Exploring Stroke Outcomes Following a Door-to-Needle Quality Improvement Project.

BACKGROUND: Although stroke rates in Canada are expected to increase dramatically over the next decade, time-driven hyperacute stroke care with thrombolysis increases the likelihood of a good clinical outcome. Following a period of suboptimal performance results for stroke care, our tertiary care center undertook a door-to-needle (DTN) quality improvement initiative. The purpose of our study was to determine if the resulting improved median DTN times and greater proportion of patients treated within 60 minutes of arrival at our emergency department were associated with improved clinical outcomes. METHODS: Guided by the Donabedian quality framework, we retrospectively reviewed charts of consecutive patients (n = 324) who received thrombolysis pre- and post-quality improvement initiative. Data on patient characteristics, and process and outcome measures were collected. Primary study outcomes included mortality, adverse events, discharge location, and independence at discharge. Data analysis compared proportions with Chi Square and means using the two-tailed t-test and a 0.05 level of significance. RESULTS: Median DTN times and the percentage of cases with a DTN ≤60 minutes improved significantly post-intervention (p < 0.001). In-hospital mortality decreased (p = 0.013), and the proportion of favorable versus unfavorable discharge locations improved (p = 0.005). Mortality rates for all study patients with DTN ≤60 versus >60 minutes were also significantly lower (p = 0.044) post-intervention. CONCLUSIONS: Our quality improvement initiative resulted in timelier care and positively influenced clinical outcomes. This study highlights the need for ongoing, innovative investment strategies to ensure timely hyperacute stroke care and optimal patient outcomes.

Use of mobile devices and medication errors in acute care: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to synthesize the best available evidence on the effects of healthcare providers using mobile devices at any stage of medication provision on medication errors in acute care settings. Provision of medication includes prescribing, dispensing or administrating medicine in the acute care setting.

What are the professional development and mentorship needs of advanced practice nurses?

This study investigated the professional development and mentorship needs of an existing group of advanced practice nurses. A prospective mixed-methods design included a survey followed by focus groups. The Strong Model (M. H. Ackerman, L. Norsen, B. Martin, J. Wiedrich, and H. Kitzman, 1996) recently provided a framework for the survey and discussions. It consists of five domains of practice: direct comprehensive care, education, research, support of systems, and publication and professional leadership. Fourteen advanced practice nurses participated, representing a variety of clinical areas in the clinical nurse specialist and nurse practitioner roles. Results demonstrate that advanced practice nurses identify various professional development and mentorship needs in all aspects of their roles. Although research was identified as a need that develops over time, it was consistently regarded as a primary focus for development and required mentorship. Respondents offered specific examples and the positions or roles that would be helpful in meeting their professional development and mentorship needs. Main themes that arose from the focus group were formal versus informal needs, needs change over time, and intellectual, administrative, and financial support. The advanced practice nurses' willingness to contribute to a mentorship program was explored.

Nonspecific behaviors as early indications of cerebral vasospasm.

This study investigated nonspecific behaviors as early indications of vasospasm following subarachnoid hemorrhage. Although symptoms of vasospasm (e.g., lowered level of consciousness, focal deficits such as hemiplegia or aphasia), are well recognized, the significance of early appearance of nonspecific symptoms such as restlessness, unusual behaviors, and impulsive behavior has not been investigated in detail. The study design included descriptive quantitative elements and a small qualitative component. Nonspecific behaviors were recorded, and the prevalence of those behaviors in individuals developing vasospasm was noted. Of 60 participants, 31 developed vasospasm; 24 of the 31 initially presented with nonspecific behaviors (p < .0001). Early detection of cerebral vasospasm allows prompt intervention and treatment, with the goal of preventing further ischemia or infarction.

Analysis of nursing assessments in a cohort patients with ruptured cerebral aneurysms.

Patients admitted with subarachnoid hemorrhage are monitored for symptoms of vasospasm. A prospective study was designed to compare two monitoring instruments: a standard neurological tool (SNR) and the National Institutes of Health Stroke Scale (NIHSS). The two assessment tools were compared to evaluate their concordance and to identify areas where efficiency in recording assessments might be improved. We found no statistical difference between the two tools in detecting symptomatic cerebral vasospasm. Substantial discrepancies in the documentation of observations were noted, particularly in the assessment of limb drift. Avoidance of these discrepancies may require further definition in the SNR tool. A qualitative component consisting of a review of the nurses' notes regarding neurological status in the patients' charts was conducted. It was demonstrated that nurses commonly document information in the progress notes that is already captured in the SNR. Further education of nurses in the use of assessment tools is therefore recommended to avoid redundancies and increase efficiency in recording clinical observations.

Lumbar discectomy: developing and implementing a day surgery protocol.

In some centres, patients who require a lumbar discectomy are successfully discharged the day of surgery. With the ongoing pressure to provide safe care for patients within certain bed limitations, this option was considered. Using a continuous quality improvement method, a prospective review of patients undergoing a single-level lumbar discectomy was monitored. Based on pre-set criteria, patients were included or excluded in the day surgery protocol and both groups were monitored. A large component of nursing education was provided for all patients, and will be highlighted. Data retrieved for both groups included demographics, length of operation, length in recovery room, length of hospital stay required, and the re-admission rate. There were 47 patients monitored over 11 months. Of the 34 patients entered in the protocol, seven required an overnight length of stay. The reasons for the extended length admission will be described. Of the 13 patients excluded from the protocol, one did not require an overnight stay. Following review of the data, the criteria for inclusion of patients into the protocol has been altered and patients can safely proceed with day surgery for lumbar discectomy.

Comparison of a standard neurological tool with a stroke scale for detecting symptomatic cerebral vasospasm.

The purpose of this study was to critically analyze the effectiveness of two tools used by nurses to assess neurological status of individuals at risk of developing cerebral vasospasm following aneurysmal subarachnoid hemorrhage due to aneurysm rupture. Early detection of vasospasm provides an opportunity for prompt treatment so that further ischemia or infarction can be prevented. We hypothesized that the National Institutes of Health Stroke Scale would detect symptomatic vasospasm earlier than the standard neurological record currently used in the practice setting of a tertiary care teaching hospital. Thirty participants were entered into the study, and a differential diagnostic process identified 15 with symptomatic vasospasm. Quantitative prospective and retrospective analysis showed that there was no statistical difference between the two scales in early detection of vasospasm. This finding may partially be explained by the clinical similarities between the vasospasm and nonvasospasm groups and by the challenges experienced by nurses in administering the stroke scale. Clinically relevant observations suggested the stroke scale was more effective in the assessment of focal symptoms. Qualitative content analysis of nursing notes also provided insight into clinical findings not captured on either scale regarding generalized changes such as restlessness, impulsiveness, and unusual behavior. This study demonstrates the need to develop a more appropriate tool for early detection of vasospasm.