Background: Piedmont Atlanta Hospital identified cardiothoracic surgical (CTS) outcome metrics that were not meeting benchmarks established by the Society for Thoracic Surgeons (STS). Post-operative permanent stroke occurred in 1.303% (8 out of 616 cases) of coronary artery bypass-only patients at Piedmont Atlanta Hospital (PAH) during Fiscal Year 2015. The STS benchmark for all hospitals is 1.3%. Initially, the goal was to reduce the number of post-operative strokes to the standard of care but while reviewing this data, it was noted that there was significant delay in discovering the occurrence of stroke in this patient population. Traditional neurological assessments and stroke scales are difficult to apply to post-operative open heart patients due to intubation, variation in anesthesia recovery times, and the effects of pain management medications. To improve patient outcomes, PAH researched alternatives to standard post-operative neurological assessments to rapidly identify strokes and potential interventional candidates, ultimately reducing the frequency of disabling stroke.
Method: A CTS Stroke Pathway was created that included the Neurologic Intensive Care Evaluation (NICE), a novel assessment tool performed by the critical care nurse. NICE was chosen because of the ease of use on post-anesthesia patients. Neurological state was assessed based on the ability to complete one-step commands up to six hours post-op.
Results: Prior to NICE being implemented, stroke symptoms were discovered on average 40 hours from last known time well (LKTW). After NICE being implemented, Code Strokes (notification of neurological dysfunction) were initiated on average four hours from patients LKTW. In the first month of utilizing the NICE tool, one of three post-operative stroke patients was able to be transferred to a comprehensive stroke center for a mechanical thrombectomy.
Conclusion: Implementing NICE as the standard neurological assessment for immediate post-operative cardiac surgery patients significantly reduced the time to identify neurological changes indicating a stroke. This may lead to more rapid treatment or intervention, reducing the post-operative rate of permanent stroke.