scholarly journals A Computer-Based Stroke Education Orientation Program for Nurses on a Designated Stroke Unit: A Program Development, Quality Improvement Project

2017 ◽  
Author(s):  
Melanie Marco

<p>Evidence of improved outcomes for patients admitted to a dedicated stroke unit supports the need for specialized stroke education and protocols. The Joint Commission now requires all stroke patients be admitted to a PSC and receive care on a designated stroke unit. Care on the stroke unit is focused on preventing further debilitation, deterioration and reducing medical complications. Nurses working at a primary stroke center are required by TJC to have initial orientation stroke education and annual competency review to ensure stroke patients receive high quality, current care. The Joint Commission also requires core stroke team members receive at least eight hours of education annually, as determined by the stroke program manager. The stroke program manager determines composition of the stroke team in collaboration with hospital leadership and other stakeholders (Daniels, Johnson & Mackovjak, 2011). It is the responsibility of each primary stroke center to develop an education program for clinical staff.</p> <p>The purpose of this quality improvement project was to develop a computer-based stroke education orientation program for nurses on a recently designated stroke unit within a PSC facility.</p>

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Melanie Henderson ◽  
Susan Boesch ◽  
Kristine Peyton ◽  
Chris Hackett ◽  
Patty Noah ◽  
...  

Introduction: Dysphagia is a common comorbidity after stroke linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia screen before oral intake to reduce the risk of aspiration pneumonia in stroke patients. Prior studies have reviewed barriers to dysphagia screens being completed or documented timely on stroke patients before giving oral intake. Through Lean A3 process, we aimed to improve overall nursing documentation, including dysphagia screen, for stroke patients in the Emergency Department (ED) at an established Primary Stroke Center. Methods: The ED Charge Nurses and the Stroke Coordinator began an A3 project in May 2019 which focused on ED nurse documentation for stroke patients. Data included was 7 months prior to A3 implementation and 8 months post-implementation using Get With The Guidelines quality “Dysphagia Screen” measure. Lean A3 process involved changes to the computer system and re-education of nursing staff in July 2019 by the charge nurses and Stroke Coordinator. The post-A3 measurement period was between August 2019 and March 2020. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of meeting or exceeding goal before and after the A3. Results: Overall compliance of patients screened for dysphagia was 87.3% (n = 379/434). After the A3 project, compliance for dysphagia screening was significantly higher than prior to the A3 implementation ((91.9% (n = 228/248) vs. 81.2% (n = 151/186), OR = 2.64 [95%CI 1.47-4.75], p < 0.001). In addition, the 90% goal for dysphagia screen compliance was achieved only 1 month of 7 (14.3%) prior to A3, but was achieved in 6 months of 8 post-A3 (75%), p = 0.04. Conclusion: In conclusion, we found that dysphagia screening documentation by ED nurses improved due to the Lean A3 process improvement project conducted in the ED.


Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Pauline M Rankin ◽  
Dianne Marsh ◽  
James McLaughlin

According to The Journal of Emergency Medical Services (EMS) the goal of stroke care is to minimize brain injury and maximize recovery. The stroke chain of survival links actions taken by patients, family, EMS and healthcare providers. Recent innovations in stroke treatment require accurate identification and appropriate triage to the appropriate treatment facility. Evidence in the literature demonstrates variability with EMS correct identification of stroke patients between 30% and 80%. Our 164 bed primary stroke center in rural Pennsylvania has been active in providing stroke education on an annual basis to emergency medical services within a two county radius. As part of our ongoing process improvement we wanted to evaluate the emergency medical technicians and paramedics knowledge of stroke signs and symptoms, their understanding of the evaluation, treatment and triage of stroke patients. A standard questionnaire with 14 variables was developed using the American Heart and Stroke Association prehospital guidelines. The questionnaire included 16 stroke and non stroke symptoms, identifying transport to primary verses comprehensive stroke centers and initial evaluation. A sample population of 90 emergency medical service staff were asked to complete the questionnaire with 28 (31%) responses received. All participants indicated they were confident to recognize stroke signs and symptoms but 6 of the non stroke items were chosen as stroke symptoms. All participants indicated they were confident in the initial evaluation of a stroke patient but 14 (50%) appropriately identified airway, breathing, circulation as the first evaluation. Evaluating triage knowledge, 26 (93%) stated confidence in decision to transport to a primary stroke center and 22 (79%) to a comprehensive stroke center, however, appropriate decision to transport to a primary stroke center was identified correctly by 46% a comprehensive stroke center 66%. In conclusion, results from this study suggest that in this rural setting, barriers exist in prehospital recognition and evaluation of the stroke patient for which proper education may be remediable. Our goal is to use this information to revise our current EMS stroke education program and enhance prehospital assessment and triage.


Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Deborah R Lee-Ekblad ◽  
Nan Meyers ◽  
Kelly Becker ◽  
Milind Chinoy ◽  
Brandon Lawrence ◽  
...  

Introduction: Based on the 2013 Guidelines for Early Management of Patients With Acute Ischemic Attack, hospitals and emergency departments (ED) should develop efficient processes and protocols to manage stroke patients. The guidelines have several time targets for early stroke evaluation and treatment such as door to physician, door to CT initiation, door to CT interpretation, and door to drug. The goal of these time targets is to reduce morbidity and mortality associated with stroke. Hypothesis: We hypothesize that inpatient stroke evaluation and treatment is equivalent to patients presenting to the emergency department (ED) with stroke symptoms since the same stroke team responds to both inpatient stroke call downs and ED stroke call downs. This is to obtain initial data for a quality improvement project at Borgess Medical Center, Kalamazoo, MI. Methods: Between September 2010 and June 2013, all in-hospital stroke call down charts were retrospectively reviewed. For each month that there was an inpatient stroke call down, ED stroke call downs were retrospectively chart reviewed as well. There were 24 inpatient stroke call downs and 93 ER stroke call downs during this time period. Each chart was reviewed for time targets: door to physician, door to CT initiation, door to CT interpretation, and door to drug. Results: The hospitalized stroke patients experienced more delays in care than ED stroke patients. The inpatient target times are below recommended time targets. The average time to physician for inpatient stroke patients was 5 minutes as compared to the ED was 4.2 minutes. Time to CT initiation was 31.45 minutes for hospitalized patients as compared to 25.48 minutes for ED patients. CT interpretation was 52.83 minutes for inpatient strokes as compared to 47.21 minutes for ED stroke patients. Time to tPA was 122 minutes for hospitalized patients as compared to 94 minutes for ED stroke patients. Conclusion: Hospitalized patients developing stroke symptoms have delays in care as compared to patients that present to the emergency department with stroke symptoms. This may be due to emergency department patients getting preferential treatment for tests. Identifying these delays in care is important to improve stroke treatment for hospitalized patients.


2021 ◽  
pp. 194187442110070
Author(s):  
Felix Ejike Chukwudelunzu ◽  
Bart M Demaerschalk ◽  
Leonardo Fugoso ◽  
Emeka Amadi ◽  
Donn Dexter ◽  
...  

Background and purpose: In-hospital stroke-onset assessment and management present numerous challenges, especially in community hospitals. Comprehensive analysis of key stroke care metrics in community-based primary stroke centers is under-studied. Methods: Medical records were reviewed for patients admitted to a community hospital for non-cerebrovascular indications and for whom a stroke alert was activated between 2013 and 2019. Demographic, clinical, radiologic and laboratory information were collected for each incident stroke. Descriptive statistical analysis was employed. When applicable, Kruskal-Wallis and Chi-Square tests were used to compare median values and categorical data between pre-specified groups. Statistical significance was set at alpha = 0.05. Results: There were 192 patients with in-hospital stroke-alert activation; mean age (SD) was 71.0 years (15.0), 49.5% female. 51.6% (99/192) had in-hospital ischemic and hemorrhagic stroke. The most frequent mechanism of stroke was cardioembolism. Upon stroke activation, 45.8% had ischemic stroke while 40.1% had stroke mimics. Stroke team response time from activation was 26 minutes for all in-hospital activations. Intravenous thrombolysis was utilized in 8% of those with ischemic stroke; 3.4% were transferred for consideration of endovascular thrombectomy. In-hospital mortality was 17.7%, and the proportion of patients discharged to home was 34.4% for all activations. Conclusion: The in-hospital stroke mortality was high, and the proportions of patients who either received or were considered for acute intervention were low. Quality improvement targeting increased use of acute stroke intervention in eligible patients and reducing hospital mortality in this patient cohort is needed.


2021 ◽  
pp. 174749302098526
Author(s):  
Juliane Herm ◽  
Ludwig Schlemm ◽  
Eberhard Siebert ◽  
Georg Bohner ◽  
Anna C Alegiani ◽  
...  

