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Miriam Hospital Provides Fast, Effective Stroke Care

Monday November 29, 2010
Nurses involved in the stroke response include, from left, Jessica Brier, RN, cardiovascular clinical nurse specialist of the Center for Professional Practice Development; Mary Guenther, RN, nurse manager of interventional radiology; Beverly McGillivray, RN, ED staff nurse; Cheryl Pappas, RN, clinical coordinator; Maria Ducharme, RN, senior vice president of patient care services and CNO; Celia Gomes McGillivray, RN, quality improvement and stroke coordinator; and Diana Wantoch, RN, director of quality management.
Nurses involved in the stroke response include, from left, Jessica Brier, RN, cardiovascular clinical nurse specialist of the Center for Professional Practice Development; Mary Guenther, RN, nurse manager of interventional radiology; Beverly McGillivray, RN, ED staff nurse; Cheryl Pappas, RN, clinical coordinator; Maria Ducharme, RN, senior vice president of patient care services and CNO; Celia Gomes McGillivray, RN, quality improvement and stroke coordinator; and Diana Wantoch, RN, director of quality management.
(Photos by Heather Cygan)
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Stroke victims who are delivered directly to Miriam Hospital in Providence, R.I., are met by a 24/7 stroke team trained to quickly diagnose and treat their condition. The team, comprised of a stroke coordinator, clinical nurse specialist, neurologist on call, CT scan technologist, interventional radiologist and on-call ICU physician, has a proven track record of success — Miriam has been designated a Primary Stroke Center by The Joint Commission three times.

Part of Miriam’s aggressive stroke care protocol is the facility’s use of tPA, a lifesaving drug that dissolves blood clots. “Nationally, hospitals give tPA 3% to 4% of the time,” said Jessica Brier, RN, MS, CV CNS-BC, cardiovascular clinical nurse specialist of the Center for Professional Practice Development at Miriam. “We give tPA 10% of the time many months.”

Paramedic and ED Watchdogs

When the paramedics pick up a possible stroke patient, they have been trained to call ahead to alert the charge nurse. This allows the nurse to have the rescue team ask family members, who often are on the scene, about time elapsed since stroke symptoms began to determine tPA treatment, said Cheryl Pappas, RN, BS, clinical coordinator.

In Rhode Island, hospitals also can divert patients to certified stroke hospitals if paramedics report a patient is presenting with stroke symptoms. This allows patients to be transferred more quickly, Brier said. “Every minute 1.9 million brain cells die if the patient is ischemic,” Brier said. “[Paramedic diversion is] doing what’s best for the patient.”

When warned of a stroke patient on the way, an alert page is sounded overhead in the hospital so the stroke team can convene and assess the patient through an immediate, multidisciplinary approach.

Upon arrival at Miriam, the paramedics check a computer monitor with MedHost software, which shows in which room they should place the patient. This saves time, and patients get help right away because a stroke order set is started immediately, said Maria Ducharme, RN, MS, NE-BC, senior vice president of patient care services and CNO.


During an ED fair, Janet Engvall, RN-BC, professional development specialist, instructs nurses how to properly mix tPA, a lifesaving drug that dissolves blood clots. Standing, from left, are Lois A. Ginsburg, RN, professional development specialist, and Stacey Cascione, RN. Sitting, from left, are Jamie Fielder, RN, ED staff nurse; Joann Kane, RN; Kelsey DeCorte, CNA/EMT; and Kassie DaSilva, RN.
As soon as an order set is started, tPA is sent from the pharmacy before the stroke time frame is determined. To save time, the pharmacy allows ED nurses to mix the tPA from a vial provided through the medication storage computer, Brier said. In the rest of the hospital, the pharmacy mixes tPA first before sending. If staff cannot use tPA on the patient because too much time has elapsed, they can send it back since it isn’t already mixed. “When you give tPA, [patients] are fading, and then you can see them go back to baseline [after administering the drug],” Pappas said.

