Mm whooley 16_oct2018_final

1. Stroke Orderset Use in a World of
Accreditations and Quality Metrics
Peter Whooley, DO, MBA, PGY3
Morbidity and Mortality Conference
October 16, 2018

2. © 2015 Virginia Mason Medical Center
M&M Conference - Purpose
• Component of a culture of safety
• An organized case review examining
decision making, patient experience
& outcomes, and processes of care,
with a goal of raising awareness and
seeking opportunities for
improvement
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3. © 2015 Virginia Mason Medical Center

4. © 2015 Virginia Mason Medical Center
Agenda
• Review background of VM as a
Comprehensive Stroke Center
• Review of cases
• Analysis of our defects
• Explore improvement opportunities
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Roadmap to Stroke Care Excellence
5Adapted from DNV GL Healthcare Stroke Care Certification Programs

6. © 2015 Virginia Mason Medical Center
Certification Process
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Adapted from https://www.dnvglhealthcare.com/certifications/comprehensive-
stroke-center-certification

7. © 2015 Virginia Mason Medical Center
Certified; now monitor…
Measur
e ID
Measure Short Name
STK-1 Venous Thromboembolism (VTE Prophylaxis)
STK-10 Assessed for Rehabilitation
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
Two
STK-6 Discharged on Statin Medication
STK-8 Stroke Education
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Set Measure
ID
Measure Short Name
CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic
Stroke Patients)
CSTK-02 Modified Rankin Score (mRS at 90 Days)
CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)
CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )
CSTK-05 Hemorrhagic Transformation (Overall Rate)
CSTK-06 Nimodipine Treatment Administered
CSTK-07 Median Time to Revascularization
CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)
CSTK-09 Arrival Time to Skin Puncture
CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome)
CSTK-11 Timeliness of Reperfusion: Arrival Time to TICI 2B or Higher
CSTK-12 Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

8. © 2015 Virginia Mason Medical Center
Case Review (since Jun 2018)
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67 W p/w slurred
speech, LUE & LLE
weakness found to
have left thalamic
ischemic stroke
[Medicine Service]
No stroke
orderset on admit
Statin started hospital
D2
Metric Missed:
LDL assessed prior to
discharge
65 M p/w weakness
found to have
cerebellar
hemorrhage, embolic
w/ conversion
[CCU Service]
No stroke
orderset on admit
Statin started hospital
D10
Metric Missed:
LDL assessed prior
to discharge
71 M s/p surgery for
aortic dissection with
post-op vision changes
found to have embolic
right occipital stroke
[CTS team]
No stroke
orderset
Metric Missed:
Stroke education
41 W p/w severe
HA found to have
ruptured PCOM
with SAH
[CCU service]
No stroke (SAH)
orderset on
admit
Metrics Missed:
- Nimodipine not <24hr
- PT/OT/ST not <24hr
- Nursing cues initiated
late (NIHSS
assessments)
76 M p/w L
hemiparesis found to
have R MCA stroke
with near complete
occlusion of R ICA
[Medicine service]
No stroke
orderset used
Metric(s) Missed:
- No dysphagia
screen before PO
- NIHSS not
documented at
admission
71M p/w weakness
and falls found to
have R pontine
ischemic stroke on
MRI
[ Medicine service]
No stroke
orderset on
admit
Metric(s) Missed:
- No dysphagia
screen before PO
- Incorrect statin
dosing (& reason not
documented)

9. © 2015 Virginia Mason Medical Center
Performance
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Recognition
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Why it matters
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Stroke Ordersets
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• Stroke, Ischemic HOSPStroke / Suspected Stroke
• Stroke, Ischemic Post tPA, HOSPReceived tPA
• Rad Neurovascular Intervention - Post
HOSP
Thrombectomy/Emergent
Stenting Performed
• Intracerebral Hemorrhage Admit HOSP
Intracranial Hemorrhage
(ICH)
• NEUROSURG Subarachnoid Hemorrhage
Aneurysmal CCU admit, HOSP
Subarachnoid Hemorrhage
(SAH)

