Audit Forms for Patient Chart

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					Stroke Mock Tracer

  JC Stroke Specific Visit Preparation
  UH Case Medical Center Cleveland,
     Chris Sydenstricker RN BSN Quality Nurse
                      Mock Tracer Prep

• The UH stroke tracer teams were three teams that
  included a Neurologist or ED physician, a nurse
  manager and a quality nurse Each team was
  assigned an area to trace within a two week time
   - Emergency Department and Intervention radiology
   - Telemetry floors
   - The stroke unit and division
• An additional mock tracer was done by the Coverdell
  Nurse as an outside perspective
       Inpatient Mock Code

• Two patients were selected from the inpatient stroke
  service census for a chart audit and patient tracer
• Tracer team used a JC prep checklist and the Inpatient
  Mock Code form as a guide thru the tracer
• The staff was interviewed related to knowledge of how to
  call a Brain Attack and stroke care interventions
• Feedback was shared with the Stroke Quality committee
• If patients were not available to trace the Inpatient Mock
  Stroke scenario would have been utilized
   *This check sheet is just a starting point. It will need to be modified to reflect your
   institution’s policies.

Date _______________
Time _______________
Location ____________________

Staff that found patient
Staff responding to Code CVA

Pre-Treatment Work-Up / Inpatient                                              Yes     No    Time
   1.   Nursing staff on unit recognized/or alerted to patient
        change in neuro status. Suspected stroke call
        Stroke/Rapid Response Team.
   2.   Nursing staff assessed ABCs/vital signs
   3.   Obtain IV access; obtain blood samples (CBC,
        electrolytes, coagulation studies)
   4.   Check blood sugar; treat if indicated
   5.   Obtain 12-lead ECG; check for arrhythmias
   6.   Family notified of change in condition
   7.   (Steps 2-6 goal: <10 minutes from notification)
   8.   Obtain the pre-printed orders/packet
   9.   Radiology notified of Code Stroke/ aware of potential need
        for CT scan
   10. Stroke Team/Rapid Response Team responds
   11. Stroke/Rapid Response Team rapidly performs NIHSS
   12. Stroke/Rapid Response Team RN evaluates patient for
       inclusion and exclusion criteria for tPA
   13. Med Reconciliation
   14. Admitting physician notified within 10 minutes
   15. Patient transferred to Radiology for CT
   16. Patient transferred to appropriate bed from Radiology
          Sample Mock Scenarios

Scenario 1-Inpatient
• A 65 year old male patient is found with right
  sided weakness and facial droop by a
  certified nursing assistant while delivering
  breakfast meal trays. He was previously
  admitted for angioplasty and kept overnight
  for observation. He is diabetic and has a
  history of heart disease.
• What happens next?
     ED Mock Code

• A window of time was set aside by the tracer team to
  evaluate an actual Brain Attack
• It was beneficial to evaluate the team “in action”
• Utilize Mock Stroke Code ED arrival form as evaluating
• If a Brain Attack did not arrive within the designated time
  frame a Mock patient scenario would have been utilized
• Triage RN and transfer center staff were interviewed
  related to 3 hour TPA time window. RN bedside
  interviewed related dysphasia screening and TPA
*This check sheet is just a starting point. It will need to be modified to reflect your institution’s policies.
Pre-Treatment Work-Up / ED Patient                                              Yes     No       Time
1.   Patient arrives at ED
2.   Triage RN assess for Code Stroke Status as per institution policy
3.   Time patient last known well documented (<3 hours for fibrinolytics)
4.   Obtains the pre-printed order set
5.   Notifies ED physician immediately of positive findings
6.   Notify CT personnel
7.   Patient transported to CT scan and Code Stroke called (door to CT
     scan performed: goal <25 mins from arrival)
8.   Stroke Team performs NIH Stroke Scale (or ED RN as per
     institution policy)
9.   Keep patient NPO until swallow screen is performed
10. Read CT scan (door to – CT read: goal<45 mins from arrival)
Following takes place concurrently to save time / 3-hour                         Yes      No           Time
11. Positive neurological findings and absence of contraindications:
12. IV access (two IV lines)
13. Lab studies drawn and sent to lab
14. Stroke team repeats neuro exam: are deficits variable or rapidly
15. Review fibrinolytic exclusions: are any observed?
16. Med. Reconciliation with emphasis on anticoagulants?
17. Review patient data: Is symptom onset now >3 hours?
18. Neurologist notified
19. If no, ED physician informs patient / family of risks & benefits
20. Place patient on ECG monitoring
21. Monitor VS per institution policy
         BP above 185/110: treat per AHA guidelines/your
         institution protocol
22. Nurse/ pharmacy mixes tPA per hospital protocol
23. Administer thrombolytic therapy (door to treatment goal <60
24. Admit to appropriate level of care bed or transfer per institution
25. Handoff/Med. Reconciliation include dysphagia screen, vital signs,
    complications before going to floor
26. Serial neurological assessments per institution protocol
Those listed in italics are patient safety goals.
Scenario 2 – ED

• Patient 013 was found on the floor beside the commode by the
  charge nurse at Starlight Nursing Home on her night rounds at
  12:45 am on 12/01/2007. He wasn't able to talk or move, but his
  left leg was shaking. There were no problems reported with
  Patient at change of shift. They think that the evening nurse
  would have seen him between 9 and 10 pm on her rounds.
  Information was provided by sheet sent from the nursing home.
  A phone call to the charge nurse does not reveal any further
  information from the patient's medical chart. ED arrival date and
  time is 12/01/2007 1:37 am.
• Time and date of last known well are known as 11/30/2007
  21:00, and time and date of discovery are known as 12:45 a. m
Scenario 3– Interventional Capabilities

• 57 year old female with sudden onset aphasia and
  dense right sided weakness witnessed by her
  husband at 22:00, Husband called the Volunteer Fire
  Department. Squad arrived at pt’s home 22:55.
  Arrived at Critical Access Hospital at 00:15. No tech
  available to perform CT scan. ED physician calls your
  ED as you are the nearest Primary Stroke Center (50
  min. away by air) and patient is accepted for transfer.
  Life Flight helicopter arrives for transport at 01:20.
  Patient arrives in your at ED 02:20. Pt with NIHSS of
  18, and history of HTN. Family is driving from Critical
  Access Hospital and expected to arrive in your ED at
• What happens next?
    Mock Tracer Coverdell Nurse Visit

• Tracer seemed more realistic with an outside evaluator
• Coverdell Nurse focused more on the hand off process in
  each treatment area
• Tracer more focused on staff knowledge of process
  improvement projects- TPA mixing, stroke education ,
• TPA flowsheet developed after tracer to improve hand off
• Q&A session with Coverdell nurse to review expectations
  of JC Primary Stroke Certification visit
Lessons Learned

• Outside evaluator very beneficial to JC stroke prep
• Incorporate evaluation of ALL National Patient Safety
  Goals into Mock Tracers
• Do chart tracer audits as well as walk arounds to
  evaluate stroke documentation and stroke care with
  consideration to National patient safety goals
• Involve staff in performing tracers
• Focus on hand off from one area to another
• Monitor dysphasia screening and TPA prep process
  in mock tracer
Questions ????

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