A Successful Quality Improvement Project for Detection and Management of Acute Stroke in Hospitalized Patients

Abstract

BACKGROUND: The incidence rate of stroke in hospitalized patients ranges between 2% and 17% of all strokes—a higher rate than in the community. Delays in recognition and management of stroke in hospitalized patients lead to worse outcomes. At our hospital, the existing in-hospital stroke (IHS) code showed low usage and effectiveness. In a quality improvement (QI) project, we aimed to improve the identification of and the quality of care for inpatient strokes. METHODS: A nurse-driven IHS protocol was implemented, which alerted a specialized stroke team and cleared the computed tomography (CT) scanner. The protocol focused on prioritizing staff education, simplifying the process, empowering staff to activate an IHS code, ensuring adequate support and teamwork, identifying well-defined quality metrics (eg, time to CT and documentation tool use), and providing feedback communication. We analyzed 2 years of postimplementation IHS data for impact on stroke detection and outcomes. RESULTS: In the 2 years post QI, there was a more than 10-fold increase in IHS (pre-QI, n = 8; first year post QI, n = 94; second year post QI, n = 123). In the post-QI cohort, after excluding patients with missing information (n = 26), 69 cases had new stroke diagnoses (63 ischemic, 6 hemorrhagic), and 148 were stroke mimics. The mean (SD) time from IHS to CT was 18.7 (7.0) minutes. Of the 63 new ischemic stroke cases, 25 (39.7%) were treated with thrombolytic therapy and/or mechanical thrombectomy. CONCLUSION: The new IHS protocol has led to a marked increase in cases identified, rapid evaluation, and high utilization rate of acute stroke therapies.

Quality Improvement

“…Bravata 2 Kamal 31 Levi 32 Sui 33 Chiu 34 Klingner 35 Hill 36 Droegemueller 37 Pines 38 Wharton 39 Kishore 40 Hospital engagement…”

“…36 Other successful multicomponent QI studies focused on the identification and care of acute stroke in hospitalized patients. 37,38 Implementation of a pediatric stroke protocol over 7 years improved the use of magnetic resonance imaging (68%-78%) and increased National Institutes of Health Stroke Scale documentation (42%-82%). 39 Kishore et al 40 used an educational intervention (didactic session and hands on practice with simulation) to improve the detection of atrial fibrillation in 112 patients with stroke by ensuring delivery of early cardiac monitoring (20%-66%).…”

Nurses Lead the Way for In-hospital Stroke Care

“…To their own admission, there is a limited amount of published research on this topic; however, I was dismayed to see none of the published work from JNN made it into the referenced work used for the ASA's scientific statement. 4,6 For instance, our JNN article was able to show how an interdisciplinary group successfully developed and implemented an inpatient stroke response process that achieved an 11% treatment rate, nearly matching the treatment rate seen in our emergency departments. 5 This was a peer-reviewed, retrospective analysis of stroke treatment for the population of interest.…”

“…Although the absence of previous guidance has been somewhat disappointing, I applaud the efforts of the ASA in creating these new recommendations. To their own admission, there is a limited amount of published research on this topic; however, I was dismayed to see none of the published work from JNN made it into the referenced work used for the ASA's scientific statement 4,6…”

Bundled Approach to Improve Inpatient Stroke Recognition and Time to Treatment

“…Successful stroke programs use standardized order sets and inpatient staff education to improve stroke response times and IHS care 17,18. A nurse-driven IHS alert protocol empowered staff and improved the IHS process and response times 15. Nursing staff have more patient contact, and identify and activate stroke alerts earlier than other healthcare providers; therefore, nursing processes should be targeted to improve stroke patient outcomes 22…”