14 recommendations developed
The University HealthSystem Consortium in Oak Brook, IL, sponsored a study, Ischemic Stroke Clinical Benchmarking, that identified risk, process, and outcome measures for ischemic stroke.
The study was conducted from Jan. 1, 1996, to March 31, 1996, and involved 36 academic health care institutions. Each institution collected clinical data from 30 consecutive medical records meeting the following criteria:
· Patients are older than 17 and have a primary diagnosis of occlusion and stenosis of precerebral arteries (ICD-9 433), occlusion of cerebral arteries (ICD-9 434), or acute but ill-defined cerebrovascular disease (ICD-9 436) with infarction.
· 31 cases were trimmed from the database because they were three standard deviations above the mean length of stay (LOS) in the data base (35 days).
The study's executive summary lists the its key goals, criteria for identifying better performers, findings, and recommendations:
o compelling comparative data that illustrate variations in processes of care;
o comparisons of their institutions with cen ters having similar characteristics and clinical outcomes, including descriptions of best demonstrated practices;
o implementation strategies for adopting or adapting aspects of best practices.
Criteria for identifying better performers:
o short LOS, discharged home;
o short LOS, discharged to rehabilitation;
o early/immediate discharge planning;
o short LOS in the emergency department;
o percentage of cases admitted to neurology;
o early rehabilitation consultation;
o established blood pressure parameters;
o little use of indwelling urinary catheters;
o deep vein thrombosis prophylaxis;
o carotid examination.
o Mean LOS varied considerably among participants, regardless of severity status at admission and discharge.
o Mean hours spent in the emergency department are significant.
o More than 50% of patients in the database had no blood pressure parameters established by physician order.
o The percentage of patients receiving heparin during their hospitalization varied from 10% to 90%; the number of patients who received heparin and oral anticoagulants after presenting with atrial fibrillation also varied widely.
o Some hospitals never use pulse oximetry, while others use it routinely for all or most patients; the number of patients who received oxygen varied from less than 10% to 70%.
o In most hospitals, less than 40% of ischemic stroke patients received a swallowing assessment, although in some hospitals that figure was closer to 80%.
o The percentage of patients with an indwelling urinary catheter varied from none to 56%.
o Most patients were walking in less than four days, although the mean number of days to ambulation varied from less than one day to eight days.
o The use of compression devices, whether full leg or calf, varied by hospital and by type.
o Most patients took less than four days from admission to initial discharge plan evaluation, although the mean number of days varied from less than one to eight.
o The percentage of patients who received an ultrasound or MRI scan or an angiogram varied from 30% to 90% for a carotid examination, and from less than 10% to more than 70% for a CT and MRI.
o Use physician-led teams to develop patient management tools in the form of protocols, pathways, and guidelines that focus on hours, not days; measure variance only on key issues.
o Use comparative data for accreditation surveys by the Joint Commission on Accredita tion of Healthcare Organizations to illustrate continuous improvement.
o Develop a protocol with screening criteria to determine appropriateness of tPA use.
o Establish a community outreach program.
o Develop a stroke "code" or brain attack team.
o Have CT or MRI available 24 hours a day with standard orders to prompt for imaging specific vascular regions; use a CT scan only to rule out hemorrhage.
o Develop a diagnostic algorithm for using MRI/MRA or CT scans.
o Perform triage in the emergency department using a stroke pathway, the National Institutes of Health stroke scale, or standing orders; develop educational material to explain these guidelines.
o Implement immediate discharge planning that evaluates family support.
o Provide immediate and continuing patient and family education.
o Develop a screening tool for nurses to use to identify patients who are at risk for aspiration or need speech therapy.
o Forge a strong relationship with rehabilitation facilities that will accept acute patients, such as those on heparin.
o Continue antithrombotic therapy after discharge.
o Provide a follow-up assessment (at least a year).