What are we measuring?

We measure the percentage of Ischemic or Hemorrhagic stroke patients who received treatment to keep blood clots from forming anywhere in the body within two days of hospital admission.

Why is it important?

Stroke patients are at an increased risk of developing venous thromboembolism (VTE).  One study noted proximal deep vein thrombosis in more than a third of patients with moderately severe stroke.  Reported rates of occurrence vary depending on the type of screening used. Prevention of VTE, through the use of prophylactic therapies, in at risk patients is a noted recommendation.

How are we performing?

Summa performed 3.1% better than the National Average for 2021.

How are we working to improve?

We are routinely educating staff on the use of customized order sets and documentation. An electric health record (EHR) has helped us to improve this.

What are we measuring?

We measure the percentage of Ischemic stroke patients who received a prescription for stroke prevention medication at discharge.

Why is it important?

Data at this time suggests that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist.

How are we performing?

Summa performed 0.5% better than the National Average for 2021.

How are we working to improve?

We encourage use of neurology customized order sets and the use of stroke template for physician documentation, which requires this measure to be addressed.

What are we measuring?

We measure the percentage of Ischemic stroke patients with a type of irregular heartbeat who were given a prescription for a blood thinner at discharge.

Why is it important?

The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke. 

How are we performing?

Summa performed 2.0% better than the National Average for 2021.

How are we working to improve?

We encourage the use of stroke template for physician documentation, which requires this measure to be addressed.

What are we measuring?

We measure the percentage of Ischemic stroke patients who received clot buster medication within three hours of stroke symptoms starting.

Why is it important?

The earlier that IV thrombolytic therapy is initiated, the better the patient outcome is. Ideally, the target for IV t-PA initiation is within 3 hours; however, guidelines support giving the clot buster drug up to 4.5 hours after symptom onset.

How are we performing?

Summa performed 6.4% better than the National Average for 2021.

How are we working to improve?

Summa encourages EMS to activate stroke alerts from the field. We also provide ongoing education to Emergency Department staff.

What are we measuring?

We measure the percentage of Ischemic stroke patients who received medicine for stroke treatment within two days of hospital admission.

Why is it important?

Data at this time suggests that antithrombotic therapy should be administered within two days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity, as long as no contraindications exist.

How are we performing?

Summa performed 0.6% better than the National Average for 2021.

How are we working to improve?

Summa encourages the use of neurology customized stroke order sets which require this measure to be addressed. And electronic health record has helped us to improve this.

What are we measuring?

Some stroke patients are identified as having high cholesterol. We measure the percentage of stroke patients that are prescribed medication to help lower their cholesterol levels when leaving the hospital.

Why is it important?

Intensive lipid lowering therapy using statin medication has been associated with a dramatic reduction in the rate of recurrent ischemic stoke and major coronary events. Intensive lipid lowering therapy through the use of a statin medication is now recommended by American Heart Association guidelines.

How are we performing?

Summa performed 1.3% better than the National Average for 2021.

How are we working to improve?

Updated stroke order sets to include intensive statin dosing. Physician use of a stroke template requires documentation of this measure. An electronic health record has helped us to improve as well.

What are we measuring?

We measure the percentage of Ischemic or Hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following:

• Activation of an emergency medical system
• Need for follow-up after discharge
• Medications prescribed at discharge
• Risk factors for stroke
• Warning signs and symptoms of stroke

Why is it important?

There are many examples of how patient education programs for specific chronic conditions have increased healthful behaviors, improved health status, and/or decreased health care costs of their participants.

How are we performing?

Summa performed 4.6% better than the National Average for educating stroke patients in 2021.

How are we working to improve?

Use of SMARTphrase for nursing to document required stroke education information.  Daily audits of nursing documentation, providing immediate feedback.

What are we measuring?

We measure the percentage of Ischemic or Hemorrhagic stroke patients who were assessed for rehabilitation services.

Why is it important?

Effective rehabilitation interventions initiated early following a stroke can enhance the recovery process and minimize functional disability. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function.

How are we performing?

Summa performed 0.6% better than the National Average for 2021.

How are we working to improve?

Summa's goal is to ensure that all stroke patients are screened for rehabilitation needs.

What are we measuring?

Ischemic Stroke patients for whom an initial National Institutes of Health Stroke Score (NIHSS) is performed prior to any acute stroke treatment or within 12 hours of arrival.

Why is it important?

A neurological examination for all patients presenting to the hospital with signs & symptoms of stroke should be performed in a timely manner. The NIHSS is the preferred scoring tool recommended by the American Heart Association / American Stroke Association. Scores aid in the initial diagnosis of the patient, facilitate communication among healthcare professionals, and identify patients that may be eligible for treatment interventions or potential for complications.

