Ensuring a Successful Neurointerventional Radiology (NIR) Tracer

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As mechanical thrombectomy science evolved over the past decade, the neurointerventional (NIR) suite became a critical area for patient care and a focus of regulatory review for stroke certification.When assisting programs in seeking successful certification visits, we’ve noted a few common themes in need of attention in the NIR suite to ensure successful certification tracers. 

  • Staffing: There tends to be variation in how NIR suites are staffed across the nation in terms of number of staff, credentials of staff and roles of each staff member in the suite.  This is often more pronounced in organizations when the NIR suite is maintained separately from the cardiac catheterization suite.  Leadership should be aware of the differences and articulate how their model of staffing ensures patient safety while in the NIR suite.  Differences between how cardiac intervention cases and stroke intervention cases are staffed should be explored by leadership and easily explained if asked.  
  • Educational competencies: NIR suite leadership may manage education and competency assessment from several perspectives.  Companies with knowledge about devices frequently host educational talks or in-services for staff.  Content covered and attendance at in-services should be noted by NIR leadership and documented in staff files.  Information from device experts should be put

    into context for NIR staff by practitioners (e.g., physicians, advanced practice providers, stroke coordinators, lead technologists) so all staff are knowledgeable about how devices will be used in procedures at the organization.  Another great approach to NIR staff education is focusing on what staff should anticipate if an unexpected complication occurs during the case.  Discussion or even simulated cases of managing complications during procedures can help all room staff anticipate what is needed during a stressful event.  Finally, any staff managing patients with critical care needs in the NIR suite should have documented education and competencies related to critical care stroke management. 
  • Knowledge of performance improvement data: NIR staff should have knowledge of the program’s performance data and how they fit into the puzzle of fast and safe care.  This includes knowledge about the time from door to thrombolysis and mechanical thrombectomy times (first pass of device, recanalization time) and outcomes (TICI scores).  Staff should be articulate about how they ensure processes are followed to minimize delay and ensure safety.  Data should be readily available for staff, and they should be able to explain the information and why it matters to patient care.  
  • Management of critically ill patients: Some patients receiving care in the NIR suite are critically ill, such as patients with subarachnoid hemorrhage in the suite for intra-arterial management of cerebral vasospasm.  Roles and responsibilities of all staff in the room related to management of critical care needs including the external ventricular drain (EVD), intracranial pressure monitoring and management, vasopressors for blood pressure management, and mechanical ventilation should be clear. Documentation of frequent vital sign assessment, EVD monitoring and mechanical ventilation should also be clear in the medical record for patient tracers. Many traditional templates for the NIR or cardiac catheterization lab in electronic health records do not offer a place for documentation of these parameters and require editing to ensure complete documentation of monitoring.

Having an organized approach to these key areas will help to ensure a smooth certification review for your stroke program and will minimize the risk of findings on your next certification review.  Most importantly, it will ensure you are providing the best care for your patients.   

And as always, Stroke Challenges has several free resources including blogs on various stroke topics.  We also offer both e-books and on-demand webinar training on topics including how to put your best foot forward during your stroke program opening presentation for certification, mastering your data tracer and several helpful on-demand data management presentations and workshops.  Visit our website to see all that we offer!

STROKE CHALLENGES, CO-FOUNDERS

Sarah Livesay, DNP, APRN, ACNP-BC, ACNS-BC

Debbie Hill, BS, FAHA

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How to Stay Current with Regulatory Changes that Affect Your Stroke Program

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Staying current with regulatory and stroke certification changes can be daunting for stroke coordinators and other stroke program leaders. Often changes are communicated to others in the organization such as those in the finance or regulatory departments. Without knowing the full impact of changes – or even discerning those related to the stroke program through a myriad of changes – updates to the stroke team may be delayed for weeks, months or even until an adverse impact to the program surface (financial losses, citations during intra-cycle or recertification reviews, etc.)

The purpose of this blog is to summarize the timing of routinely scheduled regulatory changes and provide useful resources that can be used to monitor for release of changes.

  1. Certification Standards

In the case of disease-specific certifications like stroke, agencies such as The Joint Commission, DNV-GL and HFAP, communicate directly with the hospital accreditation contact in the regulatory or compliance department. These individuals have access to the accreditation agency’s “extranet site” or “customer portal” where they receive periodic updates from the agency. Sometimes stroke coordinators have access to the extranet site or customer portal and can look for updates and other resources there. Talk to your hospital accreditation contact about access. Also, The Joint Commission, for instance, has a monthly publication called, Joint Commission Perspectives to formally notify hospitals of changes in conditions of participation, eligibility requirements and standards of compliance. DNV-GL sends stroke program Advisory Notices with updates. HFAP has a Blog on its website that may be helpful. Stroke program leaders will need to make sure that these periodic updates are forwarded to them. If e-Alerts/Advisories are offered that provide updates on certification, sign up for them. They are sent to your email daily/weekly/monthly and can help alert you to upcoming changes.

Scheduled updates are generally released once a year and most often give programs six months advance notice to implement the changes. For instance, The Joint Commission releases annual changes in June/July with effective dates at the beginning of the next year. There is also a public comment period that precedes the notice of updates. And we encourage all programs to review the proposed changes and comment. You can obviously only do that if you get the information timely.

The Joint Commission, DNV-GL and HFAP all released new certification manuals for 2019, adding their version of advanced Primary Stroke Centers performing thrombectomies. These are usually available free to already certified programs – through your hospital’s accreditation contact.

  1. CMS (Medicare) Rules

CMS has a regular schedule for annual updates outlining payments for hospital stays, emergency room visits and outpatient services for both hospitals and physicians.

Hospital scheduled updates are released for public comment in or around June/July with final regulations publicly announced in late August. Changes take effect at the beginning of Medicare’s fiscal year which is October 1.

Physician fees are updated a little later with changes effective at the beginning of the calendar year, January 1.

You may recall changes that came from CMS in the past such as stroke drip-and-ship payments, the 2-midnight rule, rehabilitation therapy payment caps, hospital 30-day readmission penalties and meaningful EHR use payments. The CMS changes are more complicated to follow. We suggest finding someone in the finance department that monitors these changes and asking them to help you stay abreast of what might impact your stroke program as they dissect the Medicare annual updates – for 2019, all 2,593 pages of it! Knowing the schedule of updates will help you know when to reach out to them.

In summary, to stay current on regulatory changes:

  • Sign up for e-Alerts/Advisories/Blogs, if available, from stroke program certification agencies
  • The Joint Commission: https://www.jointcommission.org/ealerts/
  • DNV-GL: https://www.dnvgl.us/assurance/healthcare/index.html
  • HFAP (blog available on the website): https://hfap.org/blog/
  • Sign up for list-servs through your professional organizations or regional stroke coordinator groups (AANN, ASA, etc.)
  • Connect with someone in your regulatory department and coordinate getting certification agency stroke program updates to you
  • Connect with someone in your finance department and coordinate getting any CMS changes that impact the stroke program to you

Lastly subscribe to our blog, Twitter and Facebook! We will use our social media and blog to bring you useful information on managing your program and stroke care in general.  Through our eBooks, consultative sessions and weekly postings, we hope to create a community of stroke leaders who help each other stay current!