Abstract TP377: Nurse Entered Stroke Order Sets Improve Emergency Department Metrics at a Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Tawnae C Griffith ◽  
Atul Gupta ◽  
Stacey Aggabao ◽  
Raeesa Dhanji ◽  
Denise Gaffney ◽  
...  
Keyword(s):  
Emergency Department ◽  
Stroke Care ◽  
Cardiac Monitoring ◽  
Post Intervention ◽  
Improvement Project ◽  
Order Sets ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Contrast Ct ◽  
Order Set

Introduction: The Joint Commission has established time sensitive metrics for stroke care in the Emergency Department (ED) including door to initial physician evaluation, door to lab and CT order placement, door to lab resulted and door to CT interpretation. Purpose: The purpose of this quality improvement project was to assess if nurse entered protocolized order sets for stroke patients would help to improve these metrics. Methods: A code stroke order set was initiated independently by nursing staff upon symptom recognition in the ED. The order set included CBC, electrolyte panel, BUN, creatinine, glucose, troponin, PT/INR, aPTT, non-contrast CT head, EKG, swallow screen and continuous cardiac monitoring. Data was collected for 3 months pre and post intervention. All ED nurses were trained on order set entry and their skills were validated. Data was analyzed using a T-Test. Results: 60 patient pre and 52 post-implementation were evaluated. Door to initial physician evaluation was faster (7 mins pre vs. 5 mins post; p=0.029). Door to lab order placement was faster (8 mins pre vs. 3 mins post; p=0.038). Door to CT ordered was faster (8 mins pre vs. 6 mins post; p<0.01). Door to labs resulted was faster (32 mins pre vs. 27 mins post; p=0.01). Door to CT interpretation was faster (19 mins pre vs. 18 mins post; p=0.04). Conclusion: Implementation of nurse entered order sets can improve ED metrics for door to initial physician evaluation, door to lab and CT order placement. This subsequently led to faster interpretation of the CT scan and lab results.

Abstract WP281: Pharmacists Improve Door to Needle Times in the Emergency Department

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kevin Phan ◽  
Megan Degener
Keyword(s):  
Emergency Department ◽  
Cerebral Perfusion ◽  
Stroke Care ◽  
Time Frame ◽  
Safe Delivery ◽  
Team Meetings ◽  
Stroke Team ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Background: An estimated two million brain cells die every minute cerebral perfusion is impaired. The best outcomes for acute ischemic strokes are achieved by decreasing the time from emergency department (ED) arrival to thrombolytic therapy. Alteplase, a high risk medication, was dosed and prepared in the pharmacy. This contributed to prolonged door to needle (DTN) times. Purpose: To describe the impact of pharmacist interventions on DTN times in the ED. Methods: All patients who received alteplase for acute ischemic stroke from January 2012 to April 2019 were reviewed. In November 2012, the ED pharmacy program began with a dedicated ED pharmacist for 8 hours a day and expanded to 13 hours a day in September 2014. During those hours alteplase was prepared at bedside in the ED. In November 2015, all pharmacists were trained on the ED code stroke process. Monthly case reviews and DTN times were reported to the stroke coordinators starting January 2017. Alteplase preparation and administration in the computed tomography (CT) room started April 2017. Following comprehensive stroke center certification, routine stroke competency exams were administered to pharmacists in 2018. In 2019, pharmacists started reporting DTN times at neuroscience core team meetings. Results: During this time frame, a total of 407 patients received alteplase. Average DTN times decreased from a baseline of 130.9 minutes to 45.3 minutes. Interventions that resulted in the largest decrease in average DTN times were the expanded ED service hours (34.6 minutes) and pharmacist preparation of alteplase in the CT room (21.9 minutes). Conclusions: Pharmacists directly impacted stroke care in the ED by decreasing DTN times. Presence of a pharmacist in the ED enabled fast and safe delivery of alteplase by ensuring accurate dosing and preparation. Pharmacists also performed rapid medication reconciliation and expedited antihypertensive therapies. In conclusion, having pharmacists as part of the stroke team is a model that could be adopted by hospitals to enhance stroke care.

scholarly journals LO93: Implementation of sepsis order sets to decrease the time to antibiotics in the emergency department: a quality improvement initiative

