AJHP RESIDENTS EDITION National quality measures for stroke
AJHP RESIDENTS EDITION
Increasing compliance with national quality measures for stroke through use of a standard order set
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Kimberly G. Elder, Sandra K. Lemon, and Tracy J. Costello
troke occurs in approximately 795,000 people annually. 1 Although the stroke mortality rate decreased over the 10-year period from 2001 to 2011, stroke is still the fourth leading cause of death nationwide.1 Almost 90% of strokes are ischemic, while the remainder are hemorrhagic.1 Current guidelines for ischemic stroke advocate the use of intravenous tissue plasminogen activator, the early use of antithrombotics, venous thromboembolism (VTE) prophylaxis, anticoagulation in patients with atrial fibrillation, and lipid-lowering therapy.2 Studies have shown that stroke survivors are often left with lasting disabilities, including hemiparesis, difficulty ambulating unaided, and aphasia.3 Rehabilitation is vital for patients to regain function after a stroke. However, one study showed that only about one in three stroke survivors received rehabilitation.4 Primary stroke center certification A primary stroke center (PSC) is
Purpose. Results of a study to determine the impact of physician use of a medication order set on compliance with national quality standards for acute stroke treatment are presented. Methods. The medical records of adult patients treated for ischemic stroke at three certified primary stroke centers within a large healthcare system were retrospectively reviewed to assess compliance with eight mandatory standards of care. Overall adherence to the standards and rates of compliance with individual standards were compared in random samples of patients treated with or without physician use of an order set providing guidance on acute stroke pharmacotherapy and other aspects of stroke management. Results. Treatment records indicated use of the acute stroke order set in 58% of the
an acute care hospital that has established evidence-based procedures to help ensure better outcomes for stroke patients by providing quality care.5 The recommendation for and description of PSCs were published initially in 2000 by the Brain Attack
Kimberly G. Elder, Pharm.D., BCPS, is Assistant Professor, Clinical and Administrative Sciences, Sullivan University College of Pharmacy, Louisville, KY; at the time of the research described herein, she was Postgraduate Year 2 Resident in Pharmacotherapy, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN. Sandra K. Lemon, Pharm.D., BCPS, is Site Clinical Coordinator and Clinical Pharmacy Specialist, Critical Care, Community Hospital South, Indianapolis. Tracy J. Costello, Pharm.D., BCPS, is Assistant Professor of Pharmacy Practice, Butler University College
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120 patient cases reviewed. Individual patients who were treated without physician use of the order set were more than twice as likely as those in the comparator group to receive care that was not in compliance with at least one of the eight mandatory quality standards (odds ratio, 2.4; 95% confidence interval, 1.43–4.05; p < 0.001). Use of the order set was associated with significantly improved adherence to three standards: venous thromboembolism prophylaxis, stroke education, and statin therapy at discharge. Conclusion. A retrospective review of the treatment records of patients hospitalized for acute stroke showed that adherence to national guidelines was increased when providers used a standard order set. Am J Health-Syst Pharm. 2015; 72(suppl 1):S6-10
Coalition,5 with an update published in 2011.6 Current stroke guidelines recommend that patients with stroke be taken initially to a PSC unless another life-threatening condition necessitating transport to the nearest hospital is present.2 The Joint Com-
of Pharmacy and Health Sciences, and Clinical Pharmacy Specialist, Family Medicine, Community Health Network, Indianapolis. Address correspondence to Dr. Elder ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0601-00S6. DOI 10.2146/ajhp150094
AJHP RESIDENTS EDITION National quality measures for stroke
mission is the primary organization that awards PSC certification, and more than 1000 hospitals in all 50 states and Puerto Rico have been certified.7 In order to be certified as a PSC by the Joint Commission, hospitals must demonstrate at least 80% adherence to established standards for the care of stroke patients. There are eight mandatory standards, which require that patients receive (1) VTE prophylaxis, (2) anticoagulation therapy for atrial fibrillation or flutter, (3) thrombolytic therapy, and (4) antithrombotic therapy by the end of hospital day 2; are discharged on (5) statin therapy and (6) antithrombotic therapy; and receive (7) stroke education and (8) assessment for rehabilitation. There are also two optional standards: screening for dysphagia and smoking cessation services.7 Definitions of these standards can be found in the appendix.8 Background and study sites Order sets promote safe and effective medication use and can also help ensure compliance with quality measures.9-11 Standing orders as a part of a multidisciplinary acute stroke treatment program have been shown to decrease length of stay and cost in stroke patients but have not yet been shown to increase adherence to Joint Commission standards.12 The Brain Attack Coalition recommends using written care protocols when treating patients with stroke and including the protocols within an electronic medical record (EMR) when feasible.6 The study described here was conducted within a multihospital system that included three certified PSCs (hereafter referred to as hospitals A, B, and C). Hospital A became certified in March 2008; hospital B, in January 2011; and hospital C, in September 2011. In order to help ensure compliance with the Joint Commission’s stroke care standards, a uniform medication order set
