Stroke and Neurovascular Reports

The Joint Commission Measures

The Joint Commission uses eight clinical performance measures (described below) for stroke care. These measures were developed in collaboration with the American Heart Association (AHA), American Stroke Association (ASA) and Brain Attack Coalition (BAC) for use by Disease-Specific Care (DSC) certified primary stroke centers. The measures were endorsed by the National Quality Forum (NQF) in July 2008, and aligned with the Centers for Medicare and Medicaid Services.

Measures to Prevent Another Stroke

Discharged on antithrombotics — the patient is discharged with medication that prevents the formation of blood clots.
Patients with atrial fibrillation receiving anticoagulation therapy — about 15 percent of strokes occur in people with atrial fibrillation (abnormal heart rhythm). During atrial fibrillation, the atria (two upper chambers of the heart) quiver instead of beating normally. Blood does not pump completely out of the atria and may pool and clot. If a piece of a blood clot leaves the heart and becomes lodged in a brain artery, a stroke results. Anticoagulation therapy involves prescribing blood thinning medication that prevents the formation of blood clots.
Discharge on Statin Medication — an elevated serum lipid level is a risk factor for coronary artery disease. Elevated lipid levels are also related to the incidence of stroke. The reduction of LDL cholesterol, through lifestyle modification and medication, for the prevention of stroke and other vascular events is recommended for patients with coronary artery disease. It is also recommended that all patients with ischemic stroke or TIA with coronary heart disease or symptomatic atherosclerotic disease who have an LDL ≥ 100 mg/dl (or with LDL < 100 mg/dl due to being on lipid lowering therapy prior to admission) should be treated with a statin.

A lipid profile blood test is recommended for all stroke patients. A lipid profile usually includes total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides and low-density lipoprotein (LDL) cholesterol.
Stroke education — providing education about stroke for patients and care providers
Antithrombotic medication within 48 hours of hospitalization — patients recovering from a mild stroke or who have had a recent transient ischemic attack (TIA or “mini” stroke) are at high risk of having another stroke. Antithrombotic drugs, which prevent the formation of blood clots, should be given with 48 hours of symptom onset in acute ischemic stroke patients who meet certain guidelines for these drugs. Antiplatelet therapy is also recommended for most patients w/TIAs.

Emergency Measures
Thrombolytic Therapy — tPA is a clot-dissolving drug approved by the FDA to treat ischemic stroke (blood clots in the brain) in the first three hours after the start of symptoms. The sooner tPA or other appropriate treatment is begun, the better the chances for recovery.

Measures to Prevent Complications
Venous Thromboembolism (VTE) Prophylaxis (prevention of leg vein blood clots) — deep vein thrombosis (DVT) involves the formation of a clot in the veins in the lower leg and the thigh. This clot may interfere with circulation and may break off and travel through the blood vessels and cause another stroke. Patients experiencing stroke that involves a partially or totally paralyzed leg are at increased risk of developing DVT. DVT prevention is recommended for at-risk patients to reduce the risk of another stroke. Preventive measures include the use of blood thinning medications, compression stockings and pneumatic (air) compression of the legs.
Assessed for Rehabilitation — before discharge, stroke patients should be assessed or receive rehabilitation services to enhance their recovery and minimize functional disabilities.

Note: The chart below shows how the Froedtert & the Medical College Stroke & Neurovascular Program compared to other hospitals in the country.

“All hospitals” are those participating in Get with the Guidelines-Stroke (GWTG-Stroke) developed by the American Stroke Association. GWTG-Stroke is the American Stroke Association’s process for continuous quality improvement of acute stroke treatment and ischemic stroke prevention. The program helps hospitals collect and analyze stroke data, and provides a way for physicians and hospital staff to monitor their performance. GWTG-Stroke focuses on care team protocols to ensure that patients are treated and discharged appropriately.
“Midwest hospitals” are those participating hospitals in the Midwest region that participate with Get with the Guidelines-Stroke.

In all cases in the chart above, the higher percentage is preferred.

The above information addresses the Institute of Medicine’s aim for health care that is effective.

FAST — When Minutes Count

Minutes count when responding to a stroke. That’s just one reason why the Froedtert & the Medical College Acute Stroke Team (FAST) is available 24 hours a day, seven days a week. This acute response team provides stroke patients with rapid access to diagnosis and treatment.

Stroke neurologists, critical care neurologists, neurosurgeons, interventional neurologists, emergency medicine physicians and nurse specialists work around the clock to beat stroke.

Clot-Busting Drugs

Studies have shown that thrombolytic drugs, or clot-busters, effectively stop strokes and improve patient outcomes if specialists trained in giving the drugs are immediately available. All FAST doctors are trained to administer clot-busters and have been successfully using them since their approval in 1996. Some of these miracle drugs need to be administered intravenously within the first three hours of the onset of symptoms. It’s just another reason to act fast when stroke symptoms occur.

Tissue plasminogen activator (tPA) considered (a JCAHO measure for stroke care) — tPA is a clot-dissolving drug approved by the FDA to treat ischemic stroke (blood clots in the brain) in the first three hours after the start of symptoms. The sooner tPA or other appropriate treatment is begun, the better the chances for recovery.

In 2008, 100 percent of patients treated at Froedtert Hospital received IV tPA within the three hour treatment window.

The above information addresses the Institute of Medicine’s aim for health care that is timely.

Date: Feb. 26, 2010