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Acute Stroke: It's All About Process and Team Improving Patient Outcomes in the Emergency Department
Acute Stroke: It’s All About Process and Team Improving Patient Outcomes in the Emergency Department j Diane L. Miller, MSN, RN, CEN ABSTRACT: Earlier focused care from prehospital has demonstrated that stroke teams from prehospital to rehabilitation improve the care of stroke patients. Time is brain is the impetus for identifying patients quickly with stroke symptoms and initiating neuroprotective treatments. This article will discuss how effective team process: the merging of multidisciplinary care teams is the foundation of safe stroke care for patients in both the community and the hospital. (J Radiol Nurs 2016;35:198-204.) KEYWORDS: Stroke; Intervention; Prehospital; Emergency department; Radiology; Team.
Stroke care is time sensitive and requires a team response to promote optimal patient outcomes. Stroke teams are interdisciplinary and care for the patient at different points of the care continuum. These specialized stroke teams improve stroke outcomes by providing earlier more focused care, reduce delay to treatment, decrease hospital length of stay, and decrease costs (Schouten et al., 2008). Building emergency department process based on best practice from prehospital to disposition requires effective communication and collaboration among interdisciplinary team members. STROKE RECOGNITION AND PUBLIC AWARENESS Stroke is the fifth leading cause of death in the United States and a major cause of disability (Mozaffarian et al., 2016, p. e170). Diane L. Miller, MSN, RN, CEN, Nurse Educator, Emergency Department, Brigham and Women’s Hospital, Boston, MA. A PowerPoint presentation of this material and case study was presented at the New England Chapter of The Association of Radiologic and Imaging Nursing: Autumn Conference 2015, Boston, MA. The author has no financial disclosures. Corresponding author: Diane L. Miller, MSN, RN, CEN, Nurse Educator, Emergency Department, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2016 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2016.06.007
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In 2013 On average, every 4 min, someone died of a stroke. B Stroke accounted for z1 of every 20 deaths in the United States. B When considered separately from other cardiovascular disease, stroke ranks Number 5 among all causes of death, behind diseases of the heart, cancer, chronic lower respiratory disease, and unintentional injuries/accidents (Mozaffarian et al., 2016, p. e170). The public’s knowledge of stroke signs and symptoms remains poor. When stroke symptoms are not recognized by victims, their family, friends, or bystanders, the patient may delay presenting for care. These delays in presentation place the patient at risk for being “outside the window” of intervention for stroke. Despite the public education to call 911 in 2011, only 53% of stroke patients arrived by emergency medical services (EMSs; Jauch et al., 2013). In the United States, treatment rates remain low with only 3.4%-5.2% of patients with acute ischemic stroke receiving tissue plasminogen activator (t-PA) the only drug treatment for ischemic stroke approved by the Food and Drug Administration (Cheng & Kim, 2015). Contributing factors to this low treatment rate include delays in recognition and activation of EMS, narrow treatment windows, and medical infrastructure (Cheng & Kim, 2015; Jauch et al., 2013). B
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Table 1. Stroke chain of survival Detection Dispatch Delivery Door Data Decision Drug Disposition
Patient or bystander recognition of stroke signs and symptoms Immediate activation of 9-1-1 and priority EMS dispatch Prompt triage and transport to most appropriate stroke hospital and prehospital notification Immediate triage to high-acuity area Prompt emergency department evaluation, stroke team activation, laboratory studies, and brain imaging Diagnosis and determination of most appropriate therapy: discussion with patient and family Administration of appropriate drugs or other interventions Timely admission to stroke unit, intensive care, or transfer
Adapted from Jauch et al., 2013, p. 4.