was created by a multidisciplinary team of stroke experts from the three hospitals using evidence-based guidelines jointly published by the American Heart Association and the American Stroke Association.2 This team included neurologists, a neuroscience clinical nurse specialist, and a clinical pharmacist. The order set was first developed in 2005 and modified slightly over time to reflect physician preferences and changes in evidencebased recommendations. The order set was made available at all sites to serve as a tool to guide clinicians providing stroke care. The acute stroke order set was available for easy access via the hospital system’s intranet site to assist clinicians when a patient was admitted for stroke or in the event of stroke development during a hospital stay. There was no requirement for use of this order set during the admission or treatment of patients with suspected stroke. In the years after the initial release of the order set, stroke order set utilization by physicians throughout the network was inconsistent, and it was observed that compliance with standards regarding stroke education and use of statins was lower than was required within the hospital system. The aim of the study described here was to investigate whether implementation of the order set for acute stroke had a positive influence on compliance with Joint Commission standards and short-term outcomes in patients with stroke. The primary objective of the study was to determine if the use of a predefined order set resulted in adherence to all eight required standards of stroke care. The secondary objectives were to determine rates of adherence to specific standards, the impact of standard adherence on length of hospitalization, and the discharge dispostion of patients. Methods Data collection. A retrospective chart review was performed to iden-
Kimberly G. Elder, Pharm.D., BCPS, is an assistant professor at Sullivan University College of Pharmacy. She received her doctor of pharmacy degree from the University of Kentucky in 2010. Dr. Elder completed a postgraduate year 1 pharmacy residency at Indiana University Health and a postgraduate year 2 residency specializing in pharmacotherapy at Community Health Network/Butler University College of Pharmacy & Health Sciences. Her current research interests are in the areas of diabetes, geriatrics, and transitions of care.
tify adult patients treated for ischemic stroke at hospital A from January 1, 2007, to August 31, 2011, and at hospitals B and C from September 1, 2009, to August 31, 2011. A database with information regarding adherence to the stroke measures was used to facilitate chart review, and its availability determined the dates for data collection. A random number generator was used to select 70 patients from hospital A, 30 patients from hospital B, and 20 patients from hospital C. Demographics and other data on patients who were treated using the acute stroke order set were compared with data on those treated without the use of the order set. Patients were excluded from the analysis if they were pregnant, less than 18 or greater than 89 years of age, or incarcerated
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or had hemorrhagic stroke. All patient information was deidentified in order to maintain confidentiality. The data collected included patient age and sex, admitting hospital, admitting physician and specialty, and use (or nonuse) of the order set. Data on adherence to standards set forth by the Joint Commission were collected and examined. Finally, information regarding patient discharge status and length of hospitalization was collected. Patients were categorized by discharge status as follows: discharged home with no deficits, discharged home with assistance (e.g., home health, physical/occupational/speech therapy, assistive device), admission to acute rehabilitation facility, admission to subacute rehabilitation facility or extended-care facility, and deceased prior to discharge. Before chart review, approval was obtained from the hospital system’s institutional review board. Statistical analysis. Descriptive statistics were used to analyze the patient population. Chi-square and Fisher’s exact tests were used to analyze adherence to standards and discharge status. The Mann–Whitney U test was used for comparisons of data on length of hospitalization. The a priori level of significance was 0.05. Statistical analyses were performed by a statistician using Microsoft Excel (Microsoft Corporation, Redmond, WA) and SPSS, version 19.0 (IBM Corporation, Armonk, NY). Results A total of 120 patient charts were reviewed. Overall, the median patient age was 65 years (range, 29–89 years), and 46% of the patients (n = 55) were male. The order set was used in 70 patients (58%). No statistically significant differences among groups were present. The admitting physician breakdown by specialty was as follows: neurology (n = 99, 82%), internal medicine (n = 11, 9%), critical care S8
(n = 2, 2%), and other (n = 8, 7%); specialties represented in the latter category included family medicine, nephrology, and pulmonology. Of those physicians who used the order set, 94% (n = 66) were neurologists, 4% (n =3) were internal medicine specialists, and 2% (n = 1) were in other specialties. Among neurologists, 67% used the order set when admitting patients. Internal medicine physicians used the order set in 27% of admissions for acute stroke; physicians in other specialties used the order set in 13% of admissions. When the order set was used, nonadherence to at least one standard occurred in 40% of the evaluated cases (28 of 70 cases). In comparison, without the use of the order set, nonadherence to at least one standard occurred in 74% of cases (37 of 50). A patient treated without the order set was 2.4 times more likely to receive care that was not in compliance with all eight mandatory standards (95% confidence interval, 1.432–4.051; p < 0.001). Data on adherence to individual standards is presented in Table 1. When the order set was used, adherence to the standard of VTE prophylaxis was 91% (64 of 70 cases), compared with 74% adherence (37 of 50 cases) without use of the order set (p = 0.01). Similarly, patients were discharged on statin therapy in 91% of cases (64 of 70) when the order set was used, compared with 68% of cases (34 of 50) in which the order set was not used (p = 0.001). When the order set was used, stroke education was documented in 81% of cases (57 of 70), compared with 54% of cases (27 of 50) not involving order set use (p = 0.001). Overall, the median hospital length of stay was 3 days (range, 1–12 days). Patients treated using the order set had a median length of stay of 3 days (range, 1–12 days), and those treated without the use of the order set had a median length of stay of 3 days (range, 1–11 days); that differ-
