Abstract T P253: A Quality Improvement Project to Improve Stroke Assessment Adherence for Patients After Surgical or Interventional Radiology Intervention

Abstract

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.