Stroke Nurse Research Articles

Abstract W P286: Effect of a Dedicated In-House Stroke Nurse on Stroke Quality Outcome Measures: A Single Center Experience

Background and Purpose: As a comprehensive stroke program with a large transfer population, the transfer process initially was coordinated by the Intensive Care Unit charge nurse. As the program grew, a strain was placed upon the nurses. The focus of the Code Neuro Nurse role was to coordinate all stroke transfer patients and responding to all internal strokes. We sought to determine the efficacy of the Code Neuro Nurse role in improving documentation and education as it relates to the stroke population. Methods: A retrospective analysis of seven quality indicators was performed before and after program inception. Dysphagia screening (n=1071), Stroke education (n=870), National Institute of Health Stroke Scale (NIHSS) on admission (n=1197), NIHSS on discharge (n=2302), modified rankin score (mRS) on admission (n=1567), mRS on discharge (n=2302) and door to intravenous (IV) tissue plasminogen activator (tPA) within 60 minutes (n=35). A two tailed t-test was performed analyzing data from July 2011 through June 2013 comparing two twelve month data groups (2012 and 2013). Results: Significant improvement from 2012 to 2013 quality indicators was demonstrated in documented stroke education from a mean of 95.6% to 100% ( p= 0.0153), NIHSS on discharge from mean 72.6% to 82.3% (p=0.0416), mRS documentation at admission from a mean 67.7% to 92.6% (p<0.0001) and mRS documentation at discharge mean 62.5% to 78.4% (p=0.0049). Although not statistically significant, quality indicator improvement was demonstrated 2012 to 2013 in NIHSS reporting on admission from mean 96.1% to 98.5% (p=0.074), dysphagia screening from mean 85.4% to 89.1% (p=0.053), and door to IV tPA in 60 minutes from mean 31.3% to 58.7% (p=0.15). Conclusions: The “Code Neuro Nurse” program demonstrated an increase in documentation related to the care of the stroke patient. While other areas showed increased improvement related to testing and process, the results were not statistically significant. Further evaluation is warranted to determine the opportunities for further growth and development of the program.

Abstract W P289: Hyper Acute Stroke Nurse Initiative Improves Time to Initiation of Reperfusion Therapy

Background: Following Primary Stroke Center designation in 2008, several factors contributed to our hospital's influx of stroke patients. In 2010, the Emergency Medical System covering our county began diverting stroke patients to our facility. In 2011, our 400+ bed medical center became the only organization capable of providing endovascular treatments in the region. This catalyzed another surge of stroke patients transferred to our hospital from outside facilities. Nurses and physicians in the ED noted increased workloads in an attempt to deliver stroke care in a timely manner. In May 2013, the innovative Hyper Acute Stroke (HAS) nurse was created to meet the time sensitive needs of our expanding stroke population. Purpose: The purpose of this initiative is to show the addition of the HAS nurse would improve time to IV tPA and endovascular intervention in stroke care, as well as physician and nurse satisfaction. Methods: With strong administrative and medical support, the Stroke Program Director and 15 critical care neuroscience nurses formed the HAS team. Initial training for the HAS nurse comprised of NIHSS certification and enhancement of neuroscience knowledge. Orientation included training with the Stroke Program Director on inter-facility transfer processes, response to ED Code Strokes, and formation of stroke care algorithms. Upon training completion, daily rotation ensured 24/7 HAS nurse coverage. Pre and post HAS nurse performance measures for IV tPA door to needle (DTN) and door to endovascular intervention times were analyzed. Physician and nursing satisfaction was also surveyed pre- and post HAS nurse involvement. Results: Data refers to the 12 months pre HAS compared to data post HAS nurse. When comparing pre HAS to post HAS time periods, DTN decreased from an average of 82 minutes to 38 minutes, while door to endovascular intervention decreased from an average of 136 to 111 minutes. Physician and nurse satisfaction improved since the institution of the HAS nurse. Conclusions: In conclusion, when responding to Code Strokes or assisting with transfers requiring emergent endovascular intervention, HAS nurse involvement improved time to intervention, and physician/nurse satisfaction.

