Improving Stroke Care for Indigenous Patients

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Improving Stroke Care for Indigenous Patients

Introduction

Researchers have raised concerns over the prevalence of stroke in Indigenous populations across the globe. Existing literature indicates a 14-fold prevalence of stroke in the Aboriginal population in 2019-2020 (Nedkoff et al., 2020). Even when scholars have recommended evidence-based therapies in emergency departments, incidents of preventable mortality rates are still higher in Aboriginal and Torres Strait Islander patients are still higher compared to non-Indigenous populations (Blacker & Armstrong, 2019). Research has identified the higher prevalence of stroke in the Indigenous population as the leading cause and recommended improved service delivery in emergency departments (McInnes et al., 2020). The identified case scenario at XYZ is just but a fraction of what Aboriginal patients are facing in the country. Hospitals are available but inaccessible, and for those that are accessible, the services in EDs are slow to the extent that they are not serving the purposes they are supposed to serve. This proposal seeks to address the service delivery at XYZ Hospital with the knowledge that the recommended strategies will have significant positive outcomes on the quality of life of Aboriginal patients and physicians in the hospital. The proposal recommends a change in protocol regarding service delivery in the ED and changes in discharge and follow-up care as a strategy for improving patient safety and satisfaction.

Main body

The scope of the problem in the XYZ hospital as well as its impact on the Aboriginal health and quality of life cannot be underscored. Stroke is among the leading causes of death in the Aboriginal population, with significant variations compared to non-Indigenous populations. The Australian government has been striving to reduce the inequality gap between the Aboriginal and non-Indigenous populations, but significant systematic barriers are undermining the efforts. XYZ Hospital faces significant challenges in the ED that undermine the quality of care and service delivery that could alleviate the problem of delayed service delivery, evidence of delayed transfer of Aboriginal patients from the regional hospital, delayed services for Aboriginal patients presenting to the ED, and poor outcomes for Aboriginal patients. A report by the Health Safety Investigation Branch (n.d.) indicated what happens when emergency services fail to admit stroke patients due to the closure of services or due to an out-of-hours schedule. Educating the service providers will alleviate this problem. Delays in discharge have also contributed to crowding of the hospital, leading to a shortage of beds in the Acute Stoke Unit. There is also a problem with the process of care where patients wait for more than 48 hours before getting the necessary attention. Other problems include delays in assessments, incomplete and inconsistent documentation, lack of palliative care units for stroke patients, and failure to identify patients requiring palliative care and those that do not require palliative care. The hospital environment is not ready to provide emergency services for acute stroke patients.

Desired Changes or Improvements and why they are required

Based on the case scenario and evidence presented in the case-mix, process of care, and shortage of the process, it is evident that there is a need for improving service delivery while also addressing the healthcare concerns and challenges faced by Aboriginals in XYZ Hospital. A growing body of research and literature has indicated that emergency departments are the first point of contact for patients suffering from acute stroke (Philip-Ephraim, 2018). In a study carried out by Lip et al. (2022), the authors found that improvement in emergency services for stroke patients such as lowering of temperature and immediate evaluation of airways in the emergency department improves the outcomes in stroke patients. The ED at the XYZ hospital is at the lowest level, considering that stroke patients are attended to after >48 hours of arrival. This process is slow and does not meet the standard protocol of less than 24 hours of immediate attention. The delayed time increases additional injuries to the patient and lowers the survival rate as explained by Bernaitis et al. (2019). An improvement in the ED will make sure that patients presenting to the ED with acute stroke get immediate and sufficient care while also reducing the possibility of adverse outcomes such as death. It will also improve the aspect of patient safety as explained by Vincent (2010). The goal of patient safety is to reduce harm and prevent adverse risks that could cause injury to the patient during the process of care.

The second intervention entails reducing the time of moving patients from the regional hospital, as this interferes with the urgency of care and service delivery. If there is a need for transferring the patients, they should be accompanied by a qualified physician who has the welfare of Aboriginal patients at heart. There should also be a specific acute unit section equipped with a sufficient number of Aboriginal physicians, including in the ED (Heikkila et al., 2019). The goal of having a sufficient number of Aboriginal physicians is that they understand the scope of the problem and its impact on Aboriginal health. As a result, they will be well-positioned to deliver patient-centered care that resonates with the needs and preferences of Aboriginal patients. The reduction in movement can also be accounted for by the presence of an ED unit, with an emphasis on addressing delays and making sure that the amount of time spent in processing and admitting patients in the ED is less than an hour.

