Be sure no eligible patient misses new treatment window for stroke

Exclusion criteria is different, should be readily available

With an expanded treatment window of 4.5 hours, more of your stroke patients are eligible for treatment with tissue plasminogen activator (tPA). Minutes still count, however.

"The expanded time window allows for increased treatment opportunities," says Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain & Spine Center at Brackenridge Hospital in Austin, TX. "However, just because there is more time now, there should be no deviation in the American Heart Association's established times for door-to-CT or door-to-drug."

"Also, there are additional exclusion criteria that should be readily available. These are different from the zero to three-hour time frame," says Brandt. These include patients older than 80 years old, those with a baseline National Institutes of Health Stroke Scale score more than 25, those with a history of both stroke and diabetes, and those taking oral anticoagulants with an international normalized ratio (INR) less than or equal to 1.7. "So, a patient taking an oral anticoagulant is automatically excluded in the expanded time window," says Brandt.

Is the exact time of onset of symptoms unclear? Ask what your patient was doing at that time. "One patient remembered the radio show she was listening to," says Brandt. "By finding out the exact time of the show, the ED nurse was able to determine the time the patient was last 'known normal.' She did really well, with minimal weakness, but some expressive aphasia."

Remember, too, that tPA is only one possible treatment for your patient. "Know if you have comprehensive stroke center capabilities, such as intra-arterial or mechanical embolectomy, or if there are any nearby. Also, your facility or others may be participating in a research trial for an expanded time frame," says Brandt.

If your patient is not eligible for treatment, be ready to explain why. "More and more patients know there is a treatment and are upset when something isn't done," says Brandt. "If there are no other treatment options and the patient didn't receive tPA, giving the patient and family an 'FAQ' sheet about why they weren't eligible is helpful." [The FAQ sheet used by ED nurses is included.]

Minutes still count

When ED nurses at Emory University Hospital in Atlanta received a report that a stroke patient was coming in, an hour and a half was left of the treatment window for tPA. However, the patient's transport time was almost 45 minutes. ED nurses jumped into action.

"We stopped in the ED long enough for vitals to be obtained and labs to be drawn, then went to CT," says Theresa Sullivan, RN, CEN, one of the ED nurses who cared for the patient.

The patient was assessed by the ED physician on the way to CT, while the stroke page was activated. Neurology met the patient in the ED on the way back from CT while the radiologist was looking at the films. "The entire time I was watching the clock, counting down in 15-minute increments the time left on our tPA window," says Sullivan. "As it happens, pharmacy was ready at the bedside with the tPA with about 10 minutes left in the window, when we got the CT read that this patient had a bleed and could not receive the drug. This was the closest I have ever come to losing the window."

Here are three ways that Emory's ED nurses cut delays in stroke care:

All the necessary forms are easy to grab.

"These are kept at the nurse's station on clipboards," says Sullivan. "ED nurses mark down times of the EMS report, arrival of the patient, the ED physician's arrival at the bedside, and the time the patient left for CT."

Patients with a possible stroke are registered immediately at the bedside.

"The doctor and assigned nurse are called to the room using the portable radios we all carry," says Sullivan. "Since we work in teams, the assigned nurse's partner and tech will also come to the room. It is a team effort to rapidly obtain vital signs and labs, including point-of-cares for INR and blood glucose."

The "stroke page" alerts CT to clear a table and neurology to come to the ED for a stat evaluation.

"Nothing delays getting the patient to CT. Neurology has been known to assess patients on the way to CT and on the CT table," says Sullivan. "We even have a stretcher scale in the hallway on the way to CT, to obtain an accurate weight on the patient for tPA dosing."

While CT is being done, pharmacy is mixing the tPA based on this weight. "If the tPA window is closing, neurology can read the CT to ensure that if tPA is not contraindicated, it can be given before it is too late," says Sullivan. "If tPA is given, pharmacy brings it to the ED while the nurse is doing a complete neurological assessment and the partner nurse is gathering supplies."

