Stroke coordinators manage acute stays

At Good Samaritan Hospital in San Jose, CA, care for stroke patients is coordinated by a registered nurse who follows the patient throughout his or her hospital stay, educates the patient and family members, and coordinates with the hospital’s other case managers on discharge needs.

"The nurse stroke coordinators are essentially fulfilling the role of a case manager. The goal is getting the patients home. Often there is a lot of coordination involved," says Steve Matarelli, PhD, RN, vice president of clinical practice administration.

The 422-bed hospital has two stroke coordinators who are in-house from 8 a.m. to 5 p.m., seven days a week and who rotate being on call during the other hours. The nurse stroke coordinators are part of the team that swings into action when someone calls a Code Brain Attack, similar to the hospital’s Code Blue.

Good Samaritan’s Stroke Care and Brain Attack Program is nurse-driven, Matarelli says.

Any RN can call a stroke alert and activate a response team when a patient is admitted to the emergency department with symptoms of a stroke or begins to show signs of a stroke while in the hospital. All of the nurses have been educated to recognize stroke symptoms.

"The key element in stroke survival is time. The stroke coordinators respond immediately and guide the team to successful treatments," he says.

Good Samaritan was one of the first five hospitals in the United States to be certified under the Joint Commission on Accreditation of Healthcare Organizations’ Survey on Stroke Care and Code Brain Attack. The Joint Commission survey is part of its disease-specific certification, which allows an organization to demonstrate mastery in a clinical program.

Stroke coordinators are "the captain of the ship" when a Code Brain Attack is called, says Matarelli. "The stroke coordinators are usually among the first responders. They make sure the protocols are started and followed and are in constant communication with the neurologists."

They use the National Institutes of Health Stroke Scale to assess the severity of the stroke and institute appropriate interventions and treatments and make sure the hospital’s stroke protocols are instituted. "The staff are well versed in following the protocols. They’re pretty cut and dried, simple to follow, are based on evidence-based medicine, and have been in effect at Good Samaritan Hospital for the past seven years," he notes.

Staff who automatically respond include a phlebotomist from the laboratory, patient transport staff, vascular imaging technicians, the neurologist on call, and (since in 90% of the cases, the patient will end up in the intensive care unit) the medical-surgical intensive care nurse.

The radiology department is alerted to expedite freeing up a CAT scan table. The stroke protocols call for notification of the laboratory to send a phlebotomist, the transportation staff, and the radiology department to expedite freeing up a CAT scan table. The hospital has a policy that only one of its two CAT scan tables can be used for an involved procedure at any given time, leaving one CT scanner for simple cases and emergencies such as the Code Brain Attack program.

The stroke coordinators follow the patient during the acute recovery stage, ensuring that the treatment protocols are utilized in the intensive care unit and on the floor. After the initial crisis has passed, the RN stroke coordinators become the family liaison. They continue to make rounds, working with the patient and family to discuss discharge options. They do a lot of education on medication regimes, managing hypertension, weight loss, smoking cessation, and other risk factors for stroke.

"Their work with the patient and family is similar to disease-specific case management. They try to help them understand the American Heart Association and American Stroke Association risk factors and to modify their lifestyles to avoid a recurrence," he says.

They coordinate with the hospital’s other case managers about placing patients in a skilled nursing facility, acute rehab center, or discharging them home with home health service and/or durable medical equipment. If it is appropriate, the stroke coordinator calls on a durable medical equipment company to do a home evaluation.

"They do a home assessment and give us a flavor of what the home environment is like. For instance, if a patient has trouble walking or other residual stroke deficits and their home has 11 steps, going home may not be an option unless those barriers can be modified or resolved.

A day or two before discharge, the stroke coordinator connects with the internal case management staff doing discharge planning and utilization review. Managed care makes up more than 70% of Good Samaritan’s market.

"Our case managers and utilization review nurses rapidly identify benefits and connect to post-discharge service providers. It is one of our highest obligations. The patients have an insurance product for a reason, and they deserve to get their maximum benefits," Matarelli says.

While Good Samaritan is a community-based hospital, the RN stroke coordinators also work on the hospital’s clinical drug trials, just as neighboring teaching hospitals Stanford and UC-San Francisco. The nurses enroll patients in the study, following them throughout the study and handling disenrollment and study conclusion.

Good Samaritan uses a number of state-of-the art techniques to treat stroke patients, including tPA, a bioscience drug used in clot dissolution in cerebral and cardiac vasculature.

Good Samaritan has on staff a group of neuro-interventional radiologists who can isolate the location of the ischemic stroke and intervene only on that area, possibly with a small does of tPA, a treatment method that Matarelli calls cutting edge.

"The desired benefit or advantage of interventional radiology is that a percentage of patients, such as those with peptic ulcers or those who have had recent surgery, can now take a lower treatment of tPA because it’s a localized dose, rather than the previously larger systemic dose," he says.