When recognizing signs and symptoms of stroke in a patient, ED nurses also have been trained to notify the stroke team immediately to make sure the patient is triaged quickly, said Beverly McGillivray, RN, BSN, ED staff nurse. They immediately start an order set by inputting “acute neuro deficit” into the electronic medical record. The response team’s goal is to take the patient from the ED door to CT scan in 25 minutes, McGillivray added. The ED also has been screening for dysphagia instead of ordering nothing by mouth immediately after the CT scan.

While assessing the patient, the nurse or physician grabs a stroke binder, created by Brier, and fills out the stroke form. All forms in the binder also are available online. The stroke team response is treated like a code, allowing nurses to order tests, such as the CT, before the physician sees the patient. The CT department also will postpone any nonimmediate tests to get the stroke patient in as fast as possible.

On medical unit 3 East, Kristen Young, RN, BSN, clinical coordinator, said each stroke patient and his or her family members are given an orange folder that includes educational materials, support group information and care instructions. About half of all stroke patients end up on her unit, Young said. After receiving the packet, patients or family sign that they received and reviewed the information and are given an ACT F.A.S.T! card that describes stroke signs and symptoms.


Nancy Robin, RN, ED nurse educator, poses in front of a poster about “The Finer Points of Neuro Assessment” to help refresh Miriam Hospital nurses about proper stroke care.
Applying Data Outcomes

Hospital staff regularly review internal and external research and update their stroke guidelines accordingly to ensure the multidisciplinary team stays on the same page. “We are always trying to customize and make sure that care is concurrent,” said Celia Gomes McGillivray, RN, BSN, MPH, CHES, quality improvement and stroke coordinator.

Staff also continually work to reduce door-to-CT times, increase tPA usage and mainstream dysphagia screening.

To improve communication, Pappas also has been working with paramedics on survival rates for patients for whom they called ahead. This improves paramedic buy-in because they often wonder how the patients they dropped off fared, she said. With the data, paramedics can share quality indicators, such as whether they responded fast enough to get the patient tPA.


Miriam Hospital nurses Cheryl Pappas, RN, clinical coordinator, left, and Beverly McGillivray, RN, ED staff nurse, review the Stroke Resource Manual binder created by Jessica Brier, RN, cardiovascular clinical nurse specialist of the Center for Professional Practice Development. While assessing a stroke patient, the nurse or physician will grab the binder and take it to the patient’s room.
Resource Allocation

The rapid response protocol, which follows the National Institutes of Health’s stroke scale, has been effective because of the buy-in and support of nursing supervisors, Gomes McGillivray said.

Requested resources also have been granted, such as the clinical nurse specialist and stroke coordinator positions, enabling the stroke team to improve their care, Ducharme said.

Teaching tools also play an important role in communication and education, such as grand rounds, on-the-spot training, RN education and certification, competency training, newsletters, quality indicator boards, an ED fair and an annual forum for clinical excellence during which staff discuss data, Pappas said.

Another invaluable group is the stroke leadership team that reviews quality indicators monthly and examines outlier cases to enhance quality, Brier said. The interdisciplinary team, cochaired by two physicians — a neurologist and an ED physician — includes Brier and Gomes McGillivray; Carol Lamoureux, director of the stroke center who co-leads the committee with the MDs; an interventional radiologist; and Diane F. Wantoch, RN, BSN, MBA, CPHQ, director of quality management. In addition, a broader stroke committee meets quarterly, which includes members of the stroke leadership team, rehabilitation and all staff nurses and nurse managers on units who care for stroke patients.

Miriam also has provided stroke support and advice to Newport Hospital and Rhode Island Hospital, both Lifespan hospitals, as they pursued stroke center designation, said Gomes McGillivray, who helped create the Rhode Island Stroke Coordinators Network, a statewide group that meets quarterly to share best practices and quality initiatives.

Miriam has come a long way in improving its stroke care. “We took a vision of what we wanted to have happen and made it happen,” Wantoch said.

Pappas agrees. “We don’t want to meet the standard, we want to improve it,” she said.

For a photo gallery from Miriam, visit www.Nurse.com/gallery/Miriam.


Heather Cygan is managing editor. Send letters to editorNE@nursingspectrum.com or comment below.