Inconsistencies and incomplete documentation of patient data have a direct impact on the quality of care and create room for medication errors. The presence of this problem at XYZ Hospital means that there are issues with patient safety that need to be addressed. In this regard, there is a need for continuous monitoring of service delivery, including documentation and evaluation of patient data and records to make sure that nurses capture and document the correct documentation that reflects the type and specific need of the patient. A process-based approach will yield positive outcomes as explained by McInnes et al. (2020). The management team at the top should undergo formal training on patient safety and pass the knowledge of accountability and responsibility to physicians and nurses to avoid incomplete and inconsistent documentation. Addressing inconsistencies and incomplete documentation will make sure that physicians are dealing with the correct type of patient and are treating the specific disease without creating room for medication errors in the hospital.

The final area of concern is in the discharge and follow-up of patients to avoid crowding in the hospital and the eventual shortage of hospital beds. All patients should be discharged within five to seven days (Powers et al., 2019). During this team, a multidisciplinary team should be working to evaluate the impact of stroke on the patient while also making sure that there is a sufficient plan for rehabilitation. The team at the XYZ Hospital should stick to this plan and make sure that no patient stays more than the stipulated period. There should be also phone follow-up for all discharged patients to make sure that they stay connected and their welfare is catered for. This will create therapeutic relationships and improve the utilization of ED and other mainstream hospital services by the Aboriginal and Torres Strait Islander communities who have been marginalized for years.

Options for Actions

Vincent (2010, p. 131) cited the incident of the Paddington Rail Accident of 1999. In this accident, 31 people died when a train went through red lights and collided head-on with an express approaching the station. Investigators found that there was laxity in training and persistent failure to examine poor signals, including poor communication between the departments. This example applies to the case scenario at XYZ Hospital. Cases of inconsistent and incomplete documentation can be attributed to poor training on patient safety and patient-centered care. McClelland et al. (2022) discussed the impact of emergency interventions on stroke patients and emphasized the need for improvement of time as a determinant factor for positive outcomes. The option of training physicians and nurses on accurate and consistent documentation will help alleviate the negative consequences while making sure that every patient receives the required attention in the hospital.

The second option entails improving the quality of service at the hospital by reducing the door-to-needle time (DNT). Hasnain et al. (2019) defined DNT as the time that elapses from the presentation of the patient at the ED to the start of intravenous thrombosis in ischemic stroke. Low DNT increases the number of patients attended to while also making sure that there is an improvement in quality of life. This intervention will be implemented by following the Plan, Do, Study/Check, Act (PDSA/ PDCA) as a loop for evaluating quality improvement at the hospital. This is the option that will be used to address the problem of low and poor service delivery at XYZ Hospital.

A growing literature has pointed out the importance of using PDSA as a tool for testing and improving quality in the change process. While the PDSA model is not specific to any discipline, Vincent (2010) explained that the model is effective when utilized by frontline teams in measuring and evaluating rapid small-scale changes before employing the desired change to the entire organization. Previous studies such as Kishore et al. (2020) and Herpich and Rincon (2020) have already tested the model and found it to be effective in the management of Ischemic stroke. The next section provides a comprehensive explanation of how the strategy will be used.

PDCA/PDSA for Improving Care in the Emergency Department

PDSA model is effective in quality improvement in organizations. According to Vincent (2010), the model breaks down the process into specific steps or improvement stages while creating room for the team to evaluate how each section can be improved. The choice of this approach for XYZ Hospital is to make sure that every aspect of quality improvement is addressed. While every area of the XYZ hospital is affected by the low and poor quality of services, the PDSA cycle will begin with addressing emergency medical services in the ED. The choice of ED as a point of concern is that it is the first point of contact in the hospital for patients suffering from Ischemic stroke as explained by McClelland et al. (2022). The intervention will be divided into two places at the hospital; PDSA at the ED and the discharge units to avoid a shortage of beds.

Plan

The initial intervention at the ED will entail process mapping at the ED and the discharge point to determine the logistics behind the delayed service delivery. The mapping process will guide the team in identifying what is holding the organization back and be able to come up with a strategy for overcoming the obstacles. This process will help the quality improvement team to identify the root cause of delays at the ED and the discharge unit and set goals for addressing the problem. A DNT of 60 minutes per patient will be set both at the ED and at the discharge point.