Abstract TMP86: Evaluation of NIHSS Application Program to Stroke Nurses

Background and purpose: Neurologic assessment for stroke nurse is very important, since exact examination and finding for neurologic symptoms greatly affect prognosis of stroke. NIHSS is a tool to best reflect neurologic status for acute ischemic stroke and this is mostly measured by neurologists. Although the closest medical team member is a nurse, indeed there are not many hospitals where a nurse measures NIHSS and related researches are also insufficient. The purpose of this study is to evaluate quality of nursing as NIHSS Application Program (NAP) to stroke nurses. Methods: NAP was performed from April to July, 2010 as following. Theoretical and practical educations for NIHSS by a stroke clinical nurse specialist were performed for stroke nurses and they completed learning for video lectures and certification individually by website. NIHSS was measured every shift and integrated with electrical medical records. This research compared medical records before and after NAP and set participants who were hospitalized in acute stroke unit through emergency room and diagnosed ‘ischemic stroke’. Pretest group (n=100) was set from January to March, 2009 and posttest group (n=115) was set from January to March, 2011. Pearson’s t-test and chi-square test were used to measure differences between two groups. Results: Nursing records for neurologic assessment items were all increased (50% versus 95%, p =.008). Especially items for ‘neglect, dysarthria, visual disturbance, pupil status, and EKG’ were significantly increased. Number of notified cases for neurologic changes by nurse was increased (21% versus 39%, p =.004). Most of notified reasons were focused on ‘limb motor function’ in pretest group while items for ‘alertness/awareness, facial palsy, limb ataxia’ were newly reported for posttest group. Among notified cases, patients detected extensions of stroke lesions (6% versus 10%, p =.000) and patients treated induced hypertension therapy were both increased (13% versus 22%, p =.000). Conclusions: NAP improved nurses’ degree of knowledge for stroke patients and this contributed to prevention of deterioration of stroke. It is widely needed to apply NIHSS by stroke nurses for quality of nursing.

Abstract TP365: Think Big: Weekly Stroke Education for Registered Nurses on the Stroke Unit

Background: Nurses play a pivotal role in all phases of care of the stroke patient. Stroke Nurses have responded to the challenge of making stroke systems of care a reality in recent years. We wanted our stroke nurses to use evidence-based practice to organize and deliver stroke services and facilitate optimal outcomes for stroke patients. One of the most important components of a Stroke Program is having a designated unit where patients receive specialized stroke care. Nurses who are a part of a stroke center should be trained to recognize medical complications that can arise in someone who has suffered a stroke. One of the most important reasons why primary stroke centers are the premier places for the treatment of strokes is that, by having specialized stroke units, patients have better outcomes. Is weekly stroke education for RNs on the stroke floor helpful to the nurses?<br Does it influence or impact the way they care for their patients? Methods: Since information,research and even nursing staff is always changing, education needs to be provided to nurses taking care of stroke patients so they have the latest and greatest knowledge to share with their patients and loved ones. We asked the staff what topic they wanted to cover and posted a suggestion box on the unit entitled “Ask a Stroke Nurse,” analyzed the attendance and did a survey to get the nurses’ feedback. Collectively we decided the best way to capture all staff on all shifts was to do weekly in-services and education sessions covering everything from Journal articles, updates about the program, interesting case studies, breaking science and even guest speakers from other departments. Conclusion: The survey showed that 96% of RNs on the stroke floor found the weekly education very valuable. 96% found that it positively impacted their practice,additionally, 91% said it greatly increased their knowledge about stroke & TIA. We will continue weekly education and continue to get feedback from the nurses. This endeavor has proven to be a very successful. We were pleased to see the positive comments from the staff about how much they enjoy and look forward to the classes each week.

Abstract WP373: A Novel High-risk TIA and Minor Stroke Rapid Assessment Day-unit to Improve Quality of Care and Patient Outcomes

Background: About one in four ischemic strokes are preceded by a TIA; 43% of TIAs occur within one week before stroke. Patients with a TIA require urgent assessment, risk stratification, and preventative treatment, but often cannot access a Stroke Prevention Clinic in a timely fashion. Therefore, these patients are often admitted to hospital for evaluation but it is unclear if inpatient evaluation is optimal or specifically necessary for this patient population. Methods: We developed a novel high-risk TIA and Minor Stroke (TAMS) day-unit to provide rapid access to patient assessment, investigations, initiation of prevention strategies, and stroke prevention education. The TAMS Unit patient assessments were based on a collaborative model led by stroke Nurse Practitioners and an attending stroke Neurologist. All patients had cerebrovascular imaging (CT angiography, MR angiography, or carotid Doppler if there were exclusions to CT or MR angiography), and as appropriate, echocardiography and Holter monitoring initiated at the TAMS Unit visit. We evaluated the feasibility of this novel care model. Outcomes including time to assessment, investigations, and treatment for high-risk TIA/stroke etiologies and stroke risk factors, as well as return emergency department visits or readmissions within 30 days were assessed. Results: Between Sept. 6, 2011 and Aug. 8, 2012, 142 patients were seen in the TAMS Unit. Median time from emergency department visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 41% of patients and minor stroke (NIHSS < 4) in 27.5% of patients. Atrial fibrillation was diagnosed in 8 (5.6%) patients; anticoagulation was initiated promptly upon diagnosis. High-grade carotid stenosis was diagnosed in 4 (2.8%) patients and these patients were referred for urgent endarterectomy. There were 12 (8.5%) patients that had a return visit to the emergency department within 30 days; 2 (1.4%) with stroke, 8 (5.6%) with recurrent TIA or fluctuating symptoms, and 2 (1.4%) with other diagnoses. Conclusion: Our novel TAMS Unit is a feasible care model that provides rapid access to assessment and treatment of high-risk TIA and minor stroke patients, and is another level of care between hospital admission and the outpatient Stroke Prevention Clinic.

