Journal of Neuroscience Nursing:
Standardized Admission and Discharge Templates to Improve Documentation of the Joint Commission on Accreditation of Healthcare Organization Performance Markers
Whited, Karen; Aiyagari, Venkatesh; Calderon-Arnulphi, Mateo; Cursio, John; Pandey, Dilip; Hillmann, Maureen; Ruland, Sean
Venkatesh Aiyagari, MBBS DM, is an associate professor of neurology and co-director in the Neurosciences Critical Care Division, Universtiy of Illinois at Chicago, Chicago, IL.
Mateo Calderon-Arnulphi, MD, is a neurology resident in the Department if Neurology, University of Illinois at Chicago, Chicago, IL.
John Cursio, MS, is a statistician in the Department of Neurology, University of Illinois at Chicago, Chicago, IL.
Dilip Pandey, PhD MBBS MS, is an associate professor and director of Neuroepidemiology, Outcome Research, and Clinical Trials, Department of Neurology & Rehabilitation, University of Illinois at Chicago, Chicago, IL.
Maureen Hillmann, RN, is a stroke care coordinator at the University of Illinois at Chicago, Chicago, IL.
Sean Ruland, DO, is the director of the Neuro-Critical Care Unit, University of Illinois at Chicago, and associate professor, associate head, and director of Neurocritical Care and Stroke, Department of Neurology and Rehabilitation, Universtiy of Illinois at Chicago College of Medicine, Chicago, IL.
Questions or comments about this article may be directed to Karen Whited, APN, at Karen.Whited@gmail.com. She is an acute care nurse practitioner in Surgical Intensive Care, Edward Hines, Jr. VA Hospital, Hines, IL.
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There is an increasing emphasis on the delivery of quality care and assessment for stroke patients. The Joint Commission (TJC) has offered a Disease-Specific Care Certification for stroke centers that are able to demonstrate exceptional stroke care by compliance with 10 performance markers. The 10 performance markers chosen were deep vein thrombosis (DVT) prophylaxis, discharged on antithrombotic therapy, patients with atrial fibrillation receiving anticoagulation therapy, tissue plasminogen activator (TPA) considered, antithrombotic medication within 48 hours, lipid profile, screen for dysphagia, stroke education, smoking cessation, and plan for rehabilitation considered (http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pm_edition_2.htm).
It has been recommended that comprehensive stroke centers have a stroke registry and also a data collection tool in place (Alberts et al., 2005). We created a Standardized Stroke Admission and Discharge Template to use at the University of Illinois at Chicago Medical Center to capture all 10 performance markers for each stroke patient.
The goals of the templates were to prompt ordering of the performance markers, to improve documentation of the 10 performance markers, and to improve accuracy of the data abstraction. First, the standardized templates prompted the ordering physician to include each performance marker in the stroke orders. Secondly, quality stroke care may have been given before the use of the templates but may not have been captured because of poor documentation. The resident may have ruled out a certain treatment such as TPA but did not document clearly that this treatment was considered and the reason the treatment was not given. The new templates helped improve documentation by directly prompting the user to clearly document each performance marker. For example, if the treatment for TPA was considered, the resident is prompted to document reperfusion therapy eligibility. Finally, the last goal of the templates was to improve the data abstraction. Before implementation of the templates, the individual abstracting data from the Care and Prevention Treatment Utilization Registry would search numerous areas in the medical record because performance markers were not being consistently documented in the same area each time. This may have caused the data abstractor not to have captured markers that may have been documented. The creation of the templates has facilitated a process to monitor quality improvement that was easy to follow and helped to abstract data.
The purpose of this study was to evaluate whether instituting a standardized template would improve documentation of the 10 performance markers, to improve accuracy of the data abstraction, and to measure if the improvement was sustained over time.
Initially a stroke committee was constituted (Alberts et al., 2000). The committee included stroke neurologists, one emergency room physician, clinical nurses, research nurse coordinators, unit nurse managers, and other staff from the utilization review and quality improvement departments.
Stroke care guidelines and algorithm, which were based on the American Hearth Association guidelines (Alberts et al., 2005), were placed on the hospital intranet under clinical guidelines (Summers & Soper, 1998). A stroke order set was created for the physician and placed in the electronic medical record for use and to ensure the stroke orders included each of the performance markers (Summers & Soper, 1998). Monthly lectures were given to the nursing staff and the stroke residents 5 months before the implementation of the templates, which included the review of the 10 performance markers. Each resident was given a pocket card with the 10 performance markers listed. One month before the implementation of the Standardized Stroke Admission and Discharge Templates, all the neurology residents received an in-service during their weekly meeting; in addition, an e-mail was sent out to each neurology resident with a copy of the template (Regnier, Murray, Lane, & Alden, 2005). Finally, Standardized Stroke Admission and Discharge Templates were implemented on January 1, 2006. See Appendix 1 (available online at http://links.lww.com/JNN/A3) for the Stroke Admission Template and Appendix 2 (available online at http://links.lww.com/JNN/A4) for the Stroke Discharge Template. Between these two templates, all the 10 TJC performance markers were captured.
The nurse coordinator also rounded with the stroke team, provided in-services to the new residents each month on the 10 performance markers and the templates, and assured the use of the templates by the residents. If it was noted that the stroke template was not being used, the individual was contacted by the nurse coordinator and reminded that the use of this template was an expectation (Regnier et al., 2005).
