Abstract Body: Background: The 2023 American Heart Association/American Stroke Association’s Guideline for Management of Patients with Aneurysmal Subarachnoid Hemorrhage (SAH) support use of the Ottawa Rule to screen individuals at risk. Data showed SAH patients who presented to the Emergency Department (ED) with headache (HA) and hypertension frequently had long wait times before evaluation by a provider. The ED lacked a formal triage process for identification of SAH resulting in delayed treatment. This gap could lead to suboptimal patient outcomes.
Purpose: The goal of this project is to create a nurse-led screening tool for identifying patients at risk for SAH and aid in the decision for computed tomography (CT). Earlier identification, along with order set initiation, supports best practice.
Method: Patients presenting with nontraumatic HA are assessed by an ED RN to determine if HA reached maximum intensity within one hour of initial onset. If criterion is met, a best practice alert (BPA) triggers within the electronic medical record. The Ottawa Rule displays in the BPA to provide guidelines to determine next steps. If the patient age is 40 or older, or meets criteria of the Ottawa Rule, the ED RN initiates a stat head CT per protocol. Patients with identified SAH are immediately roomed and seen by an ED physician, who consults the stroke team. Guideline-based cares, including blood pressure management are initiated.
Results: Use of the Ottawa Rule screening tool on patient arrival to the ED leads to earlier identification of patients with SAH, reduction of door to seen by provider time and door to diagnostic times, plus allows for expediated initiation of blood pressure management. A total of nine direct arriving patients were reviewed over a one-year period. The six patients treated before the practice change had a median door to CT of 90 minutes and a median door to stroke provider time of 134 minutes. Following implementation, the door to stroke provider median time was 33 minutes and door to provider time decreased to 52 minutes. This reflects a decrease of 63% of median arrival time to CT and a 61% decrease of median arrival time to stroke provider. Since implementation, 100% of patients with SAH were immediately identified and treatment initiated.
Conclusion: Nurse driven screening tool utilizing the Ottawa Rule expedited care for ED patients diagnosed with SAH. Faster time to diagnosis allows for targeted BP management and adherence to standard of care.