Abstracts From the 2010 International Stroke Conference: Poster Presentations
Quality improvement initiatives in stroke care tend to be organized on a hospital-by-hospital basis. The ability to monitor statewide trends in stroke is hampered by a shortage of adequate statewide clinical data, due in part to the lack of a common database. We report here on the adherence to hospital-based quality indicators for stroke, as seen broadly in Colorado over a period of 13 quarters (Q2-2006 through Q2-2009). Methods: The Colorado Stroke Alliance is a grassroots collaboration of 36
... ospitals, representing approximately 80% of the strokes occurring in Colorado. Our database now includes more than 10,000 stroke events. In concert with the Colorado Department of Public Health and Environment (CDPHE), we have prospectively monitored clinical measures of stroke care since 2006, using the American Stroke Association's Get With the Guidelines SM patient management tool (GWTG-Stroke). Here, we report the temporal change in our hospitals' average overall adherence to 7 standard quality indicators. We calculate the linear regression of average adherence rates by quarter, and we indicate the statistical significance for these regressions by ANOVA P values. We also compare adherence data for the first 6 quarters with those of the most recent 7 quarters, using the Chi Square test for significance. Results: For five of the seven indicators, linear regression showed statistically significant improvement. For the two indicators without significant improvement (anticoagulation for atrial fibrillation and anti-thrombotic at discharge), the initial adherence rates were already above 90%. For all indicators except anticoagulation for atrial fibrillation, the most recent 7 quarters were significantly better than the first 6 quarters. The greatest absolute improvement (ϳ12%) was noted for giving IV t-PA within one hour of arrival, for patients presenting within 2 hours of symptom onset. Conclusions: GWTG-Stroke data have typically been used for individual hospital quality improvement, but by sharing data important trends in statewide patterns of care may be identified. In Colorado, we have seen significant, positive changes in the adherence to stroke quality indicators over the past 13 quarters. A common, shared dataset of this sort may be useful to inform the planning of state systems of stroke care, and to monitor changes in the care that is rendered. Background and Issues: Falls among stroke patients during hospitalization are a major concern. The National average is 2.23 versus 7 South Neuro/Stroke Unit was 2.91. Risk factors include, being in a strange environment, altered mental status, altered nutrition, and confusion, muscle weakness, including balance and gait issues. The Neuro/Stroke Unit at the University of Tennessee Medical Center in Knoxville, Tennessee, launched a performance improvement (PI) team to address the falls rate among stroke patients. The PI team tested methods to reduce falls through evidence based practice. Methods: The team elected to use a 90 day, Plan, Do, Study Act model (P.D.S.A.). A "Near Miss" form was created to keep a daily log of at risk patients who attempted to get out of bed without assistance. This log was monitored in two week increments during the three P.D.S.A. cycle and evaluation. Strategies used to develop performance improvement plan included review of the most recent literature and brainstorming. The team determined that a valid more realistic approach was to alter the traditional unit routines rather than altering a characteristic of the population. The three P.D.S.A. cycles were: 1. Reschedule routine vital sign monitoring to allow more flexibility for staff to be available during high risk periods. 2. Coordinated patient assessment rounds prior to high risk periods. 3. Reference cards for float personnel including stroke risk factors, warning signs and patient care standards. Results: A baseline measurement of "near misses" was evaluated for the period prior to the first P.D.S.A. cycle. The baseline count was 139 "near misses". At the end of the three P.D.S.A. cycles the "near miss" count was 10. In addition, the average monthly fall rate for 2008 was 2.91 and for the 90 day P.D.S.A. cycle the average monthly rate was 1.67. Conclusions: The result of this project indicates that when staff restructures daily nursing care and activities to accommodate special needs of the stroke patient, fall rates and "near misses" can be dramatically reduced. The nursing team is more aware of the process of fall risk assessment, prevention and outcomes. This first hand knowledge has allowed the staff to focus more on developing a comprehensive plan of care which includes thorough education, more frequent, timely assessments, and ultimately, a safer environment.