QCI-Nascar Quality Care Improvement with Nursing-driven Acute Stroke Care
This study is planned as a multi-phase initiative involving the staged optimization and exportation of a clinical protocol for acute stroke codes. After two intensive rounds of processes improvement at a single site, the ultimate goal is to make marked improvements in door-to-treatment (DTT) times, treatment rates, and consistency of care in the regions served by the UTSW and UT-Houston telestroke networks over a period of 24 months.
Phase 1a x Research, Planning, Preparation
Taking advantage of existing monthly Quality Improvement (QI) meetings, the UTSW Stroke Team will identify [Quote]champions[Quote] from all clinical disciplines involved in acute stroke codes (including nursing, Emergency Department (ED) physicians, stroke specialists, laboratory, radiology, and pharmacy.) In this initial period, champions will agree to an intensive process of weekly meetings for at least four weeks to review historical stroke cases in the St. Paul emergency department to identify issues that may prolong the delivery of expedited acute stroke care. Particular attention will be paid to the necessity of ordinal events in the sequence of stroke codes and the role of gatekeepers in the triage workflow.
The next four weeks of meetings will then focus on the collaborative creation of a formal, recognized clinical pathway, tentatively termed [Quote]NASCAR1.[Quote] The focus of NASCAR1 will be creating a workflow that emphasizes simultaneous, non-ordinal processes and specified roles for team members during an acute stroke code. For example, one nurse ([Quote]the driver[Quote]) will be in charge of organizing all aspects of care (e.g. notification of specialists for tele-consultation, alerting CT for impending scan) while other nurses may be assigned to starting IV's. Meanwhile, a pharmacist may verify allergies and home medications. The role of the nurse driver will be particularly important as he or she will ultimately responsible for the completion of the entire sequence of the code and will stay with the patient through the entirety of the code. This will be a purposeful de-emphasis of the roles of physicians (both stroke specialists and ED physicians) as they are not physically present continuously during the encounter.
Phase 1b x [Quote]Go Live 1[Quote]
The NASCAR1 protocol will be implemented at St. Paul University Hospital. Nurse drivers will be responsible for ensuring the completion of a data collection tool for each encounter: noting all significant task completion times and protocol violations. Additionally, immediately following each stroke code, the nurse driver will complete a short survey with free-text answers (to reduce bias). The survey, based on the identified domains associated with early treatment time, will ask the nurse to identify (in her/his own words) what helped or hindered the stroke code process.
Division champions will participate in monthly meetings to review every stroke code with scrutiny given to both successful and unsuccessful outlier cases. Feedback for such cases will be directly transmitted to stroke code team members via e-mail. Any identified systematic problems in NASCAR1 itself will be addressed with protocol revisions on a quarterly basis.
Phase 2a x [Quote]Interim Analysis[Quote] - see attached protocol
Phase 2b x [Quote]Go Live 2[Quote] x see attached protocol
Phase 3 x see attached protocol
1. Patient was admitted to the St. Paul emergency department.
2. Patient was identified, through retrospective chart review, as having a ICD-10 stroke code.