Abstract WP504: Utilizing a Nurse Driven Hand off Tool to Improve Neuro Interventional Post Procedural Documentation

Abstract

Introduction: In preparation for Comprehensive Stroke Certification (CSC) survey, auditing of pre-, intra-, and post-procedural documentation of neuro-interventional (NIR) angiograms was performed. Auditing identified post-procedural documentation was not consistent with physician orders or clinical practice guidelines (CPG) designated by the Joint Commission. Nursing developed a post-procedure tool to improve nurse to nurse hand-off and documentation compliance. Methods: A post-procedure tool was developed for nurse hand-off when transferring patients from NIR to Critical Care. The one-page tool contained the type of procedure performed, post procedure orders, time of sheath removal, type of required documentation (vital signs, neurological and neurovascular exams), and time-frame grid when documentation was due. Also included was criteria for issues requiring physician notification and management of groin hematoma flow chart. Results: Initial audits revealed virtually no post assessments were documented 100% correctly per order. After implementation and during time of CSC survey, auditing revealed an improvement to only 31%, but demonstrated a significant improvement from having substantial assessments missing to only 1-2 items. The CSC designation was granted with a requirement for improvement (RFI) to improve documentation. Additional focused auditing identified at-risk time frames, and specific assessments and staff locations to target further education. Editing of the tool was made with suggestions from nursing. Jan-Jun 2017 auditing demonstrated >80% compliance in all three assessment requirements with June having 91% neuro assessments documented, and 100% with neurovascular and vital signs documented appropriately for the required six hours of focused assessments. Nurses feel the tool has improved communication and provides a better hand-off between NIR and Critical Care. Conclusions: Compliance with orders and CPG required documentation, as well as improved nurse to nurse hand-off can be achieved utilizing a comprehensive tool identifying the type of assessment and designated time assessments are required.