ED is the future of stroke treatment: Are your practices up to par?
Put your stroke protocols in line with current research
Do you consider every stroke patient a potential candidate for thrombolytic therapy? If not, you’re not up to date with current approaches for stroke management, according to experts interviewed by ED Nursing. (For more information on new guidelines for "mini-strokes," see ED Nursing, January 2000, p. 25.)
A recent study demonstrated the importance of stroke being treated in the ED, showing that stroke patients can be treated with tissue plasminogen activator (t-PA), the only FDA-approved clot-busting medication, as rapidly by ED physicians as neurologists.1 (See story on study, p. 97.) This study gives added weight to the concept of the ED as the future of stroke treatment, says Christi DeLemos, RN, stroke research coordinator at Mercy General Hospital in Sacramento, CA, and the study’s co-author.
Every second counts, says Patricia Kunz Howard, RN, MSN, CCRN, CEN, EMS training coordinator for the Lexington (KY) Fayette Urban County Government Division of Fire and Emergency Services and former ED director and stroke team coordinator at Central Baptist Hospital, also in Lexington. "Now that the ED can implement treatment, it has the potential to improve outcomes."
Still, many EDs haven’t adopted t-PA for stroke as a standard of practice, and many nurses aren’t aggressively identifying patients who are candidates for treatment, DeLemos emphasizes. "It wasn’t too long ago that we had nothing to do for stroke, so it’s a major change in how we practice medicine," she says. (See Nursing Guidelines for Thrombolytic therapy and nursing management inserted in this issue.)
You should make judgments about specific interventions for stroke patients and not wait for a neurologist, Howard emphasizes. "Previously, patients were not evaluated by a specialist quickly enough, or in some cases, the specialists did not want to come in to see an acute stroke at all."
Your ED’s stroke protocol is key in reducing delays to treatment, says Howard. "Protocols should allow the triage nurse to initiate the workup, thus facilitating diagnosis and treatment."
Patients who are eligible for thrombolytic therapy must receive treatment within three hours of onset of symptoms, and studies have shown that the earlier the drug is given, the better the outcome, Howard notes.2,3 (See related story on ways to reduce door-to-needle times, p. 95.)
Patients not given t-PA might sue
Despite guidelines and research that stress early treatment in the ED, many EDs are still not prepared to care for acute strokes, Howard reports. "Acute stroke treatment in the ED is where treatment for myocardial infarction was 15 years ago," she says.
Many EDs still are poorly prepared to care for acute stroke patients, reports Howard. "Most EDs have inadequate stroke protocols or none at all, no stroke team in place, and don’t assess patients quickly," she says.
You might face liability risks if you aren’t up to date with your stroke practice, warns DeLemos. "Multiple lawsuits have been filed for failing to treat patients with t-PA."
To avoid problems, document the reasons for deciding not to treat, DeLemos emphasizes. Your careful documentation is key. "There are patients who have sued over not getting the drug when they were actually not good candidates, but there was no documentation of the reasons why."
Many stroke patients come to the ED on their own instead of calling 911, she notes. "Those patients must be triaged quickly, so you need to be on the lookout for signs and symptoms of stroke," DeLemos says. "Having those patients sitting in the waiting room is a big no-no and huge source of litigation."
Here are ways to utilize current approaches in stroke care in your ED:
• Be familiar with inclusion criteria.
Follow specific criteria to determine who should and shouldn’t receive thrombolytics, says DeLemos. "If you select poorly, your patients could end up having terrible complications."
t-PA inclusion and exclusion criteria are well-accepted, says Howard. "The current thought is that any patient with a National Institutes of Health [NIH] Stroke Scale score over 6 with a sustained and not improving neurologic deficit, in the absence of exclusion factors, should receive t-PA," she says. "Also, exclusion for hypertension refers to sustained hypertension, not just a reading or two." (For more information on the NIH Stroke Scale, see ED Nursing, March 2000, p. 61.)
