Joint Commission Certification Research Articles

Abstract WP117: Post-procedural Screening With ROTEM For Risk Of Hemorrhage Following Revascularization Therapy For Acute Ischemic Stroke

Introduction: Hyperfibrinolysis is associated with intracerebral hemorrhage (ICH) after the use of tPA for acute ischemic stroke (AIS). Point-of-care Rotational ThromboElastoMetry (ROTEM) testing may rapidly detect hyperfibrinolysis and identify AIS patients at high risk for hemorrhage. Hypothesis: Evidence of fibrinogen depletion on ROTEM will accurately predict bleeding following revascularization therapy for AIS. Methods: We reviewed medical records of AIS patients who underwent revascularization therapy between 2019-2020. All patients underwent ROTEM testing post-procedure to facilitate targeted blood product transfusion should hemorrhage occur. However, transfusion was not performed prophylactically. Repeat imaging with dual-energy CT was performed within 24 hours. A quality control registry of all AIS patients who undergo revascularization is maintained for purposes of Joint Commission certification. All variables, including ROTEM values and occurrence of intra- and extracranial hemorrhage, were entered prospectively. We examined the predictive value of a FIBTEM-A10 <10mm for post-procedural hemorrhage. Results: A total of 52 patients were included. Median age was 68 years (Interquartile Range, IQR 60-83), and median admission NIHSS was 16 (IQR 10-20). Thirty-four patients (65%) received tPA, 46 (88%) received mechanical thrombectomy, and 28 (54%) received both. Median post-procedure FIBTEM-A10 was 16mm (IQR 14-22); 5 patients had values <10mm. Overall, 19 (37%) suffered radiographic ICH, 5 (10%) symptomatic ICH, and 3 (6%) extracranial hemorrhage. FIBTEM-A10 <10mm had sensitivity 17% and specificity 97% for any post-procedural hemorrhage. For symptomatic ICH, sensitivity was 0% and specificity 89%. Conclusions: The use of ROTEM to identify hyperfibrinolysis following AIS revascularization therapy achieved poor sensitivity and high specificity for prediction of any post-procedural hemorrhage, but was inaccurate for the prediction of symptomatic ICH.

Abstract 222: Changing Practice of Thrombolytic Therapy for Acute Ischemic Stroke in a Community Hospital After Implementation of Vascular Neurology Program

Introduction: Despite significant increase in intravenous tissue plasminogen activator (IV tPA) treatment rates in the US, only 9.0% of patients with acute ischemic stroke (AIS) receive IV tPA in certified Primary Stroke Centers (PSC). The goal of this study is to analyze the effects of the implementation of a vascular neurology program in a PSC certified community hospital on IV tPA treatment rates and related stroke metrics. Methods: This quality improvement project (QIP) was undertaken at a community hospital, in Arlington, VA, which is 380 bed hospital, with The Joint Commission certification as a PSC. Intervention included implementation of evidence-based ischemic stroke IV tPA pathways with extensive hospital-wide medical and nursing staff training (25 lectures for nurses and 6 for MDs) by two newly appointed board certified vascular neurologists from Department of Neurology, George Washington University, Washington, DC. Study outcome measures were: IV tPA utilization rate (IV tPA/total AIS = %), proportion of patients with door to needle time (DTN) < 60 minutes (%), discharge home (%), and symptomatic intracerebral hemorrhage (SICH). We compared one year outcomes, pre- (August 1, 2017-18) and post-intervention (August 1, 2018-19). No IRB approval was required, as this was a QIP. Results: There were n=752 AIS admissions: n=337 pre- and n=415 post-intervention. There was a significant increase in stroke patient volume after intervention (1.4% vs. 1.8%, p=0.0006). There was significant increase from 28.0% (7/25) to 66.7% (24/36) in proportion of patients with DTN < 60 minutes pre- versus post-intervention (p=0.0032). Although IV tPA utilization rate [7.4 % (25/337) vs. 8.7% (36/415), p=0.52] and proportion of patients discharged home were higher after intervention (52% vs. 61%, p=0.48), they did not reach statistical significance. There was no difference in the rate of symptomatic hemorrhagic transformation between two cohorts (8.0% pre vs. 8.3% post, p=0.96). Conclusions: Implementation of an evidence-based vascular neurology program in a PSC community hospital resulted in a significant increase in proportion of patients with DTN less than 60 minutes, an increase in stroke patient volume, and a trend towards higher IV tPA utilization rate and better AIS outcome.

Achieving Disease-Specific Care Joint Commission Certification: The Impact of Clinical Nurse Specialist Practice.

