Clues offered on queries for stroke certification

Are you ready to put your ED’s stroke care under the microscope to be inspected by surveyors from the Joint Commission on Accreditation of Healthcare Organizations? A growing number of EDs are applying for Joint Commission’s Primary Stroke Center Certification program, which requires an on-site survey to assess whether stroke care meets national quality standards.

Here are specific questions asked at recently surveyed EDs:

  • What do nurses document?

"The surveyor was interested in the preprinted chart form that we use for suspected cerebrovascular accident /transient ischemic attack [CVA/TIA], which gives us the timelines that we are to meet," says Ken Lanphear, RN, BSN, ED nurse at Borgess Medical Center in Kalamazoo, MI. (See form used for stroke/ TIA notes.)

The form contains all the information needed to make a quick determination of the patient’s neurological status, including nursing assessment, the time they were last seen normal, time to room, time when the ED was notified of the patient’s arrival, door-to-physician time, when labs were drawn, time the stroke team was notified, time to computerized tomography/magnetic resonance imagine (CT/MRI), and time when tissue plasminogen activator (t-PA) was started.

  • Which nurses care for stroke patients?

The surveyor wanted to know if all nurses in the ED cared for stroke patients or if certain nurses were identified as "stroke" nurses, says Lanphear. "We explained that in our ED, all nurses care for CVA/TIA patients," he says. All nurses use the National Institutes of Health (NIH) stroke scale, Lanphear says. "There are a few of us who have a more extensive neuro background, and we act as resources for our peers," he says.

  • How often are patients given thrombolytic treatment?

"Unfortunately, as in most EDs, the answer is that we don’t do it very often, because the patient usually doesn’t fall within the required timelines," says Lanphear. "She asked why, and the answer was given that community education was needed, and that we are actively engaged in that process."

  • What happens when a stroke patient arrives?

Ideally, the Joint Commission surveyor would have followed an actual stroke patient’s care from the moment of their arrival in the ED, says Diana Everley, RN, BSN, ED clinical educator at Deaconess Hospital in Evansville, IN. "Since we did not have a patient that came in during the hours that the surveyor was here, we pretended."

Here is what the surveyor asked:

— The surveyor informed the triage nurse of her symptoms, to ensure that she asked, "When was the last time you were seen without symptoms?" "She also asked the triage nurse how she would assign her a bed, and what would happen if the ED was full and we did not have any beds at the time," says Everley. "She let the triage nurse take her to a treatment room in the back."

— The surveyor told an ED nurse what she had told the triage nurse about her symptoms and their onset. "She then asked what would happen from there and asked the nurse if she would like to get any references, and let her grab the stroke folder that we have available," she says.

The nurse said she would get vital signs, do a quick assessment, start an intravenous line and draw blood, put an order in for a computerized tomography (CT) scan, notify the ED physician, and call the CT scan room to alert them that the patient was on the way.

— The surveyor asked the nurse what would happen when she returned from CT. The nurse discussed that she or the physician would complete the NIH stroke scale. The physician would review the results, lab work, CT results, and the patient’s current vital signs.

— The surveyor gave the nurse hypothetical results: A negative CT, normal lab results, an NIH stroke scale score of 11, and normal vital signs. The nurse said she would get the inclusion/exclusion criteria from the physician, and the ED physician would discuss the results with the on-call neurologist.

— The surveyor asked the nurse to assume that the neurologist gave the OK to give t-PA, and questioned the nurse on how this would be given. She allowed the nurse to refer to the order set, and the nurse said that the patient would be transferred to the intensive care unit (ICU).

"The surveyor continued this line of questioning as she went to radiology and lab, up to the ICU, and so on," says Everley.

Sources

For more information on the Primary Stroke Center Certification, contact:

  • Diana Everley, RN, BSN, Clinical Educator, Emergency Department, Deaconess Hospital, 600 Mary St., Evansville, IN 47747. Telephone: (812) 450-7173. E-mail: diana_everley@deaconess.com.
  • Ken Lanphear, RN, BSN, Emergency Department, Borgess Medical Center, 1521 Gull Road, Kalamazoo, MI 49048. Telephone: (269) 383-8232. E-mail: kenl55@yahoo.com.