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ence was not statistically significant (p = 0.991). Among the patients treated using the order set, 37% (26 of 70) went home without assistance, 14% (10 of 70) went home with assistance, 30% (21 of 70) were admitted for acute rehabilitation, 10% (7 of 70) were admitted to a subacute rehabilitation or an extended-care facility, and 8% (6 of 70) died. Among patients who were not treated using the order set, 30% (15 of 50) went home without assistance, 18% (9 of 50) went home with assistance, 26% (13 of 50) were admitted for acute rehabilitation, 24% (12 of 50) were admitted to a subacute rehabilitation or an extendedcare facility, and 2% (1 of 50) were transferred to another facility. Discussion Nonuse of the stroke order set was associated with an overall lack of adherence to all of the required standards in an individual patient. However, individual patients treated using the order set received care compliant with all required standards only 60% of the time (42 of 70 cases), compared with 26% of the time (13 of 50 cases) when the order set was not used. Although the primary endpoint findings might suggest otherwise, it is important to note that overall adherence to individual standards is very good within the multihospital network that provided the study sites. The study data indicate that average adherence to all individual standards—regardless of use or nonuse of the order set—was above the 80% acceptability threshold set by the Joint Commission. According to 2013 data from the Get With the Guidelines—Stroke Quality of Care Measures program, 97.3% of patients treated for acute stroke in U.S. hospitals that year received antithrombotics less than 48 hours after admission, 98.4% received VTE prophylaxis by the second hospital day, 98.1% were receiving antithrombotics at discharge,
AJHP RESIDENTS EDITION National quality measures for stroke
94.3% received anticoagulation for atrial fibrillation at discharge, and 96.1% received antihyperlipidemic therapy.1 When the order set was used in the study institution, those percentages were exceeded for two standards: use of antithrombotics at discharge (100%) and anticoagulation for atrial fibrillation (98.6%). The use of the order set was not associated with a decreased length of stay within the study hospital system. According to the data from 2013, the median length of stay for stroke in U.S. hospitals was three days.1 In this study, the overall median length of stay was consistent with those data. Use versus nonuse of the order set was associated with between-group differences in discharge status, but it is difficult to assess the appropriateness of discharge decisions through retrospective chart review. Rehabilitation is recommended for stroke patients to help them regain function in order to lead an active lifestyle, but a preference for acute versus subacute rehabilitation is not specified.8 Patients in acute versus subacute rehabilitation typically receive therapy for a longer period each day, which could be relatively more beneficial depending on patient status. Individual patient circumstances that were not
considered as part of this study may explain between-group differences in discharge status. Studies have shown that treatment for stroke at a PSC results in decreased mortality.13,14 According to the stroke care data, the U.S. inpatient mortality rate for stroke patients was 6.6%1; in our study, mortality was lower (5%). Interestingly, in our study, there were two deaths among patients who were treated using the acute stroke order set and none among those treated without use of the order set. One hypothesis to explain this result is that neurologists at the study sites might have been more likely than physicians of other specialties to be treating higher-acuity stroke patients and, thus, to use the order set. Data on patient acuity were not collected in this study. Other studies that have examined the effect of order set use on mortality have shown improved outcomes.15,16 One interesting anecdotal finding of the study was that physicians often made modifications to the order set. Order sets ideally are used to reduce the ambiguity and potential confusion of handwritten orders. They are typically created by experts in a particular subject matter using evidence-based guidelines, sug-
gesting that items included should generally not be omitted or changed. The fact that many physicians made changes to the acute stroke order set suggests that it may not have been used as intended. The updated recommendations for PSCs suggest efforts to incorporate order sets into the EMR whenever possible.6 The hospital system will soon implement an EMR with computerized prescriber order-entry functionality, and an electronic version of the acute stroke order set will be built into the new system. This should increase the use of the order set and prevent modifications. The study had several limitations. Information on stroke severity was not collected, which made it challenging to interpret some results, including those pertaining to the appropriateness of discharge decisions. It was also a relatively small (i.e., three-site) study; thus, the findings do not represent a complete picture of adherence to Joint Commission standards for stroke treatment within the health system. Accurate documentation was not always easy to find while completing chart review, especially for stroke education. Additionally, it was very difficult to find documentation on reasons
Table 1.
