Abstract WP435: Post Procedural Monitoring Tool Improves the Joint Commission Comprehensive Stroke Center Standard Compliance

Abstract

Background: The Joint Commission (TJC) Comprehensive Stroke Center standard requires monitoring of patients after IV tPA administration, diagnostic angiography, aneurysm coiling, carotid angioplasty and stenting, mechanical endovascular reperfusion (MER) and carotid endarterectomy. Meeting 100% compliance of the standard is challenging. In 2018, monitoring and documentation were among the TJC’s top ten cited survey findings. Purpose: To determine if an electronic tool can improve documentation compliance and reduce delays in monitoring of vital signs, and neurologic, pedal pulse and skin site assessments. Methods: The initiative was implemented in 2018 with the objective for all patients to have 100% of their post procedural monitoring completed. A documentation tool was created and introduced to nursing units via annual stroke education updates. The tool was added to an online nursing resource SharePoint website and application, which was accessible to all nurses within the hospital. The procedure end time was entered in the tool, which automatically calculated the documentation times. Data was compared 12 months pre and post intervention. Analysis and reporting of data were conducted monthly via the program’s quality oversight committee. Data was analyzed using T-Test. Results: In post-IV tPA patients, more patients had 100% complete documentation (79% post vs. 29% pre-implementation; p=0.006). For all post neuro-interventional radiology procedures, more patients had 100% complete documentation (68% post vs. 17% pre-implementation; p<0.001). For post carotid endarterectomy revascularization, there was a trend toward more patients with 100% complete documentation (83% vs 38%; p=0.07). Conclusion: Utilization of an electronic monitoring tool for post procedural documentation adherence can improve the percentage of patients who have 100% completed assessments and help meet the TJC standard.