• Avoid dosing errors.
The dose of t-PA for stroke is 0.9 mg/kg, which is approximately two-thirds of the cardiac dose. The dose is critical, stresses DeLemos. "The European Cooperative Acute Stroke Study looked at a dosage of 1.1 mg/kg, which is only 0.2 mg more, but the hemorrhage and mortality rates were so high that the study was stopped."4
Weighing the patient can be overlooked in the hectic ED, but avoid "guesstimates" about the patient’s weight, says DeLemos. Dosage charts are also helpful, she adds.
• Monitor blood pressure carefully.
Check blood pressure every 15 minutes for two hours, every 30 minutes for the next six hours, and every hour for the next 16 hours, says DeLemos. "Blood pressure management is an essential element of thrombolytic therapy," she says. "We now know if the patient’s blood pressure is elevated over 185/110, the likelihood of intracerebral hemorrhage goes up."
If you don’t manage blood pressure carefully and take steps to keep it down, the risk of a bad outcome from the treatment is higher, DeLemos adds.
• Determine when the patient was last normal.
TPA needs to be given within three hours of onset of symptoms, DeLemos emphasizes. You might be the first person to talk to the EMS provider, so you need to find out as much information as possible, she adds.
"Ask them when the patient was last known to be normal, instead of when they were found," she advises. "That’s an important distinction to make."
• Take a team approach.
Make sure that all ancillary departments such as lab and radiology are aware the patient is a potential candidate for t-PA, says DeLemos. "If everyone involved in the process understands that we need to move quickly, it can make a big difference in door-to-needle time."
• Ensure proper management of complications.
Your ED’s protocol should address management of severe hypertension before, during, and after administration of t-PA and bleeding complications, cautions Nanette H. Hock, RN, MSN, program coordinator for the Stanford Stroke Center in Palo Alto, CA. "Rapid administration of t-PA is important," she says. "But more important is the clinical acumen of the ED physician in managing severe hypertension and potential complications such as intracranial hemorrhage." (See story on ED stroke protocol, p. 98.)
Because there is the possibility of bleeding complications, protocols must include frequent neurological checks, management of vital signs within close parameters and a noncontrast computerized tomography scan if any neurologic changes occur, Howard says.
"The more aggressive the treatment is on the front end, and the more quickly the patient’s problem is recognized, the better the functional outcome," she says.
References
1. Akins PT, DeLemos C, Wentworth D, et al. Clinical outcomes are similar when stroke neurologists and emergency room physicians prescribe intravenous tissue plasminogen activator for acute ischemic stroke. Abstract presented at the American Stroke Association's 25th International Stroke Conference. New Orleans; February 2000.
2. Carok JJ, Huybrech TS. Stroke treatment economic model: Predicting long-term costs from functional status. Stroke 1999; 30:2,574-2,579.
3. Holloway RG, Benesch CG, Rahilly CR. A systematic review of cost-effectiveness research of stroke evaluation and treatment. Stroke 1999; 30:1,340-1,349.
4. Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: The European Cooperative Acute Stroke Study (ECASS). JAMA 1995; 274;1,017-1,025.
For more information about stroke treatment in the ED, contact:
• Christi DeLemos, RN, Mercy General Hospital, Regional Stroke Intervention Program, 4001 J St., Sacramento, CA 95819. Telephone: (916) 453-4114. Fax: (916) 453-4587. E-mail: cdelemos@ chw.edu.
• Nanette H. Hock, RN, MSN, Program Coordinator, Stanford Stroke Center, 701 Welch Road, Suite 325, Palo Alto, CA 94304. Telephone: (650) 723-4468. Fax: (650) 723-4451. E-mail: [email protected].
• Patricia Kunz Howard, EMS Training Coordinator, Lexington Fayette Urban County Government Division of Fire and Emergency Services, 219 E. Third St., Lexington, KY 40508. Telephone: (859) 259-1904. Fax: (859) 273-4222. E-mail: [email protected].
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