Warn patients to come to ED early for stroke

According to a report from the Atlanta-based Centers for Disease Control and Prevention, almost half of all deaths from stroke occur before the victim can get to the emergency department (ED). In 1999, there were 167,366 stroke deaths in the United States, and 80,589 occurred before the patient arrived at the ED, says the report.

This underscores the key role you play in educating patients at risk for stroke, emphasizes Pat Spurlock, RN, clinic administrator at Neurological Associates of Des Moines (IA) and former director for emergency services at Mercy Medical Center, also in Des Moines. "ED nurses will be leaders in teaching patients and their families about management of strokes, diagnostic testing, and treatment options," she says.

Here are ways to improve education and management of stroke patients:

• Inform patients of warning signs. The report shows that many individuals are unaware of the five most common warning signs of stroke, says Janice Fitzgerald, MS, RN, CEN, clinical practice manager at Baystate Medical Center in Springfield, MA. They are:

— sudden numbness or weakness of the face, arm, or leg on one side of the body;

— sudden dimness or loss of vision, particularly in one eye;

— difficulty speaking, loss of speech, or trouble talking or understanding speech;

— sudden severe headache with no apparent cause;

— unexplained dizziness, confusion, unsteadiness, or sudden falls, especially along with any of the previous symptoms.

The opportunity to educate patients with high-risk factors as well as their families often present at the time of discharge from the ED, says Spurlock. "Capitalize on those moments," she urges. Spurlock gives the example of a patient with a laceration who also has hypertension. "While the focus at discharge is to cover suture care, the opportunity presents to recheck their blood pressure and educate the individual on the risks of untreated or uncontrolled hypertension." She recommends writing down the patient’s blood pressure readings to share with his family physician.

• Educate patients about risk factors. The report stressed that high blood pressure, diabetes, high cholesterol, and smoking are all long-term risk factors for stroke. "Any patient who has cardiovascular disease, such as a patient with myocardial infarction, is at risk of stroke as well," notes Fitzgerald. "The risk factors are the same."

Spurlock advises against stereotyping patients according to age. "The educational focus should remain on the recognition of symptoms of stroke and seeking early evaluation," she says. The general public has long recognized that elderly age groups have strokes, she explains. "But today, we see patients in their 30s, 40s, and 50s having strokes — some even younger," she says. "By reinforcing the concept that elderly individuals are at risk for strokes, younger patients deny warning signs and delay seeking an evaluation, especially when the symptoms resolve spontaneously," she says.

• Don’t overlook subtle symptoms. Much like victims of heart attacks, stroke patients do not always present to ED with classic symptoms, says Spurlock, adding that this can cause further delay to diagnosis and treatment of a stroke in progress. "The nurse is generally the first health care provider to assess the patient," notes Spurlock. "A high degree of suspicion when patients present with subtle symptoms such as dizziness will lead to rapid diagnosis and treatment."

By keeping a high degree of suspicion when patients present with subtle symptoms, the patient will be triaged to the highest priority and the stroke team can be activated, Spurlock says. "Rapid computerized tomography scanning is crucial to the diagnosis of a stroke in progress," she adds.

• Take a team approach. Spurlock stresses that a systematic team approach to the diagnosis and treatment of stroke patients is rapidly becoming the standard of care. "A stroke patient should be treated with the same urgency as trauma and cardiac patients," she says. Spurlock says that physician and nursing leaders with an interest in stroke should establish timelines to rapid diagnosis and treatment. "Critical to the success of the team is the inclusion of radiologists, neurologists, and ED nurses and physicians," she says.

• Get the word out. The news media may be interested in covering the formation of your stroke team, Spurlock suggests. "This is an opportunity to educate the public on why the team was developed," she says. If your marketing budget allows, Spurlock recommends running an educational television commercial featuring the warning signs of stroke with emphasis on seeking early evaluation. "Direct-mail pieces that provide bulleted warning signs of a stroke in progress and a clear message to seek early evaluation can be useful in conjunction with the television coverage," she says.

She also recommends placing brochures in the waiting rooms of your ED, with posters to reinforce the message. (See resources at the end of this article to obtain patient educational materials about stroke.) Spurlock also recommends developing a "speakers bureau" of ED nurses willing to lecture at meetings of community groups. "Organizations frequently are looking for speakers and seem to be open to topics related to health care," she says.

Sources and resources

For more information about management of stroke patients, contact:

Janice Fitzgerald, MS, RN, CEN, Clinical Practice Manager, Baystate Medical Center, 759 Chestnut St., Springfield, MA 01199. Telephone: (413) 794-2531. Fax: (413) 794-8866. E-mail: Janice.fitzgerald@bhs.org.

Pat Spurlock, RN, Neurological Associates of Des Moines, 1601 N.W. 114th St., Suite 338, Des Moines, IA 50325. Telephone: (515) 223-1917. Fax: (515) 223-0284. E-mail: bpspurlock@aol.com.

The American Stroke Association offers several patient education resources for stroke. Are You at Risk for Heart Attack or Stroke? (Item No. 50-1494) is an eight-page brochure to assess risk with questions about smoking, cholesterol, blood pressure, obesity, diabetes, and physical exercise to help readers determine whether they need to make lifestyle changes. The cost is $18 for 50 brochures. A brochure, Warning Signs: Is it a stroke? (Brain Attack) (Item No. 31991) lists common stroke symptoms and instructs readers what to do if they occur, including transient ischemic attacks. The cost is $1.10 each for up to 99 brochures, with discounts for larger quantities. Shipping is $7.35 for orders less than $100. To order, contact:

AHA Fulfillment Center/Channing Bete Co., One Community Place, South Deerfield, MA 01373-0200. Telephone: (800) 477-4776. Fax: (800) 499-6464. E-mail: custsvcs@channing-bete.com. Orders also can be placed on-line at http://shop.channing-bete.com/images/pdfs/DMO_OF.pdf.