Detection is the first and critical link in the American Heart Association’s (AHA) Stroke Chain of Survival (Table 1). In May of 2009, the AHA and the American Stroke Association (ASA) recommended expansion of the t-PA window to 4.5 hr based on evidence from the European Cooperative Stroke Study (ECASS 3); this represented an important advance in the treatment of ischemic stroke care. As providers of stroke care, we may have a longer treatment window, but we must always remember that the sooner the treatment the more the opportunity for improved patient outcomes (del Zoppo et al., 2009; Jauch et al., 2013). EMERGENCY MEDICAL SERVICE OR WALK-IN: THE CLOCK STARTS The clock starts at Emergency Department arrival for the time targets recommended by research done for over 20 years. The 3-hr window for treatment of ischemic stroke with t-PA was established in 1996 by the National Institute of Neurological Disorders and Stroke Trial. In 2009, the treatment window for t-PA was expanded to 4.5 hr after time of symptom onset based on the research from the ECASS 3. The time of symptom onset or last known well time is the critical piece of information that treatment options are based on. The treatment window for t-PA has been expanded, but the treatment team must consider that some patient’s treatment window may be expanded to 6 hr for endovascular intervention (Powers et al., 2015). EMERGENCY DEPARTMENT (ED) TIME TARGETS: BEST PRACTICE Best practice for acute stroke patient care in the emergency department is a complex set of time sensitive tasks (Table 2). These tasks involve interdisciplinary teams from multiple specialties who interact at different points during the patient care continuum. The key to optimal outcomes in caring for the acute ischemic stroke patient is process and teamwork from admission (referred to as “Door”) to the emergency department to disposition and handoff to the next team. VOLUME 35 ISSUE 3
EMERGENCY DEPARTMENT PROCESS FOR ACUTE STROKE Triage: Advantages of Prenotification Patients arrive to the emergency department in two ways. They walk in or arrive by EMS. The call to 911 is the first link in the stroke chain of survival (Table1). Similar to the chain of survival for myocardial infarction (Figure 1), the chain of survival for stroke starts with recognition and calling for help using EMS. Multiple studies have shown when stroke patients come to the emergency department by EMS, prehospital delays are minimized, patients have shorter door to provider times, the time to computerized axial tomography (CT) scan is shorter, and there is an increase use of t-PA (McKinney et al., 2013). For example, in our emergency department, when EMS calls in to report a patient with stroke-like symptoms, the stroke team is activated. This reduces door-todoctor time, door-to-stroke team, and door-to-CT times. Prenotification by EMS gives us a time period to activate the emergency, radiology, and neurology teams. Triage: Potential Pitfalls With Walk-in Presentations The triage nurse at walk-in must recognize and initiate the ED process for acute stroke. The role of the triage nurse in the emergency department is considered an advanced role for the emergency nurse. The Emergency Nurses Association (ENA) sets specific criteria for triage training and recommends the role for experienced emergency nurses who have additional certifications Table 2. Emergency Department Process for Acute Stroke Task Door Door Door Door Door Door
to to to to to to
physician stroke team CT initiation CT interpretation drug (R80% compliance) stroke unit admission
Time target %10 min %15 min %25 min %45 min %60 min %3 hr
CT Z Computerized axial tomography. Adapted from Jauch et al., 2013, p. 9.
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Figure 1. The chain of survival for myocardial infarction (MI). Available at www.ahajournals.org.
such as advanced cardiac life support, pediatric advanced life support, and certification in emergency nursing before they are trained to the triage role (ENA, 2011). The triage nurse is the gatekeeper for the department and communicates closely with the treatment teams in the department. The role of the triage nurse is to prioritize patients for treatment and decide who can wait for treatment. Stroke care is critically time sensitive, and stroke patients can present with uncommon and atypical signs and symptoms that may evolve over time (Edlow & Selim, 2011). The triage nurse should use a validated stroke screening tool to help with decision making and a reliable and valid triage tool to assign acuity to this high-risk population (Gilboy et al., 2005). For patients who walk into the emergency department, triage will set the trajectory of their care. Stroke patients who are undertriaged are placed at risk for becoming outside of narrow treatment windows for optimal functional outcomes. This patient population is particularly challenging for the triage nurse as signs and symptoms of stroke such as headache, dizziness, or numbness may suggest other causes (Edlow & Selim, 2011). Triage Classification: ESI 2 High-Risk Patient The Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) recommend the use of the 5 level Emergency Severity Index (ESI; Figure 2; Summers et al., 2009). The ESI is a reliable and valid triage tool with tested interrater reliability used by emergency departments to classify patients at triage (Gilboy et al., 2005). ESI is used nationally and internationally by emergency nurses. Stroke patients should be triaged as an ESI level 2- high risk patient. This acuity level identifies the urgency of stroke care by emergency nurses and acknowledges that stroke is a medical emergency (Gilboy et al., 2005). This acuity level is the first step in facilitating access to early diagnosis in the emergency department, notifying the stroke team and accessing radiology for the critical CT scan. Patients that present to the emergency department with signs and symptoms suggestive of TIA or stroke meet the criteria for ESI level 2 unless they require immediate lifesaving inter200
Figure 2. The Emergency Severity Index. Available at www.ahrq. gov/esi.org. HR: Heart Rate; RR: Respiratory Rate; SAO2: Oxygen Saturation.