Adherence to Individual Standards for Acute Stroke Care at Study Sites With and Without Order Set Use Adherence, No. (%) Cases With Order Set Use (n = 70)
Standard Venous thromboembolism prophylaxis Anticoagulation therapy for atrial fibrillation or flutter Thrombolytic therapy Antithrombotic therapy by end of hospital day 2 Discharged on statin therapy Discharged on antithrombotic therapy Stroke education Assessed for rehabilitation Smoking cessation counseling Dysphagia screening
64 (91.4) 69 (98.6) 69 (98.6) 64 (91.4) 64 (91.4) 70 (100.1) 57 (81.4) 64 (91.4) 69 (98.6) 59 (84.3)
Without Order Set Use (n = 50)
37 (74.0) 49 (98.0) 50 (100.0) 46 (92.0) 34 (68.0) 49 (98.0) 27 (54.0) 42 (84.0) 49 (98.0) 35 (70.0)
p 0.01 1 1 1 0.001 0.417 0.001 0.211 1 0.061
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for nonuse of the order set or the reasoning behind nonadherence to individual standards. This could have led to care being erroneously deemed as nonadherent when a patient had a clear contraindication to that specific standard. The fact that the data were collected by one person should have ensured consistency among data collection methods. Conclusion A retrospective review of the treatment records of patients hospitalized for acute stroke showed that adherence to national guidelines was increased when providers used a standard order set.
7.
8.
9.
10.
11.
References 1. Mozaffarian D, Benjamin EJ, Go AS et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015; 131:e29-322. 2. Jauch EC, Saver JL, Adams HP et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2013; 44:870-947. 3. Kelly-Hayes M, Beiser A, Kase CS et al. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003; 12:119-26. 4. Centers for Disease Control and Prevention. Outpatient rehabilitation among stroke survivors—21 states and the District of Columbia, 2005. MMWR Morb Mortal Wkly Rep. 2007; 56:504-7. 5. Alberts MJ, Hademenos G, Latchaw RE et al. Recommendations for the establishment of primary stroke centers. JAMA. 2000; 283:3102-9. 6. Alberts MJ, Latchaw RE, Jagoda A et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the
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12.
13.
14.
15.
16.
Brain Attack Coalition. Stroke. 2011; 42:2651-65. Joint Commission. Facts about primary stroke center certification (January 6, 2015). www.jointcommission.org/ facts_about_primary_stroke_center_ certification/ (accessed 2015 Feb 25). American Heart Association, American Stroke Association. Stroke fact sheet (February 2009). www.icahn.org/files/Stroke_ Library_/Measurement/factsheetsweb.pdf (accessed 2015 Mar 15). Walker KA, Nachreiner D, Patel J et al. Impact of standardized palliative care order set on end-of-life care in a community teaching hospital. J Palliat Med. 2011; 14:281-6. Britton DJ, Bloch RB, Strout TD et al. Impact of a computerized order set on adherence to Centers for Disease Control guidelines for the treatment of victims of sexual assault. J Emerg Med. 2013; 44:528-35. Fowkes CT, Gee C, Bluemink T et al. Audit of physicians’ adherence to a preprinted order set for communityacquired pneumonia. Can J Hosp Pharm. 2010; 63:289-94. Wentworth DA, Atkinson RP. Implementation of an acute stroke program decreases hospitalization cost and length of stay. Stroke. 1996; 27:1040-3. Xian Y, Holloway RG, Chan PS et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA. 2011; 305:373-80. Meretoja A, Roine RO, Kaste M et al. Effectiveness of primary and comprehensive stroke centers. PERFECT stroke: a nationwide observational study from Finland. Stroke. 2010; 41:1102-7. Ballard DJ, Ogola G, Fleming NS et al. The impact of standardized order sets on quality and financial outcomes. In: Henriksen K, Battles JB, Keyes MA et al., eds. Advances in patient safety: new directions and alternative approaches. Vol. 2: culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008 Aug. Hanzelka KM, Yueng SC, Chisholm G et al. Implementation of modified earlygoal directed therapy for sepsis in the emergency center of a comprehensive cancer center. Support Care Cancer. 2013; 21:727-34.
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Appendix—Measures of compliance with acute stroke care standards8 •
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Venous thromboembolism prophylaxis: Percentage of ambulatory patients with ischemic or hemorrhagic stroke who receive deep vein thrombosis prophylaxis by the end of hospital day 2 Discharged on antithrombotic therapy: Percentage of patients with an ischemic stroke who are prescribed antithrombotic therapy at discharge Anticoagulation therapy for atrial fibrillation or flutter: Percentage of patients with ischemic stroke with atrial fibrillation or flutter who are discharged on anticoagulation therapy Thrombolytic therapy: Percentage of patients with acute ischemic stroke who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom i.v. tissue plasminogen activator was initiated at this hospital within 180 minutes (3 hours) of time last known well Antithrombotic therapy by the end of hospital day two: Percentage of patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day 2 Discharged on statin medication: Percentage of patients with ischemic stroke who have a low-density lipoprotein (LDL) cholesterol value of >100 (or in whom LDL cholesterol was not measured) or were receiving cholesterolreducing therapy prior to hospitalization who are discharged on statin medication Stroke education: Percentage of patients with ischemic or hemorrhagic stroke (or their caregivers) who were given education and/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 at discharge Assessed for rehabilitation: Percentage of patients with an ischemic or hemorrhagic stroke who were assessed for rehabilitation services Smoking cessation: Percentage of 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 the 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) Dysphagia screening: Percentage of patients with ischemic or hemorrhagic stroke who undergo evidence-based bedside testing protocol approved by the hospital before being given any food, fluids, or medication by mouth