The aims of this study are to describe a program to achieve disease-specific care (DSC) certification from The Joint Commission and highlight the value of the advanced practice nurse in the certification outcome. The expertise in clinical practice, performance improvement, and leadership skills demonstrated by the clinical nurse specialist (CNS) can be instrumental in building a strong foundation for a DSC certification program. As an organization prepares for a DSC on-site review, the CNS can guide the program stakeholders in identifying gaps in care, developing action plans to meet certification standards, and preparing team members for the DSC on-site review. At this Midwestern, 504-bed facility, The Joint Commission DSC certifications were achieved in 5 separate categories: diabetes, stroke, sepsis, total hip replacement, and total knee replacement. By influencing a certain patient population throughout the organization, population-focused CNSs are in a unique role to lead an interprofessional team or serve as an expert consultant in pursuing DSC certification from The Joint Commission.

A Primer on Quality Assurance and Performance Improvement for Interprofessional Chronic Kidney Disease Care: A Path to Joint Commission Certification.

Interprofessional care for chronic kidney disease facilitates the delivery of high quality, comprehensive care to a complex, at-risk population. Interprofessional care is resource intensive and requires a value proposition. Joint Commission certification is a voluntary process that improves patient outcomes, provides external validity to hospital administration and enhances visibility to patients and referring providers. This is a single-center, retrospective study describing quality assurance and performance improvement in chronic kidney disease, Joint Commission certification and quality outcomes. A total of 440 patients were included in the analysis. Thirteen quality indicators consisting of clinical and process of care indicators were developed and measured for a period of two years from 2009–2017. Significant improvements or at least persistently high performance were noted for key quality indicators such as blood pressure control (85%), estimation of cardiovascular risk (100%), measurement of hemoglobin A1c (98%), vaccination (93%), referrals for vascular access and transplantation (100%), placement of permanent dialysis access (61%), discussion of advanced directives (94%), online patient education (71%) and completion of office visit documentation (100%). High patient satisfaction scores (94–96%) are consistent with excellent quality of care provided.

Intersocietal Accreditation Commission Accreditation Status of Outpatient Cerebrovascular Testing Facilities Among Medicare Beneficiaries

Accreditation of cerebrovascular ultrasound laboratories by the Intersocietal Accreditation Commission (IAC) and equivalent organizations is supported by the Joint Commission certification of stroke centers. Limited information exists on the accreditation status and geographic distribution of cerebrovascular testing facilities in the United States. Our study objectives were to identify the proportion of IAC-accredited outpatient cerebrovascular testing facilities used by Medicare beneficiaries, describe their geographic distribution, and identify variations in cerebrovascular testing procedure types and volumes by accreditation status. As part of the VALUE (Vascular Accreditation, Location, and Utilization Evaluation) Study, we examined the proportion of IAC-accredited facilities that conducted cerebrovascular testing in a 5% Centers for Medicare and Medicaid Services random Outpatient Limited Data Set in 2011 and investigated their geographic distribution using geocoding. Among 7327 outpatient facilities billing Medicare for cerebrovascular testing, only 22% (1640) were IAC accredited. The proportion of IAC-accredited cerebrovascular testing facilities varied by region (χ(2)[3] = 177.1; P < .0001), with 29%, 15%, 13%, and 10% located in the Northeast, South, Midwest, and West, respectively. However, of the total number of cerebrovascular outpatient procedures conducted in 2011 (38,555), 40% (15,410) were conducted in IAC-accredited facilities. Most cerebrovascular testing procedures were carotid duplex, with 40% of them conducted in IAC-accredited facilities. The proportion of facilities conducting outpatient cerebrovascular testing accredited by the IAC is low and varies by region. The growing number of certified stroke centers should be accompanied by more accredited outpatient vascular testing facilities, which could potentially improve the quality of stroke care.

