For patients who suffer a stroke, immediate care in the first hours is essential. This can be a challenge for patients living in rural or outlying areas that do not have access to a neurology specialist. Telestroke centers across the country facilitate consultations 24 hours a day. A telestroke system allows a neurologist and an attending nurse to use videoconferencing capabilities to remotely evaluate a patients motor skills, talk to the patient about symptoms, view the patients CT scan and prescribe treatment based on whether he or she experienced a hemorrhagic or ischemic stroke.
Those who suffered an ischemic stroke can reduce or eliminate their risk of death and disability through the administration of tissue plasminogen activator or tPA, if it is administered within three hours of the onset of a stroke (for most patients), according to the American Stroke Association. Telestroke services aid in meeting optimal treatment times by eliminating or reducing the need to transfer patients to a stroke center.
Hospitals involved in telestroke programs become either a hub (the facility offering services) or a spoke (a smaller facility utilizing them) in the wheel that is stroke care. Telestroke services fill the gap for smaller hospitals, or those in outlying areas who dont have a board certified neurologist on staff to provide an immediate acute neurologic evaluation, said Karin Nystrom, RN, MSN, APRN, FAHA, of the Yale New Haven (Conn.) Stroke Center.
Beyond the bedside
Typically a telestroke program coordinator is an advanced practice nurse or clinical nurse specialist who oversees the clinical, technical and administrative policies of the program, Nystrom said. Staff nurses working at the bedside must be familiar with all the diagnostic elements needed during the work-up and treatment decision process during the initial golden hour.
Nystrom said nurses may be responsible for making the initial contact with the on-call telestroke physician and for mobilizing and operating the videoconferencing equipment. In busy emergency departments, the nurse will be the primary person collaborating with the telestroke physician when performing the neurologic exam and keeping family members informed of the process, Nystrom said. Crucial demographic and clinical information such as frequent vital signs and lab results are also usually retrieved by the nurse and shared with the telestroke physician.
Diagnosis and treatment
While there is no certification specific to telestroke programs for nurses, Nystrom said there are several important elements of the initial diagnostic work-up and frequent assessments that have been built into the training of the nursing staff in order to run a seamless operation. First, nurses involved with acute stroke codes must be familiar with the acute stroke algorithm and the time-sensitive activities during the first golden hour, Nystrom said. Second, in addition to being familiar with the basic functions of the videoconferencing equipment, nurses are usually certified in the National Institutes of Health Stroke Scale assessment as this tool has been deemed a reliable and standardized tool for assessing stroke severity.
Jean Estes, RN, BSN, CEN, stroke nurse coordinator at Falmouth Hospital in Falmouth, Mass., a spoke facility and part of the Partners Telestroke program operated in conjunction with Boston-based hospitals Massachusetts General and Brigham and Womens, said nurses must remember the time targets, the most important one being the golden hour in which to give t-PA.
Estes said telestroke programs are excellent at providing training, as well. Not only do telestroke programs provide patient evaluation, they also provide education to the physicians and nurses at the Spoke hospitals, Estes said. We have had guest speakers at our hospital discussing latest stroke care, stroke in the community and t-PA for stroke.
Each stroke case that is presented provides nurses with a real-time learning experience. Telestroke neurologists are excellent at explaining to nurses how to perform a test on the patient if the results are difficult to interpret, Estes said. For instance, the telestroke physician might suggest that the nurse attempt visual threat on patients that are aphasic, or they might ask to veer from the normal NIHSS and ask the nurse to hold the patients leg at the knee to assess the movement of the lower extremities.
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