Quality & Patient Safety

quality & patient Safety

Stroke Performance Measures

Stroke, also called brain attack, occurs when blood flow to the brain is disrupted. Disruption in blood flow is caused when either a blood clot or piece of plaque blocks one of the vital blood vessels in the brain (ischemic stroke), or when a blood vessel in the brain bursts, spilling blood into surrounding tissues (hemorrhagic stroke).

The following graph shows how MUSC handled certain factors when treating stroke patients when compared to the national average.  The national average is comprised of other hospitals using Get With the Guidelines (GWTG) who are also Primary Certified Stroke Centers through Joint Commission accreditation. t.

The numbers reported are from October - December 2013.  In all cases, a higher score is better.

Appropriate Care Measure
Stroke


Stroke Measurements

graph legend

Deep Vein Thrombosis Prophylaxis
Discharged on Antithrombotics
Patients with Atrial Fibrillation Receiving Anticoagulation Therapy
Thrombolytic Therapy Administered

Antithrombotic Medication within 48 Hours of Hospitalization
Discharged on Cholesterol Reducing Medication
Screen for Dysphagia
Stroke Education
Smoking Cessation Advice/Counseling
A Plan for Rehabilitation was Considered

Deep Vein Thrombosis Prophylaxis

Patients with an ischemic stroke or a hemorrhagic stroke and who are non-ambulatory should start receiving DVT prophylaxis by end of hospital day two. Patients experiencing a stroke that involves a paretic or paralyzed lower extremity are at increased risk of developing deep vein thrombosis (DVT). One study noted proximal deep vein thrombosis in more than a third of patients with moderately severe stroke. Reported rates of occurrence vary depending on the type of screening used. Prevention of DVT, through the use of prophylactic strategies, in at risk patients is a noted recommendation in numerous clinical practice guidelines. *


Discharged on Antithrombotics

Patients with an ischemic stroke prescribed antithrombotic therapy at discharge.  The effectiveness of antithrombotic agents in reducing stroke mortality, stroke related morbidity and recurrence rates has been studied in several large clinical trials. While the use of these agents for patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study, substantial evidence is available from completed studies. Data at this time suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist. *

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Patients with Atrial Fibrillation Receiving Anticoagulation Therapy

Patients with an ischemic stroke with atrial fibrillation discharged on anticoagulation therapy.  Nonvalvular atrial fibrillation (NVAF) is a common arrhythmia and an important risk factor for stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke. It has been estimated that over 2 million adults in the United States have NVAF. While the median age of patients with atrial fibrillation is 75 years, the incidence increases with advancing age. *

Thrombolytic Therapy Administered

Acute ischemic stroke patients who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom IV t-PA was initiated at this hospital within 180 minutes (3 hours) of time last known well.  The administration of thrombolytic agents to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials. These included two positive randomized controlled trials in the United States; The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. *

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Antithrombotic Medication within 48 Hours of Hospitalization

Patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two.  The effectiveness of antithrombotic agents in reducing stroke mortality, stroke related morbidity and recurrence rates has been studied in several large clinical trials. While the use of these agents for patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study, substantial evidence is available from completed studies. Data at this time suggest that antithrombotic therapy should be initiated within 48 hours of symptom onset in acute ischemic stroke. *

Discharged on Cholesterol Reducing Medication

Ischemic stroke patients with LDL>100, or LDL not measured, or on cholesterol-reducer prior to admission, who are discharged on cholesterol reducing drugs. An elevated serum lipid level has been a well-documented risk factor for coronary artery disease (CAD). Recently, there has been an increased focus on examining the relationship between elevated lipid levels and the incidence of stroke. In particular, some recent clinical trials have analyzed the association between lipids and non-hemorrhagic stroke. The reduction of LDL cholesterol, through lifestyle modification and drug therapy, for the prevention of strokes and other vascular events is recommended for patients with CAD in the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) Guidelines. *

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Screen for Dysphagia

Patients with ischemic or hemorrhagic stroke who undergo screening for dysphagia with a simple valid bedside testing protocol before being given any food, fluids, or medication by mouth. Dysphagia is a potentially serious complication of stroke. The importance of assessing a patient’s ability to swallow, before approving the oral intake of fluids, food or medication, has been noted in multiple practice guidelines including the Agency for Healthcare Research and Quality (AHRQ) Post-Stroke Rehabilitation guideline. It has been estimated that 27-50% of stroke patients develop dysphagia. Furthermore, 43-54% of stroke patients with dysphagia will experience aspiration and of those patients 37% will develop pneumonia. Dysphagia may contribute to malnutrition and increased length of hospital stay. *


Stroke Education

Patients with ischemic or hemorrhagic stroke or their caregivers who were given education or educational materials during the hospital stay addressing all of the following: personal risk factors for stroke, warning signs for stroke, activation of emergency medical system, need for follow-up after discharge, and medications prescribed. There are many examples of how patient education programs for specific chronic conditions have increased healthful behaviors, improved health status, and/or decreased health care costs of their participants. Clinical practice guidelines include recommendations for patient and family education during hospitalization as well as information about resources for social support services. *

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Smoking Cessation Advice/Counseling

Patients with ischemic or hemorrhagic stroke with a history of smoking cigarettes, who are, or whose caregivers are, given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.  Cigarette smoking is the single most alterable risk factor contributing to premature morbidity and mortality, accounting for approximately 430,000 deaths in the United States. Smoking nearly doubles the risk of ischemic stroke. *


A Plan for Rehabilitation was Considered

Patients with an ischemic stroke or hemorrhagic stroke who were assessed for rehabilitation services.  Each year about 700,000 people experience a new or recurrent stroke, which is the nation's third leading cause of death. Approximately two thirds of these individuals survive and require rehabilitation. Stroke is a leading cause of serious, long-term disability in the United States, with about 4.4 million stroke survivors alive today. Forty percent of stroke patients are left with moderate functional impairment and 15 to 30 percent with severe disability. More than 60% of those who have experienced stroke, serious injury, or a disabling disease have never received rehabilitation. Stroke rehabilitation should begin as soon as the diagnosis of stroke is established and life-threatening problems are under control. *

* Source: The Joint Commission "Stroke Performance Measurement Implementation Guide."

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