Abstract WP341: Improving Nursing Documentation Compliance for Patients Treated with Alteplase Diagnosed with Ischemic Strokes
Purpose: This project developed an audit tool for improving documentation post Alteplase infusion.
Background: The American Heart Association and Brain Attack Coalition have set forth guidelines for the monitoring of ischemic stroke patients receiving Alteplase. These guidelines are standards of practice required for Primary Stroke Center certification.
Methods: This real-time audit tool allows for entry of the precise start time of the Alteplase infusion and auto populates the subsequent time frames for care within the first 24 hours. The tool facilitates documentation of necessary components related to vital signs and neurological checks and triggers follow-up warnings when a “NO” is entered. The tool creates a very visual snapshot to facilitate concurrent auditing and promote accuracy in documentation. The audit tool can be used as either a hard copy or electronic version. The electronic version automatically calculates compliance percentages. The tool is handed off from shift to shift to maintain consistent follow through across direct care nurses. Key measures within the tool include venous thromboembolism prophylaxis, dysphagia screening, and lipid management.
Results: Eighteen inpatients received stroke care from January 2012 to May 2012 with a documentation compliance rate of 86.7% Documentation compliance for the 9 stroke patients cared for following tool implementation increased to 94.4%. Stroke Core Team members conduct ongoing evaluations of the tool to ensure quality control.
Conclusion: Initiation of a real time audit tool used during the first 24 hours of ischemic stroke care for patient receiving Alteplase has shown improvement in documentation compliance rates. Of note, this tool was recognized by a Joint Commission site surveyor as highly innovative and a potential best practice in the care of stroke patients.
- © 2012 by American Heart Association, Inc.