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S41-S42
Author(s):  
K. Akilan ◽  
V. Teo ◽  
D. Hefferon ◽  
A. Verma
Keyword(s):  
Emergency Department ◽  
Retrospective Chart Review ◽  
Electronic Record ◽  
Quality Improvement Initiative ◽  
Chart Audit ◽  
Post Intervention ◽  
Sepsis Management ◽  
Order Sets ◽  
Time To Antibiotics ◽  
Order Set

Background: Sepsis is a life-threatening syndrome, and delays to appropriate antibiotic therapy increases mortality. Order sets have shown decrease in time to antibiotics in pneumonia, and in sepsis, the implementation of order sets resulted in more intravenous fluids, appropriate initial antibiotics and lower mortality. Aim Statement: The goal was to create an order set for an approach to septic patients, to improve sepsis management. We sought to improve time from triage to first antibiotics, by 15 minutes, for Emergency Department (ED) patients with sepsis in three months after implementation compared to three months before. Measures &amp; Design: We used a literature review, as well as comparison to existing order sets at other EDs to design our initial order set. We underwent multiple revisions based on stakeholder feedback. We educated physician and nursing teams about the order sets, although use was ultimately at physician discretion. We implemented the order set on April 9, 2017. After three months, an electronic retrospective chart review identified patients with a final sepsis diagnosis admitted to the critical care unit. For each patient, we captured triage time using the electronic record, and time to antibiotics from when the antibiotic was taken out of the medication cart. Finally, utilization of order sets was checked via manual chart audit. Evaluation/Results: A run chart did not demonstrate any shifts or trends suggesting a change after implementation. Median time to antibiotics in minutes, 3 months prior (n = 45) and post (n = 55) intervention, increased from 245 to 340 minutes, although the range was very large. Chart audits demonstrated clinicians were not using the order sets. There was 10% usage for 2 of the months and 0% usage the other month, post-intervention. Disucssion/Impact: There was insufficient uptake of the Sepsis Order Set by the Sunnybrook ED to result in any impact on time to antibiotics. Order sets require more than just implementation to be effective. Difficulties in implementation were due to the document not being readily available to physicians. To mediate, we have organized nursing staff to attach the order set onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

scholarly journals Implementation of disease-based standard order sets in emergency department of tertiary care hospital, Pakistan- a novel approach for enhancing patient care

2020 ◽  
pp. 1-13
Author(s):  
Feroza Parveen ◽  
Asif Khaliq ◽  
Nadeem Ullah Khan ◽  
Zainab Mazhar ◽  
Aisha Akram ◽  
...  
Keyword(s):  
Emergency Department ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Care Hospital ◽  
Order Entry ◽  
Post Intervention ◽  
Order Processing ◽  
Standard Order ◽  
Order Sets ◽  
Order Set

Abstract Objectives: To evaluate the efficacy of disease-based standard order sets in reducing time of order entry, order processing and medication dispensation in emergency department of a tertiary care hospital. Methods: The pilot study was conducted as part of a retrospective clinical audit using pre- and post-intervention design comprising data from July to September 2013 of the emergency department of a tertiary care hospital in Karachi. Data collected related to the reduction in medicine order entry, processing and dispensing time of eight common emergency conditions with standard order set.  Subsequently, standard medication orders for the selected medical conditions were developed together with physicians of emergency and other specialties. Post-intervention data was collected and the two data sets were compared using SPSS version 23.0. Results: Mean medication order entry and processing time from the physician end improved from 67.7±22.7 seconds to 20.5±7.1 seconds.  Mean order processing and medication processing and dispensing time at pharmacist end reduced from 70.0±22.4 to 20.6±8.8 seconds. The difference between pre- and post-intervention values was significant (p<0.001). Conclusion: Implementation of disease-based standard order set significantly improved efficiency. Key Words: Standard, Order sets, Emergency department, Disease, Time management. Continuous...

