Stroke Certification

Written by Merrilee Phillips, Director of Neuroscience Services

The Medical Center of Aurora reached yet another milestone last month in the development of our Neuroscience Center of Excellence. On September 30, 2009, we invited the Joint Commission to our facility to complete a Primary Stroke Center certification survey.

What did the Disease-Specific Certification survey entail? We were required to show our ongoing commitment to "Every Standard, Every Day," as denoted by the Joint Commission.  In addition, we needed to show compliance with an additional set of Joint Commission Stroke Program standards above and beyond the day-to-day Joint Commission standards. Primary Stroke Certification is an elite designation for hospitals that shows a commitment and dedication to excellence in stroke assessment, diagnostics and secondary prevention.

Thanks to the incredible efforts of a tremendous number of people, we were able to showcase the extent of our Comprehensive Stroke Services and the great care we provide to stroke survivors and their family members. Our surveyor was very impressed with the commitment to safety and quality we offer as she toured our organization and spoke to our staff. Some of the highlights that she pointed out during her exit conference included:

• Exceptional physician commitment to this program; specifically the team of ED physicians, Neurologists, Neurosurgeons, Neuroradiologists, and Interventional Neuroradiologists who participated in the survey process
•  Excellent documentation of vital signs and neuro checks following tPA administration

• Depth of our internal educational efforts to ensure all staff and physicians are trained in stroke protocols and processes

•  Extensive education provided to patients, family members and our community partners on stroke risk factors

•  Active involvement of our EMS partners in the implementation of the Stroke Alert process.

The surveyor also identified some areas that we need to continue to focus on to ensure that we are consistent in our program implementation. Our policy and procedures say that we should be doing the same process for all patients, 100 percent of the time. Our recommendations for improvement involved the surveyor finding instances in which we did not follow our protocols 100 percent of the time:

• NIH Stroke Scale was not completed on ONE Stroke Alert patient.

• Speech Therapy Swallowing Evaluation was not completed on ONE patient who had failed a dysphagia screen

• Medications were given by mouth prior to documentation that ONE patient had successfully passed a dysphagia screen

• Documentation of individual patient's educational needs and comprehension of response to stroke education provided

We will continue to refine our processes to ensure that our stroke orders/ protocols are implemented 100 percent of the time and that TMCA's Comprehensive Stroke Services continue to provide world class care and outcomes. An action plan and updated results will be submitted to Joint Commission by mid-November as the final step in our quest for Primary Stroke Center Designation.

Primary Stroke Center Designation is an incredible achievement, and the physicians and staff at TMCA can be pleased and proud of what we have accomplished. The volume of ischemic and hemorrhagic stroke patients treated by TMCA's Comprehensive Stroke Services has grown significantly year over year, which speaks to the quality of care and strength of our partnerships with our EMS agencies.

Primary Stroke Center certification is an important step in establishing TMCA as a regional Neuroscience Center of Excellence for Stroke and all neuroscience services. On behalf of the Core Stroke Team, the Stroke Physician Leadership Committee and the Stroke Implementation Team, I would like to extend personal thanks and gratitude to all who provided support during the extensive survey preparation activities and the actual survey process. The surveyor made a specific note that Dr. H. Rai Kakkar's involvement in the survey process was extraordinary. We appreciate Dr. Kakkar's invaluable guidance as Medical Director of our Stroke Services.