ORIGINAL ARTICLE
A quality improvement programme with a specialist nurse in a neurovascular clinic Jacqueline McKee, Carrie Wade and Mark O McCarron
Aims and objectives. To measure the impact of a quality improvement programme with a stroke specialist nurse and increased capacity at neurovascular clinics. Background. Transient ischaemic attack and minor stroke are medical emergencies prompting urgent assessment and treatment. Delays in specialist assessment and management are frequent and may increase stroke risk. Design. Pre- and post evaluation of intervention. Methods. All patients referred to a neurovascular clinic were recorded during two phases: 2006–2008 and 2010–2012. For the 2010–2012 period, a stroke specialist nurse contacted all patients with appointment details, provided driving advice and asked for an eyewitness to attend the clinic. Diagnosis, delay in specialist assessment, prevalence of transient ischaemic attack/minor stroke as confirmed at the clinic and compliance with UK driving regulations were measured and compared before and after this intervention. Results. A total of 1327 patients were assessed in the two study phases. Referrals to the neurovascular service increased without a decrease in the prevalence of transient ischaemic attack/minor stroke. Delays from clinical event to assessment were decreased for referrals from 365–13 days, and adherence to the UK driving restrictions improved for confirmed transient ischaemic attack/minor stroke patients from 61–94%. Fewer patients failed to attend a neurovascular appointment arranged by the stroke specialist nurse than those who failed a general neurology appointment arranged by partial booking. Conclusions. This quality improvement programme reduced delays for all referred patients, improved compliance with driving regulations and demonstrated efficient use of neurovascular clinic spaces. Increasing local capacity may unmask more transient ischaemic attack/minor stroke patients. Relevance to clinical practice. A stroke nurse can help improve the efficiency of a neurovascular clinic and improve patient safety with driving advice.
What does this paper contribute to the wider global clinical community?
• Increased capacity at a neurovas• •
cular clinic can unmask unrecognised cerebrovascular disease. A stroke specialist nurse can improve the efficiency of a neurovascular clinic. A stroke specialist nurse can improve adherence to driving regulations for patients with TIA or minor stroke.
Key words: nurse roles, quality and safety, stroke Accepted for publication: 14 March 2014
Authors: Jacqueline McKee, BSc, RGN, Stroke Specialist Nurse, Acute Stroke Service, Altnagelvin Hospital, Londonderry; Carrie Wade, BSc, Medical Secretary, Department of Neurology, Altnagelvin Hospital, Londonderry; Mark O. McCarron, MA, MD, FRCP, Consultant Neurologist, Acute Stoke Service and Department of Neurology, Altnagelvin Hospital, Londonderry, UK
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Correspondence: Jacqueline McKee, Stroke Specialist Nurse, Acute Stroke Service, Altnagelvin Hospital, Londonderry BT47 6SB, UK. Telephone: +44 (0)2871345171. E-mail:
[email protected] © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 386–392, doi: 10.1111/jocn.12609
Original article
Introduction Recognition that transient ischaemic attacks (TIA) and minor stroke are risk factors for stroke has spurred early assessment and treatment (Coull et al. 2004). An 8% risk of stroke at one month is front-loaded with almost 50% of strokes with a preceding TIA/minor stroke occurring within 24 hours of the initial neurological deficit (Chandratheva et al. 2009). There is some evidence that early intervention may lessen the stroke burden (Lavallee et al. 2007, Rothwell et al. 2007, Wang et al. 2013). In addition, a risk classification for confirmed TIA patients (ABCD2 score – see Appendix 1) has evolved to help stratify patients so that higher-risk patients may receive earlier assessments, investigations and treatment (Rothwell et al. 2005, Johnston et al. 2007, Giles et al. 2010).
Stroke nurse and TIA clinic
reduce delays for patients referred with a suspected TIA. Our research question sought to determine the clinical impact of the quality improvement programme and in particular what measurable outcomes could be derived from the activity of a stroke specialist nurse. We report the yearly results of a number of patients attending neurovascular clinics in a district general hospital, the impact on TIA/ minor stroke prevalence at the clinics, the delays from event to assessment and adherence to the Driver and Vehicle Licensing Authority (DVLA) regulations prior to assessment at a neurovascular clinic. We also compared attendance rates in a general neurology clinic with the neurovascular clinic. Our goal or prior hypothesis was that the programme would improve the patient’s experience at the neurovascular service.
