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CE Article: Perfecting stroke care through certification*

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Accreditation helps fine-tune processes

Learning objectives: After reading this article, you will be able to:

  • Identify strategies to build an effective stroke care program
  • List The Joint Commission's 10 stroke care indicators
  • Recall efficient methods to collect data from stroke care indicators

The recipe for creating a successful stroke care program at your facility may include many items. Teamwork, leadership, and commitment are just a few examples. And while not necessary for success, The Joint Commission's 10 indicators may be the most important—and most helpful—ingredient.

Take St. Joseph's Regional Health Center (SJRHC) in Bryan, TX, as an example. Amy Plotts, RN, chest pain and stroke coordinator, was hired in July 2006 to coordinate the stroke program there. Beverly Welch, RN, director of emergency services at SJRHC, had already spent months pulling together information to present to a team of people, called the clinical operations performance improvement committee (COPIC).

Welch credits leadership's involvement with this team from day one as the reason that in December 2007, 18 months after the program officially began, SJRHC received stroke care certification from The Joint Commission (formerly JCAHO). Read more on The Joint Commission's stroke certification

Teamwork, leadership, and commitment also played roles at Anne Arundel Medical Center (AAMC) in Annapolis, MD. In Maryland, where someone is hospitalized for a stroke every 30 minutes and someone dies every three hours, there was a severe need for a certified stroke center. AAMC answered the call, and received its stroke care certification from The Joint Commission

Starting at square one

Creating a program from scratch, like both AAMC and SJRHC did, requires dedication and commitment from more than just leadership--it needs willingness from an interdisciplinary team to make stroke care a priority. Lori Massaro, MSN, CRNP, an acute care nurse practitioner at the University of Pittsburgh Medical Center's Stroke Institute (UPMC), says that every member of the hospital staff needs to be able to recognize the signs of stroke and verbalize what mechanisms are in place if a patient is having a stroke.

The American Stroke Association (ASA) lists the following warning signs of stroke:

  • Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
  • Sudden confusion, trouble speaking, or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance, or coordination
  • Sudden, severe headache with no known cause

Read more about the ASA.

"[Nurses] have got to be prepared mostly for the mock-walk, the tracer methodology that is part of the survey," Massaro says. "No matter who [the surveyors] encounter on their walkthrough, they want to see that hospitalwide, there is a system in place for contacting the stroke team."

Turning data into new processes

Once a stroke care program gets going, data is going to be flowing from many different points. The Joint Commission requires data to be collected on each of its indicators including:

  1. Institution of deep vein thrombosis prophylaxis
  2. Patients discharged on antithrombotics
  3. Patients with atrial fibrillation get anticoagulation therapy
  4. Thrombolytic therapy given to patient
  5. Antithrombotic medication is administered within 48 hours of patient being hospitalized
  6. Patient is discharged on medicine that can reduce cholesterol
  7. Facility screens patients for dysphagia
  8. Facility offers patients stroke education
  9. Facility offers smoking cessation programs
  10. Facility considers a plan for patient rehabilitation

Massaro recommends sticking with one or two people to collect data.

"It's important to have one person dedicated to data gathering," Massaro says. "I'm a strong advocate of one or two people; otherwise the data tends to look different."

SJRHC used some of its data to create a dysphasia screening tool for use at the bedside by nursing. When a patient is admitted, he or she is screened before any oral medications are administered. If any problems are identified, the nurse has the authority to designate the patient an NPO (nothing by mouth) and order a speech therapy consult before even speaking with the physician.

SJRHC also developed a stroke alert in the ED in response to data trends. If a patient arrives with an onset of symptoms of less than three hours, he or she is immediately seen by a physician, a stroke alert folder is pulled, and a stroke alert group page is sent out to all team members, says Plotts. The folder contains any document that may be needed for a stroke patient.

Providing education and feedback

Before their certification, nurses at SJRHC took a stroke care course to acclimate themselves to the new policies and procedures.

"We had over 300 nurses that went through an eight-hour stroke care course," Plotts says. "It was mandatory for the nurses that might at any point put their hands on a stroke patient. We wanted to make sure they had the background and clinical information they needed."

SJRHC implemented a stroke-specific patient satisfaction survey in December 2007 and hopes to gather meaningful feedback from patients. As for staff feedback, Welch credits stroke champions recruited from each of the four major units with keeping the COPIC in the loop.

An immediate feedback loop has been established to bring information to those staff members who work closely with stroke patients, says Plotts. They like to know how their patients are doing, and the program also provides a chance for some staff recognition.

"They get very excited about it, but they also get very upset when [a patient's condition] doesn't go the way they think it's supposed to go," Plotts says.


1. AAMC earns designation as stroke center at
2. ASA Policy Recommendations at
3. Primary Stroke Center Certification Frequently Asked Questions at

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