Abstract NS5: Utilization Of A Post-Neuro Interventional Radiology Procedure Handoff Smartphrase Leads To Improved Completion Rates Of Mandatory Nursing Monitoring And Documentation

Background: In 2009, The Joint Commission (TJC) mandated hospitals to establish handoff communication measures in preventing sentinel events. Comprehensive Stroke Centers in the U.S. have similar mandates. Additionally, one of the top ten TJC CSC survey finding is missed assessment and documentation, particularly on post-neuro interventional radiology (NIR)procedures. Achieving 100% compliance is challenging due to the intricacy of NIR workflow and gaps in the handoff communication process between NIR and PACU or ICU. Purpose: To determine if the utilization of a post-NIR handoff smartphrase, the PAMM, can improve the completion of post-NIR procedure documentation and help achieve the TJC standard. Methods: The stroke team, NIR stroke champion and nursing informaticist developed the PAMM smartphrase. The acronym stands for procedure, assessment, medication, and monitoring- encompassing all compulsory post-NIR monitoring parameters. Education and training commenced in May 2021. The project was implemented in June 2021. NIR nurses were added to the PAMM smartphrase in the Epic system and provided a one-pager jobaid. July to December2021 data were analyzed using Microsoft Excel and reported bi-monthly to the Stroke Committee. Results: There were 172 records reviewed. Of that, 129 used the PAMM smartphrase. 81%(105) had 100% documentation completed. Of the 43 cases that did not use the PAMM, only67% (29) of the cases had 100% documentation completed. The remaining 33% (14 cases) had missed assessments, from a missing pulse check to a missed puncture site check. The data showed the PAMM smartphrase utilization was correlated with a higher documentation completion rate versus the non-utilization of the PAMM [81% (105) vs 67% (29)]. Conclusion: Utilization of the PAMM post-NIR procedure standardized handoff smartphrase resolved handoff communication gaps, improved the monitoring and documentation completion rates, and helped achieve TJC standard compliance.