Nurses have ‘crucial’ role in stroke care, from ED admission through discharge

The American Heart Association released a set of three scientific statements that outline the nurse’s role in the management of ischemic stroke, with separate statements for hyperacute/emergency care, the ICU and stroke units.

The scientific statements, which were announced in a press release from the American Heart Association (AHA), were published as three separate pieces in Stroke.

“On average, someone in the United States has a stroke every 40 seconds, and ischemic stroke is the fifth leading cause of death in the U.S.,” the press release stated. “As assessment tools, treatment protocols and overall care for acute ischemic stroke have evolved in recent years, best practice in nursing for care of the patient with a stroke continue to be revised and updated. Stroke care is increasingly complex, and nurses who care for stroke patients are expected to maintain levels of competency in both the acute and recovery care phases of patient care.”

’Time is brain ’

The first statement focused on nursing during emergency care for patients with suspected stroke. Susan Ashcraft, DNP, APRN, FAHA, of Novant Health, and colleagues highlighted the “time is brain” principle in their statement, which reinforces the need to quickly identify patients with a suspected ischemic stroke and intervene early to prevent “irreversible tissue damage” and poor patient outcomes.

The statement reviewed the nurse’s role helping the public recognize the signs of stroke to expedite the call for emergency medical services and highlighted nurses as “the communicating link” between the team caring for the patient prior to arrival at the hospital and the ED team. It also reviewed the “pivotal role” nurses have in the triage process for patients with suspected acute ischemic stroke who arrive at the ED via emergency medical services or a private vehicle.

“The time-sensitive acute stroke treatment options warrant highly skilled nurses to understand the elements of the prehospital stroke screening tools used by the local [emergency medical services] agencies that justify a prehospital stroke code activation,” the researchers wrote. “Similarly, triage nurses must rapidly recognize and evaluate patients who arrive by modes other than ambulance (ie, walk-ins) and present with one or more of a multitude of suspected stroke symptoms.”

According to Ashcraft and colleagues, triage nurses may be the first group to assemble the stroke code team. The researchers called neuroscience nurses “architects of stroke care” who have an important role in coordinating care across multiple providers.

The statement then described the role of nurses in the early treatment of patients who have had an ischemic stroke, care which is becoming “increasingly complex in the new reperfusion era,” according to the researchers. Ashcraft and colleagues examined drugs as well as devices used to manage stroke, including tissue plasminogen activator (alteplase) within the first 3 hours of symptom onset and mechanical thrombectomy with stent retrieval devices among eligible patients with large vessel occlusion.

The first statement also examined the role of telehealth and the transition of care for patients with ischemic stroke, or the transfer of patients from the ED to an ICU or stroke unit. Ashcraft and colleagues described telehealth care for stroke, or telestroke, as a tool that can increase equitable care and decrease stroke morbidity and mortality through “access for all patients.” Additionally, they noted that nursing interventions during transitions in stroke care — which include everything from prehospital emergency care through long-term management — improve outcomes.

Endovascular, ICU treatment

The second statement focused on endovascular and ICU treatment, according to the press release. The statement reviewed current evidence, complications, best practices and clinical strategies to provide nurses with “current comprehensive scientific information” in the neuroendovascular area and ICU care in conjunction with medical treatment, such as IV thrombolysis and mechanical thrombectomy.

Mary L. Rodgers, DHA, ANP, CNS, RN, of the Veterans Affairs Western New York Healthcare System, and colleagues reviewed the role of the nurse at various stages of endovascular care, including preprocedural, procedural and postprocedural care. The researchers highlighted airway assessment, oxygenation and patient history in preprocedural care. These factors are considered in a preprocedural nursing assessment, in addition to a review of medications and allergies, among other things.

Periprocedural monitoring “follows current practice guidelines,” Rodgers and colleagues stated, and includes assessment of vital signs and consciousness. Evaluations of vital signs and level of consciousness are performed every 5 minutes during a procedure, according to the researchers. Rodgers and colleagues specifically examined the role of the nurse in mechanical thrombectomy procedures with and without anesthesia in the section on periprocedural monitoring, citing the nurse’s role in either the administration of procedural sedation or, conversely, the role of circulator, in which a nurse would be required to obtain endovascular devices.