AJHP RESIDENTS EDITION
Increasing compliance with national quality measures for stroke through use of a standard order set
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Kimberly G. Elder, Sandra K. Lemon, and Tracy J. Costello
troke occurs in approximately 795,000 people annually. 1 Although the stroke mortality rate decreased over the 10-year period from 2001 to 2011, stroke is still the fourth leading cause of death nationwide.1 Almost 90% of strokes are ischemic, while the remainder are hemorrhagic.1 Current guidelines for ischemic stroke advocate the use of intravenous tissue plasminogen activator, the early use of antithrombotics, venous thromboembolism (VTE) prophylaxis, anticoagulation in patients with atrial fibrillation, and lipid-lowering therapy.2 Studies have shown that stroke survivors are often left with lasting disabilities, including hemiparesis, difficulty ambulating unaided, and aphasia.3 Rehabilitation is vital for patients to regain function after a stroke. However, one study showed that only about one in three stroke survivors received rehabilitation.4 Primary stroke center certification A primary stroke center (PSC) is
Purpose. Results of a study to determine the impact of physician use of a medication order set on compliance with national quality standards for acute stroke treatment are presented. Methods. The medical records of adult patients treated for ischemic stroke at three certified primary stroke centers within a large healthcare system were retrospectively reviewed to assess compliance with eight mandatory standards of care. Overall adherence to the standards and rates of compliance with individual standards were compared in random samples of patients treated with or without physician use of an order set providing guidance on acute stroke pharmacotherapy and other aspects of stroke management. Results. Treatment records indicated use of the acute stroke order set in 58% of the
an acute care hospital that has established evidence-based procedures to help ensure better outcomes for stroke patients by providing quality care.5 The recommendation for and description of PSCs were published initially in 2000 by the Brain Attack
Kimberly G. Elder, Pharm.D., BCPS, is Assistant Professor, Clinical and Administrative Sciences, Sullivan University College of Pharmacy, Louisville, KY; at the time of the research described herein, she was Postgraduate Year 2 Resident in Pharmacotherapy, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN. Sandra K. Lemon, Pharm.D., BCPS, is Site Clinical Coordinator and Clinical Pharmacy Specialist, Critical Care, Community Hospital South, Indianapolis. Tracy J. Costello, Pharm.D., BCPS, is Assistant Professor of Pharmacy Practice, Butler University College
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120 patient cases reviewed. Individual patients who were treated without physician use of the order set were more than twice as likely as those in the comparator group to receive care that was not in compliance with at least one of the eight mandatory quality standards (odds ratio, 2.4; 95% confidence interval, 1.43–4.05; p < 0.001). Use of the order set was associated with significantly improved adherence to three standards: venous thromboembolism prophylaxis, stroke education, and statin therapy at discharge. Conclusion. A retrospective review of the treatment records of patients hospitalized for acute stroke showed that adherence to national guidelines was increased when providers used a standard order set. Am J Health-Syst Pharm. 2015; 72(suppl 1):S6-10
Coalition,5 with an update published in 2011.6 Current stroke guidelines recommend that patients with stroke be taken initially to a PSC unless another life-threatening condition necessitating transport to the nearest hospital is present.2 The Joint Com-
of Pharmacy and Health Sciences, and Clinical Pharmacy Specialist, Family Medicine, Community Health Network, Indianapolis. Address correspondence to Dr. Elder ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0601-00S6. DOI 10.2146/ajhp150094
AJHP RESIDENTS EDITION National quality measures for stroke
mission is the primary organization that awards PSC certification, and more than 1000 hospitals in all 50 states and Puerto Rico have been certified.7 In order to be certified as a PSC by the Joint Commission, hospitals must demonstrate at least 80% adherence to established standards for the care of stroke patients. There are eight mandatory standards, which require that patients receive (1) VTE prophylaxis, (2) anticoagulation therapy for atrial fibrillation or flutter, (3) thrombolytic therapy, and (4) antithrombotic therapy by the end of hospital day 2; are discharged on (5) statin therapy and (6) antithrombotic therapy; and receive (7) stroke education and (8) assessment for rehabilitation. There are also two optional standards: screening for dysphagia and smoking cessation services.7 Definitions of these standards can be found in the appendix.8 Background and study sites Order sets promote safe and effective medication use and can also help ensure compliance with quality measures.9-11 Standing orders as a part of a multidisciplinary acute stroke treatment program have been shown to decrease length of stay and cost in stroke patients but have not yet been shown to increase adherence to Joint Commission standards.12 The Brain Attack Coalition recommends using written care protocols when treating patients with stroke and including the protocols within an electronic medical record (EMR) when feasible.6 The study described here was conducted within a multihospital system that included three certified PSCs (hereafter referred to as hospitals A, B, and C). Hospital A became certified in March 2008; hospital B, in January 2011; and hospital C, in September 2011. In order to help ensure compliance with the Joint Commission’s stroke care standards, a uniform medication order set