Methods Background In Northern Ireland, Improving stroke services (Department of health, Social Services & Public Safety 2008) was an initiative launched by the Department of Health aimed at providing faster assessments of suspected TIA patients. We previously described our limited service and highlighted the inherent problems of compliance with UK driving restrictions for confirmed TIA patients (one month ban for car drivers) and the sometimes unnecessary driving restrictions for nonTIA patients awaiting a diagnosis (McCarron et al. 2008). There is limited but emerging evidence of the impact of specialist nurses in clinical medicine (Clarke et al. 2005). There has been some published evidence of the potential benefits of a stroke specialist nurse in the emergency department (Considine & McGillivray 2010) and stroke ward (Catangui & Slark 2012). There is much literature on the value of epilepsy specialist nurses. Benefits of epilepsy specialist nurses have been demonstrated in terms of emotional support (Noble et al. 2013) and education of patients with epilepsy. The epilepsy specialist nurse literature highlights themes, which could also be developed for stroke specialist nurses, including the need to collate relevant data to prove the value of the specialist nurse (Higgins 2008) and recognise that their value may go beyond randomised controlled evidence. In general, specialist nurses have high commitment to provide expert and personalised care (Hopkins & Irvine 2012). With funding for a stroke specialist nurse and increased clinic capacity from Improving Stroke Services (Department of health, Social Services & Public Safety 2008), we implemented a quality improvement programme in an attempt to
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 386–392
Study design A prospective pre- and postintervention design was used. Demographic and vascular risk factors were prospectively recorded along with the diagnoses made at clinic. Setting The study was performed at Altnagelvin Hospital, a 484bed district general hospital in Northern Ireland. Participants Consecutive patients over the age of 16 years referred to a neurovascular clinic with suspected TIA or minor stroke between 1 January 2006–31 December 2012 were studied. Referrals were accepted from primary and secondary care. Exclusion criteria were patients under 16 years of age and patients admitted directly to hospital. This included patients with an ABCD2 score of 6 or 7 (see Appendix 1; they were deemed high risk (Johnston et al. 2007) and were admitted directly to hospital. In total, 1327 patients were assessed.
Intervention In 2009, a stroke specialist nurse was appointed by the trust, and in 2010, clinic capacity was enhanced with funding from Improving Stroke services (Department of health, Social Services & Public Safety 2008). Following the launch of regional guidance, the intervention was tailored to our local service with educational meetings with relevant stakeholders similar to published and effective strategic changes adopted elsewhere (Wright et al. 2006).
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To reduce time delays, the neurovascular service improved from a twice a week outpatient clinic to three days per week. Local referral forms with ABCD2 risk stratification (Johnston et al. 2007) were disseminated with intranet access for the emergency department and primary care. In the 2010– 2012 period of study, all patients referred to the neurovascular clinic were contacted by the stroke specialist nurse to provide appointment details and to reinforce DVLA guidance (one month driving ban for TIA/stroke patients) at least until the diagnosis was confirmed (when driving restriction was again explained) or refuted (when driving restriction for TIA/minor stroke removed) at the clinic. The stroke specialist nurse contact with the patient to arrange the clinic appointment was also instigated in an attempt to reduce missed appointments. Daily carotid Doppler and neuroimaging (CT brain and subsequently MRI brain) services were initiated from the quality improvement programme along with same-day dispensing of antiplatelet and statin medication, if not already implemented as advised in the referral form. Our stakeholder meetings resulted in the planned pharmacy involvement in the neurovascular clinic and increased radiology input to meet the demands of the service.
Data collection Delays from the onset of the clinical event to neurovascular clinic assessment were measured as was compliance with the UK DVLA regulations for patients with suspected TIA or minor stroke (Driver & Vehicle Licensing Authority 2013). The variables of time delay from event to clinical assessment and compliance with the DVLA guidelines were compared between each study period. In addition, we measured the rate of missed appointments for new patients at one of the three weekly neurovascular clinics and a weekly general neurology clinic in 2011 and 2012.
Statistical analyses The number and proportion of new patients in whom a diagnosis of TIA or minor stroke was confirmed at the neurovascular were calculated with 95% confidence intervals for the proportions using the Wilson procedure with a correction for continuity (Wilson 1927). Categorical data were compared using chi-squared tests, ordinal data using the Mann– Whitney U-test and continuous data using Student’s t-test.
Results In total, 1327 new patients were assessed at the neurovascular clinic in the two- to three-year study periods.
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Between 2006–2008, 379 patients (mean age 587 (SD 150) years) were assessed. In the second part of the study between 2010–2012, 948 patients (mean age 613 (SD 144) years) were assessed, representing almost threefold increase in activity (Table 1). The patients in the 2010– 2012 phase of the study were slightly older than the group of patients studied in the 2006–2008 period (p = 0004). Delays from clinical event to assessment were decreased for all patients from the 2006–2008 period until the 2010–2012 period (p < 0001). More than half the patients were car drivers. Diagnostic yield for TIA and minor stroke is demonstrated for each year in Fig. 1 before the intervention programme (2006–2008) and following the launch of the programme (2010–2012). Overlapping confidence intervals demonstrated little change in the proportion of patients diagnosed with cerebrovascular disease as their presenting complaint despite an increase in the number of patients assessed per year; in other words, the prevalence of TIA/ minor stroke at 48% did not change at the neurovascular clinic despite the increase in capacity and number of patients assessed. During the transition within the service in 2009, data were not collected. Patients with a confirmed TIA/minor stroke were older than the non-TIA/minor stroke patients in both the 2006– 2008 period (p < 001) and the 2010–2012 period of the study (p < 0001). Violations of the driving ban for TIA/ minor stroke patients dropped from 39% in the 2006–2008 period to just 6% following the intervention in the 2010– 2012 study phase (Table 2, p < 0001). In 2011 and 2012, missed clinic attendances at one of the neurovascular clinics were proportionately less than missed appointments at a general neurology clinic (p < 0001, see Table 3).
Table 1 Demographics, delays and driving status among all neurovascular referrals before and following intervention
Variable Men/women Mean age in years (SD) Median delay to clinic in days (interquartile range) Number of group 1 drivers (%) Number of patients with confirmed transient ischaemic attack/minor stroke at clinic (%)
2006–2008 n = 379
2010–2012 n = 948
p-value
174:205 587 (150) 365 (23, 49)
452:496 613 (144) 13 (6, 25)
0004