Abstract T P274: Accreditation Status of Outpatient Cerebrovascular Testing Facilities Among Medicare Beneficiaries: The VALUE (Vascular Accreditation, Location &amp; Utilization Evaluation) Study

OBJECTIVE: Accreditation of cerebrovascular ultrasound laboratories by the Intersocietal Accreditation Commission (IAC) or equivalent bodies is supported by The Joint Commission certification of stroke centers. Limited information exists on the accreditation status and geographic distribution of these testing facilities in the US. The aims were to: (1) Identify the proportion of IAC accredited vascular testing facilities used by Medicare beneficiaries for outpatient cerebrovascular testing services; (2) Describe the geographical distribution of these facilities; and (3) Identify variation in the types and volumes of cerebrovascular testing procedures by accreditation status. METHODS: As a part of the VALUE (Vascular Accreditation, Location &amp; Utilization Evaluation) Study, we examined the proportion of IAC accredited facilities that conducted cerebrovascular testing in a 5% CMS random Outpatient Limited Data Set (LDS) for the US in 2011 and investigated their geographical distribution using the Medicare Provider of Services (POS) file. RESULTS: Of the 7,864 total facilities billing Medicare for cerebrovascular testing procedures, only 22% (n=1,723) were IAC accredited. The percentage of facilities conducting cerebrovascular testing that were IAC accredited varied by region (Χ2[3]=400.4, p&lt;0.0001), with 43%, 21%, 17% and 13% located in the Northeast, South, Midwest, and West, respectively. However, when examining the total number of cerebrovascular outpatient procedures conducted in 2011 (total n=38,646), 41% (15,729) were conducted in IAC accredited facilities. Moreover, when examining procedure type across all sites, 98% (38,011) of all cerebrovascular testing procedures conducted were carotid duplex, of which 41% (15,417) were conducted in IAC accredited facilities. In contrast, 1% (n=315) of all cerebrovascular procedures were transcranial (TCD), of which 56% (n=177) were conducted in IAC accredited facilities. CONCLUSIONS: The proportion of IAC accredited facilities conducting outpatient cerebrovascular testing is low and varies by region. The growing number of certified stroke centers should be accompanied by more accredited vascular testing facilities that could potentially improve quality of stroke care.

Abstract W P287: Does Comprehensive Stroke Certification Demonstrate a Significant Effect on Volume and Quality of Care?

Introduction/Background information: At the onset of acute stroke symptoms, speed, capability, safety and skill are essential-lost minutes can be the difference between full recoveries, poor outcome, or even death. The Joint Commission's Certificate of Distinction for Comprehensive Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. While many hospitals have been surveyed, Cedars Sinai was the 5 th hospital in the nation to receive this certification. Researchable question: Does Comprehensive stroke certification (CSC) demonstrate a significant effect on volume and quality of care? Methods: We assembled a cross-functional, multidisciplinary expert team representing all departments and skill sets involved in treating stroke patients. We carefully screened eligible patients with acute ischemic stroke We assessed the number of patients treated at Cedars-Sinai with IV-T-pa t 6 months before and then 6 months after CSC and the quality of their care including medical treatment and door to needle time. Results: In the 6 months prior to Joint Commissions Stroke Certification we treated 20 of 395acute stroke patients with t-PA with an average CT turnaround time of 31±19minutes and an average Door to needle time (DTNT) of 68±32minutes. In the 6 months since Joint Commission Stroke Certification we have increased the number of acute stroke patients treated by almost double. There were 37 out of 489(P=0.02, Chi Square) patients treated with IV t-PA with an average CT turnaround time of 22±7minutes (p=0.08, t-test, compared to pre-CSC) and an average DTNT of 61± 23minutes (not different than pre-CSC). Conclusion: We conclude that Joint Commission Certification for stroke was associated with an increased rate of treatment with IV rt-PA in acute ischemic stroke patients. We were not able to document an effect on quality of care. Further studies of the impact of CSC certification are warranted.