vention. ED triage sets the stage and trajectory for the stroke patient. A CASE TO CONSIDER A 42-year-old man presents by car to the emergency department walk-in triage nurse. He reports feeling dizzy, blurry vision, and numbness in his right arm and hand while eating lunch at work a little after 1 p.m. He describes difficulty holding his coffee cup with his right hand. He then states to the triage nurse “But I feel fine now.” His vital signs at triage are: Heart rate 82 beats per minute, blood pressure 187/86, respiratory rate 20 breaths per minute, and his oxygen saturation 99%, on room air. He reports taking no medications every day; he has no medical problems and reports no allergies. WHAT THE TRIAGE NURSE DID NOT KNOW? When he was at lunch, he called his girlfriend (a nurse) and told her about the dizziness, blurry vision, and numbness in his right hand. He also did not tell the triage nurse that he had a recent weight loss of 100 pounds and no longer needed his antihypertensive medication and antidiabetic medications. This was
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important information that would have made the nurse consider risk factors for stroke. During the phone call with his girlfriend, she told him to call 911 and go to the emergency department because he had stroke symptoms. He thought that his symptoms were getting better, and he decided to wait. It was only after a second call by the girlfriend; he decided to drive himself to the emergency department arriving at 3:45 p.m., more than 2 hours and 45 minutes after the onset of his symptoms. Potential Pitfall An inexperienced triage nurse could consider the problem resolved and classify the patient as a nonurgent patient and send him to the waiting room. On arrival to the ED, he was symptom free. An experienced triage nurse may recognize that his presentation may be atypical for stroke and classify him as a high-risk patient initiating the ED stroke protocol moving him forward in the process for the teams to evaluate. ED waiting areas are high-risk areas for high-risk patients. Under triage of a stroke patient as a nonurgent, patient changes the trajectory of the patient visit, places the stroke patient at risk for decompensation in the waiting room, and impacts time sensitive treatment options. Screening for Stroke at Triage When a patient with stroke-like symptoms presents to the ED, the triage nurse considers the “five sudden stroke warning signs and symptoms” described by the ASA (AS, 2015, 2016) and the AHA (see the list below). Stroke screening should be considered for any patient accessing care with a current or transient complaint of neurological dysfunction caused by brain, spinal cord, or retinal ischemia (Easton et al., 2009). The triage nurse should suspect stroke in any patient with abrupt onset of neurological symptoms. This includes any patient who presents with signs and symptoms of: Sudden numbness or weakness of face, arm, or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause (Adapted from National Stroke Association, n.d. Access from www.stroke.org) It is important to remember that stroke does have uncommon manifestations, and some patients will initially present with various uncommon and atypical stroke symptoms. Acute stroke should be considered in neurological syndromes where the abrupt onset of VOLUME 35 ISSUE 3
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symptoms figures prominently in the presenting problem and particularly in patients with cerebrovascular risk factors (Edlow, 2011). At triage, a validated neurological screening tool will help the triage nurse identify patients with stroke. The Cincinnati Prehospital Stroke Scale (Figure 3) tests three signs for abnormal findings which may indicate that the patient is having a stroke (Kothari et al., 1999). Patients with one abnormality of the three findings as a new event have a 72% probability of an ischemic stroke. If all three findings are abnormal, the probability of an acute stroke is more than 85% (Kothari et al., 1999). If the Cincinnati Prehospital Stroke Scale is positive for one or more abnormal findings, the triage nurse should contact the providers in the emergency department for an immediate provider evaluation and initiate ED stroke protocols as indicated. What if the patient has no abnormal findings using the Cincinnati Prehospital Stroke Scale? Should the triage nurse stop the assessment at this point? The triage nurse should continue the assessment, consider the patient’s risk factors for stroke, and evaluate the patient’s vital signs. If the nurse remains unsure, consult a more expert nurse or the team inside the emergency department. “Time is Brain” neurological injury can have a devastating disability for your patient. ED EVALUATION: TEAM AND PARALLEL PROCESS When a potential stroke patient arrives at the emergency department from triage or EMS, the emergency department team will immediately start the stroke team process by evaluating the patient, notifying the stroke team of the patient’s arrival, and notifying the radiology team to clear a table for the CT scan. A stroke patient requires a hospital-wide team response, and a lot of things happen at once just as it does in a trauma situation. High-acuity, high-risk patients require excellent communication and collaboration between teams. Many processes happen in parallel. Collaboration among the teams with clear process and defined agreement on protocol fosters an intensive focus on the medical management of the stroke patient maximizing productivity and effective use of personnel. Everyone has their role and responsibility, and everyone should understand the goals of care for the patient. TEAM COMMUNICATION AND COLLABORATION: ARE THEY THE SAME? Communication is the critical antecedent to effective team collaboration. Taking care of high-acuity patients requires getting accurate information. The Joint Commission (2016) analysis of root causes of sentinel events
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Facial droop: Have the person smile or show his or her teeth. If one side doesn't move as well as the other so it seems to droop, that could be a sign of a stroke. Normal: Both sides of face move equally Abnormal: One side of face does not move as well as the other (or at all) Arm drift: Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. If one arm does not move, or one arm winds up drifting down more than the other, that could be a sign of a stroke. Normal: Both arms move equally or not at all Abnormal: One arm does not move, or one arm drifts down compared with the other side Speech: Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be a sign of stroke. Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or mute Figure 3. The Cincinnati Prehospital Stroke Scale. Adapted from Target Stroke accessed at www.strokeassociation.org.
for 2013dthe third quarter of 2015dlists human factors, communication, and leadership as three of the most commonly identified categories and subcategories of sentinel events in health care (Figure 4 for the top three categories and subcategories for sentinel events). There are potential barriers to getting complete information in a critical, time-sensitive response to a patient with stroke signs and symptoms or any critically ill or injured patient. Factors to consider are members of the care team arrive at different times, there are many modes of communication activated, and multiple handoffs occur. Each member of the different interdisciplinary teams has expertise that is needed to optimize the care of the stroke patient. Team performance goes beyond the contributions of the individual team members (Flin & Maran, 2004).
