CAMC Stroke CenterSeptember 12,2013

Drill down: Variance in capturing individualized risk

factors Med Reconciliation discrepancies Education not documented Staff feedback – request visual cue

Nursing staff own Stroke/TIA Education

Admission Assessment- added trigger ‘Is this pt a possible stroke/TIA?’ If yes,

EMR will prompt a workflow for Stroke/TIA Education

Stroke Education order in EMR

To facilitate documentation of patient specific risk factors, added risk factor

drop- down box

Med Reconciliation process streamlined

Per nursing feedback, added Stroke/TIA Education order to Nursing Scheduled assessments

Once Stroke Education flowsheet is opened, cannot exit flowsheet without addressing risk factors.

Variances in practice reported to Nurse Managers for individualized follow-up

TCT Stroke Champions

Continue ongoing and monthly monitoring to achieve goal of 100% compliance

Compliance rate increased from 82.37% 2012 to 91.11% Jan-Jun2013

June 2013 at 100% compliance

Benchmarks: TJC Nat’l Avg. 91.58% Premier top 25% 93%