Introduction: Appropriate documentation impacts patient care and quality monitoring. The required documentation elements for level 1 stroke cases varies and does not yet have a standardized format. Mounting evidence supports endovascular stroke treatment, decreasing time to treatment initiation will also likely be critical to improving patient outcomes. However, there is no clear way or format to document the various important time points during a case. We sought to provide a template for operating room nurses to be prompted to assess and record important patient and team information.
Methods: We evaluated the closed charts from 2013 for patients who underwent Level 1 acute stroke surgical intervention. Charts for all patients who received acute stroke interventions in 2014 and 2015 were also reviewed. Review focused on seven key items; pre and post neurological assessment in the operating room, time puncture, to clot, to revascularization, of groin seal, and TICI score. These items were important based on patient care and the ability to review the efficiency of the team in starting a case.
Results: There were 36 charts reviewed from 2013 for patients who underwent Level 1 acute stroke surgical intervention. There was no documentation of the seven key items in any of the 2013 charts. The standardized form was initiated in 2014 after an educational campaign. This method was continually evaluated and did show overall improvement. A deeper dive showed 23% of the Level 1 acute stroke surgical intervention charts were still missing all seven key items.
Conclusions: The documentation of Level 1 acute stroke surgical intervention cases still remains a challenge. The current results demonstrate that further automation may be needed to ensure to proper care and documentation of these patients. The development of documentation should not be a burden, but rather aid in enhancing the quality of care for patients.