In 2014, Cleveland Clinic main campus was certified as a Comprehensive Stroke Center by the Joint Commission. To earn and maintain designation, the inpatient stroke units are required to track and document numerous metrics and tasks, many related to patient stroke education. When nursing leaders tracked documentation compliance related to stroke education in the fourth quarter of 2015, it was only 65%.
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“We realized there was a gap in understanding about what documentation was required,” says Katie Zacharyasz, BSN, RN, CPAN, nursing quality program manager with Cleveland Clinic. “Nurses are teaching patients all the time, but they don’t always take credit for it and document it. So we had to make the requirements clear.”
In 2015, main campus created an audit tool to monitor required documentation and launched stroke education prevalence rounds. The goal was to improve compliance of daily individualized stroke education and increase clinical nursing’s responsibility and engagement in care of stroke patients. “We have honed in on customizing education for each patient,” says Zacharyasz. “It’s all about getting to know the patient and building the education they need.”
Creating an audit tool for compliance
The project began on the hospital’s med-surg neurological unit, then expanded to the two neurological step-down units and the neurological ICU. Zacharyasz collaborated with members of the stroke team, nursing education, nurse managers and clinical nurse specialists to create the audit tool and rounding. They surveyed clinical nurses to ascertain what they were documenting and where. “It was very collaborative, involving the nurses who do the work,” says Zacharyasz.
The team created an audit tool that tracks several items related to the patient, including the following:
- Admit date and time.
- Length of stay.
- Individualized risk factors, such as atrial fibrillation, smoking and diabetes.
- Dissemination of the “Your Guide to Managing Stroke” binder.
- Daily documentation of at least one teaching point.
- Completion of the National Institutes of Health Stroke Scale on Day 1, Day 2, Day 3 and upon discharge.
“With stroke, what nurses have to document is very comprehensive,” says Zacharyasz. “There is a requirement for documentation of a daily teaching point specific to stroke education every day the patient is hospitalized.” The audit tool helps ensure adherence. In addition, nurses are reminded to complete stroke education documentation during unit huddles and via stroke education posters displayed on the unit.
Instituting monthly rounds and nurse education
Nurse managers track stroke education on their units daily, and a formal review of stroke patients is conducted on the first Wednesday of each month. These stroke education prevalence rounds are led by Zacharyasz, stroke program managers and nursing unit leaders, who utilize the audit tool. Feedback is relayed to nurses on the unit during the daily huddle, and the data collected is reported to nurse managers and directors during their huddles.
If opportunities or gaps in compliance are identified, real-time feedback and education is provided to the nurses via one-on-one conversations and displays of screen shots that show the correct way to document compliance.
The team also worked with nursing informatics to create a stroke report in the nurse manager dashboard in the electronic medical record system. “This has helped streamline the review process,” says Zacharyasz.
Compliance rates remain high
Since implementing the audit tool and stroke education prevalence rounds five years ago, compliance rates continue to improve. Overall compliance rates increased to 86% in 2016 and were at 90% during the first half of 2019. From January through May 2020, compliance with “one daily teaching point” was 92%.
“The nurses have a better understanding of expectations for documentation,” says Zacharyasz. “And when nurses know and understand expectations, we set them up for success.” That success translates to individualized education geared toward patients and better quality patient care.