Each profession has information and skills that all the team members will need to practice successfully (Lindeke & Sieckert, 2005). It is the nontechnical skills such as collaboration, communication, task management, and leadership that are highly critical to effective patient management (Flin & Maran, 2004; Lindeke & Sieckert, 2005; Vazirani et al., 2005). It is vital that all team members understand what the plan and goals of care are for the stroke, critically ill or injured patient. RECOGNIZING TEAMWORK IN HEALTH CARE AS AN EFFECTIVE STRATEGY FOR IMPROVING PATIENT OUTCOMES Once the patient has been identified as a possible stroke patient, the different specialty teams (see Figure 5 for stroke team members) merge and work from a common
Human Factors
Staffing levels, staffing mix, staff orientaon, in-service educaon, competency assessment, staff supervision, medical staff credenaling/privileges, medical staff peer review, other (e.g. rushing, fague, distracon, complacency, bias)
Communicaon
Oral, wrien, electronic, among staff, with/among physicians, with administraon, with paent and family
Leadership
Organizaonal planning, organizaonal culture, community relaons, service availability, priority seng, resource allocaon, leadership collaboraon, standardizaon (e.g. clinical pracce guidelines), direcng department /services, integraon of services, inadequate policies and procedures, non-compliance with policies and procedures, performance improvement, medical staff organizaon, nursing leadership
Figure 4. Top three categories and subcategories for sentinel events from root cause analysis. EMS Z emergency medical service. Adapted from Sentinel event data: Root causes by event type 2004-3Q 2015. Accessed at www.jointcommision.org/sentinel-event-statistics. 202
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Stroke Paent Family, Friend or By-stander EMS Team and Hospital Triage Team Pre hospital dispatcher EMS Team: Paramedic and or emergency medical technician (EMT) Emergency department triage nurse Emergency Department Team Emergency Medicine Physician team: Aending, Resident or mid- level provider (physician assistant or advanced pracce nurse) Primary nurse Scribe Nurse Nurse assistant Pharmacist Registraon Transport Radiology Team Radiology Aending, Resident or Fellow Radiology Technologist
Neurology or Neurosurgery Team Neurology or Neurosurgery Aending, Resident or Fellow
Interventional radiology (IR) is considered for patients who present for care outside of the t-PA window or are ineligible for t-PA, as well as patients who have received t-PA and may need further intervention. Stroke patients who have a delayed presentation to the hospital and are outside the window for t-PA and the interventional window may be admitted to the hospital for intermediate care. Observation stroke care may be considered for lowrisk transient ischemic event patients waiting for magnetic resonance imaging (MRA)/magnetic resonance angiogram (MRA). Neurology teams may follow these patients while they are in observation status. The AHA/ASA recommends that stroke patients be transferred to stroke center for stroke care. Certification of stroke centers is done by external or state health departments. Criteria to be designated a Stroke Center is rigorous and encompasses patient management, data collection, and continuous quality improvement (Jauch et al., 2013). WHEN ACUTE STROKE OCCURS IN A PROCEDURE AREA OR ON AN INPATIENT UNIT
Intervenonal Radiology Intervenonist Intervenonal Radiology Nurse Intervenonal Radiology Technologist
Figure 5. Stoke Team members.
set of clinical guidelines or protocols specific to your institution. In the emergency department, a standardized process and clinical pathway optimizes the patient’s treatment decisions and outcomes. Emergency Department Stroke Process The Acute Stroke Page from the ED is a physician-tophysician page. This brings the stroke team to the patient’s bedside in the emergency department; it notifies the ED radiologist and the ED radiology technician to clear the table and hold the table for the stroke patient. It also alerts the ED pharmacist to obtain the t-PA from the pharmacy or automated medication dispenser. During the time, the specialty teams are preparing for the patient: the ED team begins the assessment process, identifying the last known well time, the patient’s signs and symptoms, and transports the patient to the CT scan. The CT scan is the critical screen for t-PA. ED TEAM HANDOFF: WHICH WAY DO WE GO? The neuroscience intensive care unit receives all stroke patients who received t-PA and all critically ill stroke patients including most hemorrhagic stroke patients. Ischemic stroke is 10 times more frequent than hemorrhagic stroke, yet hemorrhagic stroke is associated with a considerable increase in mortality within the first 3 months after stroke (Andersen et al., 2009). VOLUME 35 ISSUE 3
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Nurses throughout the hospital should recognize stroke signs, symptoms, and assess patient’s risk factors for a stroke event. It is important to know your hospital’s stroke notification process for inpatients. The nurse must understand that stroke care is time sensitive and follow protocol for getting specialty stroke care to the bedside. Facility protocols will help determine the sequence of events. When a patient who is undergoing a procedure in the radiology department suffers a possible stroke, the radiology nurse should know what protocols and procedures are to be followed in that particular modality. For the diagnostic imaging area, it may mean transferring the outpatient to the ED as soon as possible or if the event occurs in the IR setting, it might mean taking the patient to CT as soon as possible in addition to notifying the Stroke Team or starting treatment in the IR area. Each facility’s procedures will dictate the course of action. Regardless, the radiology nurse should be familiar with the stroke assessment scales to be better able to inform the receiving area nurse and physician of the event. If t-PA is to be started in the IR setting, the nurse will need to know the procedure to obtain the medication if it is not readily available there. Know your facilities resources and best practice for the administration of t-PA. Inpatient stroke teams often have a critical care nurse who is familiar with the administration of t-PA as it is a high-risk medication that requires intensive care unit (ICU)-level patient monitoring. Your facility protocols will have guidance
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for patient transfer and handoff to the appropriate care teams. Stroke patients are high-risk patients, and untoward events may occur during the continuum of care. Hospital best practice should be built on the best evidence available to maximize patient’s functional recovery and limit disability from stroke. CONCLUSION Care of the acute stroke patient begins with identifying these patients in the community, in the emergency department, and within our hospitals. These high-risk patients require multidisciplinary teams who merge together at different points in the patient’s continuum of care. Excellent communication, protocols, and clinical pathways/guidelines specific to your hospital will guide teams to navigate and optimize stroke patient outcomes. Acknowledgment The author would like to thank John J. O’Reilly, BSN, RN, and Robert Fine, MS, RN, for their review and comments regarding this article.
