Use of admission order sets to improve adherence to evidence-based performance measures for acute stroke care: Results from the Massachusetts Paul Coverdell National Acute Stroke Registry

Introduction:

The use of pathways and standing orders has been proven to standardize and improve patient care 1-2. These admission tools serve to remind clinicians of evidence-based guidelines for the care of particular conditions and improve the quality and clarity of documentation. This cross-sectional analysis examines the use of admission orders with hospital adherence to evidence-based performance measures for acute stroke in-patient care including: dysphagia screening, deep vein thrombosis (DVT) prophylaxis, and antithrombotics use by end of hospital day two. Data from 55 Massachusetts hospitals participating in the Paul Coverdell National Acute Stroke Registry (PCNASR), co-funded by the Centers for Disease Control and Prevention (CDC), were reviewed. Participating hospitals have state Primary Stroke Service designation which requires stroke written care protocols. Individualized feedback on submitted admission orders and samples of reviewed admission orders were provided. Findings compare adherence to the three measures listed above among hospitals when admission orders were used versus not used.

Findings:

This cross-sectional analysis reviewed over 18,000 cases from the 55 participating hospitals, entered between June 2005 and July 2007. While 100% of hospitals reported using admission orders, orders sets were used in only 40.2% of the cases (n=7,245) overall. The rate of use varied among the hospitals from .68% to 100%. There was a strong and statistically significant correlation between the use of order sets and adherence to the three performance measures. Odds ratios were 2.66 for dysphagia (95% CI 2.46-2.88; p-value < .0001); 3.47 for DVT prophylaxis (95% CI 3.02-3.99; p-value <.0001); and 1.74 for antithrombotics use by end of day two (95% CI 1.42 -2.13; p-value <.0001).

Conclusions:

The use of stroke admission order sets among hospitals increased the odds of guideline-based care reflected by improved adherence to performance measures. Admission order sets were used in less than half of the cases thus highlighting room for improvement. In light of the findings, efforts must be made to identify barriers to admission order use and strategies developed to address them. Ensuring that stroke order sets are used for all stroke patients is a systems change that should result in permanent improvement for acute stroke care.

References:

1California Acute Stroke Pilot Registry (CASPR) Investigators. The impact of standardized stroke orders on adherence to best practices. Neurology. 2005;65:360-365.

2 Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. British Medical Journal. 1998;316:133-137.