We identified consecutive stroke admissions to the University of Illinois at Chicago (UIC) Medical Center between July 1, 2005, and March 31, 2007, from a stroke registry called the "Care and Prevention Treatment Utilization Registry for Stroke (CAPTURE Stroke Illinois)." The report for each year is divided in quarters. For all of the admissions, we collected data related to the 10 performance markers, two quarters before and five quarters after the implementation of the "Standardized Stroke Admission and Discharge Summary Template."
To assess if the introduction of these templates improved compliance, we measured the percentage compliance with each performance marker. First, we measured two quarters before the implementation of the template and compared them with the percentage in the first quarter after implementation of the templates using the chi-square statistics and the Fisher's exact test. We also measured two quarters before the introduction of the templates and compared them with the percentage compliance in the five quarters after the introduction of the templates to ascertain if the noted changes were sustained over time. The Cochran-Armitage test for trend analysis was used to assess significant changes in the performance markers throughout the seven reviewed quarters.
Data were collected retrospectively on 741 consecutive stroke admissions within the study period. In the first quarter after implementation of templates, performance increased for lipid panel assessment (61.45% to 80.43%, p = .03) and dysphagia screening (50.34% to 77.63%, p ≤ .01) from preintroduction measures. There was no significant change in DVT prophylaxis smoking cessation counseling, antithrombotic prescription at discharge, antithrombotic administration within 48 hours, stroke education provided to patient and/or caregiver, rehabilitation plan documentation, atrial fibrillation patients discharged on warfarin, and TPA consideration (Table 1).
Trend analysis for the remaining quarters (Table 2) showed a positive trend improvement for TPA considered (2.5845, p .01), antithrombotic medication within 48 hours (2.8829 p ≤ .01), lipid profile (3.3968, p ≤ .01), screen for dysphagia (2.4565, p ≤ .01), stroke education (−3.3658, p ≤ .01), smoking cessation (4.8818, p ≤ .01), and plan for rehabilitation considered (5.0672, p ≤ .01). Discharged on antithrombotic medication and patient with atrial fibrillation receiving anticoagulation therapy were the acceptable compliance for DVT prophylaxis; performance markers were higher than 93% in the two quarters before the implementation of the templates and were maintained and improved toward greater compliance.
Because TJC certification was based on recognizing a stroke center that made additional strides to provide outcomes better for stroke patients, stroke centers need to be compliant with the 10 performance markers that promote these outcomes. In a study comparing data before and after the certification from the Joint Commission on Accreditation of Healthcare Organization (2007), Stradling et al., (2007) studied 1,161 stroke admissions for a total of 16 quarters and showed that after their stroke certification from the Joint Commission on Accreditation of Healthcare Organization, lipid profile testing improved from 71% before to 86% after and DVT prophylaxis from 80% before to 98% after (p < .01). Also, the number of patients undergoing lipid profile testing and DVT prophylaxis increased after the implementation of a stroke service, which was formed 6 months after their certification (Stradling et al., 2007). Our findings are consistent with Stradling et al. because there was an improvement in compliance with the lipid profile being ordered. The DVT prophylaxis was high before certification and remained after certification. We also demonstrated sustained improvement and improvement over time for the other eight performance markers.
To demonstrate better outcomes for stroke patients, medical record documentation is an important issue and needs to be a focus (Leape & Berwick, 2005). Before our stroke templates, there were general neurology templates available for use, but it was not mandatory, and these templates did not capture the 10 performance markers. Each performance marker needs to be documented clearly and accurately. If a stroke patient did not receive a treatment because of exclusionary criteria, this information needs to also be documented clearly in the medical record (Frankovich & Rensing, 2002). Data need to be available for easy extraction. If documentation is not clear or difficult to find in the medical record, this leads to an inconsistent method of abstracting data (Katzan et al., 2003).
Implementation of the templates was a landmark in this process; however, it may have not been the only reason why the compliance improved. The pocket cards provided and the multiple in-services given to the residents and nurses regarding the performance markers may have also improved compliance. Nurse coordinators rounding with the stroke team 5 days a week assuring performance markers were being carried out may have had an important role in the improvement of compliance. Also, the nurse coordinators providing stroke education were an adjunct to the staff nurses. With the current analysis, it is not possible to determine if the templates improved the actual care being given or whether it improved the documentation of the care. We speculate that it affected both. The positive trends for the performance markers in this study may be due to better documentation with the templates and not overall stroke care.
The process of stroke certification along with the Stroke Admission and Discharge Template has positively impacted nursing and the quality of patient care in numerous ways. Foremost, education was key in increasing quality of care to stroke patients. Education provided through monthly in-services on stroke for 5 months before the implementation of the templates. In addition, the nurse coordinator having a strong presence on the stroke unit for education as well as being a member of the stroke team also positively impacted quality of care. In many teaching institutions, the nurses assist educating the new residents on the standards and expectations on the unit. The templates were used as a tool to assist with the process of delivering compliance with the standards expected from the performance measures.
Overall, there was a strong multidisciplinary effort to assure compliance that could have not been possible without having the templates as a focus tool. Creation of the templates implemented a process to monitor quality improvement. The templates were easy to follow, helped to abstract data, and possibly contributed to better stroke care.
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