13. © 2015 Virginia Mason Medical Center
Order sets? Why?
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Reduce
time/effort to
place common
orders
Accelerate/move
forward patient
care
Standardization
/ Patient safety /
(adherence to
guidelines/EBM)
/ don’t miss
things
Comprehensiveness &
completeness of care
Improved
mortality,
morbidity,
LOS,
cost/utilization
Outcomes/future
research
Comparable
care across
institutions/sites

14. © 2015 Virginia Mason Medical Center
Why we should use order sets
ED Stroke order set use (KP NC ‘07-12)1
• Increased use of tPA w/o adverse effects
• Decreased risk of inpatient pneumonia/aspiration
• Mortality benefit at 30 & 90 days post-admit
Admit Pneumonia order set use (BHS;SGH)2,3
• Reduced inpatient mortality
• Reduced length of stay
• Improved Joint Commission Core Measures
Other disease-specific ex. further include:
• Septic Shock4, CHF5, UGIB in cirrhosis6, ACS7
• Improved adherence to guideline-based therapies (ACS,
CHF, UGIB)
• Decreased mortality (Septic Shock)
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15. © 2015 Virginia Mason Medical Center
Stroke Ordersets
• Vital Signs / Vital Measures
• Notify Physician / Communications
• Activity
• Diet
• Clinical Orders
• IV Fluids
• Medications
• Reason for no thrombolytic
• Anti-platelets
• Miscellaneous
• Blood pressure, prn
• Lipid lowering
• Pain, prn
• Radiology & Other Diagnostic Tests
• Labs/AM Labs
• Consults
• Patient Education Bundle
• Summary of Performance Metrics for Hospitalized Patients w/
Acute Stroke
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16. © 2015 Virginia Mason Medical Center
Why are we not using it?
Fishbone - Graphical tool that enables the visualization
of causal relationships between variables in a process
• Purpose: search for root causes
• ~5-7 minutes to work in small groups & then share
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*Adapted from VMPS Methods Class
In Pursuit of Defect Free Care
Mistake proofing

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What’s good enough?
Imagine 96% quality at VM…
600defective surgeries/year
501defective transfusions/year
40,000 defective medication
administrations/year
10,800 wrong meals served/year
68,000 defective bills sent/year
5,000 defective paychecks/year
*Adapted from VMPS Methods Class
In Pursuit of Defect Free Care
Mistake proofing

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Imagine 99.9% quality at VM…
15 defective surgeries/year
17 defective transfusions/year
1,000 defective medication
administrations/year
182wrong meals served/year
1,700 defective bills sent/year
125defective paychecks/year
*Adapted from VMPS Methods Class
In Pursuit of Defect Free Care
Mistake proofing

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Zero defects is the only acceptable
amount!
Imagine 100% quality at VM…
ZERO! defective surgeries/year
ZERO! defective transfusions/year
ZERO! defective medication
administrations/year
ZERO! wrong meals served/year
ZERO! defective bills sent/year
ZERO! defective paychecks/year
ZERO! misses/defective management
of stroke patients
*Adapted from VMPS Methods Class
In Pursuit of Defect Free Care
Mistake proofing

22. © 2015 Virginia Mason Medical Center
VMPS Methods
Mistake Proofing
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The basic elements of mistake-proofing:
• Inspection
• Standard work
• Visual control
• Devices
*Adapted from VMPS Methods Class PPT

23. © 2015 Virginia Mason Medical Center
In Pursuit of Defect Free Care
Mistake proofing
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*Adapted from VMPS Methods Class PPT
Inspection = checking work to ensure it was completed correctly