was created by a multidisciplinary team of stroke experts from the three hospitals using evidence-based guidelines jointly published by the American Heart Association and the American Stroke Association.2 This team included neurologists, a neuroscience clinical nurse specialist, and a clinical pharmacist. The order set was first developed in 2005 and modified slightly over time to reflect physician preferences and changes in evidencebased recommendations. The order set was made available at all sites to serve as a tool to guide clinicians providing stroke care. The acute stroke order set was available for easy access via the hospital system’s intranet site to assist clinicians when a patient was admitted for stroke or in the event of stroke development during a hospital stay. There was no requirement for use of this order set during the admission or treatment of patients with suspected stroke. In the years after the initial release of the order set, stroke order set utilization by physicians throughout the network was inconsistent, and it was observed that compliance with standards regarding stroke education and use of statins was lower than was required within the hospital system. The aim of the study described here was to investigate whether implementation of the order set for acute stroke had a positive influence on compliance with Joint Commission standards and short-term outcomes in patients with stroke. The primary objective of the study was to determine if the use of a predefined order set resulted in adherence to all eight required standards of stroke care. The secondary objectives were to determine rates of adherence to specific standards, the impact of standard adherence on length of hospitalization, and the discharge dispostion of patients. Methods Data collection. A retrospective chart review was performed to iden-
Kimberly G. Elder, Pharm.D., BCPS, is an assistant professor at Sullivan University College of Pharmacy. She received her doctor of pharmacy degree from the University of Kentucky in 2010. Dr. Elder completed a postgraduate year 1 pharmacy residency at Indiana University Health and a postgraduate year 2 residency specializing in pharmacotherapy at Community Health Network/Butler University College of Pharmacy & Health Sciences. Her current research interests are in the areas of diabetes, geriatrics, and transitions of care.
tify adult patients treated for ischemic stroke at hospital A from January 1, 2007, to August 31, 2011, and at hospitals B and C from September 1, 2009, to August 31, 2011. A database with information regarding adherence to the stroke measures was used to facilitate chart review, and its availability determined the dates for data collection. A random number generator was used to select 70 patients from hospital A, 30 patients from hospital B, and 20 patients from hospital C. Demographics and other data on patients who were treated using the acute stroke order set were compared with data on those treated without the use of the order set. Patients were excluded from the analysis if they were pregnant, less than 18 or greater than 89 years of age, or incarcerated
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or had hemorrhagic stroke. All patient information was deidentified in order to maintain confidentiality. The data collected included patient age and sex, admitting hospital, admitting physician and specialty, and use (or nonuse) of the order set. Data on adherence to standards set forth by the Joint Commission were collected and examined. Finally, information regarding patient discharge status and length of hospitalization was collected. Patients were categorized by discharge status as follows: discharged home with no deficits, discharged home with assistance (e.g., home health, physical/occupational/speech therapy, assistive device), admission to acute rehabilitation facility, admission to subacute rehabilitation facility or extended-care facility, and deceased prior to discharge. Before chart review, approval was obtained from the hospital system’s institutional review board. Statistical analysis. Descriptive statistics were used to analyze the patient population. Chi-square and Fisher’s exact tests were used to analyze adherence to standards and discharge status. The Mann–Whitney U test was used for comparisons of data on length of hospitalization. The a priori level of significance was 0.05. Statistical analyses were performed by a statistician using Microsoft Excel (Microsoft Corporation, Redmond, WA) and SPSS, version 19.0 (IBM Corporation, Armonk, NY). Results A total of 120 patient charts were reviewed. Overall, the median patient age was 65 years (range, 29–89 years), and 46% of the patients (n = 55) were male. The order set was used in 70 patients (58%). No statistically significant differences among groups were present. The admitting physician breakdown by specialty was as follows: neurology (n = 99, 82%), internal medicine (n = 11, 9%), critical care S8
(n = 2, 2%), and other (n = 8, 7%); specialties represented in the latter category included family medicine, nephrology, and pulmonology. Of those physicians who used the order set, 94% (n = 66) were neurologists, 4% (n =3) were internal medicine specialists, and 2% (n = 1) were in other specialties. Among neurologists, 67% used the order set when admitting patients. Internal medicine physicians used the order set in 27% of admissions for acute stroke; physicians in other specialties used the order set in 13% of admissions. When the order set was used, nonadherence to at least one standard occurred in 40% of the evaluated cases (28 of 70 cases). In comparison, without the use of the order set, nonadherence to at least one standard occurred in 74% of cases (37 of 50). A patient treated without the order set was 2.4 times more likely to receive care that was not in compliance with all eight mandatory standards (95% confidence interval, 1.432–4.051; p < 0.001). Data on adherence to individual standards is presented in Table 1. When the order set was used, adherence to the standard of VTE prophylaxis was 91% (64 of 70 cases), compared with 74% adherence (37 of 50 cases) without use of the order set (p = 0.01). Similarly, patients were discharged on statin therapy in 91% of cases (64 of 70) when the order set was used, compared with 68% of cases (34 of 50) in which the order set was not used (p = 0.001). When the order set was used, stroke education was documented in 81% of cases (57 of 70), compared with 54% of cases (27 of 50) not involving order set use (p = 0.001). Overall, the median hospital length of stay was 3 days (range, 1–12 days). Patients treated using the order set had a median length of stay of 3 days (range, 1–12 days), and those treated without the use of the order set had a median length of stay of 3 days (range, 1–11 days); that differ-
