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Stroke center certification

Preparing for PSC certification

Preparing for PSC certificationThe Joint Commission's Certificate of Distinction for Primary Stroke Centers (PSC) recognizes and certifies centers that make exceptional efforts to improve stroke treatment and patient care. This includes an educated and prepared stroke team, established protocols for assessment, diagnosis and treatment of stroke, and a commitment to community outreach and stroke awareness education. Achievement of certification can signify a greater level of care and capability to your community.

The Joint Commission PSC certification program was developed in collaboration with the American Stroke Association and is based on the Brain Attack Coalition's "Recommendations for the Establishment of Primary Stroke Centers."

Stroke centers may also be certified at the state level. Centers seeking this type of certification should contact their state legislatures or regional stroke networks.

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Preparing for PSC certification

Preparing for Joint Commission PSC certification can be optimally managed in 4 key steps:

Step 1: Defining the acute stroke process1-3

Preparing for PSC certificationThe goal is a detailed plan for administering IV t-PA to eligible patients within 60 minutes from time of arrival. This plan may include:

  • Training ED staff to recognize stroke signs and symptoms
  • Assembling a "Code Stroke" packet with:
    • – A system for notifying team members
    • – A time tracking tool
    • – All physician and nursing documents
  • Developing standardized orders for:
    • – Diagnostic testing
    • – Lab notification
    • – National Institutes of Health Stroke Scales (NIHSS)
    • – Dysphagia screening
    • – t-PA inclusion and exclusion criteria
  • The Joint Commission requires that 80% of ED providers know the acute stroke process.

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Step 2: t-PA training is critical for certification1-3

Preparing for PSC certificationKey training points include:

  • Staff awareness of the 60-minute door-to-needle goal
  • Inclusion and exclusion criteria for t-PA administration
  • Location of t-PA and determining who will mix and administer it
  • How the dose is administered
  • BP goals before, during, and after t-PA administration
  • Vital sign and neurologic monitoring following t-PA bolus dose
  • Recognizing and managing potential post treatment bleeding
  • Medications to avoid (24 hours) after treatment with t-PA
    • – Drugs that alter platelet function (eg, acetylsalicylic acid [aspirin], dipyridamole, and abciximab), antithrombotics (eg, heparin), and oral anticoagulants (eg, warfarin sodium)

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Step 3: Conducting mock codes2,3

Preparing for PSC certificationMock codes are an ideal way to practice the in-house stroke protocol.

  • Identify stroke response team members
  • Train hospital staff in:
    • – Stroke signs and symptoms
    • – Determination of onset time
    • – Activation of stroke response team
  • Develop acute stroke "tackle box"
    • – Standardized acute stroke orders
    • – t-PA inclusion and exclusion criteria
    • – Patient education materials related to t-PA
    • – NIHSS
    • – Dysphagia screen
    • – Foley catheter insertion instructions
  • t-PA administration training and practice

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Step 4: Providing feedback and relevant information about outcomes with the stroke team, ED, and EMS staff helps to optimize care and allows for continual process improvement3

Preparing for PSC certificationPossible communication methods include:

  • EMS notification of patient outcomes
  • ED bulletin board
  • Quarterly EMS awards
  • Sharing of case studies
  • Monthly staff meetings
  • Newsletters
  • Medical executive meetings
  • Press releases

The Joint Commission released the following consensus performance measures in January 2009 that went into effect in primary stroke centers4,5:

NumberPerformance measures
STK-1*†Venous thromboembolism (VTE) prophylaxis
STK-2*†Discharged on antithrombotic therapy
STK-3*†Anticoagulation therapy for atrial fibrillation/flutter
STK-4*†Thrombolytic therapy
STK-5*†Antithrombotic therapy by end of hospital day 2
STK-6*†Discharged on statin medication
STK-7Screen for dysphagia
STK-8*†Stroke education
STK-9Smoking cessation
STK-10*†Assessed for rehabilitation

Note: Effective January 1, 2008, all ten measures are required for certification.

  • *
  • CMS Informational ONLY.
  • †
  • The Joint Commission ONLY.

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Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Important Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-1711.
2.
National Institute of Neurological Disorders and Stroke. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. December 12-13, 1996. Bethesda, MD: National Institutes of Health; 1997. NINDS Web site. http://www.ninds.nih.gov/news_and_events/proceedings/strokeworkshop.htm. Updated June 19, 2008.
3.
Estes D. Preparing for primary stroke center certification: optimizing stroke outcomes with t-PA. Paper presented at: Medical City Dallas Hospital; 2008; Dallas, TX.
4.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Disease-specific care stroke measure harmonization. Conference call: performance measure update. November 16, 2007. The Joint Commission Web site. www.jointcommission.org/assets/1/18/Stroke_Performance_Measures_Update_10-28-09.pdf. Accessed October 21, 2008.
5.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Specifications Manual for National Hospital Quality Measures. Version 3.0. The Joint Commission Web site. www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/. Accessed May 12, 2009.