Abstract WP430: Implementation of Inpatient Stroke Champions Leads to Improved Inpatient Code Stroke Metrics

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Katherine V Lapsys ◽  
Jasmine Rochelle B Belmonte ◽  
Nathalie De La Pena-Gamboa ◽  
Raeesa Dhanji ◽  
Regina I Cuenca ◽  
...  
Keyword(s):  
Stroke Care ◽  
Final Diagnosis ◽  
Post Intervention ◽  
Specific Symptom ◽  
Delayed Treatment ◽  
Symptom Recognition ◽  
Number Of Patients ◽  
Inpatient Nursing ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Stroke Champions (SC) are AHA recommended designated inpatient nurses that serve as expert resources for their units to ensure that evidence-based practices for stroke care are implemented. Inpatient Code Strokes (ICS) are difficult to recognize which results in delayed treatment. The purpose of this study is to determine if there was an improvement in inpatient acute stroke metrics with the addition of SC in the hospital. Methods: Over a 12-month period at a Comprehensive Stroke Center (CSC), 12 nurses in the inpatient stroke units were trained as SC. This training consisted of advanced education in CSC metrics, guidelines and required documentation. SC provided peer-to-peer education, served as expert resources, conducted comprehensive chart reviews, shift huddles, and “on the spot” feedback to nurses and physicians. The metrics were examined pre and post intervention and included: Symptom Recognition Time (SRT) to CT interpretation, SRT to tPA bolus time, and SRT to groin puncture. SRT is equivalent to Emergency Department door time for inpatient strokes. Statistical analysis was performed using T-test and the Mann-Whitney test. Results: There were 114 pre-SC and 101 post-SC ICS. There was a trend toward more patients being accurately diagnosed with a TIA or stroke (75.3% post vs. 65.8% pre-SC; p=0.06). The SRT to CT interpretation time for patients who received tPA improved from 43 to 35 mins. The number of patients treated with tPA increased from 10 to 17. SRT to tPA bolus time trended toward improvement from 57 to 42 mins (p=0.07). SRT to groin puncture time in patients who received both tPA and thrombectomy trended toward improvement from 81 vs. 65 mins (p=0.07). There were twice as many inpatient thrombectomy cases in post-SC (n=23) vs. pre-SC (n=12). Conclusion: The knowledge and expertise provided by SC resulted in a higher percentage of ICS having a final diagnosis of stroke. This demonstrates an increased accuracy of stroke specific symptom recognition by the inpatient nursing teams. There was improved SRT to tPA bolus and groin puncture time. This is the only study that shows implementation of the AHA recommended SC program improves inpatient code stroke recognition and treatment metrics.

Abstract T P253: A Quality Improvement Project to Improve Stroke Assessment Adherence for Patients After Surgical or Interventional Radiology Intervention

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Tovah R Adler ◽  
Alexandra Graves ◽  
Christy Casper ◽  
Stephanie Cox ◽  
William Jones ◽  
...  
Keyword(s):  
Interventional Radiology ◽  
Quality Improvement ◽  
Clinical Care ◽  
Audit Tool ◽  
Post Intervention ◽  
Improvement Project ◽  
Data Analyst ◽  
Post Procedure ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Objective: The Joint Commission (TJC) Comprehensive Stroke Center (CSC) certification includes the standard that hospitals must use processes based upon clinical practice guidelines (CPGs) or evidence-based practice to facilitate the delivery of clinical care, including patients admitted directly from the Operating Room or Interventional Radiology. Included in this standard is the requirement that assessment and documentation post-procedure be consistent with selected CPGs. This project was designed to improve assessment and documentation adherence at a single academic hospital. Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to improve compliance for required assessments when recovering a patient. The team reviewed current policies, guidelines, and order sets related to post procedure assessments. Comparison of pre-intervention and post-intervention adherence to charting standards was performed. Pre-intervention patients included a review of 4 records by TJC CSC reviewers during their on-site visit. Each patient had insufficient documentation; therefore, the institution was cited in this area. Post-intervention patients were prospectively identified. A Neuro ICU Self-Audit Tool was created to identify patients, remind staff of required assessments, and serve as a self-audit tool affirming their adherence to the guideline. Additional interventions included education (via email, poster in-services, staff meeting updates, and one-on-one teaching) for Neuro ICU nurses. A Post Cerebral Arteriography order set was created and the electronic health record modified to make it easier to document assessments. Results: Compliance improved to 98% in 4 consecutive months. 100% of cases were reviewed by the primary and charge nurses. 10% of cases were reviewed by the stroke program data analyst to ensure accuracy and inter rater reliability. Outliers were reviewed by the stroke leadership team and feedback given to unit nursing leadership and the nurse. Conclusions: Improvement of adherence to post-procedure assessments is possible using the PDSA methodology. The success of this project allowed this hospital to achieve its TJC CSC certification.