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Comparison of Inspection Levels
Mistake Proof Level Inspection
Method
Inspection
Location
Mistake or
Defect
Correction Feedback Correction
Delay
Level 1:
No Inspection
N/A N/A Defect Uncorrected Delayed
Complaints
Very long*
Level 2:
End of Line
Human
judgment
End of Line Defect Very
difficult*
Delayed
Statistics
Long*
Level 3:
Self-Check/Judgment
Human
judgment
At point of
work
Mistake Easier* Instant
from self
None*
Level 4:
Successive Check
Human
judgment
Directly
after work
Defect Difficult* Verbal with
Slight delay
Slightly
delayed*
Level 5:
Self-Check/Warning
By device At point of
work
Mistake Easier Instant by
warning
None
Level 6:
Self-Check/Control
By device At point of
work
Neither Not Needed Not Needed None
*Adapted from VMPS Methods Class PPT
?
In Pursuit of Defect Free Care
Mistake proofing

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Mistake-
Proofing
Inspection
Standard
Work
Visual
Control
Devices
*Taken from VMPS Methods Class PPT
In Pursuit of Defect Free Care
Mistake proofing

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*Taken from VMPS Methods Class PPT
In Pursuit of Defect Free Care
Mistake proofing
Visual controls in the medical center
• Kanbans
• Andons
• Templates

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*Taken from VMPS Methods Class PPT
In Pursuit of Defect Free Care
Mistake proofing

28. © 2015 Virginia Mason Medical Center
Any ideas to establish level 5-6
mistake proofing?
What about visual management tools
or devices?
Take 5-10 minutes to brainstorm with
small group
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In Pursuit of Defect Free Care
Mistake proofing

29. © 2015 Virginia Mason Medical Center
Take Home Points
• Certification & recognition status helps bring us the patients we
want to treat and learn from
• Our work as this next generation of physicians will require
participation in and awareness of performance metrics, whereby
we will be involved in efforts to meet targets of care
• VM has a competitive advantage for quality and purpose, which
we can use to ensure quality and ultimately sustainability of our
learning environment
• Ordersets have shown to improve morbidity, mortality, quality of
care, efficiency of care, LOS, patient safety – we need to use them
• Potential exists for PDSA cycles for mistake proofing in acute stroke
care (i.e., improvements in onboarding of housestaff and newly hired
hospitalists; EMR triggers/devices; dotphrase prompts from rad
reports; development of neurohospitalist team)
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30. © 2015 Virginia Mason Medical Center
Thank you!
• Kellie Hurley, Stroke Coordinator
• Fatima Milfred, MD
• Evan Coates, MD
• You all!
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31. © 2015 Virginia Mason Medical Center
References
1. Ballard DW, Kim AS, Huang J, et al. Implementation of Computerized Physician Order
Entry is Associated With Increased Thrombolytic Administration for Emergency
Department Patients With Acute Ischemic Stroke. Annals of emergency medicine.
2015;66(6):601-610. doi:10.1016/j.annemergmed.2015.07.018.
2. Fishbane S, Niederman MS, Daly C, et al. The impact of standardized order sets and
intensive clinical case management on outcomes in community-acquired pneumonia. Arch
Intern Med. 2007;167(15):1664–9.
3. 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., editors. Advances
in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and
Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008
Aug.Available from: https://www.ncbi.nlm.nih.gov/books/NBK43723/
4. Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital
order set for the management of septic shock. Crit Care Med. 2006;34(11):2707–13.
5. Reingold S, Kulstad E. Impact of human factor design on the use of order sets in the
treatment of congestive heart failure. Acad Emerg Med. 2007;14(11):1097–105.
6. Mayorga CA, Rockey DC. Clinical utility of a standardized electronic order set for the
management of acute upper gastrointestinal hemorrhage in patients with cirrhosis. Clin
Gastroenterol Hepatol. 2013;11:1342–8.
7. Milani RV, Lavie CJ, Dornelles AC. The impact of achieving perfect care in acute coronary
syndrome: the role of computer assisted decision support. Am Heart J. 2012;164(1):29–
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