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Patients not given diagnostic tests in recommended time frames
Do stroke patients in your ED always receive a computed tomography (CT) scan within 25 minutes, and do you have results within 45 minutes? If not, you’re not following recommended time frames for stroke care — a scenario commonly occurring in community EDs, according to a just-published study.1
To track compliance with time targets established by the Bethesda, MD-based National Institute of Neurological Disorders and Stroke (NINDS), researchers assessed care of 1,003 stroke patients presenting to community EDs in Cleveland and discovered that median time to CT scan was 65 minutes, and time to imaging results was 105 minutes — substantially longer time frames than recommended. (See NINDS time targets, below.)
If you don’t follow the current NINDS guidelines for stroke care, your ED may face potential adverse outcomes, warns W. Scott Burgin, MD, assistant professor of neurology and radiology at the University of Rochester (NY). And that’s not all. "When guidelines are issued about fairly routine issues in management, it does open you up for liability issues if they aren’t followed," Burgin warns.
Here are ways you can effectively reduce delays in care of stroke patients:
• Intervene immediately if you suspect stroke. As soon as a suspected stroke patient is identified, an acute stroke pathway is initiated and the stroke team is called, says Heidi Jahnke, RN, BSN, clinical research nurse at Barrow Neurological Institute of St. Joseph’s Hospital and Medical Center in Phoenix. (See facility’s Acute Stroke Pathway.) "Nurses do not need a physician’s order to initiate the stroke pathway if they suspect a patient is having a stroke," adds Jahnke.
To meet timelines, nurses should take the initiative and aggressively move the patient through the pathway, emphasizes Jahnke. "For instance, if CT scan is ready to scan the patient, and the physician is examining the patient, the CT should take precedence over the exam," she says. The physician can accompany the patient to CT scan and finish the exam after the test, she explains. "Most of the neurology residents and attendings concur with this approach in decreasing delays," says Jahnke.
• Get patients to CT quickly. Having a CT scanner within the ED is very helpful in reducing delays, Jahnke says. "Also, the CT tech carries a portable cell phone so the ED nurse can notify him or her of a stroke patient that needs a stat CT scan," she says. After the acute stroke pathway was implemented, the ED decreased its average door-to-completion of CT scan time from 88 minutes to 38 minutes, says Jahnke. "When the CT scanner was placed in the ED, it was further decreased to around 20 minutes," she reports.
• Identify obstacles to meeting timed goals. At Community Medical Center in Toms River, NJ, a multidisciplinary committee was formed to identify obstacles to meeting time goals for ED stroke patients, says Debra Graf, RN, BSN, CEN, ED educator. The committee consisted of the ED administrative director, ED medical director, ED physicians, ED nurses, representatives from information technology, pharmacy, radiology, neurology nurses, and a neurologist.
The following obstacles were identified:
To address these problems, the following steps were taken:
1. A dedicated rapid assessment area was created for stroke patients. The rapid assessment area is a five-bed monitored area staffed by a nurse and a licensed practical nurse certified in intravenous (IV) lines. It is located by the ambulance and triage entrances. Patients with stroke symptoms bypass triage and registration and are seen within 10 minutes of arrival by an ED physician, Graf explains. Here are the steps that occur:
A. The triage nurse notifies an ED physician and registration.
B. Bedside registration is performed while standing orders are initiated.
C. The ED physician examines the patient and enters orders from an ED order set. If a patient is ruled out as a candidate for thrombolytic therapy, he or she can be moved to a regular treatment bay and receive a CT scan on a lower priority, says Graf. "Potential candidates are given priority in CT scan based on the ED order set used, then moved to the ED to await the decision to treat," she says.
2. Nursing standing orders and ED physician order sets were developed. These orders facilitate the treatment protocols decided on by the committee, says Graf. (See checklist of nursing standing orders, below.)
3. The computerized order entry system was changed to give priority to stat CT scans for patients eligible to receive thrombolytics vs. regular stat CT scans.
"We have been able to meet the time goals of 10 minutes for door-to-physician and 25 minutes for door-to-CT most of the time," says Graf. The average door-to-CT time was previously about 60 minutes, she notes. "We have reduced this by at least 30 minutes in thrombolytic candidates," says Graf. The 30-minute reduction has allowed some patients to receive treatment with thrombolytics who otherwise would have been excluded because of the three-hour window of time for treatment, she adds.
• Identify causes of delays. An "immediate-response" committee reviews all stroke patients that are admitted through the ED on a monthly basis, says Jahnke. "We look for delays in ordering lab work and CTs, and in administration of thrombolytics," she says. If delays are noted, the ED educator inservices the specific nurses, physicians, and technicians involved about the importance of following the pathway, says Jahnke. Sometimes the committee identifies necessary delays, such as problems with blood pressure or airway management, she adds. "We allow nurses to carry antihypertensive medications with them when they take the patient to CT scan so they will be able to administer it if necessary," says Jahnke.
• Educate staff. When problems were identified with staff knowledge about the stroke protocol at Community Medical Center, an educational seminar was given to ED and neurology nurses, says Graf.
At St. Joseph’s, an ED nurse attends the monthly stroke meeting, the stroke team reviews specific issues at ED staff meetings, and the ED educator works with individuals to review the process, says Donna Zadrozny, RN, BSN, an ED nurse at the facility. "During our nursing orientation, the stroke protocol is emphasized," she adds. "Also, general updates are passed on to the staff at our monthly staff meetings and through our ED newsletter."
• Use a team approach. The following steps occur simultaneously when a stroke patient arrives in the ED, says Zadrozny:
"All of the staff and ancillary services pull together to expedite the care of the patient," says Zadrozny.
Delays may occur due to difficult IV starts, but that should not delay care, says Zadrozny. "In those cases, we have our lab draw the blood work and take the patient to CT scan," she says. "While we are waiting for the reading, we start the IV."
By making changes such as these, the ED has dramatically reduced delays and improved consistency of care, says Jahnke. "We have come a long way since the institution of the pathway and stroke team concept," she says. "We continue to look for ways to improve our times in order to give quality stroke patient care."
1. Katzan IL, Graber TW, Furlan AJ, et al. Cuyahoga County Operation Stroke: Speed of emergency department evaluation and compliance with National Institutes of Neurological Disorders and Stroke time targets. Stroke 2003; 34:994-998.
For more information about meeting time targets for stroke care in the ED, contact:
• Debra Graf, RN, BSN, CEN, Emergency Department, Community Medical Center, 99 Route 37 W., Toms River, NJ 08755. Telephone: (732) 557-8000, ext. 11925. Fax: (732) 557-2124. E-mail: DGraf@sbhcs.com.
• Heidi Jahnke, RN, BSN, Clinical Research Nurse, Barrow Neurological Institute of St. Joseph’s Hospital and Medical Center, 222 W. Thomas Road, Suite 404, Phoenix, AZ 85013. Telephone: (602) 406-6976. Fax: (602) 406-4117. E-mail: firstname.lastname@example.org.
• Donna Zadrozny, RN, BSN, Staff Nurse, Emergency Department, St. Joseph’s Hospital and Medical Center, 222 W. Thomas Road, Suite 404, Phoenix, AZ 85013. E-mail: DZadroz@chw.edu.