“During treatment, the intradisciplinary team needs to know if the patient is improving, staying the same or decompensating,” Rodgers said in the press release. “Nursing care and identification of patient changes is key during this time. Nursing assessments and interventions assist the team in critical decisions related to treatment efficacy and the needs of the patient.”

In postprocedural care, the nurse’s role involves neurological assessments and checking for complications, according to the press release. Postprocedural care involves supportive care as well, which may include monitoring for fever and extremes in glycemic control, Rodgers and colleagues noted. Administering prophylaxis for venous thromboembolism and providing nutritional support are additional aspects of postprocedural care.

Finally, the statement from Rodgers and colleagues examined the nurse’s role in understanding the goals of care.

“A sudden onset of an acute stroke can lead to overwhelming cognitive and functional changes, which can increase patient suffering and decrease quality of life,” the researchers wrote. “To understand the goals of care, early communication with the patient and family by the care team is essential.”

Monitoring complications, coordinating discharge

The final statement addressed the role of nurses in caring for patients with stroke after the hyperacute stage and prior to hospital discharge, according to the press release.

Theresa L. Green, PhD, RN, FAHA, of the University of Queensland School of Nursing in Australia, and colleagues primarily examined best practices for nursing care in acute stroke units, noting that “the benefits of a stroke specific-unit are well documented.” Specifically, they cited a group of three studies that demonstrated better overall mortality at 90 days to 1 year following a stroke when patients received care in an acute stroke unit. Being treated in a stroke unit also led to a greater chance of functional recovery, as assessed by Barthel scores, according to Green and colleagues.

While “acute stroke units appear to save lives,” the researchers acknowledged that it is challenging to compare research because of variation from hospital to hospital regarding outcome measures and varying follow-up periods. They wrote that, in the absence of a stroke unit, patients “should still receive stroke nursing care” that aligns with best practices regardless of the unit to which they are admitted.

“More research using consistent methods, measures and time frames is required, particularly for patients cared for in acute stroke units,” Green and colleagues wrote. “Specifically, more research is necessary to address the impact of nursing care on patient outcomes in acute stroke units and for patients experiencing in-hospital strokes.”

The researchers then examined nursing assessments across the span of stroke care. Specifically, they addressed the monitoring of vital signs and watching for fever, hyperglycemia and swallowing issues, and highlighted the use of the NIH’s Stroke Scale, which allows for classification of stroke severity and patient eligibility for stroke or endovascular therapy.

Green and colleagues also discussed the role of the nurse in assessing complications from stroke, including cerebral edema and poststroke seizures, dysphagia and pneumonia, and urinary and gastrointestinal complications, among others, and in care transitions, from the acute setting to the community. The researchers, who called this period “one of the most vulnerable and significant periods ... for patients with stroke and their families,” highlighted the nurse’s role in assessing rehabilitation needs and communicating with family members as well as therapists and social workers, among others.

“We know that what we do as nurses is important and crucial to the care of patients and families living with stroke, and this statement strengthens and supports the knowledge and provision of evidence-informed nursing care that will enhance and promote recovery and reintegration for patients transitioning across care environments to home and within their community,” Green said in the press release.

Green also highlighted the absence of an international definition about what specialized stroke care involves.

“There is also a lack of well-planned nursing research detailing the specific contribution nursing makes to patient and family outcomes following stroke, and whether it makes a difference to patient care and outcomes if nurses are certified in a subspecialty area such as stroke nursing,” she said. “This statement provides much-needed guidance that can contribute to improved patient outcomes.”

References:

American Heart Association. Updated guidance confirms crucial role of nurses for patients with acute ischemic stroke. Available at: https://newsroom.heart.org/news/updated-guidance-confirms-crucial-role-of-nurses-for-patients-with-acute-ischemic-stroke?preview=dbd1. Accessed March 11, 2021.
Ashcraft S, et al. Stroke. 2021;doi:10.1161/STR.0000000000000356.
Green TL, et al. Stroke. 2021;doi:10.1161/STR.0000000000000357. Rodgers ML, et al. Stroke. 2021;doi: 10.1161/STR.0000000000000358.