At Inova Healthcare System in Virginia, a revolution in the nurses role on the stroke team has contributed to a dramatic reduction in the door-to-needle times for tPA administration. With the shorter times, Inova Fairfax Hospital in Falls Church has increased the number of patients who receive tPA from 2.1% in 2006 to 14.8% in 2012.
Their success is due in part to training nurses as primary stroke responders, allowing these RNs to perform the initial assessment to determine if the patient is a candidate for tPA. The nurse can notify other members of the stroke team and quickly facilitate a patient having a CT scan to rule out a hemorrhage. Previously, physicians fulfilled this role, but the demands of caring for other emergency patients ran the risk of slowing down the door-to-needle times.
Stroke nurses have become so efficient and expert over time that now the physicians look to them for an accurate analysis of all the information, and together they determine if a patient is a candidate for tPA, said Barbara Mancini, RN, MBA, CNRN, FAHA, service line director for neurosciences at Inova Fairfax Hospital.
If the stroke physician is at home or at another Inova facility, the rapid response stroke nurses can convey this information via telestroke, which allows the physician to see the patient and the nurse on a smartphone, computer or other electronic device, said Larisa Golding, RN-BC, MSN, a patient care director at Inova Alexandria Hospital. The process at Inova Alexandria has become so efficient that average door-to-needle times in the last quarter of 2013 was 52 minutes compared to 135 minutes only two years earlier.
Daily report card
Even though time is critical in the initial stages of stroke care, there are other important factors that influence a patients long-term outcome. To determine how a facility is faring in critical areas of stroke care, hospitals participate in Get with the Guidelines-Stroke, a database produced by the American Heart Association. Data from each stroke patient is entered in categories such as dysphagia screening, treatment for venous thromboembolism, evaluation for statins and patient education.
At UNC Health Care in North Carolina, stroke program coordinator Nicole Burnett, RN, BSN, CNRN, CCRN, was one of the members of the stroke team who analyzed the hospitals data to determine areas for improvement. They realized that historically nurses learned how well they were doing in certain categories after patients had been discharged. By giving caregivers daily updates from the database, they could remedy a failed measure before the patient had left the hospital.
As a result of this change, the scores in several areas of stroke care have improved dramatically. In 2013, 96% of patients received dysphagia screening before discharge at UNC Health Care compared to 55% in 2011. This is important because patients who do not receive the screening are at risk of choking or contracting pneumonia, Burnett said. The nurses have appreciated having the daily feedback, and they like the positive reinforcement when they reach so many months of compliance.
Barbara Lutz, RN, PhD, CRRN, FAHA, FNAP, FAAN, a professor in the School of Nursing at University of North Carolina-Wilmington, recently completed a study funded by the National Institute of Nursing Research, which focused on the needs of stroke survivors and their caregivers. When stroke patients return home, caregivers are suddenly expected to fill a job that was previously performed by many trained staff, she said.
Conclusions of her research included that nurses should:
Assess a caregiver not just the patient before discharge from a rehabilitation facility. Assess factors such as the caregivers physical and mental health, financial resources and prestroke roles responsibilities. (Lutz and her team plan to develop an assessment tool for this.)
Develop a nurse-led transitional care intervention during rehabilitation to help caregivers develop a detailed plan to manage their new responsibilities. (The plan can include finding family members or friends to assist the caregiver during the first week, a system for organizing follow-up appointments and medication administration, and a contact list of people and organizations who can be called for help.)
Have a nurse who is familiar with the caregiver call within the first 24 hours and provide follow-up support for the first 30 days post-discharge.
For assessment ideas, see Lutzs article in the Jan. 28, 2014 issue of Disability and Rehabilitation.
To see what else is trending in stroke, visit www.Nurse.com/Stroke.