Date of Graduation

Summer 8-8-2024

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Carla S. Martin, DNP, RN, CIC, CNL, NEA-BC, FACHE

Second Advisor

Cathy Coleman

Abstract

Abstract

Problem: The COVID-19 pandemic precipitated a significant departure from the nursing profession, leaving healthcare organizations grappling with critical staffing shortages and compromising patient care standards. In 2023, an advanced Primary Stroke Center in a Northern California hospital’s STK-8 scores fluctuated between 80-100%, with an average annual score of 92.8%, putting the facility's primary stroke certification and long-term patient outcomes at risk.

Context: A 24-bed acute stroke and telemetry unit in a Northern California hospital and designated primary stroke center.

Interventions: The following measures were implemented to improve the quality of stroke care and enhance STK-8 compliance, including dot “smart” phrases created within the electronic medical record (EMR) to aid clinical staff with consistent and complete stroke education documentation, staff re-education, and implementation of standardized protocols to foster interdisciplinary collaboration among stroke-certified nurses, physicians, and unit leaders.

Measures: Documentation compliance of at least 95% or greater for stroke measure STK-8 during the implementation period from January 2024 through April 2024.

Results: 100% compliance with the STK-8 measure in the last two months of the four-month intervention period. This success is a promising sign, but it's important to note that more long-term data is needed to ensure ongoing compliance with STK-8 documentation.

Conclusion: The initiative effectively standardized stroke education practices among healthcare providers, enhancing their understanding and application of essential components of stroke education measures.

Keywords: TJC stroke measures, STK-8, stroke education, stroke documentation, primary stroke center, smart phrase

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