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ence was not statistically significant (p = 0.991). Among the patients treated using the order set, 37% (26 of 70) went home without assistance, 14% (10 of 70) went home with assistance, 30% (21 of 70) were admitted for acute rehabilitation, 10% (7 of 70) were admitted to a subacute rehabilitation or an extended-care facility, and 8% (6 of 70) died. Among patients who were not treated using the order set, 30% (15 of 50) went home without assistance, 18% (9 of 50) went home with assistance, 26% (13 of 50) were admitted for acute rehabilitation, 24% (12 of 50) were admitted to a subacute rehabilitation or an extendedcare facility, and 2% (1 of 50) were transferred to another facility. Discussion Nonuse of the stroke order set was associated with an overall lack of adherence to all of the required standards in an individual patient. However, individual patients treated using the order set received care compliant with all required standards only 60% of the time (42 of 70 cases), compared with 26% of the time (13 of 50 cases) when the order set was not used. Although the primary endpoint findings might suggest otherwise, it is important to note that overall adherence to individual standards is very good within the multihospital network that provided the study sites. The study data indicate that average adherence to all individual standards—regardless of use or nonuse of the order set—was above the 80% acceptability threshold set by the Joint Commission. According to 2013 data from the Get With the Guidelines—Stroke Quality of Care Measures program, 97.3% of patients treated for acute stroke in U.S. hospitals that year received antithrombotics less than 48 hours after admission, 98.4% received VTE prophylaxis by the second hospital day, 98.1% were receiving antithrombotics at discharge,
AJHP RESIDENTS EDITION National quality measures for stroke
94.3% received anticoagulation for atrial fibrillation at discharge, and 96.1% received antihyperlipidemic therapy.1 When the order set was used in the study institution, those percentages were exceeded for two standards: use of antithrombotics at discharge (100%) and anticoagulation for atrial fibrillation (98.6%). The use of the order set was not associated with a decreased length of stay within the study hospital system. According to the data from 2013, the median length of stay for stroke in U.S. hospitals was three days.1 In this study, the overall median length of stay was consistent with those data. Use versus nonuse of the order set was associated with between-group differences in discharge status, but it is difficult to assess the appropriateness of discharge decisions through retrospective chart review. Rehabilitation is recommended for stroke patients to help them regain function in order to lead an active lifestyle, but a preference for acute versus subacute rehabilitation is not specified.8 Patients in acute versus subacute rehabilitation typically receive therapy for a longer period each day, which could be relatively more beneficial depending on patient status. Individual patient circumstances that were not
considered as part of this study may explain between-group differences in discharge status. Studies have shown that treatment for stroke at a PSC results in decreased mortality.13,14 According to the stroke care data, the U.S. inpatient mortality rate for stroke patients was 6.6%1; in our study, mortality was lower (5%). Interestingly, in our study, there were two deaths among patients who were treated using the acute stroke order set and none among those treated without use of the order set. One hypothesis to explain this result is that neurologists at the study sites might have been more likely than physicians of other specialties to be treating higher-acuity stroke patients and, thus, to use the order set. Data on patient acuity were not collected in this study. Other studies that have examined the effect of order set use on mortality have shown improved outcomes.15,16 One interesting anecdotal finding of the study was that physicians often made modifications to the order set. Order sets ideally are used to reduce the ambiguity and potential confusion of handwritten orders. They are typically created by experts in a particular subject matter using evidence-based guidelines, sug-
gesting that items included should generally not be omitted or changed. The fact that many physicians made changes to the acute stroke order set suggests that it may not have been used as intended. The updated recommendations for PSCs suggest efforts to incorporate order sets into the EMR whenever possible.6 The hospital system will soon implement an EMR with computerized prescriber order-entry functionality, and an electronic version of the acute stroke order set will be built into the new system. This should increase the use of the order set and prevent modifications. The study had several limitations. Information on stroke severity was not collected, which made it challenging to interpret some results, including those pertaining to the appropriateness of discharge decisions. It was also a relatively small (i.e., three-site) study; thus, the findings do not represent a complete picture of adherence to Joint Commission standards for stroke treatment within the health system. Accurate documentation was not always easy to find while completing chart review, especially for stroke education. Additionally, it was very difficult to find documentation on reasons
Table 1.
