Pilot Program

Using Stroke Order Sets to Improve Compliance With Quality Measures for Ischemic Stroke Admissions

Creation of electronic health record order sets may improve adherence to The Joint Commission National Quality Measures for care of veterans with ischemic stroke.

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Stroke and cardiovascular disease (CVD) create a heavy economic burden on the health care system in the US.1 About 795,000 people have a stroke in the US each year. In 2013, stroke was the cause of 1 in every 20 deaths in the US.2 On average, someone in the US has a stroke every 40 seconds, and someone dies of one about every 4 minutes.3 Stroke also accounts for 889,000 hospitalizations per year.4,5

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Stroke has been studied widely, and evidence-based guidelines have been created for the management of stroke. Despite these published guidelines for stroke care, inconsistencies in stroke management of veterans still exist. These inconsistencies led to the creation of guidelines that include quality measurements for the care of veterans with stroke.

Several campaigns have been mounted to bolster quality care for veterans with ischemic stroke. These include the Primary Stroke Center Certification by The Joint Commission (JC),6 Get With the Guidelines by the American Stroke Association,7 the Paul Coverdell Registry by the Centers for Disease Control and Prevention,8 and other efforts by the National Quality Forum (NQF) and the Centers for Medicare and Medicaid Services.9 These organizations have independently and collaboratively established quality metrics associated with health care delivery for the care of veterans with stroke. Some of these metrics have been distinguished as performance measures, or metrics that are suitable for public reporting, and may be used for comparing institutions and rewarding those who meet specific thresholds (ie, pay for performance).10

The aim of this project was to increase compliance at the Atlanta VA Medical Center (VAMC) in Decatur, Georgia, with JC National Quality Measures for the care of veterans with ischemic stroke, thus providing optimal care for veterans admitted for ischemic stroke management.

There are 3 phases in the management of a patient with a stroke: stroke presentation, admission/management, and discharge. This project focused on the admission/management phase. The stroke presentation phase is completed in the emergency department (ED), and the discharge phase has a check list for stroke, including atrial fibrillation (AF) and counseling prior to discharge. Data from the check list and counseling were not included in this project.

Specific attention was given to the following JC measures: stroke (STK) 1, STK 5, and STK 10 because the Atlanta VAMC was below the national average for these core measures for fiscal year 2015. Compliance was accomplished by creating order sets for the admission and subsequent care of veterans with ischemic stroke, tracking order set usage, and reporting regularly to the medicine/admitting team members on use rates and meeting quality measures. This project underwent the quality vs research review process and was determined to be a quality improvement (QI) project, so the project did not require institutional review board approval.

Methods

At the Atlanta VAMC, all patients admitted for stroke workup or management are admitted to the medicine service. The medicine admitting teams are composed of an attending physician, a medicine resident, a nurse practitioner (NP), a pharmacist, and 2 interns; and the hospitalist team composed of a hospitalist. The project began January 1, 2016, and ended December 31, 2016.

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