References American Stroke Association and the American Heart Association (2015). Learn more stroke warning signs and symptoms. Retrieved from http://www.strokeassociation.org/STROKE ORG/WarningSigns/Learn-More-Stroke-Warning-Signs-andSymptoms_UCM_451207_Article.jsp#.V54g5bgrLIU. American Stroke Association (2016). Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Pro fessionals/Target-Stroke_UCM_314495_SubHomePage.jsp. Andersen, K.K., Olsen, T.S., Dehlendorff, C., & Kammersgaard, L.P. (2009). Hemorrhagic and ischemic strokes compared: Stroke severity, mortality, and risk factors. Stroke, 40, 2068-2072. Cheng, N.T., & Kim, A.S. (2015). Intravenous thrombolysis for acute ischemic stroke within 3 hours verses between 3 and 4.5 hours of symptom onset. The Neurohospitalist, 5(3), 101-109. del Zoppo, G.J., Saver, J.L., Jauch, E.C., & Adams, H.P. (2009). Expansion of the time window for the treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke, 40, 2945-2948. Easton, J., Saver, J., Albers, G., Alberts, M., Chaturvedi, S., Feldmann, E., et al. (2009). Definition and evaluation of transient ischemic attack: A scientific statement for healthcare professionals from the American Heart Association/ American Stroke Association Stroke Council. Stroke, 40, 2276-2293. Edlow, J.A., & Selim, M.H. (2011). Atypical presentations of acute cerebrovascular syndromes. The Lancet/Neurology, 10, 550-560.
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Emergency Nurses Association (2011). Emergency nursing scope and standards of practice: 2011 edition. Park Ridge, IL: Emergency Nurses Association. Flin, R., & Maran, N. (2004). Identifying and training non-technical skills for teams in acute medicine. Quality Safety in Health Care, 13, i80-i84. Gilboy, N., Tanabe, P., Travers, D.A., Rosenau, A.M., & Eitel, D.R. (2005). Emergency Severity Index, Version 4: Implementation handbook, AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/research/esi. Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J., Demaerschalk, B., et al. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/ American Stoke Association. Stroke, 44, 870-947. Kothari, R., Pancioli, A., Liu, T., Brott, T., & Broderick, J. (1999). Cincinnati Prehospital Stroke Scale: reproducibility and validity. Annals of Emergency Medicine, 33(4), 373-378. Lindeke, L.L., & Sieckert, A.M. (2005). Nurse-physician workplace collaboration. OJIN: The Online Journal of Issues in Nursing, 10(1). Manuscript 4. McKinney, J.S., Mylavarapu, K., Lane, J., Roberts, V., Ohman-Strickland, P., & Merlin, M.A. (2013). Hospital prenotification of stroke patients by emergency medical services improves stroke time targets. Journal of Stroke and Cerebrovascular Diseases, 22, 113-118. Mozaffarian, D., Benjamin, E.J., Go, A.S., Arnett, D.K., Blaha, M.J., Cushman, M., et al. (2016). Heart disease and stroke statisticsd2016 update: A report from the American Heart Association. Circulation, 133, e38-e60. National Stroke Association. (n.d.). Signs and symptoms of stroke. Retrieved from www.stroke.org Powers, W.J., Derdeyn, C.P., Biller, J., Coffey, C.C., Hoh, B.L., Jauch, E.C., et al. (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46, 3020-3035. Schouten, L.M.T., Hulscher, M.E.J.L., Akkermans, R., van Everdingen, J.J.E., Grol, R.P.T.M., & Huijsman, R. (2008). Factors that influence the stroke care team’s effectiveness in reducing the length of hospital stay. Stroke, 39, 2515-2521. Summers, D., Leonard, A., Wentworth, D., Saver, J.L., Simpson, J., Spilker, J.A., et al.; the American Heart Association Council on Cardiovascular Nursing and the Stroke (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke, 40, 2911-2944. The Joint Commission. (2016). Sentinel event data: Root causes by event type 2004-2015. Retrieved from http://www. jointcommission.org/sentinel_event_statistics/ Vazirani, S., Hays, R.D., Shapiro, M.F., & Cowan, M.C. (2005). Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71-77.
