JCAHO is impressed with stroke care at Seattle ED

A 45-year-old man was brought by ambulance to the ED at Swedish Medical Center in Seattle. He presented with aphasia and left hemiparesis with symptom onset two hours before arrival.

"He was ruled in as a candidate for treatment and given t-PA [tissue plasminogen activator]," recalls Judy Street, RN, manager of emergency services. "He shook our hand with his left hand the next day. All of us were in tears."

This was the first patient treated by ED nurses with a new stroke protocol that has dramatically improved patient care. After implementing many practice changes to ensure timely care for acute stroke patients, the hospital received the 2005 Ernest Amory Codman Award from the Joint Commission on Accreditation of Healthcare Organizations. The award recognizes excellence in the use of outcomes measurements to improve quality and patient safety.

A stroke algorithm was developed using guidelines published by the National Institute of Neurological Disorders and Stroke.1 (Editor’s note: To access the guidelines, go to circ.ahajournals.org. Click on "Scientific Statements, "By subject," "Stroke," and "2005 Update: Guidelines for the Early Management of Patients with Ischemic Stroke.")

Although only patients with onset of symptoms within three hours are candidates for t-PA, other interventions can be done for patients with symptom onset greater than three hours, such as blood pressure control, repeat computed tomography (CT) scans, or getting the patient in the care of a neurologist, says Stanalee Reisinger, RN, an ED nurse and a "champion" of the stroke project.

Here are the steps that occur when a potential stroke patient comes to the ED:

  • While the ED physician assesses the patient, the nurse simultaneously assures intravenous access is obtained, an electrocardiogram (ECG) is completed and read, and labs are drawn and reviewed within 30 minutes.
    "The lab slip is color-coded to alert the lab technician running the tests that this color was a potential CVA [cerebral vascular accident]," says Street.
  • If a CVA is suspected, a CT is ordered. The stroke team and radiologist are alerted by pager. The CT scan is completed.
  • If the ED physician considers the patient a potential thrombolytic candidate, admitting arrangements are made while the patient is still in CT.

The ED did the following to improve stroke care:

• A CT scanner was installed in the ED.

This facilitates the assessment, evaluation, and treatment of stroke patients, says Street. "Transport time to the CT scanner in the radiology department was a minimum of 15 minutes as it required an elevator, attachment of transport monitors, and staff to transport the patient," she says. "We eliminated this time entirely."

The cost of the CT scanner, including construction, was $1.2 million.

• All ED physicians and nurses became certified in the National Institutes of Health Stroke Scale (NIHSS).

Every ED nurse needs to be able to perform this assessment, says Reisinger. "All our ED nurses are capable of doing the NIHSS," she says. "We are all certified, and this is mandatory."

Nurses take a four-hour class given by the hospital’s clinical stroke team and they must pass an exam to be certified, with nurses paid for this time, adds Reisinger.

• Nurses are given feedback on success stories and problem cases.

ED nurses attend monthly meetings where recent stroke cases are reviewed, including the total times from door-to-drug or door-to-intervention.

"The immediate feedback gives us the ability to celebrate our successes," says Street. "There is also a monthly stroke team that meets to identify any system or practice issues, and these [changes] are implemented immediately." For example, the team reviewed a case in which there was a delay in getting the CT scan report to the ED physician, so the results now must be given within two minutes.

• The ED physician, charge nurse and triage nurse act collaboratively.

"Any time we have a stroke patient with onset of symptoms under 12 hours, we want them into a treatment room on an emergent basis," says Reisinger. When the triage nurse identifies a patient as a possible candidate for treatment, the charge nurse is called immediately, and the two nurses keep in constant contact with two-way radios.

This was a huge change for Swedish Medical Center, Reisinger says. "Previously when a patient came in with weakness or dizziness, we may not have immediately thought of stroke, and they may have sat out in the lobby," she says. "Now these patients are prioritized as emergent and are placed in a treatment room within two minutes."

• Nurses are trained to pinpoint the time of onset.

Some patients may wake up in the morning with stroke symptoms and don’t have a timeframe to go by for when the symptoms began, and they are ruled out for treatment as a result, notes Reisinger. "If we don’t know the exact onset of symptom time, we can’t give them t-PA," she says.

ED nurses now ask patients specific questions to narrow down the timeframe, such as "Did you feel normal when you went to bed?" "Did you wake up in the middle of the night at any point?" "Many patients were ruled in for t-PA as a result of this," Reisinger says.


  1. Adams H, Adams R, Del Zoppo G. Guidelines for the Early Management of Patients With Ischemic Stroke-2005 Guidelines Update: A Scientific Statement From the Stroke Council of the American Heart Association/American Stroke Association. Stroke 2005; 36:923. Erratum in: Stroke 2005; 36(7):1,626. Stroke 2005; 36(6):1,352.


For more information about stroke care in the ED, contact:

  • Stanalee Reisinger, RN, Emergency Department, Swedish Medical Center, 747 Broadway, Seattle, WA 98122-4307. Telephone: (206) 386-2573. E-mail: Stanalee.Reisinger@swedish.org.
  • Judy Street, RN, Manager, Emergency Services, First Hill Campus, Swedish Medical Center, 747 Broadway, Seattle, WA 98122-4307. Telephone: (206) 386-2592. E-mail: Judy.Street@swedish.org.

The National Institute of Neurological Disorders and Stroke offers a training DVD for the National Institutes of Health Stroke Scale. To order on-line, go to www.ninds.nih.gov. Click on "Stroke Scale Training." The cost is $50 including shipping. After viewing the stroke scale, nurses may return to the site and enter scores to earn a maximum of 3.5 contact hours or continuing education credit. For more information, call (800) 352-9424 or (301) 496-5751 or e-mail: nindspubs@iqsolutions.com.