Implementation of Stroke Protocols in the Pediatric Practice Setting

Abstract

Background: A large amount of work and research has been completed by many teams to show the impact of stroke along with the increased incidence of stroke diagnosis within the pediatric population. There is a critical need for guidelines and established protocols to support standardized care delivery expectations within the pediatric population. A process improvement project aimed at early diagnosis of stroke, rapid testing indications, and well-defined treatment regimens was the focus for a pediatric setting that had no established standardized practice to care for the pediatric stroke patient. Methods: The project work took place in a 260-bed acute care pediatric hospital and the practice setting was the Emergency Department. The patient population focused on included newborn to 21 years of age and further defined by the patient encounters in which initial assessment focused on altered mental status, changes in behavior, sluggishness, slurred speech, delayed response times, seizure, and changes in personality. Through the incorporation of a step-by-step protocol guided by policy allowed for early recognition, rapid testing to aid in diagnosis, neurology consultation, and implementation of treatment plan applicable to diagnosis. A systematic review and extensive literature review were completed along with a randomized control trial conducted. Data collection occurred through a pre- and post- education survey, summative survey, and review of emergency department patient encounters data. Results: Stroke is a major cause of morbidity and mortality in children. Centers that focus on streamlining protocols inclusive of imaging minimize diagnosis delays, enhance recognition, and have led to fostering improved patient outcomes. Prior to the implementation of pediatric stroke protocols the organization encountered 60-80 patients a year (2015-2019) diagnosed with pediatric stroke. Of these identified patients, 100% were transferred out to a higher level-of-care facility. Over the course of 2020, timing related to radiological testing was greater than 2 hours with neurology consults occurring only 25% of the time. With the implementation of pediatric stroke protocols in 2021, over the course of just 3 months (April-June), the timing of assessment, provider consult, and radiological testing in now completed under 2 hours. The average response time for the Emergency Department provider is 7 minutes. The average radiological test is now 60 minutes and the pediatric intensivists response time is under 30 minutes. From April 2021 to June 2021, there were a total of 9 patient encounters in the emergency department with a diagnosis of stroke. Of these patients, 50% were transferred to a higher level-of-care facility and 50% were admitted and treated within the practice setting. Prior to education amongst clinicians, 37% of surveyed staff were unfamiliar with standardized stroke care and recognition of stroke in the pediatric patient. Following focused education along with implementation of pediatric stroke protocols, 100% of surveyed staff are now confident in distinguishing stroke and in managing care. Conclusions: Implementing pediatric stroke protocols has led to improved safety, efficiency, quality, and decreased disparity. The protocols built and implemented have allowed for standardized practice amongst the providers and clinicians. Additionally, the close collaboration and communication with the entire multidisciplinary team throughout the course of the project has led to sustained practice and enhanced relationships based on trust and respect. Ongoing education is indicated and has been incorporated into staff onboarding and training. The ability to recognize stroke in pediatrics is life saving and life changing.

Description

Keywords

Stroke, Protocols, Pediatrics

Citation

DOI