Background and Purpose: Due to short hospital stays and fragmented education attempts, inpatient stroke education can be inadequate. The purpose of this randomized feasibility study was to determine if an enhanced inpatient/post discharge telephonic stroke education strategy improved patient recognition of signs and symptoms of stroke and the need to call 911 compared to usual stroke unit education by staff nurses. Methods: This pilot study consisted of 25 stroke or TIA inpatients discharged to home, who were randomly assigned to an intervention or usual care group. Of the 18 patients with complete data, 9 were intervention and 9 were control patients. The educational intervention included a sit-down, in-patient, formalized education session, encouraging family/significant other involvement, a 30 day follow-up phone call, and 60 day educational mailings. Usual care education involved a stroke education booklet and variable verbal instruction by staff nurses. All patients received a 90 day telephone call to evaluate outcomes. Results: An average time of 27 minutes was spent on education with intervention patients. Stroke symptoms such as trouble speaking, numbness, tingling and weakness were correctly identified by both groups 95-100% of the time. Dizziness and loss of balance were also correctly identified by 95% of participants. Additionally 95% of participants said they would call 911 with stroke symptom onset; whereas, only 56% of the patients originally arrived on site via EMS. Conclusions: Staff nurse education on stroke units is highly effective. The control group retained as much information as the intervention group at 90 days post discharge, leaving little to no room for improvement by enhanced education. These data indicate that the inpatient stroke education was sufficient to ensure recognition of signs and symptoms of stroke and the need to call 911 90 days post discharge. Further research is necessary to determine the effectiveness of stroke education provided by community education initiatives and the media, as well as its effects on lifestyle modifications.
Background and Issues: The benchmark goal for stroke treatment is door to IV tPA in 60 minutes. In 2010, average door to IV tPA treatment time for acute stroke patients at our acute care, tertiary teaching hospital was 87 minutes. Purpose: As a TJC certified primary stroke center, our purpose was to improve door to IV tPA times. Methods: Causes for lengthy tPA treatment times were identified by the stroke interdisciplinary team using a root cause analysis approach. Identified delays included: lab turn-around times, order entry, clinical decision making time, and tPA preparation, delivery, and administration. Process improvement initiatives for order entry included revisions to electronic order sets to auto-populate and enhance efficiency and safety of order entry. Lab audits revealed that the BMP took the most time to process, resulting in initiation of point of care testing. For clinical decision making delays by neurology, immediate feedback was provided to the neurologist after each tPA administration. A year end summary was compiled showing door to tPA times for each attending neurologist. In addition, 3 APNs completed a neurovascular advanced practice fellowship program. Pharmacy instituted a tracking log to audit prep-to-delivery time which encouraged earlier notification and faster delivery times. Mixing of tPA was changed from (2) 50mg vials to reconstitution of (1) 100mg vial. Nurses who administer tPA were re-competencied using a simulation lab. Patients were triaged to a room in ED closer to the CT scanner. And, a count-down clock was initiated upon patient arrival to ED to enhance time awareness for all stroke team members. Results: Average door to tPA time has decreased from 87 minutes in 2010 to 50 minutes YTD 2013, a 37 minute improvement. In addition, volume increased by 25 more tPA administrations in 2012. Chi square comparisons of discharge dispositions showed no statistical differences for 2010 vs 2013 (p=.56) or 2012 vs 2013 (p= .18). Our hospital has received the American Stroke Association’s Target Stroke award for the past 2 years. Conclusions: An interdisciplinary approach using a root cause analysis is effective in identifying and implementing process improvements, ultimately leading to decreased door to IV tPA times.
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