ORIGINAL ARTICLE

Standardised care plans for in hospital stroke care improve documentation of health care assessments Ulrika P€ oder, Marie Fogelberg Dahm, Nina Karlsson and Barbro Wadensten

Aims and objectives. To compare stroke unit staff members’ documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record. Background. Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital. Design. Quantitative, comparative. Methods. Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record. Results. Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients’ micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. Conclusions. An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. Relevance to clinical practice. Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.

What does this paper contribute to a wider global clinical community?

• A standardised care plan seems



to provide valuable support to health care staff, as a reminder of the need to register health status assessment results in patients’ health care records. Evidence-based standardised care plans may assist staff in working according to existing guidelines and, thereby, promote patient safety.

Key words: adherence, clinical pathway, electronic health care record, multiprofessional, nursing, occupational therapy, patient safety, physiotherapy, standardised care plan, stroke management Accepted for publication: 4 April 2015

Authors: Ulrika P€ oder, PhD, RN, Senior Lecturer, Department of Public Health and Caring Sciences, Caring Sciences, Uppsala University, Uppasala; Marie Fogelberg Dahm, RN, MSc, Development Leader, Unit for Care Development, Uppsala University Hospital, Uppasala; Nina Karlsson, RN, MSc, Development Leader, Unit for Care Development, Uppsala University Hospital, Uppasala; Barbro Wadensten, PhD, RN, Senior Lecturer, Associate Professor, Depart-

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ment of Public Health and Caring Sciences, Caring Sciences, Uppsala University, Uppsala, Sweden Correspondence: Ulrika P€ oder, Senior Lecturer, Department of Public Health and Caring Sciences, Caring Sciences, Uppsala University, Box 564, Uppsala 751 22, Sweden. Telephone: +46 18 471 61 60. E-mail: [email protected]

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2788–2796, doi: 10.1111/jocn.12874

Original article

Introduction Stroke is a common illness state, and stroke care demands considerable resources. In Sweden, around 30 000 individuals suffer from stroke annually (Riks-Stroke 2012). Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is therefore imperative that patients be observed, assessed and treated in accordance with evidence-based practice (EBP) in hospital. It is also important that a reliable clinical diagnosis be established soon after occurrence of the stroke and that this diagnosis forms the basis for continued management. A stroke unit is by definition an organised in-patient unit dedicated to taking care of patients with stroke and run by a multi-professional team specialised in stroke care. One integral part of the stroke unit concept is the use of a standardised basic assessment, the aims of which are to chart neurological symptoms, exclude differential diagnoses, establish which main type the stroke belongs to and assess functional consequences and rehabilitation requirements. The Swedish National Board of Health and Welfare publish regular guidelines for care and treatment of stroke that are based on scientific data as well as proposals for measurable quality indicators (The National Board of Health and Welfare 2006, 2009). Improved knowledge and routines, including establishment of the national guidelines on stroke care, were discussed as a contributing factor to the improvements made from 1995–2010 regarding patients’ outcomes after a stroke (Appelros et al. 2014). Carpenito (2013) suggested that a standardised care plan (SCP) could be considered a general action plan or a sort of guideline for care. An SCP contains a diagnostic cluster, nursing diagnoses, associated problems and interventions. An SCP is predetermined for a specific group of patients, and use of an SCP may help ensure that all patients receive the same high-quality care. An SCP may also be multi-professional (Edlund & Forsberg 2013). In the optimal case, an SCP is based on up-to-date, evidence-based knowledge. Clinical pathway is another concept used to describe a multi-professional care plan used to translate evidence or guidelines into local practices (Kinsman et al. 2010). To be declared a clinical pathway, no matter which term is used, additional criteria must be fulfilled. According to Kinsman et al., interventions in the detailed care plan should have been designed for a specific problem, procedure or episode of health care and should include time frames or criteriabased progression in a specific population. Besides clinical pathway and SCP, other terms used for this concept are, for example, protocols, critical or integrated care pathway.

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2788–2796

Standardised care plans improve documentation

Which concept is used varies across countries. SCP will be used here, because it the most common concept in Sweden.

Background Studies have shown that hospital staff believe SCPs increase their ability to provide high-quality patient care (Lee 2005, 2006, Dahm & Wadensten 2008, P€ oder et al. 2011, Svensson et al. 2012, Bjurling-Sj€ oberg et al. 2013, Jakobsson & Wann-Hansson 2013). SCPs may also help staff improve patient outcomes, reduce length of hospital stays, and enhance teamwork and record keeping (Rycroft-Malone et al. 2004, Deneckere et al. 2013, Deng et al. 2014). Furthermore, a Cochrane review including 27 studies concluded that use of SCPs is associated with reduced hospital complications and improved documentation (Rotter et al. 2010). However, use of evidence-based SCPs still seems to be low in nursing practice in Sweden (Olsson et al. 2009, Bjurling-Sj€ oberg et al. 2014). This might depend on the perceived risks associated with standardised care: that staff will lose their autonomy (Ebben et al. 2012) or that person-centred care will be jeopardised. Thus, the individual patient’s desires and needs might become secondary to the procedures specified in the SCP (Andreae et al. 2011). With the intention to improve use of evidence-based knowledge at a stroke unit, a multi-professional evidencebased SCP for stroke care was derived from the national guidelines for stroke care in Sweden. The aim of the study was to compare staff members’ documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based SCP with a quality standard for stroke care in the electronic health record (EHR) at a stroke unit.