Abstract TP251: The Direct and Indirect Impact of the Acute Stroke Nurse Role on Thrombolysis Treatment Times and Rates

Background: The Acute Stroke Nurse (ASN) role at Box Hill Hospital is a business hours (weekday 8am - 4.30pm) first responder role designed to fast track acute stroke patients through thrombolysis screening in the Emergency Department. Since 2004, this role has been filled in either a full-time (FT) or part-time (PT) capacity, except for a 5-month period in 2010 where the role was vacant. We sought to explore the influence of having a full-time ASN, compared to part-time or no ASN, on thrombolysis rates and times. Methods: Data was extracted from the hospital’s stroke thrombolysis database for the period 2004 to 2012. Comparisons were made for those patients seen by the ASN, when FT and PT and those who saw medical staff only. Statistical comparisons were made using Mann-Whitney Rank Sum test. Results: Almost half (43% n=182) of the 428 thrombolysis cases occurred during business hours, the ASN attended 84% of cases when the role was filled FT and 15% when PT. No difference was seen in median door-to-CT times (25 minutes.) Faster median door-to-needle times were achieved during business hours when the patient was seen by the ASN compared to those who were not (66 mins vs. 83 mins, p=<0.001.) Faster times were seen when the ASN role was FT (68 min) or PT (79 min) compared to vacant (89 mins, p=0.006,) with more patients treated within 60 minutes of arrival (35% FT, 27% PT and 8% vacant, NS). While the ASN only works within business hours, faster door-to-needle times were seen after hours when the ASN role was filled FT and PT compared to vacant (87mins and 100 mins vs. 103 mins, p=0.013;) and treatment was only commenced under 60 minutes when the ASN was employed FT. Conclusion: The Acute Stroke Nurse role seems to have a positive impact on thrombolysis treatment times and rates, with the best results being achieved during and outside business hours when the ASN is employed FT.

Abstract WP342: Clinical Practice Guidelines supported through Interdisciplinary Stroke Rounds

Purpose: Interdisciplinary stroke rounds were created as a communication forum for staff working with the stroke survivor and family in our hospital stroke unit. The interdisciplinary team discusses patient specific needs in addition to met and unmet clinical practice guidelines. Methods: Interdisciplinary stroke rounds are scheduled daily at a set time in the stroke unit conference room. The team is comprised of the following members and disciplines: RN Unit Manager, RN charge nurse, RN caregiver for the patient, Stroke program Nurse Coordinator, Physician Director of the Stroke Program, rehabilitation specialists: speech, occupational therapy, physical therapy, registered dietician, chaplain, casemanager, liaison RN for admission to acute rehabilitation, skilled nursing or outpatient rehabilitation. A precise discussion is coordinated by the RN charge nurse or the Stroke Nurse Coordinator using a stroke performance measure template accessible to the team. The interdisciplinary team provides input related to their expertise. Eight of the standard stroke performance measures are discussed and addressed for compliance. Compliant staff documentation and patient education opportunities are discussed and interdisciplinary care plans are activated. The interdisciplinary team summarizes the needs identified in stroke rounds and each member is responsible for completion before the end of their shift. Results: Our hospital has earned the Stroke Get with the Guidelines (GWTG) gold plus award for multiple consecutive years. Compliance with the national standards for stroke reflected within our GWTG data is largely due to our interdisciplinary stroke rounds and staff accountability. Conclusions: Utilizing a specific stroke performance measure tool during interdisciplionary stroke rounds enables our team to review all stroke performance measures, ensure documentation is complete and allows an interchange of ideas among disciplines to provide the best care to the stroke survivor and family..