Comparing Hospitals on Stroke Care

STROKE IS A LEADING CAUSE OF MORBIDITY AND MORtality in the United States and worldwide and is associated with enormous health care expenditures. Approximately 800 000 new or recurrent strokes occur annually in the United States, and of these, about 87% are ischemic cerebral infarctions. Since 1996, when the use of intravenous tissue plasminogen activator was approved by the US Food and Drug Administration (FDA) for the treatment of patients with acute ischemic stroke within 3 hours of symptom onset, there has been a sea change in the approach to identification and management of stroke patients to improve their outcomes. Parallel to these advances, there has been an equally important move toward a systems-based approach to stroke care. The very short time window needed for acute therapies to reverse brain injury has inspired several national and statewide initiatives to improve hospital care of the stroke patient. The Brain Attack Coalition criteria for primary stroke centers, first recommended in 2000 and revised in 2011, have formed the basis for Joint Commission certification for stroke center status. Additional certification for comprehensive stroke centers begins in July 2012. These efforts are rooted in a developing evidence base demonstrating that organized, systems-based care, informed by guidelines and quality assurance efforts, can improve outcomes. There is evidence, for example, that patients with acute stroke are more likely to survive, return home, and regain independence if treated in hospital units specializing in the care of patients with stroke. The restructuring of health insurance in the United States, with the focus on increasing efficiency, improving outcomes, and providing value to the public, has stimulated efforts to provide valid measures of health care quality. One such measure includes assessment and ranking of hospital performance in the care of commonly encountered and significant illnesses, of which stroke is a good example. Approaches to the measurement of such outcomes, however, are potentially fraught with biases and other complexities. Although the implications of such measures are substantial, both for the individual hospital and the health care system as a whole, targeted research about health care–related outcomes is a relatively new field and optimal analytic approaches are still being developed. In this issue of JAMA, Fonarow and colleagues evaluate the influence of including or excluding stroke severity in prognostic stroke outcome models in a large Medicare insurance database. The authors used data from almost 128 000 patients with ischemic stroke from 782 Get With The Guidelines–Stroke participating hospitals. For all patients included in the analysis, information on the severity of the stroke was available in the form of the National Institutes of Health Stroke Scale (NIHSS) score. The primary outcome was 30-day mortality, and prognostic models were evaluated for their overall model discrimination as well as for differences in rankings of the hospital performance when including or excluding information on stroke severity. The main prognostic model included information on age, sex, prior stroke or transient ischemic attack, and a large number of comorbid conditions and was compared with a model that additionally included information on stroke severity. All statistical measures of model performance showed that the model including stroke severity was superior, indicating that stroke severity substantially improved the prediction of 30-day mortality above and beyond other clinical predictors. Considered at the level of the individual patient, this result does not seem surprising: a patient who has a relatively more severe stroke is at increased risk of death. Moreover, when the prediction models were used to classify and rank hospitals based on 30-day mortality, the model including stroke severity demonstrated substantially more accurate classification and substantially changed hospital rankings. Of the 782 participating hospitals, the absolute change of the median hospital rank position was 79 places. More than half (58%) of hospitals first classified as having higher than expected mortality were reclassified to having the expected mortality rate after incorporating severity into

One Programʼs Journey to Joint Commission Certification for Wound Services

One Programʼs Journey to Joint Commission Certification for Wound Services

Thrombolysis for Acute Ischemic Stroke in Joint Commission–certified and –noncertified Hospitals in Michigan

The Joint Commission (JC) for Accreditation of Healthcare Organizations has devised disease specific certification programs for hospitals, including stroke. JC certification as a primary stroke center (PSC) suggests that the hospital has critical measures in place to ensure improving stroke outcomes over the long term. In this study, we focused on the delivery of care for patients with acute ischemic and compared differences in JC-certified and -noncertified centers in Michigan. We performed a systematic chart review of patients with acute ischemic stroke from 10 Michigan hospitals, half of whom were JC-certified PSCs. Sixty charts were randomly chosen from 1 calendar year from each hospital. An experienced nurse performed the data abstraction, and data analysis was performed with the Fisher exact test. A total of 602 charts--of which 302 were from JC-certified PSCs--were chosen for the study. The 2 groups were similar with regard to stroke risk factors except that there were significantly more patients with atrial fibrillation in noncertified centers and there were more African American patients in JC-certified PSCs. Significantly more patients were considered for thrombolytic therapy in JC-certified PSCs compared to noncertified centers (90.4% v 66%; P = .0001). Overall, 3.8% of patients had received thrombolytic therapy without any significant difference between JC-certified PSCs and noncertified centers (4.6% v 3%; adjusted odds ratio 1.64; 95% confidence interval 0.64-4.19; P = .87). However, thrombolysis rates among eligible patients was significantly higher in the JC-certified PSCs (48.2% v 8.8%; P = .0001). The most common reason documented for not giving thrombolytic therapy was late arrival outside the therapeutic window, which was more common in JC-certified PSCs (72.8% v 55.6%; P = .0001) compared to noncertified centers. Seventy-four percent of patients from JC-certified PSCs were discharged home or to inpatient rehabilitation facility compared to 71% (P = .38) from noncertified hospitals. The mean length of stay was marginally shorter in JC-certified PSCs compared to noncertified centers (5.53 v 6.25 days; P = .08). Rates of thrombolysis administration for acute stroke patients across Michigan were low in both JC-certified and noncertified hospitals, although better processes were in place in JC-certified PSCs. While there was no overall difference in the administration of thrombolytic treatment, a greater number of the eligible patients received thrombolysis in the certified centers. There was a tendency to shorter lengths of stay at JC-certified PSCs, but there was no significant difference in discharge to home, inpatient rehabilitation, or inpatient mortality in this study.