Authors (including presenting author) :
Karin Chow, Michael FU, TMH Stroke nursing team
Affiliation :
Acute Stroke Unit, Department of M&G, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority.
Introduction :
Compared to community-onset stroke (COS), in-hospital stroke (IHS) patients have historically been less likely to receive timely reperfusion treatment, leading to poorer outcomes due to delays in diagnosis and evaluation for etiology. Although a structured stroke rescue chain is well established, IHS is often not recognized as an emergency, which makes reliable recognition of stroke symptoms and identification of onset time challenging for non-stroke healthcare teams.
Objectives :
A retrospective 5-year data review at Tuen Mun Hospital showed that the mean time from finding onset to accessing imaging (Plain CT Brain) was more than 120 minutes, and stroke code alerts (thrombolysis - TPA call) for IHS patients represented only 5% of those for COS patients. To address this shortfall, the NTWC stroke nursing team developed a CQI program in 2017 to bridge this quality gap.
Methodology :
In phase one, the program focused on TMH M&G wards, which had the highest rate of IHS. The strategies included a "Brain Resuscitation" campaign month, direct "Stroke Nurse" consultation on a 7/24 basis, and focused "IHS support" training for nurses in eight classes. In phase two, the program was extended to non-M&G wards, and the training was extended to supporting staff, allied health, and frontline doctors in 20 classes. The program also streamlined the AED rapid triage protocol, allowing for direct upgrade of patients to the CT-suite and rapid patient transportation through a fast-track internal portering system. In phase three, the program was expanded to cluster hospitals, including POH and TSWH, with a rapid triage protocol that included advanced imaging (CT-angiogram) support to expand reperfusion opportunities.
Result & Outcome :
The data retrieved from 2016 to 2021 showed that the CQI program had a significant impact. The number of TPA calls triggered for IHS increased overall, with M&G group calls increasing by 88% (2017-2018), 111% (2019-2020), and 74% (2021) compared to 2016. Non-M&G group calls increased by 300% (2019-20), and 290% (2021). The mean time from finding onset to accessing imaging (FO-T-CT time) decreased for both groups, with M&G group times shortening from 156 min (2016) to 104 min (2017-2018), 64 min (2019-2020), and 28 min (2021); and Non-M&G group times shortening from 174 min (2016) to 93 min (2018), 75 min (2019-2020), and 57 min (2021). The mean time from finding onset to treatment (FO-T-T time) also decreased for both groups, with M&G group times shortening from 176 min to 139 min (2017-2018), 78 min (2019-2020), and 71 min (2021); and Non-M&G group times shortening from 235 min to 198 min (2017-2018), 149 min (2019-2020), and 107 min (2021).
In conclusion, the CQI program in phased approach, developed by the NTWC stroke nursing team has had a significant impact on improving the recognition and treatment opportunities for IHS patients, led to reduced FO-T-CT and FO-T-T times for both M&G and Non-M&G groups. However, implementing a CQI program can face challenges such as resistance to change, limited resources, lack of awareness, training and education, coordination and communication issues. It is important to address them appropriately to ensure their success and continued improvement in patient care.
