A Clinical Audit of the STROND Checklist

The STROND checklist is an indispensable resource to enhance the quality of neuroepidemiological research. It provides a framework for describing study data, making comparison between results easier.

This clinical audit’s goal was to examine how closely King Hamad University Hospital adheres to the latest acute ischemic stroke (AIS) guidelines by reviewing patient charts with an electronic medical records system.

Eligibility criteria
The study included patients managed in an emergency department for acute ischemic stroke and admitted to the hospital ward for ongoing care. Patients who required short ICU stays (48 hours or less), transference to other services than stroke ward teams or discharge plans with comfort-focused goals were not included.

The primary endpoint was the impact of this app on residents’ ability to conduct and convey a comprehensive acute stroke clinical evaluation to staff neurologists, as well as record core stroke quality metrics in their medical record. Data were gathered from neurology residents six months prior and eight months post checklist implementation via survey distributed via email with anonymous surveys distributed.

Study design
One limitation of this study was its focus on only ischemic stroke patients, which may limit its applicability in other neurocritical care units which treat hemorrhagic stroke or other neurological conditions. Furthermore, as this was a retrospective investigation there may have been reporting bias.

This study was developed as a pragmatic pre/post mixed methods four-phase research project. Eligible participants will be recruited on their day of admission to an acute stroke unit (ASU). Participants in both baseline and implementation phases will receive standard allied health evaluation, while implementation participants will undergo an innovative transdisciplinary initial assessment using the novel TINSA checklist; its effectiveness in decreasing assessment times without impacting quality of care will be assessed by researchers.

Methods
Standardized handoff tools have been linked with reduced medical errors and enhanced workflow efficiency among certain patient populations. We conducted studies to investigate if such tools could enhance transfer of stroke patients from neurocritical care units to hospital wards more quickly and safely.

A multidisciplinary team developed and implemented an ICU Transfer Checklist which provided concise clinical patient summaries, immediate action items and organ system reviews of active problems. The study cohort consisted of consecutive patients admitted to neurocritical care unit with ischemic stroke who were then transferred to stroke ward for care. Provider surveys before and after implementation of this checklist helped characterize providers’ perceptions of workflow quality; results of surveys conducted before/after implementation revealed reduced ICU length-of-stay (LOS), improved provider perceptions of workflow efficiency as well as patient safety for care providers themselves.

Results
King Hamad University Hospital was discovered to have poor adherence to National Institution for Healthcare Standards and Safety Scoring System scoring, due to having this score manually documented by residents which provides room for reporting bias and increases potential reporting bias. Furthermore, this audit highlighted a need for specific strategies aimed at further improving door to needle times.

Our objective was to develop and implement an ICU Transfer Checklist as part of our efforts to standardize communication of patients suffering ischemic stroke from neurocritical care units to hospital ward services, with immediate “to-do” action items and organ system-based reviews of active medical problems. Provider surveys pre and post implementation were used to gauge provider perceptions regarding workflow efficiency and care quality.

Conclusions
The clinical audit focused on 75 patients admitted to the neurocritical care unit with an ischemic stroke diagnosis. Retrospective chart review was performed through data extraction from hospital electronic medical health records; then split into pre and post implementation periods by six and eight months respectively in order to measure sustainability.

Handoff tools were found to be successful at improving patient care during ICU-to-hospital ward transfers, according to previous studies which had noted poor communication and documentation during patient handoffs. Unfortunately, this study only included patients from King Hamad University Hospital with AIS code stroke symptoms – and thus may not represent all potential beneficiaries who could gain from an effective transfer tool.