Introduction: In 2014, the Post-tPA/Endovascular nursing monitoring flow sheet was revised to harmonize with the NIHSS exam. The challenges to performance and documentation compliance posed by the intensity and frequency of assessments have been the focus of an ongoing quality improvement initiative.
Methods: All Post-tPA/Endovascular monitoring flow sheets from June 2014- June 2016 at University Hospitals Case Medical Center were reviewed for presence of neurologic assessments, vital signs, and management of hypertension per protocol. Stroke staff conducted in-services on the enhanced assessments and modified NIHSS training and house staff mentored bedside RNs in performing the NIHSS. A tip sheet was developed for staff on the modified NIHSS and real time feedback was given on all outliers.
Results: Of 459 patients, compliance with all of the 684 monitoring data points ranged from 67-100% in the Neuroscience ICU (Patient: RN ratio 2:1), 75-100% in the Neuro-Intermediate Unit (Patient: RN ratio 3:1) and 40-100% in the Emergency Department (Patient: RN ratio 4:1). Overall compliance to > 95% of data points was seen in all but 5 patients with missing flow sheets. Symptomatic hemorrhagic complications after IVtPA decreased from 6.5% to 2.7%. Root-cause analysis of missing data points revealed seven areas of opportunity: Interference by diagnostic testing (29%), during patient transportation (22%), and following endovascular treatment (15%) or due to travelling RNs (8%). Missing documentation was most frequent during the q15 minute phase due to the intensity of monitoring (11%)- with the Emergency Department the most vulnerable location- and less during the q30 minute (4%) or q1 hour (3%) assessments. Units with dedicated neuroscience nursing adjusted more rapidly to the revision compared to units that do not routinely perform such assessments.
Conclusions: Optimum compliance with nursing assessments and monitoring occur when there is no interference with diagnostic testing or procedures, the patient needs were a high priority and the patient acuity was well matched to the RN staffing ratio. This data supports a care model where a neuroscience trained RN nurse transitions with the patient during the first 24 hours after tPA/Endovascular therapy.