Background Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392


Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Deborah Bergman ◽  

Background and Issues: Stroke patients can arrive to the emergency room via Emergency Medical Services (EMS) or ambulatory at triage. Processes are already in place to identify stroke patients in the field such as the Cincinnati Pre-hospital Stroke Scale used by the Emergency Management Services (EMS) and early notification to the hospital emergency room staff. Data showed that approximately 68% of stroke patients at this stroke center arrived by or were brought to the hospital by self, family, or coworkers and not by EMS. Our main goal was to improve the process for recognizing stroke symptoms for patients who do not arrive by EMS and minimize delays to activating the Stroke Code Team Page in the triage area. Methods: The first step was to identify the barriers or delays that nurses had with initiating a stroke code alert. Stroke code activations were delayed because of uncertainty of who should call it and some nurses did not feel confident in their decision to activate the stroke code alert without consulting the emergency room physician. It was determined that the nurse would feel more empowered if there was more clarity to their roles and responsibilities during the assessment phase and there was an assessment tool available to guide them to the decision to activate the stroke team page. A modified version of the “Recognition of Stroke in the Emergency Room” (ROSIER) scale was implemented for the nurses to evaluate a patient that presents with stroke like symptoms. In addition to clarify their roles a workflow chart was deployed to show each team member their specific roles and responsibilities during this process. Results: Prior to the implementation of the ROSIER scale at triage the activation of stroke codes at triage were inconsistent. After education of the ED nurses and implementation of the ROSIER SCALE at triage there was a significant increase in the activations of stroke codes by ED nurses and a decrease in the time from triage to stroke team activation. Conclusions: Using an assessment tool like the ROSIER Scale in addition to clarifying the roles and responsibilities of the team can reduce delays to identifying acute stroke symptoms in patients at a busy emergency room triage area and improve opportunities for timely interventions.


Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Nojan Valadi ◽  
Alexis Thomas

Background: A recent national push for optimizing stroke center performance led by the efforts of AHA/ASA to recognize high performers with the Target Stroke Honor Roll recognition have focused on achieving expedited treatment for stroke with door-to-needle (DTN) time of ≤60 minutes.Our organization recognized the need to optimize our performance and set an initial goal of achieving DTN time of ≤60 minutes in greater than 50% of our patients. The Target Stroke Initiative by the AHA/ASA identified 10 key strategies for best practice associated with reducing DTN times. Our organization adopted and implemented all of these strategies over a 30-day period. Methods: The Target Stroke best practice strategies were implemented over a 30-day period, and the Stroke Team worked collaboratively to identify other weaknesses needing to be addressed. DTN times ≤60 minutes from the 12 months prior to process improvement implementation were compared with the first 2 months post implementation. Results: There were 345 ischemic stroke patients treated at our facility during the 12 month period prior to the process implementation, with a total of 14 patients (1.12 per month) treated with tPA. The percentage of patients treated with tPA was 4%, and the percentage of patients treated with DTN ≤60 minutes was 0%. Over the two months following process implementation, 68 ischemic stroke patients were treated at our facility, with 11 patients treated with tPA (5.5 per month). The percentage of stroke patients treated with tPA was 16%, with 70% of patients treated with DTN ≤60 minutes. Conclusion: This study serves as confirmation that collaboration and implementation of the 10 key strategies for best practice as outlined by the Target Stroke Initiative, coupled with changes to identified areas of weakness, can improve and expedite the care of patients with acute ischemic stroke. This can substantially improve DTN times, as well as the overall number and percentage of patients that receive thrombolysis with a hopeful impact on their outcome as well as Target Stroke Honor Roll recognition for the facility. In conclusion, we recommend implementation of these best practice strategies to other facilities.


Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Chunjuan Wang ◽  
Zixiao Li ◽  
Yilong Wang ◽  
Yong Jiang ◽  
Xingquan Zhao ◽  
...  

Background and Purpose: Stroke is the first leading cause of death in China and millions of patients were admitted to various levels of hospitals each year. However, it is unknown how many of these hospitals are able to provide an appropriate level of care for stroke patients since the certification program of comprehensive stroke center (CSC) and primary stroke center (PSC) has not been initiated in China. Method: In 2012, we selected all 554 hospitals that joined into the China Stroke Research Network (CSRN) to start a survey. These hospitals were from 31 provinces or municipalities, covered nearly the entire Mainland China. A six-page questionnaire was sent to each of them to obtain the stroke facility information. We used the same criteria and definitions for CSC, PSC, and minimum level for any hospital ward (AHW) admitting stroke patients with that of the European Stroke Facilities Survey. Results: For all the hospitals in CSRN, 521 (94.0%) returned the questionnaire, 20 (3.8%) met criteria for CSC, 179 (34.4%) for PSC, 64 (12.3%) for AHW, and 258 (49.5%) met none of them and provided a lower level of care. Hospitals meeting criteria for CSC, PSC, AHW, and none of them admitted 70 052 (8.8%), 334 834 (42.2%), 88 364 (11.1%), and 299 806 (37.8%) patients in the whole of last year. There was no 24-hour availability for brain CT scan in 4.3% of hospitals not meeting criteria for AHW, while neither stroke care map nor stroke pathway for patients admission in 81.0% of them. Conclusions: Less than two fifths of Chinese hospitals admitting acute stroke patients have optimal facilities, and nearly half even the minimum level is not available. Our study suggests that only one half acute stroke patients are treated in appropriate centers in China, facilities for hospitals admitting stroke patients should be enhanced and certification project of CSCs and PSCs may be a feasible choice.


