Study: Emergency nurses have major knowledge gaps about stroke

Incorrect medication use increases hemorrhage risk

Do you know the recommended door-to-drug time for administration of tissue plasminogen activator (tPA) for ischemic stroke? Are you aware that the neurological status of a stroke patient should be monitored frequently for 24 hours after tPA is given? Do you know the recommended dosage of tPA?

When 20 ED nurses at two hospitals in the Mid-Atlantic region were asked these and other questions, half or more got the answer incorrect, says a recent study. Most of the ED nurses had not participated in continuing education on evidence-based ischemic stroke care within the previous 12 months.1

If you mix tPA incorrectly, you could give an overdose and increase your patient's risk of hemorrhaging, which is already at a 6.4% rate according to the National Institute of Neurological Disorders and Stroke trial, warns Susan E. Wilson, RN, MSN, C-ANP, adult nurse practitioner at the University of North Carolina in Chapel Hill's stroke center.2

"If you do not perform frequent vital sign and neurological checks, you may miss signs of hemorrhaging," adds Wilson.

Without conscientious, properly done assessments, a stroke patient can have an unnecessary poor outcome, says Ken Lanphear, RN, BSN, an ED nurse at Borgess Medical Center in Kalamazoo, MI. "All too often, changes in a neurological patient are small and, to a degree, insidious," he says. "Just a very little damage done in certain areas of the brain can have devastating outcomes for the patient."

To give stroke patients the best possible care, ED nurses must be given evidence-based education, says John P. Harper, MSN, RN, the study's author and clinical educator for the ED at Taylor Hospital in Ridley Park, PA. "There continues to be a research-practice gap in nursing. Although it was a small sample size, the findings do raise some concerns," says Harper.

Because Borgess is certified as a primary stroke center by The Joint Commission, all nurses on the stroke team must have eight hours of stroke education per year, says Lanphear. "We are very progressive in the care of all neurological patients, but especially in regard to the stroke patient. This is something that we as a staff take pride in," says Lanphear.

When the Joint Commission representatives came to review the stroke program at University of North Carolina in Chapel Hill, they traced a patient back to the ED, says Susan E. Wilson, RN, MSN, C-ANP, adult nurse practitioner at the hospital's stroke center. "They spoke to several nurses concerning triage, signs and symptoms, mixing and administration of tPA, and emergency care of the stroke patient," says Wilson.

To improve care of stroke patients, use these strategies in your ED:

• Alert nurses to clinical practice changes at staff meetings.

At Edward Hospital, ED nurses are given statistics on timeframes for tPA administration and CT scans at monthly staff meetings. "If there is new information to be given to the nurses for assessing or treating stroke patients, they are notified then," says Denise Arp, RN, BSN, interim clinical educator for emergency services.

For example, the timeframe for "stroke red" patients was increased from three hours to eight hours of symptom onset. Although candidates for tPA must have treatment initiated within three hours, patients may be eligible for other interventions that can be done for up to eight hours after the onset of symptoms, says Arp. "All ED nurses were informed about this change with a mandatory inservice," she says.

A "stroke red" patient is anyone who arrives to the ED with stroke symptoms that started up to eight hours prior to arrival, regardless if the symptoms have resolved, says Arp. "The ED physician and stroke team, including a neurologist, evaluate patients to determine if they are a tPA or coiling candidate," she says.

• Give continuing education (CE) credits for attending inservices.

At Swedish Medical Center in Seattle, ED nurses receive mandatory continuing education once a year on stroke care, says Stanalee Reisinger, RN, an emergency nurse at the hospital.

"Our stroke care coordinators are very up to date on key information and keep the staff informed on any changes to the protocols and up-and-coming treatments," she adds.

"Lunch and learn" and "nursing grand rounds" educational inservices are given to all nurses on Edward Hospital's stroke team, with continuing education credits for each nurse who completes these, says Arp. "The sessions are not mandatory, but most ED nurses attend them since it impacts their practice," she says. "The incentive is they get paid for their time, CE credits are given, and they learn a lot."

At Champlain Valley Physicians Hospital Medical Center in Plattsburgh, NY, ED physicians give nurses inservices on managing stroke patients, says Ann Heywood, RN, BSN, SANE, clinical practice coordinator of the Emergency Care Center. A recent topic was transient ischemic attacks (TIAs), since these patients now are observed in the ED to allow early diagnostic testing to be done. TIAs requires nurses to do ongoing neurological and vital sign assessments, says Heywood.

• Develop an online training module.

At University of North Carolina, educators are developing an online training module for emergency nurses on time sensitivity, mixing, dosing, and administration of tPA, reports Wilson. "We hope to make it a yearly competency," she says.

If there is any neurological change or deterioration, the nurse has to be readily aware of this and stop the tPA, notify the attending physician, and obtain a stat head CT scan to evaluate the patient for intracranial hemorrhage, says Wilson.

• Give hands-on training.

When a code stroke is called at Edward Hospital, nurses come to the patients' bedside for an initial assessment using the National Institutes of Health (NIH) Stroke Scale; the exclusion criteria form is filled out, and the dysphasia screen is done, says Arp. "We try to have some of our newer nurses in on these situations, to learn the steps for the when they would take a stroke patient themselves," she says.

Since tPA may be given only once or twice a month, dosage and pump settings are always double-checked with two nurses, says Arp. "We also make it known throughout the department when we are starting it for anyone who has not yet seen the process," she says. The charge nurse verbally notifies the newer nurses that the medication is being given, Arp explains.

• Audit charts to ensure neurological assessments were done.

"The singular, most important nursing function in acute care of stroke is assessments being done consistently and timely," says Lanphear. At Borgess, all stroke charts are audited to see that the NIH Stroke Scale assessments were done correctly, he says.

"We all were given multiple inservices on the NIH stroke scale so that it can be applied on a consistent basis," Lanphear says. Each neurological or stroke chart is audited to ensure the process is correct and that the time lines are met, he says. "If not, the personnel are questioned as to why," Lanphear says.


  1. Harper JP. Emergency nurses' knowledge of evidence-based ischemic stroke care: A pilot study. J Emerg Nurs 2007; 33:202-207.
  2. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1,581-1,587.


For more information on stroke education in the ED, contact:

  • Denise Arp, RN, BSN, Interim Clinical Educator, Emergency Services, Edward Hospital, 801 S. Washington, Naperville, IL 60540. E-mail:
  • John P. Harper, MSN, RN, Clinical Educator, Emergency Department, Taylor Hospital, 175 E. Chester Pike, Ridley Park, PA 19078. E-mail:
  • Ann Heywood, RN, BSN, SANE, Clinical Practice Coordinator, Emergency Care Center, Champlain Valley Physicians Hospital Medical Center, 75 Beekman St., Plattsburgh, NY 12901. Phone: (518) 562-7483. E-mail:
  • Ken Lanphear, RN, BSN, Emergency Department, Borgess Medical Center, 1521 Gull Road, Kalamazoo, MI 49048. E-mail:
  • Stanalee Reisinger, RN, Emergency Department, Swedish Medical Center, 747 Broadway, Seattle, WA 98122-4307. Phone: (206) 386-2573. E-mail:
  • Susan E. Wilson, RN, MSN, C-ANP, Adult Nurse Practitioner, University of North Carolina Stroke Center, CB# 7025 7003, Neurosciences Hospital, Seventh Floor, Chapel Hill, NC 27599-7025. Phone: (919) 843-2387. Fax: (919) 843-3252. E-mail: