Standardised Stroke Care for Better Outcomes

Stroke is a leading cause of morbidity and mortality worldwide, with outcomes strongly dependent on early and consistent patient care (Langhorne et al. 2020). Evidence supports the role of standardised nursing assessments and multidisciplinary coordination during the acute phase, particularly within the first 72 hours, to reduce complications, mortality, improve functional recovery and outcomes (Langhorne et al. 2020). Despite established guidelines, variability in stroke care expertise and variability in documentation remain barriers to the consistent delivery of evidence-based stroke care.

Prior to the implementation of the 72-hour Stroke Patient Care Record, delivering consistent, standardised stroke care within the RAMS and EAMU (Rapid assessment medical service/Early Assessment medical unit of The Prince Charles Hospital) was challenging due to varying levels of stroke nursing expertise and documentation practices.

A pre-implementation audit identified several gaps in documentation, making it difficult to ascertain whether key nursing stroke care interventions were delivered.

Led by two clinical nurses working in the unit, the 72-hour Stroke Patient Care Record was developed in alignment with Australian and New Zealand Living Clinical Guidelines for Stroke Management (Stroke Foundation, 2023). The 72-hour Stroke Patient Care Record provides staff caring for a stroke patient in the first 72 hours with a guideline outlining key stroke interventions. Included within this care plan are the following: type of stroke and blood pressure management appropriate to both; cardiac monitoring; neurological observation frequency; management of delirium or new confusion; monitoring of fever, swallow, and sugar; nutrition management; continence management; and referral to multidisciplinary teams.

After the trial period and evaluation of the 72-hour Stroke Patient Care Record, the core question addressed was:

How can stroke care be standardised within the first 72 hours to ensure that all patients receive timely evidence-based interventions, even when cared for by staff with varying levels of expertise in stroke care?

For the project to succeed, a review of hospital stroke care policies and procedures and national stroke clinical guidelines was necessary to ensure all key interventions in the first 72 hours of stroke care are included. A meeting with key stakeholders (as mentioned above) was also necessary to seek the expertise and input of medical staff and the multidisciplinary team in ensuring holistic stroke care is provided.

Critical to the project's success is strong engagement from the nursing team, especially during the introduction and implementation of a practice change.

Key lessons from the trial period rollout include the following:

• Allocating dedicated time to provide in-service to staff regarding stroke care was beneficial to increase compliance. The 72-hour Stroke Patient Care Record also serves as an educational tool for junior staff on stroke care.
• Using the care plan on patients who are being investigated for stroke, rather than having a confirmed stroke diagnosis, is challenging because there are areas of the care plan that are not applicable.

While it's a nursing care plan, engagement from medical officers is also beneficial to its success. For example, staff feedback highlighted uncertainty about determining the type of stroke, whether the patient needs daily ECG monitoring, or tracking investigations ordered or completed.

Limitations of the project

First, the post-implementation audit sample was small and limited to a single clinical unit. While improvements in compliance with key stroke care elements were observed, the small sample size limits the ability to detect statistically significant changes or draw causal inferences between the implementation of the 72-hour Stroke Care Plan and patient outcomes. We recommend this initiative to be trialled in other similar units to prove generalisability.

Second, the evaluation relied primarily on documentation audit and staff self-reported feedback. Although documentation completeness is a recognised proxy for care delivery, it may not fully capture all aspects of clinical practice, and improvements in documentation do not necessarily equate to improvements in care quality. Similarly, staff survey responses may be subject to response bias, with participants potentially more engaged or supportive of the care plan than non-respondents.

Despite these limitations, this QIA provides valuable insights into the feasibility, acceptability, and early impact of a structured 72-hour Stroke Care Plan in supporting evidence-based acute stroke care. The findings highlight areas for refinement and inform future cycles of improvement, re-audit, and potential expansion across other clinical areas.

We can see this project succeeding in all hospitals providing acute stroke care. We also foresee this 72-hour stroke care plan beneficial in other wards within The Prince Charles Hospital who may need to deliver stroke care under special or unforeseen circumstances.

While the main purpose of standardising stroke care within the first 72 hours has been achieved, this care plan may be further refined to include the patient journey from initial admission to discharge. We hope to further develop it into a booklet that may be used inter-ward and even inter-hospital.