ED creates shorter scale for stroke assessment
ED creates shorter scale for stroke assessment
Are you aware of the benefits of using the National Institutes of Health Stroke Scale (NIHSS) to assess stroke patients, but concerned about the time required? At University of Wisconsin Hospital and Clinics in Madison, an abbreviated version of the NIHSS was developed, called The Emergency Triage Stroke Scale (ETSS), which takes only about two minutes to perform.
"We developed a scale with the same numbers as the NIHSS, but changed how you assessed some of the more difficult parts," says Christine Whelley-Wilson, RN, BSN, stroke program coordinator. "This gives a picture of whether the patient is getting better or worse and whether the patient is a t-PA [tissue plasminogen activator] candidate."
When researchers compared the ETSS with the NIHSS for 48 patients presenting with symptoms of acute ischemic stroke, there was excellent agreement between the two scales, with a strong ability to predict whether a patient was a candidate for thrombolytic therapy.1
It’s important for nurses to be able to do the assessment, as opposed to waiting for a neurologist to come to the ED, which might take up to 15 minutes, adds Wilson. "Also, if EMS uses the scale, we can track the symptoms along the continuum," she says.
When a patient arrives with a possible stroke, the ED nurse performs the ETSS assessment on the patient. When the physician comes to the bedside, the nurse shares the findings, as well as any changes that may have occurred after the initial assessment.
A score between 4 and 22 is an indication that the patient may be a candidate, while symptoms that are fluctuating or improving may mean the patient is not a candidate, adds Wilson. "So the physician will have an idea, based on the nurse’s findings, as to whether the patient is a candidate for thrombolysis."
Score before patient hits the ED
Often, the ETSS assessment is done in the field by EMS who already are assessing the patient, says Lynn M. Sterling, RN, TNCCP, ENPC, ED triage nurse.
"Think of the time this can save in the ED," she says. Before the stroke team even shows up, the patient is set up to be scanned, to have orders initiated, and to be admitted to the inpatient unit. "I have seen it work smoothly time and time again," Sterling says.
When EMS personnel use the ETSS, nurses can get a score from the ambulance before the patient even arrives at the ED, says Wilson. "This would allow people to be better prepared for a possible t-PA patient," she says.
Benefits include "psyching up" the staff for a potential thrombolytic candidate, which will decrease time to treatment, says Wilson. "The earlier that people are put on alert, the quicker things will go in the ED," she says. "The sooner a patient receives t-PA, the better the chance of an improved outcome."
After being transferred from another hospital, one recent stroke patient’s ETSS score was done right before the computerized tomography (CT), with the exact same score as the NIHSS score that the physician gave after the patient’s CT, Wilson reports. The patient was given t-PA, is recovering, and is expected to have a short inpatient acute rehabilitation stay, she adds. "This has led to an increased understanding of the evolution of this particular patient’s signs and symptoms, as well as a better understanding of stroke syndromes for all ED personnel," says Wilson.
To educate nurses, Wilson explains the significance of the scores of individual stroke patients. "This discussion always leads to an increased understanding of the patient’s pathology for the nurse," she says. "This is one of the hidden benefits."
The ETSS helps nurses to identify the next need of the stroke patient, such as initiating orders for alteplase, says Sterling.
"It has greatly aided our stroke team in their decision-making process," she explains. "Although it takes a little time on the nurse’s part to fill out the ETSS, ultimately it benefits the patient, and that is what is most important."
Reference
- Whelley-Wilson CM, Newman GC. A stroke scale for emergency triage. J Stroke and Cerebrovascular Diseases 2004; 13:247-253.
Sources
For more information on the Emergency Triage Stroke Scale, contact:
- Lynn M. Sterling, RN, TNCCP, ENPC, Emergency Department, University of Wisconsin Hospitals and Clinics, 600 Highland Ave., Madison, WI 53792. Telephone: (608) 262-2398. Fax: (608) 262-9999. E-mail: [email protected].
- Christine Whelley-Wilson, RN, BSN, Stroke Program Coordinator, University of Wisconsin Hospital and Clinics, 600 Highland Ave., Madison, WI 53792. Telephone: (608) 264-4698. E-mail: [email protected].
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