Stroke rehabilitation and discharge planning

Nurses play a pivotal role in the rehabilitation and discharge planning process of patients who have had a stroke. The nurse's role in the wider stroke multidisciplinary team is complex and diverse and, as such, stroke nurses may find it hard to describe their role and how it fits into the rehabilitation and discharge planning process. A definition of the stroke nurse role in prominent publications such as those of the Scottish Intercollegiate Guidelines Network and the Royal College of Physicians is lacking. This article emphasises the role of the stroke nurse in the rehabilitation and discharge planning process in the stroke unit, while highlighting the complexity, diversity and importance of this role in providing holistic care and support for patients who have survived a stroke. The author draws on his clinical experience of stroke nursing practice in primary, secondary and tertiary care in west central Scotland.

Abstract 3074: Acute Stroke Nurse Response Pilot Program

Background: Less than 10% of ischemic stroke patients receive tissue plasminogen activator. Low treatment rates have been associated with delay in hospital presentation and reluctance to treat. Studies have found that a combination of community and professional education increase thrombolytic therapy from 2.2% to 11.3% with the data suggesting that professional education made the most impact. An Acute Stroke Nurse Response educational program was piloted as a means of providing specialized treatment education for nurses in North Carolina. Project goals: A. Increase the number of nurses across the state experienced to provide acute stroke assessment and treatment. B. Determine the best educational approach: on-line vs. class room vs. both. C. Develop a mock code stroke training module. D. Provide guidance in developing individualized models of stroke care protocols. Measurable objectives: A. Gauge interest in the program. B. Assess pre and post-test knowledge measuring effectiveness of modules. C. Assess nurse preference for teaching method. D. Evaluate the methodology of the mock code stroke module. Methods: The educational program covered stroke topics through on-line modules and a one day lecture series to meet the needs of the working nurse. The program consisted of 10 specialized stroke training modules: Module 1: Introduction to Stroke Module 2: Emergency Management Module 3: Acute Stroke Treatment Module 4: Management of ICH Module 5: Stroke Prevention Module 6: Nursing Care of the Stroke Patient Lecture 7: Neurological Assessment Lecture 8: Stroke Imaging Lecture 9: Quality Improvement/Joint Commission Primary Certification Lecture 10: Mock Stroke Code 6 weeks were allowed to complete the on-line modules prior to the day lecture series. Pre and post-test exams were administered to assess baseline knowledge and knowledge gained. Results: 42 nurses showed interest in the program. 12 nurses completed the pilot program. 10 were from NC, originating throughout the state and 2 from SC. Two participants were NP’s, 2 ED nurses, 3 staff nurses and 5 stroke coordinators. Participants had a mean pre-test score of 53.2, which increased significantly (p<0.001) to a mean post-test score of 77.8 (absolute mean improvement of 24.6%). The improvement in the scores ranged from 11.1 to 44.5% with one participant experiencing a decrease in test scores by 5.6%. Program feedback was positive, with strengths identified as “convenient and informative”. All participants requested the program continue as originally developed with on-line modules and the one day lecture series. Conclusions: There was a significant educational benefit from this program, as demonstrated by participant responses to the pilot program.

A survey of stroke nurses' knowledge of secondary prevention lifestyle issues

Nurses have an important role to play in providing information and advice on lifestyle risk factors for recurrent stroke. However, patients report receiving little or no lifestyle information. Aim: This study aimed to explore stroke nurses' knowledge and practice in relation to the provision of secondary prevention lifestyle information following stroke. Design: Cross-sectional survey methods were used. Participants were members of the Scottish Stroke Nurse Forum (n=97). Methods: A self-completed questionnaire was used to collect the data, with descriptive statistics summarizing the results. Results: Respondents stated that they assessed lifestyle risk factors following stroke; however, they focused on some but not all risk factors. While written and verbal information and advice was provided, knowledge of guidelines and health-related recommendations was limited. Conclusions: Stroke nurses require improved access to continuing professional development with regard to secondary prevention of stroke. They also require easy access to information resources which support evidence-based practice.

The impact of stroke consequences on spousal relationships from the perspective of the person with stroke