How are we performing?

Summa performed 9.9% better than the National Average for 2021.

How are we working to improve?

We are working with Emergency Department providers and nurses to standardize this assessment score into the electronic medical record template for all patients presenting with stroke like symptoms.

What are we measuring?

We measure the median time from patient arrival in the hospital to the start of procedure (skin puncture).

Why is it important?

Timely restoration of blood flow is effective in reducing long-term disability. Earlier treatments are associated with increased benefits.  National Goal is less than 90 minutes.

How are we performing?

In 2021, Summa's average time to procedure was 73 minutes which outperforms the national goal of 90 minutes.

How are we working to improve?

We review every thrombectomy case for potential ways of improving our communication and speed of treatment.

What are we measuring?

We measure types of bleeding complications seen after clot busting drug or mechanical clot retrieval procedures for acute stroke treatment.

Why is it important?

Bleeding is the most common risk after these treatments. Although rare, if bleeding in the brain occurs, the stroke could worsen and even be life threatening.

How are we performing?

In 2021, Summa's complication rate for bleeding was 3.8% which outperformed the National Average of 5.7%.

What are we measuring?

We measure the percentage of patients who are unexpectedly readmitted to one of our hospitals due to an ischemic stroke within 30 days of leaving. We compare our patients to a nationwide inpatient sample to create an observed versus expected ratio. An expected ratio less than 1.00 is better than average.

Why is it important?

We want our patients as healthy as they can be and not in the hospital. Unplanned readmissions may be a sign of a breakdown in care. This could happen either during the hospital stay or during the transition from the hospital to the next level of care, such as at home or in a nursing home. It’s important to keep the providers patients see after a hospital stay, such as in doctors’ offices, post-acute facilities and in the home, up-to-date on care. Preparing and supporting patients and their caregivers is important to Summa Health so patients receive the best care they can.

How are we performing?

For 2021, Summa performed above the expected ratio of 1.00 with a observed/expected ratio of 1.24.  As a Thrombectomy Capable Stroke Center, Summa provides care for more complex stroke patients.  Each and every readmission is reviewed to determine if it was preventable.

How are we working to improve?

We monitor and monthly review cases that are readmitted to the hospital to determine the cause.

What are we measuring?

We measure the number of deaths versus the expected deaths within the hospital for Ischemic stroke. We compare our patients to a nationwide inpatient sample to create an observed versus expected ratio. An expected ratio less than 1.00 is better than average.

Why is it important?

Some deaths are expected in a hospital. However, we want to make sure we always provide the best care we can to minimize the number of people who die in our hospitals.

How are we performing?

For 2021, Summa performed well below the expected ratio of 1.00.

How are we working to improve?

We monitor and review outcomes monthly. We consult palliative/hospice care when appropriate.

What are we measuring?

We measure the percentage of patients who are unexpectedly readmitted to one of our hospitals due to a hemorrhagic stroke within 30 days of leaving. We compare our patients to a nationwide inpatient sample to create an observed versus expected ratio. An expected ratio less than 1.00 is better than average.

Why is it important?

We want our patients as healthy as they can be and not in the hospital. Unplanned readmissions may be a sign of a breakdown in care. This could happen either during the hospital stay or during the transition from the hospital to the next level of care, such as at home or in a nursing home. It’s important to keep the providers patients see after a hospital stay, such as in doctors’ offices, post-acute facilities and in the home, up-to-date on care. Preparing and supporting patients and their caregivers is important to Summa Health so patients receive the best care they can.

How are we performing?

For 2021, Summa outperformed the expected ratio of 1.00 with a observed/expected ratio of 0.86.  As a Thrombectomy Capable Stroke Center, Summa provides care for more complex stroke patients.  Each and every readmission is reviewed to determine if it was preventable.

How are we working to improve?

We monitor and monthly review cases that are readmitted to the hospital to determine the cause.

What are we measuring?

We measure the number of deaths versus the expected deaths within the hospital for hemorrhagic stroke. We compare our patients to a nationwide inpatient sample to create an observed versus expected ratio. An expected ratio less than 1.00 is better than average.

Why is it important?

Some deaths are expected in a hospital. However, we want to make sure we always provide the best care we can to minimize the number of people who die in our hospitals.

How are we performing?

For 2021, Summa outperformed the expected ratio of 1.00 with an observed/expected ratio of 0.79.

How are we working to improve?

We monitor and review outcomes monthly. We consult palliative/hospice care when appropriate.