Do

The staff in the ED and the discharge team will be trained and expected to adhere to less than a minute service delivery within these areas. During the training, the staff will be taught the importance of providing patient-centered care and giving maximum attention to the Aboriginal users of the ED services due to the higher prevalence of stroke in this population. They will also learn the importance of providing fast services and the use of CT scans within the ED unit to avoid delays. The successful completion of each service will be noted. The first intervention will target serving at least 20 stroke patients. Additionally, there will be the presence of a specialized clinical nurse officer in each department to communicate with patients to make sure that their needs are understood. This will be an Aboriginal healthcare professional who has an understanding of the impact of stroke on the Aboriginal population.

Check/Study

The researcher will continuously check, record, and monitor the progress in speed, service delivery, and quality of work in both the ED and the discharge unit to determine the impact on the number of patients served and the impact on service delivery. There will also be documentation of the challenges encountered in every department for discussion and proper implementation once the pilot study has been completed. This will help the research team to identify areas of weakness and concerns that could undermine the success of change and its management in the future. The team will be able to make a successful implementation of the plan. The team will review the time used, the efficacy of the service, the impact on service delivery, and the number of patients served. The DTN time used in the pilot and final study will be compared and adjusted until the research team is satisfied that it is less than sixty minutes.

Act

The researcher will review the DTN and the total number of patients served until the weekend. The researcher will also check the impact of the intervention on the number of hospital beds available during the first week. There will be further training on the impact and rewards to the team for having made an impact. There will also be a questionnaire to determine the level of satisfaction, of both the healthcare team and the patients served. A follow-up call will be conducted with the patients family after every two days to check the progress of the patient. This information will be used to improve the service and make that change become part of the organizations culture. Since PDSA is a cycle, the program will go back to the start again and run for six months.

Conclusion

The proposed change is expected to reduce door-to-needle time, increase service delivery, reduce work overload, and reduce the number of patients in the ED. Through this intervention, it is anticipated that there will be a positive impact on the lives of Aboriginal patients as well as an impact on the efficiency of XYZ Hospital in addressing the needs of Aboriginal patients. The program will be continuously evaluated to determine the impact and address any limitations that could prevent it from achieving its intended purpose.

References

Bernaitis, N., Anoopkumar-Dukie, S., Bills, S., & Crilly, J. (2019). Evaluation of adult stroke presentations at an Emergency Department in Queensland Australia. International Emergency Nursing, 44, 25-29. Web.

Blacker, D., & Armstrong, E. (2019). Indigenous stroke care: differences, challenges and a need for change. Internal Medicine Journal, 2(3). Web.

Health Safety Investigation Branch (n.d.). The report examines safety risks to stroke patients when transferred between trusts for emergency care. Web.

Heikkila, I., Kuusisto, H., Holmberg, M., & Palomaki, A. (2019). Fast protocol for treating acute ischemic stroke by emergency physicians. Annals of Emergency Medicine, 73(2), 105-112. Web.

Herpich, F., & Rincon, F. (2020). Management of acute ischemic stroke. Critical Care Medicine, 48(11), 1654. Web.

Herpich, F., & Rincon, F. (2020). Management of acute ischemic stroke. Critical Care Medicine, 48(11).

Kishore, A. K., Fletcher, S., Mason, D., Ashton, C., Molloy, J., & Fitchet, A. (2020). Quality Improvement in Atrial Fibrillation detection after ischaemic stroke (QUIT-AF). Clinical Medicine, 20(5), 480. Web.

Lip, G. Y., Lane, D. A., Lenarczyk, R., Boriani, G., Doehner, W., Benjamin, L. A.,& & Potpara, T. (2022). Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke. European Heart Journal, 43(26), 2442-2460. Web.

McClelland, G., Hepburn, S., Finch, T., & Price, C. I. (2022). How do interventions to improve the efficiency of acute stroke care affect prehospital times? A systematic review and narrative synthesis. BMC Emergency Medicine, 22(1), 1-9.

McInnes, E., Dale, S., Craig, L., Phillips, R., Fasugba, O., Schadewaldt, V.,& & Middleton, S. (2020). Process evaluation of an implementation trial to improve the triage, treatment, and transfer of stroke patients in emergency departments (T3 trial): a qualitative study. Implementation Science, 15(1), 1-13.

Nedkoff, L., Kelty, E. A., Hung, J., Thompson, S. C., & Katzenellenbogen, J. M. (2020). Differences in stroke risk and cardiovascular mortality for Aboriginal and other Australian patients with atrial fibrillation. Medical Journal of Australia, 212(5), 215-221.

Vincent, C. (2010). Patient safety. Wiley. Web.

Philip-Ephraim, E. (2018). Emergency management of acute ischaemic stroke. In Essentials of Accident and Emergency Medicine.

Powers, W. J., Rubinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K.,& & American Heart Association Stroke Council. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50(12). Web.

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