Abstract 18: Does Quality Improvement Training Add to Audit and Feedback for Inpatient Stroke Care Processes?

Background: Despite advances in stroke care, many patients do not receive recommended care processes. Quality indicator (QI) reporting programs, like GWTG-Stroke, have been shown to improve care. We sought to determine whether training plus QI feedback was more effective than QI feedback alone in improving two stroke QIs.

Methods: We conducted a cluster randomized trial in 11 VA hospitals. Sites were randomized to a quality improvement training program plus QI feedback vs. QI feedback alone to improve DVT prophylaxis and dysphagia screening. Intervention sites received face-to-face training, developed individualized improvement plans, and had 6 months of post-training facilitation. Both groups received monthly QI feedback. Eligibility and passing for the two stroke QIs, plus nine other stroke QIs, was determined by centralized chart review. We compared pre-intervention (pre-I) to post-intervention (post-I) performance on the two stroke QIs and on defect-free care (DF, a binary patient-level variable including all QIs) in intervention vs. control sites. We constructed logistic models of the two QIs and DF care, adjusting for patient variables, time, intervention group, and time-group interaction.

Results: The five intervention sites had 1147 admissions and the six control sites had 1017 admissions during the study period. DVT prophylaxis was similar pre-I (85% vs. 90%) and improved in both groups (post-I rates 90% intervention and 94% control, ratio of ORs 0.89, p = 0.75). Dysphagia screening was higher pre-I in intervention sites (51% vs. 37%), and improved more in the control sites (post-I 56% and 52%, ratio of ORs 0.67, p=0.04). In logistic models, DVT, Dysphagia, and DF performance were associated with baseline performance and post-I time. Dysphagia performance was also associated with NIHSS and time-group interaction, and DF care was also associated with the presence of a baseline data collection program.

Conclusion: Quality improvement training did not add to the impact of data feedback in sites already motivated to participate in QI initiatives. Defect-free stroke care is associated with an ongoing stroke data collection program, emphasizing the importance of audit and feedback to achieve the highest quality stroke care.

Abstract 90: Nursing Education: A Critical Need in the Delivery of High Quality Stroke Care

Objectives: High quality stroke care is complex, and requires strong multidisciplinary teams, including nurses, to ensure care processes are timely and appropriate. The purpose of this study was to identify training needs of nurses who deliver care to patients who present with acute stroke and are admitted to inpatient units.

Methodology: Using semi-structured interviews, we conducted a qualitative study for a formative evaluation in 12 Department of Veterans Affairs Medical Centers (VAMCs) that had ≥ 50 acute ischemic stroke admissions a year and were diverse in the structure of stroke care. The interviews focused on current context and structure of stroke care, including educational practices and training needs. Secondary analyses were conducted, targeting frontline nurse and physician respondents (N = 113) in emergency, acute care and rehabilitation units.

Results: Respondents across the sites reported insufficient nurse education and training for acute stroke care as an overarching theme. Moreover, themes related to the acute stroke care quality indicators emerged as areas of competencies that nurses needed training on a continuum: a) timely recognition of acute stroke and transient ischemic attacks, b) NIH Stroke Scale and neurological exams, c) dysphagia screening, d) administration of tissue plasminogen activator and management post treatment, and e) deep vein thrombosis prophylaxis. Themes that were related to structure of stroke care and/or context also emerged and attributed to training challenges across the sites, listed in order of prevalence: a) centralized care versus decentralized care, b) low volume of acute strokes, c) nurse engagement, d) structured acute stroke care education, and e) release time.

Conclusions: VA stroke care providers identify educational needs around specific stroke quality indicators, but also describe key barriers including lower volume, time for training and engagement of nursing staff in acute stroke care. Future programs to improve VA stroke care need to address these barriers to optimally support high quality multidisciplinary stroke care.