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Stroke care is time sensitive and requires a team response to promote optimal patient outcomes. Stroke teams are interdisciplinary and care for the patient at different points of the care continuum. These specialized stroke teams improve stroke outcomes by providing earlier more focused care, reduce delay to treatment, decrease hospital length of stay, and decrease costs (Schouten et al., 2008). Building emergency department process based on best practice from prehospital to disposition requires effective communication and collaboration among interdisciplinary team members. STROKE RECOGNITION AND PUBLIC AWARENESS Stroke is the fifth leading cause of death in the United States and a major cause of disability (Mozaffarian et al., 2016, p. e170). Diane L. Miller, MSN, RN, CEN, Nurse Educator, Emergency Department, Brigham and Women’s Hospital, Boston, MA. A PowerPoint presentation of this material and case study was presented at the New England Chapter of The Association of Radiologic and Imaging Nursing: Autumn Conference 2015, Boston, MA. The author has no financial disclosures. Corresponding author: Diane L. Miller, MSN, RN, CEN, Nurse Educator, Emergency Department, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected] 1546-0843/$36.00 Copyright Ó 2016 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2016.06.007
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In 2013 On average, every 4 min, someone died of a stroke. B Stroke accounted for z1 of every 20 deaths in the United States. B When considered separately from other cardiovascular disease, stroke ranks Number 5 among all causes of death, behind diseases of the heart, cancer, chronic lower respiratory disease, and unintentional injuries/accidents (Mozaffarian et al., 2016, p. e170). The public’s knowledge of stroke signs and symptoms remains poor. When stroke symptoms are not recognized by victims, their family, friends, or bystanders, the patient may delay presenting for care. These delays in presentation place the patient at risk for being “outside the window” of intervention for stroke. Despite the public education to call 911 in 2011, only 53% of stroke patients arrived by emergency medical services (EMSs; Jauch et al., 2013). In the United States, treatment rates remain low with only 3.4%-5.2% of patients with acute ischemic stroke receiving tissue plasminogen activator (t-PA) the only drug treatment for ischemic stroke approved by the Food and Drug Administration (Cheng & Kim, 2015). Contributing factors to this low treatment rate include delays in recognition and activation of EMS, narrow treatment windows, and medical infrastructure (Cheng & Kim, 2015; Jauch et al., 2013). B
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Table 1. Stroke chain of survival Detection Dispatch Delivery Door Data Decision Drug Disposition
Patient or bystander recognition of stroke signs and symptoms Immediate activation of 9-1-1 and priority EMS dispatch Prompt triage and transport to most appropriate stroke hospital and prehospital notification Immediate triage to high-acuity area Prompt emergency department evaluation, stroke team activation, laboratory studies, and brain imaging Diagnosis and determination of most appropriate therapy: discussion with patient and family Administration of appropriate drugs or other interventions Timely admission to stroke unit, intensive care, or transfer
Adapted from Jauch et al., 2013, p. 4.
Detection is the first and critical link in the American Heart Association’s (AHA) Stroke Chain of Survival (Table 1). In May of 2009, the AHA and the American Stroke Association (ASA) recommended expansion of the t-PA window to 4.5 hr based on evidence from the European Cooperative Stroke Study (ECASS 3); this represented an important advance in the treatment of ischemic stroke care. As providers of stroke care, we may have a longer treatment window, but we must always remember that the sooner the treatment the more the opportunity for improved patient outcomes (del Zoppo et al., 2009; Jauch et al., 2013). EMERGENCY MEDICAL SERVICE OR WALK-IN: THE CLOCK STARTS The clock starts at Emergency Department arrival for the time targets recommended by research done for over 20 years. The 3-hr window for treatment of ischemic stroke with t-PA was established in 1996 by the National Institute of Neurological Disorders and Stroke Trial. In 2009, the treatment window for t-PA was expanded to 4.5 hr after time of symptom onset based on the research from the ECASS 3. The time of symptom onset or last known well time is the critical piece of information that treatment options are based on. The treatment window for t-PA has been expanded, but the treatment team must consider that some patient’s treatment window may be expanded to 6 hr for endovascular intervention (Powers et al., 2015). EMERGENCY DEPARTMENT (ED) TIME TARGETS: BEST PRACTICE Best practice for acute stroke patient care in the emergency department is a complex set of time sensitive tasks (Table 2). These tasks involve interdisciplinary teams from multiple specialties who interact at different points during the patient care continuum. The key to optimal outcomes in caring for the acute ischemic stroke patient is process and teamwork from admission (referred to as “Door”) to the emergency department to disposition and handoff to the next team. VOLUME 35 ISSUE 3
EMERGENCY DEPARTMENT PROCESS FOR ACUTE STROKE Triage: Advantages of Prenotification Patients arrive to the emergency department in two ways. They walk in or arrive by EMS. The call to 911 is the first link in the stroke chain of survival (Table1). Similar to the chain of survival for myocardial infarction (Figure 1), the chain of survival for stroke starts with recognition and calling for help using EMS. Multiple studies have shown when stroke patients come to the emergency department by EMS, prehospital delays are minimized, patients have shorter door to provider times, the time to computerized axial tomography (CT) scan is shorter, and there is an increase use of t-PA (McKinney et al., 2013). For example, in our emergency department, when EMS calls in to report a patient with stroke-like symptoms, the stroke team is activated. This reduces door-todoctor time, door-to-stroke team, and door-to-CT times. Prenotification by EMS gives us a time period to activate the emergency, radiology, and neurology teams. Triage: Potential Pitfalls With Walk-in Presentations The triage nurse at walk-in must recognize and initiate the ED process for acute stroke. The role of the triage nurse in the emergency department is considered an advanced role for the emergency nurse. The Emergency Nurses Association (ENA) sets specific criteria for triage training and recommends the role for experienced emergency nurses who have additional certifications Table 2. Emergency Department Process for Acute Stroke Task Door Door Door Door Door Door
to to to to to to
physician stroke team CT initiation CT interpretation drug (R80% compliance) stroke unit admission
Time target %10 min %15 min %25 min %45 min %60 min %3 hr
CT Z Computerized axial tomography. Adapted from Jauch et al., 2013, p. 9.
