Use these practices to stop stroke treatment delays
Use these practices to stop stroke treatment delays
Would it surprise you to learn that delays in treatment for stroke patients in the emergency department haven't changed significantly in the past few years?
"We summarized studies that examined delay in the emergency department. Overall, based on 10 studies of 12 different population samples, the analysis indicated no decline" in the time from the patient's arrival in the ED to evaluation, says Kelly Evenson, PhD, the study's lead author and a research associate professor in the Department of Epidemiology at Gillings School of Global Public Health at the University of North Carolina in Chapel Hill.1
Lorraine Salavec, MS, RN, CEN, patient care manager for the ED at Norwalk (CT) Hospital, says that "the key to reducing delay in the treatment of stroke care is early recognition of signs and symptoms." Norwalk's ED nurses use a two-step triage process to identifying patients with signs and symptoms of stroke.
"A nurse greets all patients, which supports identifying any patient with stroke symptoms. Upon the determination that there is a high probability of stroke, our process for these patients is to call a 'Stroke Alert,'" says Salavec. "This mobilizes all members of the team to allow the patient to be diagnosed and treated expeditiously."
E. Scott Metzel, RN, BSN, MA, neuroscience outreach coordinator at Alaska Regional Hospital in Anchorage, says that at his hospital, ED nurses now are required to complete the National Institute of Health Stroke Scale Certification. "Our nurses have also received education on screening the patient for potential risk for aspirating," he adds. "If the patient has a facial droop, difficulty swallowing, or decreased level of consciousness, it prompts the ED nurse to request a formal speech therapy swallow study. The patient will remain 'nothing to eat or drink by mouth' until that official swallow study is completed."
Alaska Regional's ED nurses have been trained on the use of Stroke Alert Protocols to expedite the CT scan, with a goal of 20 minutes from door-to-CT and 45 minutes from door to the radiologist interpreting the results.
"Once a Stroke Alert is called, ED nurses can shave more time off by making sure the ancillary staff are in place to expedite the CT, lab tests, and neurosurgeon," says Metzel. "This is done through our pager system, so the team is in and ready. It is essential for the ED nurse to follow up on the tests, to ensure we get the results in a timely manner."
Reference
- Evenson KR, Foraker RE, Morris DL, et al. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke 2009; 4:187-199.
Pathways are key to reducing delays The key to rapidly responding to a stroke patient in your ED, "is to have an automatic, standard process in place," says Lisa Hardy, MSN, CRNP, an ED and stroke team nurse practitioner at Huntsville (AL) Hospital. "Having a standard stroke protocol is a must," she says. Your ED's stroke protocol should include point-of-care labs, standard labs, intravenous (IV) lines, getting the patient to CT within 20 minutes, and preparing for IV thrombolytic administration or possibly radiologic intervention such as MERCI retrieval, says Hardy. "Rapid assessment and identification of a potential stroke patient is the first step," says Hardy. Hardy adds that the Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen "should be familiar to every ER nurse. Any one of the following symptoms should prompt the nurse to think stroke: facial droop, arm drift or speech difficulties. These patients should be immediately triaged to a bed." Huntsville Hospital became a Joint Commission Primary Stroke Center in September 2008. "Prior to our certification, we put a standard response in place that began in the ED," says Hardy. When a potential stroke patient meets the clinical criteria, a Stroke Alert is activated that pages CT, the lab, the pharmacy, the on-call neurologist, the nurse practitioner, the critical care supervisor, the ED charge nurse, and the neurological intensive care unit. ED nurses have a goal to get the patients' head CT completed within 40 minutes. "Usually, the nurse practitioner or neurologist is watching the CT as it's performed and can determine whether or not the patient will get tPA [tissue plasminogen activator]," says Hardy. "Since putting into place our standard stroke response, we have been able to quickly identify and reach many more patients that qualify for tPA therapy within the time window. Our nurses know the protocol, treat these patients as emergent, and are able to anticipate what they need to do to help our stroke patients achieve the best possible outcome." At Indian River Medical Center in Vero Beach, FL, patients who present to the ED with certain neurological symptoms or complaints, including sudden weakness, sudden difficulty speaking, sudden vision changes, difficulty with speech, sudden loss of balance, sudden paralysis, and sudden onset of numbness, are placed on a Stroke Clinical Pathway. "This is a set of standardized treatment orders that meet certain performance measures," says Emilia Andrascik, RN, CEN, preceptor for emergency services. "These measures have been proven to foster better quality of care and outcomes for stroke patients." ED nursing interventions included in the clinical pathways include assessment of blood glucose, comprehensive neurological assessments, screening patients for potential thrombolytic therapy, and swallowing evaluation. "These are just a few of the nursing and diagnostic interventions that assist the medical team in quickly evaluating symptoms and initiating the Stroke Clinical Pathway," she reports. Indian River's ED nurses use a "Stroke Alert" process, which is a multidisciplinary team approach to rapid initiation of diagnostic studies. "For instance, if the triage nurse calls a Stroke Alert, the primary nurse begins the Stroke Pathway. The physician is notified immediately that a potential stroke patient has presented for treatment," says Andrascik. "The laboratory and radiology departments both respond, as part of the team to begin diagnostic evaluation." Once the radiology department is contacted, all stroke patients receive the highest priority for CT scan. "All these measures ensure that the patient is diagnosed as rapidly as possible," says Andrascik. "This significantly reduces any potential delay in stroke care." Sources For more information on decreasing delays for stroke patients in the ED, contact:
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