Abstract WP41: Last Know Well Documentation Gaps in the Hemorrhagic Stroke Patient Lessons Learned

Abstract

Background: Intracerebral Hemorrhage (ICH) accounts for 10% of strokes and has higher risk for mortality and disability. Documentation of Last Known Well (LKW) for Ischemic stroke patients is firmly integrated in code-stroke processes to aid clinical decision making. Hematoma expansion may occur in ICH. LKW aids in time sensitive treatment modalities for BP management and anticoagulation reversal to reduce risk of neurological demise. LKW in ICH patients has not been well established as an important timely metric. Purpose: Translation of ICH guidelines into actionable metrics for data collection is needed to enhance outcomes. Methods: Twenty Comprehensive Stroke Centers participated in a three-year ICH learning collaborative from 2020-2022. Expanded ICH data elements were added to Get With The Guidelines® (GWTG)-Stroke registries to identify data gaps and facilitate quality improvement. Abstractors reviewed coding definitions and participated in American Heart Association® (AHA) National Office Hours to ensure data integrity. ICH data was reviewed quarterly. Records with Missing Times was one of fourteen measures analyzed; LKW documentation revealed low compliance. Findings: From 2020-2022 there were n=6,648 ICH patients entered, of that 49.1% did not have an LKW. Data was filtered by patient arrival mode to assess gaps. EMS arrival=33.7%, transfer from another hospital=55.4%, and private transport=58.5% had missing documentation. To understand documentation gaps, a fishbone diagram was used to illustrate causality. Contributing categories were as follows: patient demographics, resources, transfers, symptom presentation, clinical care, clinical specialty, and abstraction. Analysis of time sensitive treatments requiring LKW such as Anticoagulant Reversal for Direct Oral Anticoagulants (DOAC) showed 52 patients taking a DOAC on arrival did not have a LKW and were not reversed. Conclusions: Education and documentation strategies were implemented locally to optimize data capture. Providing scientific rationale for documenting LKW and its relationship to time sensitive interventions will be shared on a national level. Future considerations are to examine if adverse outcomes exist due to documentation and treatment gaps.