Abstract TP359: One Patient, One Standard, One Medical Record: Improving Documentation of t-PA Therapy across the Care Continuum

Abstract

Background and Issues: Department specific documentation systems resulted in a non-standardized approach to assessment documentation for patients receiving intravenous t-PA for treatment of acute stroke. Subsequently, compliance with documentation requirements during transition of care from the emergency department (ED) to intensive care unit (ICU) did not meet targeted benchmarks. Purpose: Design a hospital-wide standard and system for vital signs and neuro assessment documentation for patients receiving IV t-PA for the treatment of acute stroke. Methods: A multidisciplinary team analyzed current practice and collaborated to create one standardized documentation record that would satisfy requirements for the ED and the ICU. A t-PA worksheet had proven success with physicians for documenting eligibility and ordering t-PA. The team agreed to keep this worksheet as page one of the documentation record. Page two was designed for ED documentation of medications, assessments and patient response. Page three captures the documentation of mandatory vital signs and neuro assessments. The Stroke Leadership committee approved recommendations from this team for nurses to assess patients using the abbreviated NIH Stroke Scale. Prior to implementation, Physicians and Nurses received education regarding the abbreviated stroke scale and expected documentation. Results: Concurrent monitoring for compliance in documentation of post t-PA vital signs and neuro assessments began with the implementation of this revised documentation record. First month post implementation reported 95% compliance rate and 100% by the fourth month. Conclusions: Process standardization with one consistent documentation tool has sustained 99-100% compliance in documentation of assessments pre and post t-PA administration.