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Figure 1. The chain of survival for myocardial infarction (MI). Available at www.ahajournals.org.
such as advanced cardiac life support, pediatric advanced life support, and certification in emergency nursing before they are trained to the triage role (ENA, 2011). The triage nurse is the gatekeeper for the department and communicates closely with the treatment teams in the department. The role of the triage nurse is to prioritize patients for treatment and decide who can wait for treatment. Stroke care is critically time sensitive, and stroke patients can present with uncommon and atypical signs and symptoms that may evolve over time (Edlow & Selim, 2011). The triage nurse should use a validated stroke screening tool to help with decision making and a reliable and valid triage tool to assign acuity to this high-risk population (Gilboy et al., 2005). For patients who walk into the emergency department, triage will set the trajectory of their care. Stroke patients who are undertriaged are placed at risk for becoming outside of narrow treatment windows for optimal functional outcomes. This patient population is particularly challenging for the triage nurse as signs and symptoms of stroke such as headache, dizziness, or numbness may suggest other causes (Edlow & Selim, 2011). Triage Classification: ESI 2 High-Risk Patient The Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) recommend the use of the 5 level Emergency Severity Index (ESI; Figure 2; Summers et al., 2009). The ESI is a reliable and valid triage tool with tested interrater reliability used by emergency departments to classify patients at triage (Gilboy et al., 2005). ESI is used nationally and internationally by emergency nurses. Stroke patients should be triaged as an ESI level 2- high risk patient. This acuity level identifies the urgency of stroke care by emergency nurses and acknowledges that stroke is a medical emergency (Gilboy et al., 2005). This acuity level is the first step in facilitating access to early diagnosis in the emergency department, notifying the stroke team and accessing radiology for the critical CT scan. Patients that present to the emergency department with signs and symptoms suggestive of TIA or stroke meet the criteria for ESI level 2 unless they require immediate lifesaving inter200
Figure 2. The Emergency Severity Index. Available at www.ahrq. gov/esi.org. HR: Heart Rate; RR: Respiratory Rate; SAO2: Oxygen Saturation.
vention. ED triage sets the stage and trajectory for the stroke patient. A CASE TO CONSIDER A 42-year-old man presents by car to the emergency department walk-in triage nurse. He reports feeling dizzy, blurry vision, and numbness in his right arm and hand while eating lunch at work a little after 1 p.m. He describes difficulty holding his coffee cup with his right hand. He then states to the triage nurse “But I feel fine now.” His vital signs at triage are: Heart rate 82 beats per minute, blood pressure 187/86, respiratory rate 20 breaths per minute, and his oxygen saturation 99%, on room air. He reports taking no medications every day; he has no medical problems and reports no allergies. WHAT THE TRIAGE NURSE DID NOT KNOW? When he was at lunch, he called his girlfriend (a nurse) and told her about the dizziness, blurry vision, and numbness in his right hand. He also did not tell the triage nurse that he had a recent weight loss of 100 pounds and no longer needed his antihypertensive medication and antidiabetic medications. This was
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important information that would have made the nurse consider risk factors for stroke. During the phone call with his girlfriend, she told him to call 911 and go to the emergency department because he had stroke symptoms. He thought that his symptoms were getting better, and he decided to wait. It was only after a second call by the girlfriend; he decided to drive himself to the emergency department arriving at 3:45 p.m., more than 2 hours and 45 minutes after the onset of his symptoms. Potential Pitfall An inexperienced triage nurse could consider the problem resolved and classify the patient as a nonurgent patient and send him to the waiting room. On arrival to the ED, he was symptom free. An experienced triage nurse may recognize that his presentation may be atypical for stroke and classify him as a high-risk patient initiating the ED stroke protocol moving him forward in the process for the teams to evaluate. ED waiting areas are high-risk areas for high-risk patients. Under triage of a stroke patient as a nonurgent, patient changes the trajectory of the patient visit, places the stroke patient at risk for decompensation in the waiting room, and impacts time sensitive treatment options. Screening for Stroke at Triage When a patient with stroke-like symptoms presents to the ED, the triage nurse considers the “five sudden stroke warning signs and symptoms” described by the ASA (AS, 2015, 2016) and the AHA (see the list below). Stroke screening should be considered for any patient accessing care with a current or transient complaint of neurological dysfunction caused by brain, spinal cord, or retinal ischemia (Easton et al., 2009). The triage nurse should suspect stroke in any patient with abrupt onset of neurological symptoms. This includes any patient who presents with signs and symptoms of: Sudden numbness or weakness of face, arm, or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause (Adapted from National Stroke Association, n.d. Access from www.stroke.org) It is important to remember that stroke does have uncommon manifestations, and some patients will initially present with various uncommon and atypical stroke symptoms. Acute stroke should be considered in neurological syndromes where the abrupt onset of VOLUME 35 ISSUE 3
