Quality improvement activities
Our Stroke Coordinator and Core Measures Abstractor
conduct chart reviews and input data as part of our
quality improvement activities. We utilize the American
Heart Association Get With the Guidelines stroke
quality improvement program that provides evidence
based, best practice information and facilitates quality
care, patient safety, and positive clinical outcomes. Get
With the Guidelines program information can be obtained
from the American Heart Association’s website.
In addition, Joint Commission performance measures
that are utilized include:
• Deep vein thrombosis prophylaxis.
• Discharged on antithrombotic therapy.
• Patients with atrial fibrillation/flutter receiving anticoagulation
therapy.
• Thrombolytic therapy administered.
• Antithrombotic therapy by end of hospital day 2.
• Discharged on statin medication.
• Stroke education.
• Assessed for rehabilitation.
Disease-Specific Care Certification Manual, The Joint
Commission, January 2010.
In addition, nursing leaders are working with staff on
a daily basis to maintain compliance with core measures
documentation. Stroke education documentation is
monitored by the Core Measures Abstractor and Unit
Directors in order to provide timely, thorough education
of our stroke patients.