Abstract NS12: Nursing-led Intervention to Improve Use of Prolonged Arrhythmia and Polysomnography in Veterans with Ischemic Stroke

Abstract

Background: Current AHA/ASA ischemic stroke prevention guidelines provide updated recommendations regarding prolonged arrhythmia monitoring to detect occult atrial fibrillation and polysomnography referral (PSG) for obstructive sleep apnea (OSA) assessment. While these assessments are traditionally considered “outpatient” testing, we sought to determine the feasibility of starting these referrals during the hospitalization period. Methods: We used Lean Six Sigma process improvement methods to process map the current and future states of obtaining prolonged arrhythmia monitoring and PSG at a single VA Medical Center. Working with stakeholders in neurology, cardiology, and sleep medicine we devised standard operating procedures for obtaining referrals for these respective testing during hospitalization. A stroke nurse coordinated all referrals. Results: Our single site intervention period was from 10/1/2015 to 2/29/2016, during which 21 patients were admitted to the neurology service with an ischemic stroke. At baseline, no patients received orders by hospital discharge for prolonged arrhythmia monitoring or PSG. Potential benefits and adverse effects of testing were discussed with Veterans. Of the twelve patients (57.1%) eligible for prolonged arrhythmia monitoring, half the patients agreed to the testing and were discharged with either a Holter monitor/implantable loop recorder. Of the 18 patients (85.7%) eligible for PSG, six agreed to the testing, with one patient receiving testing during hospitalization and the remaining patients received PSG after discharge. One Veteran was diagnosed with atrial fibrillation, whereas all Veterans receiving PSG were diagnosed with varying degrees of OSA. Positive test results initiated referrals to appropriate specialists for additional management. Length of hospital stay was not increased in order to receive the additional coordinated care. Conclusions: Implementation of a nursing coordinated program designed to improve delivery of guideline concordant post stroke arrhythmia monitoring and OSA assessment could be feasibly implemented using existing infrastructure without prolonging length of stay.