Method Design The design was quantitative and comparative. Retrospective health record reviews were made during two time periods, pre- and one and a half years postimplementation of a multi-professional evidence-based SCP with quality standards (the EB-SCP) for stroke care in an EHR.

The evidence-based SCP The EB-SCP is judged to fulfil the criteria for clinical pathways, as recommended by Kinsman et al. (2010), and was developed by a multi-professional working team, guided by two of the authors

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(MFD & BW). The working team consisted of four registered nurses (RNs), two physiotherapists (PTs), two occupational therapists (OTs) and two physicians. As a point of departure, the working team used the Swedish National Board of Health and Welfare (2006) guidelines for care and treatment and a local care programme for stroke (Uppsala County Council 2008) together with the guidelines for evidence-based nursing in stroke care, published by the Swedish Society of Nursing (SSF) (2005). For additional description of this procedure, see P€ oder et al. (2011). The EB-SCP was implemented in the EHR in the stroke unit. Implementation included training of staff, both in care and in the technical aspects of using the SCP in the EHR, which was carried out by one of the authors (MFD) during the first weeks. Thereafter, the head nurse and RNs responsible for nursing documentation on the ward were responsible for the ongoing work and for introducing the SCP to new staff. Before the SCP was implemented, RNs, OTs and PTs answered a questionnaire, which showed that although they were familiar with the existence of the guidelines on stroke care, 20% were not familiar with its content. One year after the implementation, all stated that they were rather or well informed about its content (P€ oder et al. 2011).

Sample Every third EHR from 2008–2009 was selected for review, until the health records of 60 patients pre- (n1) and 60 patients postimplementation (n2) of the EB-SCP had been accessed. All patients had been cared for at a stroke care unit during the acute phase. There were no differences in characteristics between the respective samples in age, sex, diagnosis and days in hospital; see Table 1.

tions described in the EB-SCP for care of patients with stroke during the first three days in hospital. Variables were reviewed for presence of documentation in the EHR, together with structured response alternatives for frequency and, when applicable, length of time from arrival on the hospital ward to control and/or length of time between respective controls (repeated monitoring, e.g. x2 or x6 depending on the guideline for the respective observations), place of registration/s in the record and presence of evaluation notes. For each variable reviewed, there was space for comments in the checklist. The following variables, which should be monitored during the first 24 hours according to the guidelines described in the EB-SCB, were: Reaction Level Scale (RLS-85; Stage 1, 2, 3 and ≥4 used here: fully conscious, drowsy/disoriented, very drowsy, unconscious) and National Institutes of Health Stroke Scale (NIHSS; stroke severity – here used to assess motor strength in arms and legs; RLS-85 and NIHSS are hereafter called neurological functioning) (Starmark et al. 1988, Lyden et al. 1994), blood pressure (BP), pulse, oxygen saturation (SaO2), body temperature and blood glucose. Documented micturition ability (the postvoid residual urine test with a bladder scan) was reviewed, and the following observations, which should be performed as soon as possible/within three days, were made: swallowing capacity, mobilisation ability, and speech and communication ability as well as functioning (ability to function in daily activity) and aid needs, the latter two as assessed by OTs and PTs. For expected frequency and time for monitoring of patient status, see Table 2. The authors discussed the content of the checklist before and during the review, and it was considered easy to use by the reviewers during the EHR reviews.

Data collection and procedure A structured, study-specific checklist was used for EHR review. The checklist was tailored to measure the observaTable 1 Sample characteristics pre- (n1 = 60) and postimplementation (n2 = 60) of the evidence-based standardised care plan

Sex, female Age Diagnosis, cerebral infarction* Hospital stay, days at stroke unit

n1 n2 n1 n2 n1 n2 n1 n2

n

%

29 24

48 40

59 57

M, SD

Min–max

756, 123 756, 138

43–96 36–100

98 95

Comparisons were made using nonparametric statistics, Mann–Whitney U-test for variables on an ordinal scale (six levels, z-value reported) and Chi-square test for dichotomous variables (v2-value reported). The p-value for Fisher’s exact test was considered if the cells had an expected count of 005); *p ≤ 005, **p ≤ 001, ***p ≤ 0001. † Reaction Level Scale (RLS-85; consciousness) and National Institutes of Health Stroke Scale (NIHSS; stroke severity – here used to assess motor strength). ‡ z-Value = Mann–Whitney test, ordinal scale, v2 = Chi-square test or Fisher’s exact test, dichotomous, i.e. adherence or nonadherence to guidelines. Md = Median; IQR = Interquartile range.

n n n n

Recommended frequency of monitoring

Frequency Day 1

Adherence to recommended frequency of monitoring vs. less monitoring or not at all

NA NA

Standardised care plans for in hospital stroke care improve documentation of health care assessments.

To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional...
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