Hospital- wide Communication to Improve Quality Outcomes of Stroke Patients
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Session D presented Friday, September 15, 2017
Purpose: Time is vital in the initial care of stroke patients. Swift recognition of symptoms, immediate access to diagnostic tests, and appropriate treatment play a vital role in a patient’s functional outcomes (Middleton et al., 2015). Delays in any one of these areas can postpone treatment and thus complicate the recovery of the patient. Identified disruptions at this facility included delays in patient registration, lack of coordination for medical order entry, and communication issues regarding imaging availability. This project sought to evaluate and eliminate possible interruptions in service, with a goal of reducing the time to evaluation and treatment.
Design: This quality improvement (QI) project utilized an evidence-based algorithm to drill down on performance metrics for assessment and treatment of patients experiencing acute strokes.
Setting: This project was conducted in a suburban, ANCC Magnet recognized hospital which serves as a primary stroke center. The hospital has 136 beds, including 16 beds in the ED. The hospital experiences 24,010 ED visits and 6,619 admissions per year.
Participants/Subjects: All patients were included in the acute stroke protocol if they presented with signs and symptoms of stroke and were known to be well (LKW) less than 12 hours prior to the onset of symptoms. Staff participation in the algorithm included all ED staff (nurses, physicians, unit secretaries, techs, etc.), and staff who worked in areas impacted by stroke care (i.e. radiology and lab).
ED staff initiated a Code Stroke for all incoming patients who fit the criteria. An overhead page was implemented, which notified members of the team throughout the hospital. Radiology would prioritize the use of the cat scan (CT) for this patient, and would call the ED as soon as the CT was ready. While waiting for the call to transport to radiology, the ED team would continue assessments.Upon receipt of the CT results, the physician would determine the type of stroke and evaluate whether the patient was a candidate for tissue plasminogen activator (tPA). The acute stroke protocol algorithm, a one page diagram used to help guide care, listed indications and exclusion criteria for tPA administration. Other treatment requirements were also listed on the algorithm, including reminders for frequency of vital signs and neuro checks, interventions to consider (depending on screening results).
Results/Outcomes: After implementing the algorithm in May 2016, the ED team began to see a significant decrease in time to CT. This was due to a combination of decreased time to obtain a CT and decreased turnaround time (TAT) to obtain the results of the CT. Since implementation, CT TAT has been completed within 45 minutes increased from 62% to 83%. NIH Stroke Scale completion rose from 79% to 100% (sustained). Compliance with completing dysphasia screening increased from 86% to 93%.
Implications: These results stem from a commitment to excellence from the entire interdisciplinary team. These efforts persist as the team repeatedly revisits their processes to further improve care for stroke patients.