This paper aims to provide a subjective insight into the experience of stroke recovery within spousal relationships. The aftermath of stroke and its impact on the physical, emotional, psychological and social effects of spousal relationships are explored. Many studies have examined observable functional recovery following stroke from the perspective of health care professionals. Longer-term effects of stroke such as changes in role and perception of self can alter significantly the dynamics of spousal relationships. Despite this, little attention has been given to the subjective impact of stroke on spousal relationships. A qualitative study design was adopted. Individual, audio-taped interviews were carried out over three months. A convenience sample of 16 stroke survivors was recruited from the Stroke Nurse Specialist Register. All participants were over 18 years old and had been discharged from hospital following a diagnosis of stroke. Transcribed interviews were analysed using content data analysis to code and categorise emerging themes. Poststroke, spousal relationships altered significantly in terms of sexuality, sexual desire and sexual functioning. Within their role of husband or wife, stroke survivors described a lack of control and dramatic changes in their perception of self. Survivors of stroke experience profound, complex and multi-faceted difficulties in many areas of their spousal relationships, which are distressing to both them and their spouses. These have a significant impact on each individual's quality of life particularly in the longer term. Health care professionals and service providers need to understand and recognise the subjective experience of stroke and the complex difficulties that stroke survivors experience within their spousal relationships. It would appear that current service provision does not adequately address the range of needs that the stroke survivors described in this study.

Bridging the Gap Between Primary and Specialist Care – An Integrative Model for Stroke

Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system.

Stroke outcomes in Northern Scotland: does rurality really matter?

Stroke is the third leading cause of death in Scotland after coronary heart disease and cancer and is a major cause of long-term disability. There is evidence in other clinical conditions such as asthma, diabetic retinopathy, and cancer that rural residents may have poorer outcomes, due to relative inaccessibility of health-service provision or because the disease is at a more advanced stage at diagnosis. However, the evidence-base for stroke care and outcomes in remote and rural areas is small and the subject matter is under-researched. This study was designed to examine, over a one-year period, the incidence and outcome of stroke occurring in the Highlands and Islands of Scotland, a large geographical area with many rural and remote settlements. The study explored whether stroke care and outcome was affected by remoteness and rurality. The study was a prospective, community-based, observational survey. Patients in Highland and the Islands (Orkney, Shetland and the Western Isles) suffering first-ever stroke during a 12-month period (from 1 May 2001 to 30 April 2002) were included. All practitioners from health and social care sectors, residential homes, voluntary and charitable organisations were encouraged to notify the researchers of any individual they suspected or knew had a first-ever stroke within the designated time period. Data on 'limitation in activities' (formerly 'level of disability') and service provision were collected using questionnaires and proformas at 1, 3 and 6 months post-stroke from several sources. These included individual patients and carers, health and social care professionals, residential homes, voluntary organisations, and charitable organisations. The analysis focused on location at time of follow up, limitation in activities and service provision. Outcomes were compared across different settlement categories. Settlements were classified as urban/accessible, remote rural and very remote, based on the Scottish Household Survey. In all, 303 patients with a suspected first-ever stroke were notified to the study. The resulting crude incidence of reported stroke was 1.1 per 1000. From the notifications, 239 patients were sent a consent form, of whom 118 agreed to participate in the study. The final dataset, after exclusions for incorrect diagnosis, deaths and other reasons, was derived from 85 patients. Among these, patients from remote rural and very remote settlements were over-represented, when compared to all patients notified. The majority of patients returned home from acute hospitals during the study period and the likelihood of returning home was not related to settlement category. However, a greater proportion of patients in remote rural settlements were admitted to community hospitals and remained there at 6 months. Approximately two-thirds had some degree of disability (or limitation in activities) after their stroke. One-third of patients classed themselves as independent across all time points. Overall, the Barthel Index score increased over time (ie, patients experienced a reduction in disability) with the average score at 1 month post-stroke being 82.5 (range 0-100), at 3 months 85 (range 5-100), and at 6 months 90 (range 5-100). Uptake of services was similar across all settlement categories, with low levels of use at 6-months post-stroke. In particular, few patients used social-support and stroke-specific services, for example Chest, Heart and Stroke Scotland, and Stroke Nurse services. The proportion of patients using any service at 1, 3 and 6 months did not differ between settlement categories. Rural patients did not therefore appear disadvantaged in service provision. The low incidence of reported stroke may have been due to a number of reasons including: death prior to notification; diagnostic uncertainty; stroke severity--failure to notify very mild or very severe stroke cases; and inadequate reporting of patients managed at home. The greater proportion of patients in remote rural settlements being admitted to community hospitals and remaining there at 6 months may reflect greater availability of community hospital places in this settlement category, but may also be influenced by stroke severity. The low uptake of rehabilitation and support services generally, combined with the relatively poor functional outcome of our patients, suggests that there may be an unmet need for rehabilitation. However, rural patients did not appear specifically disadvantaged. Our study indicates that patients developing a first-time stroke in remote and rural areas of the Highlands and Islands of Scotland are not disadvantaged compared to those in urban/accessible areas, with respect to outcome or to the utilization of health and social care services. However, functional outcomes could be improved for patients in all settlement categories.

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials