Prevent strokes with ED work-up
At University Hospital in Cincinnati, transient ischemic attacks (TIA) patients are put in a 23-hour rapid diagnostic unit. (See protocol, inserted in this issue, and flowchart, p. 32.)
"If you can get the work-up done in a day, with good organization, you can avoid a hospitalization," says Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of emergency medicine at University Hospital, University of Cincinnati Medical Center and consultant for the National Stroke Association, based in Englewood, CO.
The ED’s rapid diagnostic unit is a six-bed unit with an ED nurse staffing it full time. The unit includes patients with conditions such as chest pain, asthma, and TIA who need less than 24 hours of acute therapy.
"In the beginning, the unit was really aimed toward angina patients, but we expanded it to more than one disease entity. In the case of TIA, the patient just needs a good diagnostic work-up," says Spilker.
You may have a limited time to treat TIA patients, so the sooner you have the information you need to make the best decision about what interventions to take, the better, notes Spilker.
Assess with NIH Stroke Scale
The TIA patient receives a series of pre-identified diagnostic assessments based on patient needs. The National Institutes of Health (NIH) Stroke Scale is used for assessment, vital signs, and neurological status are observed and preventive therapy is started.
Diagnostic information is collected, including a complete blood count, echocardiogram, and carotid studies. "We need to look at the vascular situation in the patient, to find out the cause of the TIA," notes Spilker. "We look at the vessels in the neck by using either a Doppler study or [magnetic resonance angiography]."
TIA patients with sudden onset of neurological deficit are candidates for the rapid diagnostic unit. Symptoms of neurological deficit include:
• weakness of face, arm, or leg;
• numbness of face, arm, or leg;
• difficulty speaking (dysarthria or expressive aphasia);
• difficulty understanding speech (receptive aphasia);
• difficulty with vision (diplopia, vision lost, vision graying, vision fogging, vision blurring, shade-type symptoms);
• dizziness or loss of balance.
Statistically, a person with TIA is at highest risk of having a stroke, Spilker warns. "So when we send them out of the ED and don’t admit them and they may not get to see a doctor for weeks or days, that is not the best practice."
Instead, obtain the diagnostic information while the patient is still in the ED, and prevention therapy can be triggered sooner rather than later, Spilker advises.
One-shot EKG doesn’t pick up everything’
A 23-hour stay also can determine whether a patient is in atrial fibrillation and should be put on an anticoagulant, says Spilker. "If you haven’t put them on a cardiac monitor, you don’t know it’s there," she stresses. "A one-shot EKG doesn’t always pick up everything you need to know, especially if the abnormal rhythms are intermittent."
Also, if you do the work-up in the ED, you can collect diagnostic information immediately so prevention therapy can be started sooner, says Spilker. Otherwise, a patient may be discharged and have a stroke before interventions can be taken, she adds.
Certain strokes are going to occur, no matter what interventions you take, Spilker stresses. "TIA patients may still fail the best therapies we have, but they may need to be assessed for new medication strategies."
TIA also provides an opportunity for you to educate patients about what to do if they have symptoms again, says Spilker. "Any TIA is a golden opportunity for education," she says. "They need to know to get back if it happens again and come back early."
Patients also need to know that they are at high risk for stroke because they’ve had a TIA, says Spilker.
"The tendency in elderly is that if it went away in the last time, they don’t want to bother anybody, which is the wrong message," she explains. "So it’s a real teaching opportunity for nursing."
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