Background and Issues: Patient volume increased significantly over first half of 2011 on the Neurology Service. Bed occupancy increased by 14% over previous year and bed availability became a major constraint. Data showed, patients were discharged late in the day or sometimes stayed an extra night because discharge orders were released too late to place patients in rehab or skilled nursing facilities. Only 16% of patients were discharged by 2:00 pm due to communication barriers and inadequate information exchanged between multidisciplinary teams. There was also an issue with inconsistent acceptance criteria from primary placement facilities which resulted in a longer length of stay. Purpose: Primary goal of project was to free up capacity on the Nursing Division to accommodate the increase in patient volumes without increasing staffing or the number of available beds. Methods: In September 2011, a multidisciplinary team was assembled to understand causes of the problems and develop solutions to resolve. Solutions implemented include working with partner Rehab and Skilled Nursing Facilities to define standardized Acceptance Guidelines to ensure issues could be addressed before day of discharge. Also, processes for releasing discharge orders were redesigned so orders were more frequently written and placed “on hold” the day before expected discharge. A mobile computer was issued to physician rounding teams so orders could be released during rounds instead of batch-released in the afternoon. Additionally, team communication was significantly improved by standardizing a daily multidisciplinary team huddle and implementing a visual communication board to track key information about patients to proactively plan for discharge. Results: The overall length of stay of patients on the Neurology Service decreased from 4.26 days in 2011 to 3.69 days in 2012. Conclusions: Many variables contributed to the decrease in length of stay for patients in this study. No decisive conclusions can be made about the effectiveness of any particular variable. Other variables during this timeframe likely contributed, however the authors of this study presented the most likely factors. Although the findings are exciting, further analysis is needed to isolate the main drivers.

Background: Literature review has shown that in an ICU setting, the use of a mobility team decreased both the ICU and hospital stay. Patients also experienced improved functional status, strength and an improved sense of well being. Many patients appear more empowered and more involved in their care when they are moving. There was no current literature available regarding the use of a mobility team with the acute stroke patient population in an inpatient setting. Purpose: The purpose of this pilot program was to evaluate the impact of a dedicated mobility team in an acute neuroscience setting on mobility levels, fall rates, patient satisfaction and discharge disposition. Methods: This pilot was implemented in a Primary Stroke Center within a large tertiary medical center. This facility admits 1200-1300 stroke patients annually. A RN-Patient Care Technician mobility team was available from 0830-1700, Monday-Friday, rotating on three neuroscience divisions. Patients with orders for chair and ambulation were mobilized per the team. If on bedrest, range of motion and turning was provided. The team attempted to round on all patients twice per day. All activities completed with patients were documented in the electronic medical record. Outcomes were analyzed in aggregate. Results: The mobility team was piloted for a 90 day period ending May 20, 2011. Of the eligible patients, 83% received mobility interventions. Patient testing and patient refusal were the top reasons an intervention was not provided. Mobility levels demonstrated an increase in ambulation of 22%. Falls decreased 37%. Patient satisfaction scores increased up to 19%. An increase in discharges to home with outpatient therapies and a subsequent decrease in inpatient rehabilitation were observed. Conclusions: In conclusion these results demonstrate the positive impact of the mobility team on patient mobility, falls, patient satisfaction and discharge disposition. The mobility team continues to be used with ongoing data collection to evaluate ongoing outcomes.

Background and Issues: In a Primary Stroke Center, which admits 1200-1300 stroke patients annually, cerebral angiography is a frequently performed diagnostic test. Frequent monitoring is important to evaluate for complications following the procedure. In 2009, the documentation compliance with site checks and vital sign monitoring was 58% and 78% respectively. Poor communication was occurring at change of shift regarding status of monitoring which resulted in lack of continuation with monitoring. Purpose: The goal of this project was to increase compliance with monitoring and documentation in order to enhance patient safety. Methods: In 3rd Quarter of 2009, education was rolled out to all RNs and Patient Care Technicians regarding the importance of monitoring and compliance with physician orders. A worksheet was developed to assist in determining the times when monitoring was due. This worksheet was handed off to the next shift and discussed in bedside shift report. All monitoring was to be documented in the electronic medical record. In 2010, a signature requirement was added to the worksheet for accountability. Results: Compliance rates in 2010 were 81% for site checks and 91% for vital signs. Compliance rates in 2011 increased to 92% for site checks and 93% for vital signs. Conclusions: A simple worksheet, for nurses to use with monitoring, improved the communication and handoff from nurse to nurse. Post cerebral angiography patient monitoring increased which improved patient safety.

The complexity of nursing care and increasing acuity of patients places demands on the ability of nurses to make critical decisions regarding patient care. In a Comprehensive Stroke Center, which admits 1200-1300 stroke patients annually, the nurses in the neuroscience intensive care unit (NICU) are challenged to provide excellent care to the critical patients who experienced massive hemorrhagic and ischemic strokes. Easy access to educational material was needed for the NICU nurses. The process improvement team in the neuroscience intensive care unit decided to develop a RN-based reference book modeled after the material the physicians had been using for years. The result is the Neuroscience ICU Red Book, a pocket guide which provides essential neuroscience and intensive care information at the fingertips of the NICU nurse. The Red Book provides comprehensive neurology, cardiology, respiratory, and pharmacology material in a matter that is not overwhelming, visually pleasing and easily understood. This Red Book has been proven beneficial for new and experienced NICU nurses, and every new staff member receives a book at the time of hire. The evidence based material contained is updated biannually; the nurses provide feedback on the topics and information needed to keep the guide useful and meaningful. The use of the Red Book in the neuroscience ICU has been highlighted as a Best Practice within the organization and similar pocket guides are being developed on the neuroscience nursing divisions.

Depression is a frequent sequela of stroke that has been associated with poor recovery and rehabilitation response. Clinical depression may occur within 3 months post stroke and can last for several years if left untreated. Utilization of a depression screen helps identify patients at risk for post-stroke depression. It is important to recognize and treat depression symptoms early to improve patient outcomes. In performing a gap analysis in preparation for our survey for Comprehensive Stroke Center Certification, it became apparent this psychological aspect of patients was not being met. A systemic literature review was performed in search of a depression screening tool that was easy to use and addressed the needs of the patient. The tool chosen is the validated 2-item Patient Health Questionnaire depression module (PHQ-2). This depression screen is also utilized in our rehabilitation center which enhances the communication between our facilities. After educating all the neuroscience nursing staff and stroke physicians, the tool became part of the patient assessment. The nurse screens each stroke patient on admission to the division or transfer from the intensive care unit. If the patient scores 3 or greater, the physician is notified so appropriate follow-up and treatment can occur. If a patient is unable to be assessed, the physician is notified so other depression assessment measures can be considered. The utilization of a depression screening tool along with staff education has increased our staff’s awareness of the potential devastating effects depression can have on stroke recovery.