2009 ◽  
Vol 1 ◽  
pp. JCNSD.S2221
Author(s):  
Byron R. Spencer ◽  
Omar M. Khan ◽  
Bentley J. Bobrow ◽  
Bart M. Demaerschalk

Background Emergency Medical Services (EMS) is a vital link in the overall chain of stroke survival. A Primary Stroke Center (PSC) relies heavily on the 9-1-1 response system along with the ability of EMS personnel to accurately diagnose acute stroke. Other critical elements include identifying time of symptom onset, providing pre-hospital care, selecting a destination PSC, and communicating estimated time of arrival (ETA). Purpose Our purpose was to evaluate the EMS component of thrombolysed acute ischemic stroke patient care at our PSC. Methods In a retrospective manner we retrieved electronic copies of the EMS incident reports for every thrombolysed ischemic stroke patient treated at our PSC from September 2001 to August 2005. The following data elements were extracted: location of victim, EMS agency, times of dispatch, scene, departure, emergency department (ED) arrival, recordings of time of stroke onset, blood pressure (BP), heart rate (HR), cardiac rhythm, blood glucose (BG), Glasgow Coma Scale (GCS), Cincinnati Stroke Scale (CSS) elements, emergency medical personnel field assessment, and transport decision making. Results Eighty acute ischemic stroke patients received thrombolysis during the study interval. Eighty-one percent arrived by EMS. Two EMS agencies transported to our PSC. Mean dispatch-to-scene time was 6 min, on-scene time was 16 min, transport time was 10 min. Stroke onset time was recorded in 68%, BP, HR, and cardiac rhythm each in 100%, BG in 81%, GCS in 100%, CSS in 100%, and acute stroke diagnosis was made in 88%. Various diagnostic terms were employed: cerebrovascular accident in 40%, unilateral weakness or numbness in 20%, loss of consciousness in 16%, stroke in 8%, other stroke terms in 4%. In 87% of incident reports there was documentation of decision-making to transport to the nearest PSC in conjunction with pre-notification. Conclusion The EMS component of thrombolysed acute ischemic stroke patients care at our PSC appeared to be very good overall. Diagnostic accuracy was excellent, field assessment, decision-making, and transport times were very good. There was still room for improvement in documentation of stroke onset and in employment of a common term for acute stroke.


Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Marc Ribo ◽  
Alejandro Tomasello ◽  
Sandra Boned ◽  
Pilar Coscojuela ◽  
Jesus Juega ◽  
...  

Background: We aim to evaluate the feasibility and safety of a direct transfer to the angio-suite protocol for acute stroke patients candidates for endovascular treatment (EVT). Methods: Starting June 2016, patients with pre-hospital stroke code activation (RACE≥4) admitted within 4.5h from symptoms-onset were directly transferred on admission to angio-suite (DTA) bypassing the emergency room. After Xpert-CT in the angio-suite for parenchymal evaluation, femoral puncture and EVT were performed as usual. Patients following DTA were compared to all patients with same admission criteria treated with EVT in the previous 2 years (control group, CG). Results: Of the 16 patients that followed DTA, 1 (6%) showed an intracranial hemorrhage (ICH) on Xpert-CT and 15 underwent EVT, representing 50% of EVT admitted within 4.5h or 34% of all EVT performed in the study period. 56% of DTA patients had previous neuroimaging at a primary stroke center, 44% were primary admissions with no previous neuroimaging. Baseline characteristics including age (71 Vs 72 years; p=0.71) and admission NIHSS (18.5 Vs 18;p=0.68) were comparable. Median time from admission to groin puncture was significantly shorter in DTA patients (15 minutes IQR:13-19 Vs 65 IQR:45-10;p<0.01). Rate of no treatable occlusion on initial angiogram was 13.3% in DTA Vs 2.4% in CG (p=0.17). Procedural time (36 Vs 55 minutes;p=0.034) was shorter in the DTA group, while recanalization (TICI 2b-3: 86% Vs 81%;p=0.24) and symptomatic ICH rates(6.7% Vs 6.6%;p=0.98) and 24h NIHSS (10 Vs 10.5; p=0.81) were comparable. The total time from admission to recanalization was significantly shorter when DTA was applied (median 52 Vs 123;p<0.01). Conclusion: In a subgroup of acute stroke patients presenting in the early window, direct transfer and triage in the angio-suite seems feasible, safe and achieves a significant reduction in hospital workflow times.


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