Adherence to Individual Standards for Acute Stroke Care at Study Sites With and Without Order Set Use Adherence, No. (%) Cases With Order Set Use (n = 70)
Standard Venous thromboembolism prophylaxis Anticoagulation therapy for atrial fibrillation or flutter Thrombolytic therapy Antithrombotic therapy by end of hospital day 2 Discharged on statin therapy Discharged on antithrombotic therapy Stroke education Assessed for rehabilitation Smoking cessation counseling Dysphagia screening
64 (91.4) 69 (98.6) 69 (98.6) 64 (91.4) 64 (91.4) 70 (100.1) 57 (81.4) 64 (91.4) 69 (98.6) 59 (84.3)
Without Order Set Use (n = 50)
37 (74.0) 49 (98.0) 50 (100.0) 46 (92.0) 34 (68.0) 49 (98.0) 27 (54.0) 42 (84.0) 49 (98.0) 35 (70.0)
p 0.01 1 1 1 0.001 0.417 0.001 0.211 1 0.061
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AJHP RESIDENTS EDITION National quality measures for stroke
for nonuse of the order set or the reasoning behind nonadherence to individual standards. This could have led to care being erroneously deemed as nonadherent when a patient had a clear contraindication to that specific standard. The fact that the data were collected by one person should have ensured consistency among data collection methods. Conclusion A retrospective review of the treatment records of patients hospitalized for acute stroke showed that adherence to national guidelines was increased when providers used a standard order set.
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References 1. Mozaffarian D, Benjamin EJ, Go AS et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015; 131:e29-322. 2. Jauch EC, Saver JL, Adams HP et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2013; 44:870-947. 3. Kelly-Hayes M, Beiser A, Kase CS et al. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003; 12:119-26. 4. Centers for Disease Control and Prevention. Outpatient rehabilitation among stroke survivors—21 states and the District of Columbia, 2005. MMWR Morb Mortal Wkly Rep. 2007; 56:504-7. 5. Alberts MJ, Hademenos G, Latchaw RE et al. Recommendations for the establishment of primary stroke centers. JAMA. 2000; 283:3102-9. 6. Alberts MJ, Latchaw RE, Jagoda A et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the
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12.
13.
14.
15.
16.
Brain Attack Coalition. Stroke. 2011; 42:2651-65. Joint Commission. Facts about primary stroke center certification (January 6, 2015). www.jointcommission.org/ facts_about_primary_stroke_center_ certification/ (accessed 2015 Feb 25). American Heart Association, American Stroke Association. Stroke fact sheet (February 2009). www.icahn.org/files/Stroke_ Library_/Measurement/factsheetsweb.pdf (accessed 2015 Mar 15). Walker KA, Nachreiner D, Patel J et al. Impact of standardized palliative care order set on end-of-life care in a community teaching hospital. J Palliat Med. 2011; 14:281-6. Britton DJ, Bloch RB, Strout TD et al. Impact of a computerized order set on adherence to Centers for Disease Control guidelines for the treatment of victims of sexual assault. J Emerg Med. 2013; 44:528-35. Fowkes CT, Gee C, Bluemink T et al. Audit of physicians’ adherence to a preprinted order set for communityacquired pneumonia. Can J Hosp Pharm. 2010; 63:289-94. Wentworth DA, Atkinson RP. Implementation of an acute stroke program decreases hospitalization cost and length of stay. Stroke. 1996; 27:1040-3. Xian Y, Holloway RG, Chan PS et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA. 2011; 305:373-80. Meretoja A, Roine RO, Kaste M et al. Effectiveness of primary and comprehensive stroke centers. PERFECT stroke: a nationwide observational study from Finland. Stroke. 2010; 41:1102-7. Ballard DJ, Ogola G, Fleming NS et al. The impact of standardized order sets on quality and financial outcomes. In: Henriksen K, Battles JB, Keyes MA et al., eds. Advances in patient safety: new directions and alternative approaches. Vol. 2: culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008 Aug. Hanzelka KM, Yueng SC, Chisholm G et al. Implementation of modified earlygoal directed therapy for sepsis in the emergency center of a comprehensive cancer center. Support Care Cancer. 2013; 21:727-34.
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Appendix—Measures of compliance with acute stroke care standards8 •
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Venous thromboembolism prophylaxis: Percentage of ambulatory patients with ischemic or hemorrhagic stroke who receive deep vein thrombosis prophylaxis by the end of hospital day 2 Discharged on antithrombotic therapy: Percentage of patients with an ischemic stroke who are prescribed antithrombotic therapy at discharge Anticoagulation therapy for atrial fibrillation or flutter: Percentage of patients with ischemic stroke with atrial fibrillation or flutter who are discharged on anticoagulation therapy Thrombolytic therapy: Percentage of patients with acute ischemic stroke who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom i.v. tissue plasminogen activator was initiated at this hospital within 180 minutes (3 hours) of time last known well Antithrombotic therapy by the end of hospital day two: Percentage of patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day 2 Discharged on statin medication: Percentage of patients with ischemic stroke who have a low-density lipoprotein (LDL) cholesterol value of >100 (or in whom LDL cholesterol was not measured) or were receiving cholesterolreducing therapy prior to hospitalization who are discharged on statin medication Stroke education: Percentage of patients with ischemic or hemorrhagic stroke (or their caregivers) who were given education and/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 at discharge Assessed for rehabilitation: Percentage of patients with an ischemic or hemorrhagic stroke who were assessed for rehabilitation services Smoking cessation: Percentage of 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 the 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) Dysphagia screening: Percentage of patients with ischemic or hemorrhagic stroke who undergo evidence-based bedside testing protocol approved by the hospital before being given any food, fluids, or medication by mouth
