Objective: The Joint Commission (TJC) Comprehensive Stroke Center (CSC) certification includes the standard that hospitals must use processes based upon clinical practice guidelines (CPGs) or evidence-based practice to facilitate the delivery of clinical care, including patients admitted directly from the Operating Room or Interventional Radiology. Included in this standard is the requirement that assessment and documentation post-procedure be consistent with selected CPGs. This project was designed to improve assessment and documentation adherence at a single academic hospital. Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to improve compliance for required assessments when recovering a patient. The team reviewed current policies, guidelines, and order sets related to post procedure assessments. Comparison of pre-intervention and post-intervention adherence to charting standards was performed. Pre-intervention patients included a review of 4 records by TJC CSC reviewers during their on-site visit. Each patient had insufficient documentation; therefore, the institution was cited in this area. Post-intervention patients were prospectively identified. A Neuro ICU Self-Audit Tool was created to identify patients, remind staff of required assessments, and serve as a self-audit tool affirming their adherence to the guideline. Additional interventions included education (via email, poster in-services, staff meeting updates, and one-on-one teaching) for Neuro ICU nurses. A Post Cerebral Arteriography order set was created and the electronic health record modified to make it easier to document assessments. Results: Compliance improved to 98% in 4 consecutive months. 100% of cases were reviewed by the primary and charge nurses. 10% of cases were reviewed by the stroke program data analyst to ensure accuracy and inter rater reliability. Outliers were reviewed by the stroke leadership team and feedback given to unit nursing leadership and the nurse. Conclusions: Improvement of adherence to post-procedure assessments is possible using the PDSA methodology. The success of this project allowed this hospital to achieve its TJC CSC certification.

Background and Purpose: It is publicly reported 2%-15% of all strokes occur in patients hospitalized for another procedure or diagnosis. The evidence suggests greater delays in the evaluation and treatment of in hospital stroke. The stroke program at University of Colorado Hospital identified these in-hospital delays as a result of an informal in-patient alert process. During the day, the stroke alert responders included the stroke attending, stroke resident and/or APP. During off hours, the stroke resident was the responder responsible for both evaluating and transporting the patient to CT scanner within the 25 minute goal window. We identified the lack of a formal process contributed to a delay in the care and treatment of stroke patients. Method: A multidisciplinary team was created to identify ways to improve the inpatient stroke alert process. This group approved the Neurosurgical ICU charge nurse to carry a stroke alert pager becoming a 24 hour responder for the acute inpatient stroke alert response team. Prior to implementation, mandatory training included the charge nurse group attending a lecture including topics of neuro assessment, stroke alert documentation and time goals. The stroke alert policy was updated to reflect this change. The stroke alert phone number was also changed to be in alignment with this hospital’s CODE response. Hospital-wide education of the new inpatient response number and our stroke alert criteria was also provided. A retrospective analysis was then performed comparing the 12 months prior to the initiation of the inpatient stroke alert process and the 12 months post implementation. Results: See image Conclusion: A consistent response team leads to a more organized stroke alert process with improved accuracy of inpatient stroke alerts diagnosis, faster CT times, an increase in treatment rates, and improved treatment times.

Background: Joint Commission Comprehensive Stroke Certification (CSC) standards include the use of a standardized stroke scale across the organization. Physicians were utilizing the National Institutes of Health Stroke Scale (NIHSS)and it was identified that nurses had a poor understanding of how to perform and interpret the scale. Purpose: To use Plan-Do-Study-Act methodology to guide a quality improvement project to increase understanding and utilization of the NIHSS by nursing staff. This includes training and certifying all the nurses in stroke patient care units; followed by implementation into nursing practice. Methods: A multidisciplinary team was created to assess the current situation,develop education and implement plans based on best evidence. A literature search was completed. A course was developed by the stroke team to train and certify 250 nurses. Course content included lecture, discussion and accepted training video offered by the National Stroke Association. The intent of the course was to expand nursing knowledge and comfort with NIHSS. A pilot course was offered to the providers outside of these three key units and feedback was used to modify the course. Nurse perceptions of the NIHSS were examined prior to the training (n=211) and 2 months after implementation of the scale into routine practice (n=68). Adjustments and resources were developed and implemented based on results. Results: The course offered a first time certification pass rate 96% and nursing documentation compliance was 83% a month after implementation. However, in the first 3 months, 80% of those who completed the survey reported feeling they could accurately perform the NIHSS but almost 60% had only performed the scale 1-6 times. Many nurses expressed concern about the scale to being too subjective (55%) and too time consuming (50%). Conclusions: Even though the staff has been trained and certified to complete the scale, steps in the scale are consistently reported as difficult to assess. Low patient volume, infrequent use and patient barriers may contribute to challenges with NIHSS.