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127Systems and Quality Care
ANSWERS
1. D The BAC was established in 1991 by a group of neurosurgeons who saw the opportunity to improve stroke care through standardization and evidence-based guidelines. They were inspired by the improved patient outcomes seen with trauma guidelines. It includes members from 17 professional organizations including the American Association of Neuroscience Nurses. In 2003, TJC started its Primary Stroke Center certification process as part of its Disease-Specific Care certification program. Many people have credited TJC with creating the standards for Primary Stroke Centers, but in fact it was the BAC (Morrison, 2014).
2. C The NQF is a not-for-profit, nonpartisan, membership-based organization that works to facilitate improvements in health care, but it does not have certifying authority. HFAP and DNV are certifying organizations in competition with TJC. There are also many states that have their own stroke center certification program, and Texas is one of them.
3. D Benchmarking is a term used to describe all the actions in A, B, and C. It has proven to be a valuable tool in driving performance improvement efforts in hospitals (Ettorchi-Tardy, Levif, & Michel, 2012).
4. 128A The term “stroke database” is used to describe a wide variety of stroke data repositories. Stroke certification only requires that some method of data collection, analysis, and reporting is demonstrated.
5. B The PDSA is also referred to as the Plan-Do-Check-Act (PDCA). It is a multicycle process for instituting a new treatment, process, and so on, and then evaluating, adjusting, and repeating the process. It can be done on a large scale with a formal research idea, or in everyday nursing care as described in the question.
6. B The American Heart Association’s stroke systems of care involve key elements of care across the continuum, based on the standards related to stroke center certification, prehospital collaboration, and rehabilitation care. It does not dictate specifics such as National Institutes of Health Stroke Scale (NIHSS) certification for nursing staff (Higashida et al., 2013).
7. D While CSC certification has MER capability as a standard, there are many PSCs with MER capability as well, who may not meet all the CSC standards, but are capable of MER. ASRHs are focused on the emergency department (ED)—identification, stabilization, treatment with IV tissue plasminogen activator (tPA), and transfer to a PSC or CSC.
8. B Neurocritical care units led by neurocritical care specialists is an essential standard for CSCs; PSCs can manage hemorrhagic stroke patients, should have MRI 24/7, as well as mix and administer IV tPA in under 60 minutes.
9. A Clinical practice guidelines are provided by a variety of expert organizations, not just the American Heart Association/American Stroke Association. They are based on research evidence and guide care of specific populations. They are not simply a compilation of provider preference for care.
10. A, C, D Evidence published in 1997 demonstrated a 28% reduction in mortality, an 8% reduction in length of stay, and a 7% increase in discharge to home for patients cared for in a dedicated stroke unit (Langhorne et al., 1997).
11. C Historically the ED providers’ professional organizations, such as the American Academy of Emergency Medicine (AAEM) and the American 129College of Emergency Physicians (ACEP), have been opposed to IV tPA on the premise that the studies done to get it approved by the U.S. Food and Drug Administration (FDA) were flawed. So it has been a common occurrence for ED providers to be less than enthusiastic about this drug. The best thing to do is to use peer influence, and support your medical director’s speaking with this provider.
12. B Progressive treatment and more effective antihypertensive medications has led to a significant impact on the ability to control hypertension, leading to better outcomes (Mozaffarian, 2015).
13. C Improved CT and MRI imaging has made it possible to see even miniscule infarcts. Now events lasting less than 24 hours that used to be labeled TIA are often found to be tiny strokes.
14. A While all of these choices are part of stroke center certification, the key element is the use of data to drive process improvement, with improved outcomes as well.
15. D Root cause analysis is the process of taking an event, usually an adverse outcome, and analyzing every aspect that led up to it to find the cause. The purpose is to then make sure that it does not happen again. DMAIC refers to a data-driven improvement cycle used for improving, optimizing, and stabilizing processes. The DMAIC improvement cycle is the core tool used to drive Six Sigma projects. Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects in any process.
References
Ettorchi-Tardy, A., Levif, M., & Michel, P. (2012). Benchmarking: A method for continuous quality improvement in healthcare. Healthcare Policy, 7(4), e101–e119. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359088
Higashida, R., Alberts, M. J., Alexander, D. N., Crocco, T. J., Demaerschalk, B. M., Derdeyn, C. P., . . . Wood, J. P. (2013). Interactions within stroke systems of care: A policy statement from the American Heart Association/American Stroke Association. Stroke, 44, 2961–2984.
Langhorne, P., Asplund, K., Berman, P., Blomstrand, C., Dennis, M., Douglas, J., . . . Wilhelmsen, L. (1997). Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. British Medical Journal, 314, 1151–1158.
130Morrison, K. J. (2014). Fast facts for stroke care nursing: An expert guide in a nutshell. New York, NY: Springer Publishing.
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman M., . . . Turner, M. B. (2015). Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation, 133, e38–e360. doi:10.1161/CIR.0000000000000350