Stroke: Best Practices
Over the past several years, the multidisciplinary stroke teams at Crozer, DCMH and Taylor have developed new guidelines and protocols to streamline stroke-related processes and ensure the excellent patient care that led to recognition by the American Heart and Stroke Association. Nurses have been at the forefront of development and implementation.
Emergency Department policy and pre-emptive treatment guidelines:
- Ascertain exact time of symptom onset, assign triage acuity, obtain bedside and diagnostic studies.
- If patient is identified as eligible for tPA therapy, a nurse is assigned 1:1 for the next hour to ensure that the three-hour timeline is met. ED physician activates stroke beeper. Responders include Neurology, CT Scan, Pharmacy, Lab and stroke coordinator.
- CT scans and lab work are completed and evaluated within 45 minutes of patients’ arrival in the emergency department. A new stroke panel was developed to streamline lab test ordering and speed results. Lab specimens are labeled with bright green “STROKE” stickers to ensure that they receive top priority.
- A dysphagia screening tool and NIH stroke scale evaluation tool and protocol were also developed and implemented.
Rapid response team protocol for stroke on inpatient units was developed to rapidly identify patients experiencing stroke symptoms and to begin diagnostic evaluation.
New Ischemic Stroke/Transient Ischemic Attack (TIA) admission order set has been implemented to help prevent the occurrence of a major stroke. According to NIH, about one-third of those patients who have a TIA will have an acute stroke some time in the future.
Patient education is a primary focus because 80 percent of all strokes are preventable, according to the literature. Bedside nurses and case managers play a critical role.
Pre-hospital EMS now conducts pre-assessment, drawing blood before arrival at hospital to speed door-to-treatment time for patients identified as stroke.
Physical Medicine and Rehabilitation team assesses all stroke patients, even if they appear to be without deficit.
Joint Commission and Get with the Guidelines Harmonized Stroke/TIA Measure Set (January 2009)
- DVT Prophylaxis (Ischemic and Hemorrhagic). Assessed and ordered on admission for appropriate patients.
- Discharged on Antithrombotic Therapy (Ischemic, TIA)
- Patient with Atrial Fibrillation or A-flutter Receive Anticoagulation Therapy (Ischemic)
- Thrombolytic Therapy Administered (Ischemic)
- Antithrombotic Therapy by End of Day Two (Ischemic, TIA)
- Discharged on a Statin (Ischemic, TIA). Includes patients with LDL≥100; patients on cholesterol reducing medication prior to admission; patients for whom no lipid profile is documented; and patients with a documented history of atherosclerosis.
- Dysphagia Screening (Ischemic and Hemorrhagic).
- Stroke Education (Ischemic and Hemorrhagic, TIA). Includes warnings signs, personal risk factors, activation of EMS system, medications and follow-up after discharge.
- Smoking Cessation Counseling (All)
- Assess for Rehabilitation (Ischemic and Hemorrhagic)