for the surveyor.

"The mock survey was an essential first step to certification," says Cooper.

Clinical Tip

Beware of low BP in stroke patients

One of the pitfalls to avoid in treating acute stroke patients is lowering the patient's blood pressure (BP), warns Adam Wolff, MD, the stroke medical director at Porter Adventist Hospital in Denver.

"That can be dangerous for the patient," he says. "You often want their BP to be elevated."

Another error to avoid is failing to give the patient a swallow screen, he says. "A lot of stroke patients have trouble swallowing and end up with aspiration pneumonia because oral medications have been given inappropriately," he says. "They should always be screened before give anything PO."