Abstract TP355: Rapid Cycle Implementation of a Standard Stroke Neurological Check Before Comprehensive Stroke Re-certification Survey

Abstract

Background: Components of ongoing stroke neurological assessment are remarkably controversial. Gap analysis preceding a Joint Commission (TJC) Comprehensive Stroke Re-Certification (CSC) survey identified organizational deficiency in defining a neurological check that trends neurological status of stroke patients. A standard stroke neuro check was implemented 30 days prior to the CSC survey. During the CSC survey, closed chart review performed on a patient hospitalized prior to the implementation revealed lack of trending patient’s original symptoms. Real time patient tracers also revealed lack of consistency of assessment between healthcare providers, missing documentation of notification to providers for a status change, missing groin checks and pulse checks. These issues resulted in a Requirement for Improvement (RFI) from TJC. Purpose: Determine if the rapid cycle implementation of standard neuro check one month prior to CSC survey was successful, and if other documentation requirements as defined by TJC were completed for the 30 day period prior to CSC Survey. Methods: Charts from 30 days prior to the survey between May 6 and June 6, 2016, were audited for compliance with standard neuro checks, groin checks, pulse checks, NIHSS agreement between healthcare providers, and status change provider notification. All ischemic stroke patients treated with IV alteplase and/or mechanical thrombectomy, Subarachnoid Hemorrhage, Craniotomy, Coiling, Clipping, Carotid Endarterectomy were included (n=30). Frequency of needed assessments varied based on stroke type and treatment. Results: A total of 30 cases revealed 89.7% overall compliance with all required documentation elements. Of 11 ischemic stroke treatment patients there were 1077 opportunities for neuro checks with 907 (84%) of those opportunities completed. Compliance with all remaining components were: NIHSS agreement between providers 92%; status change resulting in notification 96%; and vital signs 96%. Conclusions: Rapid cycle implementation of a standard neuro check was feasible in a large CSC, well received by staff and satisfied the requirements for TJC CSC 10 day clarification process in 2016. Implementation of a standard stroke neuro check needs further research.