ABSTRACT
Background: During the initial emergence of the 2019 novel coronavirus (COVID-19) and the subsequent surge of patients requiring critical care, our Joint Commission certified thrombectomycapable stroke center sought to utilize a low-intensity monitoring protocol in stable, post intravenous (IV) thrombolysis patients in our intensive care unit (ICU). The acuity level in our ICU jumped to an all-time high, with many critically ill COVID-19 patients. Our goal was simple, provide safe patient care, free up precious nursing time, and preserve the personal protective equipment supply. Purpose: The purpose of this study was to use a rapid cycle process improvement project to implement a low-intensity monitoring (LIM) protocol in stable, suspected stroke patients, who are deemed at low risk for complications, in the first twenty-four hours following IV thrombolysis. Methods: We utilized the Plan-Do-Study-Act (PDSA) model to implement this project. Collaboration between physician, nursing, and stroke program leaders occurred during the month of April 2020. Our new process utilized the Optimal Post T-pa Iv Monitoring in Ischemic STroke (OPTIMIST) protocol. We continued to admit our post IV alteplase patients to the ICU, rather than a step-down unit, in order to accommodate the 3:1 patient to nurse ratio, ensure protocol adherence, and maximize patient safety with this high-risk medication. We used change of shift huddles to educate the ICU nursing staff over a two-week period. Stroke program advanced practice nurses were onsite to ensure compliance. Results: Since implementation of the new protocol, two IV alteplase patients have met protocol criteria;both remained stable throughout the twenty-four-hour LIM period. The protocol's nursing ratio changes allowed the other, critically ill patients, to be staffed with traditional ICU ratios. Conclusion: Rapid cycle PI projects can be accomplished during times of extreme challenge, as evidenced during the COVID-19 pandemic. Nursing staff was able to adapt and even welcomed the change, while maintaining patient safety. Further study is needed to document the ongoing effect of this protocol.
ABSTRACT
Introduction: The ability to treat an acute ischemic stroke depends on the patient's timely presentation to the hospital from their last known well time. During the coronavirus disease 2019 (COVID-19) pandemic, individual state governments enacted stay-at-home orders to slow the transmission of the disease. We collected data from hospitals across four state-based networks where we provide stroke telemedicine coverage to ascertain the effects of these mandates. Objectives: We sought to evaluate the effects of stay-at-home orders on the number of patients evaluated and treated for ischemic stroke during the COVID-19 pandemic, and to evaluate the difference in treatment rate while states were under state-at-home orders versus while they were not. Methods: We retrospectively examined stroke alerts from March 1 to May 30 , 2020. We tabulated total number of stroke alerts, number of IV alteplase and intra-arterial (IA) treatment recommendations, number of less severe strokes (NIHSS 0-6) and more severe strokes (NIHSS 7- 41). Treatment rates were calculated and compared by state-based network before, during, and after the stay-at-home orders. Results: We found that the total number of alerts per week fell by 27.33% during the stay-at-home orders across all state networks. The total number of patients treated with alteplase and total number of patients treated with IA therapy per week also dropped by 29.31% and 13.69%, respectively. The alteplase and IA treatment rate increased by 10.57% and 13.85%, respectively, during the stay-at- home orders. The percentage of total strokes considered more severe slightly increased during these orders, by 5.54%. Conclusion: During the government mandated stay-at-home orders, the total number of patientsevaluated for stroke alerts decreased, as did the total number of patients treated either withalteplase or IA therapy. However, with the decrease in number treated, the rate at which patientswere treated with alteplase, IA, or both, increased. The percentage of total strokes that wereconsidered more severe slightly increased. In conclusion, while stay-at-home orders kept manystroke patients home, the most severe stroke patients continued to present to the hospital and weretreated in a timely manner via telemedicine.