Abstract TP388: Multidisciplinary Stroke Review Process and Prospective Record Review for Quality and Process Improvement

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Abstract

Background: The Comprehensive Stroke Center (CSC) standards set by the Joint Commission (TJC) include process and quality improvement. Specifically, there is to be a process to review complex stroke cases for a complications, treatment specific situations and sentinel events. The review is at program level by an interdisciplinary team.

Purpose: To maintain consistency, function and process related to complex stroke patients. To focus on issues and/or barriers with regards to complex stroke patients. To assure the hospital is meeting requirements set up by TJC for CSC designation.

Methods: Advance practice nurses (APN) within the stroke program created a stroke summary template using data elements from the inpatient hospitalization of all stroke patients. The summary data is reviewed for positive outcomes and complications related to the complex stroke population including but not limited to: ventriculostomy, decompressive craniectomy, endovascular revascularization, carotid endarterectomy, carotid artery stenting, periprocedural stroke and death. All data is collected and monitored by subcommittee inclusive of APNs and leaders from the stroke, quality and neurointerventional surgery departments. Quarterly, a team of physicians including stroke neurology, neurointerventional surgery, quality, medical executive committee, neurosurgery, emergency medicine, neurocritical care and physical rehabilitation medicine meet to further discuss cases related to the designated criteria above. A stroke review pathway created and designates all unusual findings to be reported to the physician and/or nursing peer review committees for formal inquiry.

Results: Following implementation of the stroke review process there was documented 100% review of ischemic and hemorrhagic stroke patients with special consideration for intravenous tissue plasminogen activase administration and endovascular treatment of stroke by a interdisciplinary team of physicians and nurses.

Conclusions: The developed stroke summary and interdisciplinary review process provides opportunities for quality and process improvement initiatives while demonstrating conclusive documentation supporting TJC requirements for CSC program level stroke case review.

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