New stroke pathways start in the ED: Nurses must change clinical practice
Acute interventions have affected triage, assessment, and treatment
The next stroke patient who arrives at your ED has a better chance of a complete recovery, thanks to new time-dependent treatments and interventions. In the past, stroke patients weren’t triaged with any immediacy, explains Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of neurology at University Hospital, University of Cincinnati Medical Center and consultant for the National Stroke Association, based in Englewood, CO.
"The concern for their care was largely supportive, to prevent another stroke and complications due to the current stroke," Spilker says.
The treatment of stroke patients in the ED has undergone a complete turnaround, she emphasizes. "The treatment of stroke is now time-dependent, which makes the ED important as a care delivery site," Spilker says.
Because of new treatment options, ED nurses need to re-evaluate some areas of their clinical practice. (See story on tissue plasminogen activator [t-PA], p. 24.)
"Before, we’d put in an IV, do a [CT] scan, and make sure the patient wasn’t a bleed, but otherwise there wasn’t much to do," says Teri McClean, RN, CEN, an emergency nurse at the University of California-San Diego. "Now with stroke protocols and t-PA , there is a lot we can do for patients if they qualify for treatment. That makes the situation a lot more critical than it once was."
In recent months, treatment of stroke patients in the ED has advanced from merely preventing complications to doing acute interventions.
Laura R. Sauerbeck, RN, BSN, CEN, clinical research coordinator for the Greater Cincinnati/Northern Kentucky Stroke Team in Cincinnati, says, "Previously, we never jumped on these cases. We’d do a CT sometime in the first 24 hours to see if we were dealing with an ischemic or hemorrhagic stroke, but now we are treating these patients with the same severity rating as an MI or multiple trauma. We expedite the labs, bump routine CT patients and the pharmacy runs the thrombolytics up to the ED immediately, just like they do with an myocardial infarction."
ED nurses must change their attitudes about stroke patients, emphasizes Sauerbeck.
"For years, these were the patients we put in a corner to deal with when everything else was taken care of because we knew there was nothing we could do," she says. "Attitudes are gradually changing, but some nurses are still asking, Why should we, all of a sudden, jump on these patients?’"
That mindset has become obsolete, insist experts. Karen Rapp, RN, BSN, CCRN, clinical coordinator at the University of California-San Diego Stroke Center, says, "Before, there was no rush to treatment and no need to consider stroke an emergency. But now we have an active therapy. That means the perception of a patient who comes into the ED not speaking or moving needs to change from stable to a code blue type situation."
Rapid assessment is imperative
Quick and accurate determination of the onset time of symptoms is crucial.
"We ask if the patient was awake when symptoms started. If not, we find out when they went to bed and try to ferret out the onset time," says Spilker.
If the onset time is within three hours, the patient is considered for treatment with thrombolytics.
"When the patient arrives, you have to try to pinpoint a time when symptoms began, which is a bit of detective work for the ED staff," Spilker says. "You have to try and figure out when they started feeling numb on the left side of their body or when they couldn’t move their left arm."
Pinpointing the onset of the stroke requires top-notch assessment skills.
"It is one of the hardest things to find out," says McClean. "Nine times out of ten, the person woke up with the symptom, or they don’t remember when it started."
When it was determined that one stroke patient had collapsed at the bus station, McClean quickly made numerous phone calls to track down a security guard who witnessed the incident in order to confirm the time the fall occurred.
How quickly the patient presents to the ED after noticing symptoms can make or break their eligibility for treatment. Some patients will present within 30 minutes of their symptoms beginning, and others present with 30 minutes remaining before the time window runs out, Rapp explains.
"If the patient sits at home for the first two hours, you only have one hour left," she says. "That’s why it’s important that health care providers use that one hour very wisely."
ED nurses possess the combination of skills required to quickly assess and treat a stroke patient, says Spilker.
"All time-dependent algorithms require good team effort, and EDs are the best at doing that," she notes.
A decision should be made as to whether patients will be treated with thrombolytics within one hour.
"Any ED needs to identify its time frames and compare its data to the national standards," says Spilker.
Here is the recommended time frame for treatment of stroke patients in the ED, developed by the National Institute of Neurological Disorders and Stroke in Bethesda, MD:
• door to doctor: within 10 minutes;
• door to CT: within 25 minutes;
• door to CT interpretation: within 45 minutes;
• door to treatment: within 60 minutes.
Hospitals should add ED components to their stroke pathways, recommends Spilker. (See samples of pathways from two EDs enclosed in this issue and patient evaluation form, pp. 19-20.)
"The supportive action in the ED didn’t require the knowledge, skill, and time that these interventions will require," she notes. "That’s why it’s important that the ED is on the front of the pathway, with prehospital doing prenotification of the ED the same way they do with head trauma and MI patients."
Still, the practice of starting stroke pathways in the ED is controversial. "Any professional continuing education process takes time, and not everyone is embracing this yet," Spilker acknowledges. "Some people don’t have any desire to change the way they practice. Some ED doctors may not have been trained to read CT scans or don’t have access to stat radiology interpretations and still prefer to consult the neurologist or neurosurgeon to manage acute stroke treatments."
The new pathways are expected to save money down the road, since stroke patients receiving acute treatments in the ED may be less likely to need extensive rehabilitation or care services, Spilker explains.
"Stroke is the No. 1 disabler of adults, and if we can find treatment that prevents disabilities, we can reduce the cost of stroke," she stresses. "We are putting some of the cost of care upfront to save later on the cost of rehabilitation units, outpatient care, and home care."
When a stroke code is called at the University of California-San Diego’s ED, the stroke code team often arrives in the ED before the patient does. That team, which includes the hospital’s stroke neurologist, stroke nurse, and in-house neurology resident, is paged, and radiology is alerted to get ready for a patient coming in for a CT scan.
"We push the patient through urgently and as quickly as possible and get the necessary tests completed to provide the patient as many options as possible," including t-PA, reports Rapp. "Wasting time doing unnecessary tests or treatments could mean a patient won’t be eligible for treatment."
The University of Houston’s stroke pathway ensures that not a minute is wasted.
"We designed the pathway to point out the importance of time, since whenever we’re not moving as fast as we can, the patient is actually losing brain cells, says Patti Bratina, RN, BSN, clinical research coordinator at the University of Texas Stroke Program in Houston.
After the pathway was implemented, inservices were conducted to bring that point home to ED nurses. "We emphasized that we’re operating in hypermode up until the point of determining if the patient will be treated, says Bratina.
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