Natalie Swearingen, MSN, RN, CNRN

Stroke Quality & Outcomes

Presenter Disclosure Info

•Topic: Stroke Quality and Outcomes

•Financial Disclosures: None

Objectives:•Stroke Program: Quality and Outcomes

•Modified Rankin Scale (mRS)

•Portland Stroke Standardized feedback Tool

(PSST) EMS feedback

•Providence Oregon Stroke Data

Case ScenarioPt “A” 94y.o. female sitting down to eat dinner suddenly develops left side

hemiplegia, right gaze preference, and left side inattention at 1705. Dtr witnessed

the sudden onset of stroke symptoms and called 9-1-1, initial NIHSS 21.

Treatment summary:

IV alteplase + thrombectomy

Door to needle time: 43min

Pre TICI= 1

Door to groin= 93min

1 pass with stent retriever

Right M1

occlusion

Case Scenario

Right M1

occlusion

Right MCA

openPost procedure TICI= 3

24hrs post procedure

NIHSS= 3 (left face

droop, left upper and

lower extremity drift).

Discharged: SNF

(ambulating with FWW)

90 day mRS=1

(living back at home

with DTR)

Definitions

Quality

Outcome

DATA

Oct-2017 – Aug 2018 (1year)

DATA

DATA

Improved communication with front line staff

Graphs & more Graphs

Data Exports

Data Input

Dayshift DTN median= 39min (n=53)

Nightshift DTN median= 50min (n=26)

2017 DTN median=42min (n=67)

2018 DTN median= 42min (n=79)

18% volume increase/ 70% EMS arrivals

EMS DTN median= 35.5min (n=54)

Walk-ins DTN median= 57.5min (n=24)

Median Door to CVL= 10.5min

Transfer median DTG= 24.5min (n=12)

Dayshift median= 25min (n=7)

Nightshift median= 24min (n=5)

New

DTG

Record

Jan 2017- Jan 2019 (2 yr aggregate)

PPMC and PSV LVO volume 103 cases

Overall DTG median 92min!

Jan 2018- Jan 2019 (individual cases)

PPMC and PSV LVO volume 57 cases

Overall DTG median 92min!

Awesome

times

team!

Modified Rankin Scale

0

Saver JL, Filip B, Hamilton S, et al. (2010). Improving the reliability of stroke disability grading in clinical trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke

DATA8/1/2016 - 7/31/2018

8/1/2016 - 7/31/2018

PSV mRS 0-2 (n=70)

73% Independent

PPMC mRS 0-2 (n=42)

67% independent

50% independent mRS 0-2

Modified Rankin Scale

0

112

FeedbackPortland

Standardized

Stroke

feedback Tool

PSST EMS

Case Scenario #2“Pt B”- 52 y.o. f with no past medical history, bouncing on trampoline when

husband found her 15min later not speaking or moving her right side. 9-1-1 was

called and a “stroke alert” was called in by EMS. NIHSS on arrival 24.

Treatment Summary:

IV Alteplase + thrombectomy

Door to needle time: 41min

Pre TICI= 0

Post TICI= 2b

Door to groin= 82min

Successful recanalization

with 4 passes of stent

retriever

LMCA clot

Case Scenario #2

Immediately post thrombectomy NIHSS=4 in ICU (aphasia only)!

12hrs post procedure NIHSS= 0, DC’d home day 3 NIHSS=0 no

neuro deficits!

National Quality Goals

Quality/Data Benefits• Robust database eliminates data lag for real time feedback to all team members

• Validate current process or use to initiate a new quality improvement initiative

– example: parallel process vs working in silos

• Visual data is meaningful

• Encourages rapid cycle evaluations to take action, adjust process, test ideas

• Consistent feedback to all stakeholders for clear communication of goals to improve patient

outcomes

• Reflection on clinical practices from previous years, ability to investigate trends in patient

management over time

• Benchmark with other stroke programs

Treatment

Faster treatment saves lives and reduces disability!

For every 15 minutes saved:

•Fewer patients die

•Fewer patients bleed

•More patients go home

•More patients are independent at discharge

Saver JL, Fonarow GC, Smith EE, et al. (2013). Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA.

References

1) Powers, W., Rabinstein, A., et.al. (2018). AHA/ASA Guidelines for the early management of patients with

acute ischemic stroke. Stroke. 49:e1-e344. doi:10.1161/STR.0000000000000158.

2) Saver JL, Filip B, Hamilton S, et al. (2010). Improving the reliability of stroke disability grading in clinical

trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke 41(5):992–95.

doi:10.1161/STROKEAHA.109.571364.

3) Saver JL, Fonarow GC, Smith EE, et al. (2013). Time to treatment with intravenous tissue plasminogen

activator and outcome from acute ischemic stroke. JAMA. 309(23):2480–2488.

doi:10.1001/jama.2013.6959

4) Summers, D., Leonard, A., Wentworth, D., (2009) AHA Guideline: Comprehensive overview of nursing and

interdisciplinary care of the acute ischemic stroke patient. Stroke. 40:2911-2944.

5) Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. (1988). Interobserver agreement for

the assessment of handicap in stroke patients. Stroke 19(5):604-7