Letter: A Stroke Admissions Navigator Improves Adherence to Joint Commission Specifications for Hunt-Hess and Intracerebral Hemorrhage Scores.

To the Editor: Among the quality measures used for Comprehensive Stroke Center Certification by the Joint Commission is the proportion of patients presenting with an intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) for whom an initial ICH score or Hunt and Hess (HH) grade, respectively, is documented.1,2 While these measures may seem straightforward, there are challenges in consistently adhering to them. The responsibility to document often falls on house staff, who can come from various specialties and who frequently turnover. In addition, in the setting of the patient with acute ICH or SAH, the documentation of an initial ICH score or HH grade may be overlooked. Because these 2 clinical entities are among the most staple consults overseen by neurosurgery residents and pathologies managed by the neurosurgery service line, there exists a need for a streamlined solution that can improve adherence to the Joint Commission's metrics for documentation of initial ICH scores and HH grades. To improve adherence to these Joint Commission specifications, our institution, a Comprehensive Stroke Center in New England, created an in-house, customized stroke admissions navigator on our Epic Systems electronic health record. Admissions navigators are tools that can facilitate more streamlined intake of admitted patients. Among the features built into our in-house, customized stroke admissions navigator was a panel to document ICH score for patients with ICHs and a panel to document HH grade for patients with SAHs. Once inputted, these values autopopulate into an H&P note template, ensuring their accurate documentation. All neurosurgery and neurology residents at our institution were instructed on how to use the stroke admissions navigator in March of 2019, and the use of the navigator went live in April of 2019. For statistical analysis, percentage rates in documentation before and after the intervention were compared with χ2 tests. In addition, an interrupted time series analysis using an autoregressive integrated moving average linear spline model was performed to assess for changes in documentation percentage after the intervention while adjusting for temporal variations, including across the study period and within individual years.3 The nonparametric Conover two-sample ranked square tests were used to query changes in documentation variance before and after the intervention.4 The study population was composed of 621 total patients presenting for ICH or SAH from January 1, 2018, to December 31, 2021, including 155 patients with SAH (25.0%) and 466 patients with ICH (75.0%). After the implementation of the intervention, there was a significant increase in Comprehensive Stroke Center Certification–associated documentation for the overall study population (82.1% vs 63.9%, P < .001; Figure 1A). This increase was also independently observed for patients with SAH (89.2% vs 75.0%, P = .027; Figure 1B) and ICH patients with (79.1% vs 61.1%, P < .001; Figure 1C). In an autoregressive integrated moving average time series model adjusting for longitudinal and intrayear changes in documentation during the study timeline, the intervention was associated with a significant increase in documentation for all (+11.7%, P = .004) and patients with ICH (+12.4%, P = .001; Figure 1D-1F). While documentation rates for patients with SAH underwent an increase approaching significance (+20.2%, P = .090), the intervention was nevertheless associated with a significant decrease in month-by-month variance in documentation (SD = 15.9% vs 36.7%, P = .005; Figure 1E).FIGURE 1.: Improvement in adherence to Joint Commission specifications after implementation of stroke admissions navigator. Changes to adherence to Joint Commission specifications for documenting Hunt and Hess scale for patients with SAH and ICH scores for patients with ICH after implementation of a stroke admissions navigator. A-C, Monthly percentage rates of documentation of scores for overall A, patients with stroke, B, Hunt and Hess scale for SAH and C, ICH scores for ICH from January 2018 to December 2021. D-F, Box and whisker plots for documentation of scores for D, overall patients with stroke, E, Hunt and Hess scale for SAH, and F, ICH scores for ICH before (red) and after (blue) implementation of the navigator on April of 2019. ICH, intracerebral hemorrhage; SAH, subarachnoid hemorrhage.In summation, using an in-house, customized stroke navigator, our institution improved adherence to Joint Commission benchmarks for reporting of initial ICH score and HH grade. To the best of our knowledge, this is the first publication demonstrating improvement in key documentation in stroke care through the utilization of an admission navigator. Based on this work, institutions with Comprehensive Stroke Center status should consider the utilization of a similar stroke navigator to improve documentation of this and other key metrics. Moreover, the implications of this work are extensible beyond cerebrovascular and endovascular neurosurgery, as similar admissions navigators may improve documentation of metrics and scoring systems of value to other neurosurgical subspecialties and clinical entities.