The Joint Commissions Core Measures serve as a standardized assessment measure for care given in specific areas.  Despite widespread dissemination of the core measures, safety goals, and related quality guidelines, there is significant variation in their application across hospitals.  The reasons for this are varied but include differences in guideline familiarity, provider training, and tools and systems to ensure that recommended care is provided and documented.   Also hospital type, size, and location have been found to correlate with compliance rates.   Other hospital characteristics such as physician leadership and organizational support also appear to contribute to the consistent use of evidence-based processes of care. (Andrew L. Masica, Richter, MS, MFA, ELS, Convery, MD, MMM, CPE, & Haydar, MD, MBA, 2009)

It is suggested that one reason for lack of compliance with core measures is a lack of awareness linking the evidence connecting processes of care to improved outcomes.  It has been found that compliance with core measures increases when staff is educated about the evidence supporting these measures.

We will now look at the evidence behind the Core Measure Set for Strokes             

STROKE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES

Set Measure ID #	Measure
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—8	Stroke Education
STK—10	Assessed for Rehabilitation

(Andrew L. Masica, Richter, MS, MFA, ELS, Convery, MD, MMM, CPE, & Haydar, MD, MBA, 2009).  

STK—1:  Venous Thromboembolism (VTE) Prophylaxis

Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.

• Stroke patients are at increased risk of developing venous thromboembolism (VTE). One study noted proximal deep vein thrombosis in more than a third of patients with moderately severe stroke. Prevention of VTE, through the use of prophylactic therapies, in at risk patients is a noted recommendation in numerous clinical practice guidelines. For acutely ill stroke patients who are confined to bed, thromboprophylaxis with low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux is recommended if there are no contraindications. Aspirin alone is not recommended as an agent to prevent VTE.

STK—2:  Discharged on Antithrombotic Therapy

Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge

• 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. For patients with a stroke due to a cardioembolic source (e.g., atrial fibrillation, mechanical heart valve), warfarin is recommended unless contraindicated. Warfarin is not generally recommended for secondary stroke prevention in patients presumed to have a non-cardioembolic stroke.
• Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA.

STK—3:  Anticoagulation Therapy for Atrial Fibrillation/Flutter

• 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. The Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with advancing age, from 1.5% for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Due to these figures, significance has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation. It has been found the relative risk of thromboembolic stroke was reduced by 68% for atrial fibrillation patients treated with warfarin. The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke.

STK—4:  Thrombolytic Therapy

• The administration of thrombolytic agents to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial. The Food and Drug Administration approved the use of intravenous recombinant tissue plasminogen activator (IV r-TPA or t-PA) for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset.  While controversy still exists among some specialists, the major society practice guidelines developed in the United States all recommend the use of IV t-PA for eligible patients. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment.

STK—5:  Antithrombotic Therapy by End of Hospital Day 2

• Data at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity as long as no contraindications exist.
• Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA.

STK:  6:  Discharged on Statin Medication

Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.

• All patients with ischemic stroke or TIA should have lipid profile measurement performed within 48 hours of hospital arrival unless results are available from within the past 30 days. A large body of evidence suggests that non-fasting lipid levels drawn in the first 48 hours after a major vascular event are reliable predictors of baseline lipid profiles, but after that time they may become unreliable.
• It is recommended that all patients with ischemic stroke or TIA with coronary heart disease or symptomatic atherosclerotic disease who have an LDL greater than or equal to 100 mg/dL (or with LDL less than 100 mg/dL due to being on lipid lowering therapy prior to hospital arrival) should be treated with a statin. The target goal for cholesterol lowering is an LDL-c level of less than 100 mg/dL. An LDL-c less than 70 mg/dL is recommended for very high-risk persons with multiple risk factors.

STK—8:  Stroke Education

Education includes activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.

• Patient education programs for patients with chronic conditions have improved health status, increased healthful behaviors, and increased compliance with treatment recommendations including medications. Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient’s prognosis and potential for rehabilitation.

STK-10:  Assessed for Rehabilitation

• Stroke rehabilitation should begin as soon as the diagnosis of stroke is established and life-threatening problems are under control. Among the high priorities for stroke are to mobilize the patient and encourage resumption of self-care activities as soon as possible. A considerable body of evidence indicates better clinical outcomes when patients with stroke are treated in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services. Effective rehabilitation interventions initiated early following stroke can enhance the recovery process and minimize functional disability. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function.

When reviewing a case involving a Stroke I utilize the Joint Commission Core Measures to determine if there was any lack of following these core measures with this particular patient.  If I find that the Core Measures were not adhered to I may then ask for the hospitals education files for the staff involved regarding Joint Commission Core Measures.  Nurses should be proactive with the patients in their care in making sure that the appropriate medications are given and prescribed at discharge; and that appropriate and effective patient education is performed.

 

Works Cited

Andrew L. Masica, M. M., Richter, MS, MFA, ELS, K. M., Convery, MD, MMM, CPE, P., & Haydar, MD, MBA, Z. (2009, April 22). Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Retrieved August 8, 2013, from US National Library of Medicine, National Institute of Health: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2666853/