Improving neurological examination on admission to the Stroke Rehabilitation Unit

Background

Since introducing electronic notes to Stroke Rehabilitation Unit (SRU), neurological examinations on admissions have been poorly documented and inconsistent. Documenting a good quality neurological examination is useful for rehabilitation as it allows monitoring of function recovery. It is also crucial for patient safety to differentiate new and old symptoms in case of deterioration like further stroke events. The main issues as of January 2023 was admission documentation rarely contained all components of the neurological examination (power, sensation, tone, reflexes, coordination, cranial nerves). Additionally muscle power was not routinely quantified using the gold-standard MRC scale of power1 to assess individual muscle groups. Finally there was an overall lack of consistency between clinicians despite National Clinical Guidance for Stroke2 stating the need for “common, agreed terminology and set of data collection measures, assessments and documentation”

Root Cause Analysis

Results and PDSA cycle timeline

Aim

• Introduce an online clerking proforma with a particular focus on neurological examination. It should help clinicians perform a structured and standardised neuro exam and upload detailed documentation of it on electronic patient records. This proforma should be comprehensive and accessible and needs to be completed within 24h of admission to SRU

• Spread awareness regarding the importance of including as many components as possible of a full neurological examination, and encourage the documentation of MRC scale of power grading to quantify power in individual muscle groups. A standard for power documentation was set: power should be documented when using the proforma, using the MRC scale for at least 3 separate muscle groups per limb

PDSA Cycles

Method

The proforma was designed based on the previously-used paper proforma for admission clerking. It was then printed off and trialled by a clinician for an admission. Gaps in knowledge and poor confidence in neurological examination appeared to be a barrier to filling out the proforma correctly. Over the next 2 weeks, 4 clinicians admitted 7 patients using the proforma. Each clinician was contacted to feedback on their user experience, further improving the content and wording. The proforma was then added to the electronic records system. This was paired with neurological examination teaching for all clinical staff to improve skills, knowledge and confidence in using the proforma. Two sessions were offered, on cranial nerves and limb exam. These were interactive, practical teaching sessions repeated weekly.

Proforma sample

Discussion

References 1) Compston A. By Michael O'Brien for the Guarantors of Brain. Saunders Elsevier; 2010. Aids to the investigation of peripheral nerve

The biggest success of the interventions is the outstanding levels of compliance with the proforma (Figure 3). A contributing factors of this success was likely the regular departmental meetings as well as using the teaching sessions to reiterate the importance of using the proforma. The SRU clinical team is relatively small which made it easier to reach out to staff and address personal concerns. The teaching sessions were well received. They were repeated weekly to boost attendance, and 80% of targeted staff attended these sessions. While the “confidence scores” suggest a positive outcome (Figure 4), this is quite subjective. The positive impact may be more meaningfully assessed on re-evaluation in October 2023. Results from February-April 2023 suggest a positive effect on documenting muscle power (Figure 1), but the effect on including all key parts of the neurological examination are minimal or unclear as of yet (Figure 2). This study looks at clerking documentation rather than assessment quality, and addressing knowledge gaps is as important as convincing staff to document their findings. Time constraints might encourage a focus on positive findings. Further work could stress the importance of documenting each neurological examination component and reinforce skills required for ‘difficult’ components like reflexes or cranial nerves.

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