scholarly journals Impact of order set design on urine culturing practices at an academic medical centre emergency department

2018 ◽  
Vol 27 (8) ◽  
pp. 587-592 ◽  
Author(s):  
Satish Munigala ◽  
Ronald R Jackups ◽  
Robert F Poirier ◽  
Stephen Y Liang ◽  
Helen Wood ◽  
...  
Keyword(s):  
Emergency Department ◽  
Urine Culture ◽  
Temporal Trends ◽  
Urine Test ◽  
Post Intervention ◽  
Order Sets ◽  
Ed Visits ◽  
Urine Testing ◽  
Electronic Order ◽  
Order Set

BackgroundUrinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the ‘frequently ordered test’ in the computerised physician order entry system (CPOE) on urine testing practices.MethodsWe conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining ‘urinalysis with reflex to microscopy’ as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.ResultsDuring the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (−46.6%, 95% CI −66.2% to –15.6%), but urinalysis (0.4%, 95% CI −30.1 to 44.4%), microscopy (−6.5%, 95% CI −36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI −16.9 to 67.4) were unchanged.ConclusionsA simple intervention of retaining only ‘urinalysis with reflex to microscopy’ and removing all other urine tests from the ‘frequently ordered’ window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.

scholarly journals Coronavirus disease 2019 is threatening stroke care systems: a real-world study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jiawei Xin ◽  
Xuanyu Huang ◽  
Changyun Liu ◽  
Yun Huang
Keyword(s):  
Real World ◽  
Mainland China ◽  
Stroke Care ◽  
Hospital Length ◽  
Real World Data ◽  
Care Systems ◽  
Long Term Prognosis ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Medical Burden

Abstract Background Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the stroke care systems have been seriously affected because of social restrictions and other reasons. As the pandemic continues to spread globally, it is of great significance to understand how COVID-19 affects the stroke care systems in mainland China. Methods We retrospectively studied the real-world data of one comprehensive stroke center in mainland China from January to February 2020 and compared it with the data collected during the same period in 2019. We analyzed DTN time, onset-to-door time, severity, effects after treatment, the hospital length of stays, costs of hospitalization, etc., and the correlation between medical burden and prognosis of acute ischemic stroke (AIS) patients. Results The COVID-19 pandemic was most severe in mainland China in January and February 2020. During the pandemic, there were no differences in pre-hospital or in-hospital workflow metrics (all p>0.05), while the degree of neurological deficit on admission and at discharge, the effects after treatment, and the long-term prognosis were all worse (all p<0.05). The severity and prognosis of AIS patients were positively correlated with the hospital length of stays and total costs of hospitalization (all p<0.05). Conclusions COVID-19 pandemic is threatening the stroke care systems. Measures must be taken to minimize the collateral damage caused by COVID-19.

Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

2021 ◽  
pp. neurintsurg-2021-017365
Author(s):  
Mais Al-Kawaz ◽  
Christopher Primiani ◽  
Victor Urrutia ◽  
Ferdinand Hui
Keyword(s):  
Mobile Application ◽  
Secondary Analysis ◽  
Multiple Linear Regression Model ◽  
Stroke Care ◽  
Mobile App ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
2021 ◽  
Author(s):  
Laura C.C. van Meenen ◽  
Maritta N. van Stigt ◽  
Arjen Siegers ◽  
Martin D. Smeekes ◽  
Joffry A.F. van Grondelle ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Stroke Care ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
User Friendliness ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

scholarly journals Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

2021 ◽  
Vol 2021 ◽  
pp. 1-5
Author(s):  
Cesar Velasco ◽  
Brandon Wattai ◽  
Scott Buchle ◽  
Alicia Richardson ◽  
Varun Padmanaban ◽  
...  
Keyword(s):  
Urban Areas ◽  
Stroke Care ◽  
Final Diagnosis ◽  
Medical Attention ◽  
Presenting Symptoms ◽  
Number Of Patients ◽  
Community Transmission ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p = 0.001 ). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 ( 50 ± 11.7   min ) compared to the same time period in 2019 ( 42 ± 8.2   min , p = 0.01 ). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

Sign in / Sign up

Export Citation Format

Share Document