Sources

For more information on improving care of stroke patients in the ED, contact:

  • Theresa Edison, RN, BSN, Emergency Department, Saint Francis Memorial Hospital, San Francisco. Phone: (415) 353-6132. Fax: (415) 353-6298. E-mail: Theresa.Edison@chw.edu.
  • Andrew D. Harding, RN, CEN, Emergency Department, Caritas Good Samaritan Medical Center, Brockton, MA. Phone: (508) 427-3037. Fax: (508) 427-2375. E-mail: adhardingrn@gmail.com.
  • Wayne Schmedel, RN, Emergency Department, Providence St. Vincent Medical Center, Portland, OR. Phone: (503) 216-2361. E-mail: Wayne.Schmedel@providence.org.
  • Nadya Valdovinos, RN, TNCC, Emergency Department, Northwestern Memorial Hospital, Chicago. E-mail: nvaldovi@nmh.org.

Simultaneous actions speed stroke care

If a patient presents to the ED with any symptoms that might be caused by a stroke, ED nurses at Providence St. Vincent Medical Center in Portland, OR, immediately grab a "stroke packet."

"It is brought to the bedside, and the nurse starts the stroke assessment," says Wayne Schmedel, RN, an ED nurse at the hospital. The packet contains the National Institutes of Health (NIH) Stroke Scale, a bedside swallow evaluation, and the physician order set for stroke care. (The contents of the ED's stroke packet are included.

Here are the steps that occur immediately, with many of the interventions done simultaneously:

  • The NIH Stroke Scale score is obtained.
  • Two intravenous (IV) lines are started.
  • The ED physician is notified so a "CT brain attack" can be ordered. "The rapid CT of the brain allows for the team to determine if the presentation is based on an ischemic event versus a hemorrhagic event," says Schmedel. "After the CT scan, if the stroke is an ischemic event, the ED physician calls the stroke team for immediate consultation. The ED nurse prepares the patient for the possibility of administering tissue plasminogen activator [tPA].

ED nurses now look for any possibility that the patient's presentation to the ED might be due to a stroke, including complaints of dizziness, a ground-level fall, and visual changes. 

"Raising the bar of suspicion of stroke as a potential etiology has improved our stroke care times and reduced any delays to treatment," says Schmedel.

Reduce treatment delays

At Saint Francis Memorial Hospital in San Francisco, as soon as ED nurses are alerted that a patient is coming in with stroke-like systems, they activate the stroke response team.

"This frees up our CT scanner and lab," says Theresa Edison, RN, BSN, director of emergency nursing, "As soon as the patient gets here, we are at the bedside ready to do our assessments. We get them to the CT scanner within 30 minutes, and everything starts rolling after that."

Andrew D. Harding, RN, CEN, an ED clinical nurse specialist at Caritas Good Samaritan Medical Center, Brockton, MA, says that the ED triage nurse is in "a unique position to affect the speed at which the patient receives care."

"We have found that the best way to reduce times was to implement, at code stroke, very defined role descriptions for nurses, doctors, unit coordinators, and nurses aides," Harding explains. "This allows for all efforts to occur simultaneously." For example, while the patient is in CT, the ED nurse establishes large bore IV access and draws labs.

Prepare for tPA

Harding says after the CT is complete and the patient returns to the ED, he or she needs an EKG, NIH Stroke Scale assessment, complete laboratory tests, a medical history including recent surgeries and medications, and an expert consultation prior to deciding to administer tPA.

ED nurses use a checklist to ensure all these interventions are done. Meanwhile, the patient is placed on a monitor, on oxygen, and in a hospital gown, Harding says.

Nadya Valdovinos, RN, TNCC, an ED nurse at Northwestern Memorial Hospital in Chicago, says having a stroke team has been "dramatically helpful in our department." When ED nurses call a stroke code, the neurology team is automatically paged. [The ED's protocols for stroke and dispensing tPA are included.]

"The team starts their evaluation right away to determine an accurate and immediate plan of care for the patient," Valdovinos says. "Our ED nurses know that once the patient arrives, the patient will need two IVs, a blood sugar check, and a stat head CT. Nurses work proactively and simultaneously to get these tasks done. That makes a huge difference in the time of care and the patient's outcome."


Bedside swallow is critical step

Nurses at Providence St. Vincent Medical Center in Portland, OR, perform a bedside swallow evaluation for all stroke patients during the patient's ED stay.

"This gives you great information on how the patient will do on their current dietary plan, as well as what medications they can safely swallow," says Wayne Schmedel, RN, an ED nurse at the hospital.