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symptoms figures prominently in the presenting problem and particularly in patients with cerebrovascular risk factors (Edlow, 2011). At triage, a validated neurological screening tool will help the triage nurse identify patients with stroke. The Cincinnati Prehospital Stroke Scale (Figure 3) tests three signs for abnormal findings which may indicate that the patient is having a stroke (Kothari et al., 1999). Patients with one abnormality of the three findings as a new event have a 72% probability of an ischemic stroke. If all three findings are abnormal, the probability of an acute stroke is more than 85% (Kothari et al., 1999). If the Cincinnati Prehospital Stroke Scale is positive for one or more abnormal findings, the triage nurse should contact the providers in the emergency department for an immediate provider evaluation and initiate ED stroke protocols as indicated. What if the patient has no abnormal findings using the Cincinnati Prehospital Stroke Scale? Should the triage nurse stop the assessment at this point? The triage nurse should continue the assessment, consider the patient’s risk factors for stroke, and evaluate the patient’s vital signs. If the nurse remains unsure, consult a more expert nurse or the team inside the emergency department. “Time is Brain” neurological injury can have a devastating disability for your patient. ED EVALUATION: TEAM AND PARALLEL PROCESS When a potential stroke patient arrives at the emergency department from triage or EMS, the emergency department team will immediately start the stroke team process by evaluating the patient, notifying the stroke team of the patient’s arrival, and notifying the radiology team to clear a table for the CT scan. A stroke patient requires a hospital-wide team response, and a lot of things happen at once just as it does in a trauma situation. High-acuity, high-risk patients require excellent communication and collaboration between teams. Many processes happen in parallel. Collaboration among the teams with clear process and defined agreement on protocol fosters an intensive focus on the medical management of the stroke patient maximizing productivity and effective use of personnel. Everyone has their role and responsibility, and everyone should understand the goals of care for the patient. TEAM COMMUNICATION AND COLLABORATION: ARE THEY THE SAME? Communication is the critical antecedent to effective team collaboration. Taking care of high-acuity patients requires getting accurate information. The Joint Commission (2016) analysis of root causes of sentinel events
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Facial droop: Have the person smile or show his or her teeth. If one side doesn't move as well as the other so it seems to droop, that could be a sign of a stroke. Normal: Both sides of face move equally Abnormal: One side of face does not move as well as the other (or at all) Arm drift: Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. If one arm does not move, or one arm winds up drifting down more than the other, that could be a sign of a stroke. Normal: Both arms move equally or not at all Abnormal: One arm does not move, or one arm drifts down compared with the other side Speech: Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be a sign of stroke. Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or mute Figure 3. The Cincinnati Prehospital Stroke Scale. Adapted from Target Stroke accessed at www.strokeassociation.org.
for 2013dthe third quarter of 2015dlists human factors, communication, and leadership as three of the most commonly identified categories and subcategories of sentinel events in health care (Figure 4 for the top three categories and subcategories for sentinel events). There are potential barriers to getting complete information in a critical, time-sensitive response to a patient with stroke signs and symptoms or any critically ill or injured patient. Factors to consider are members of the care team arrive at different times, there are many modes of communication activated, and multiple handoffs occur. Each member of the different interdisciplinary teams has expertise that is needed to optimize the care of the stroke patient. Team performance goes beyond the contributions of the individual team members (Flin & Maran, 2004).
Each profession has information and skills that all the team members will need to practice successfully (Lindeke & Sieckert, 2005). It is the nontechnical skills such as collaboration, communication, task management, and leadership that are highly critical to effective patient management (Flin & Maran, 2004; Lindeke & Sieckert, 2005; Vazirani et al., 2005). It is vital that all team members understand what the plan and goals of care are for the stroke, critically ill or injured patient. RECOGNIZING TEAMWORK IN HEALTH CARE AS AN EFFECTIVE STRATEGY FOR IMPROVING PATIENT OUTCOMES Once the patient has been identified as a possible stroke patient, the different specialty teams (see Figure 5 for stroke team members) merge and work from a common
Human Factors
Staffing levels, staffing mix, staff orientaon, in-service educaon, competency assessment, staff supervision, medical staff credenaling/privileges, medical staff peer review, other (e.g. rushing, fague, distracon, complacency, bias)
Communicaon
Oral, wrien, electronic, among staff, with/among physicians, with administraon, with paent and family
Leadership
Organizaonal planning, organizaonal culture, community relaons, service availability, priority seng, resource allocaon, leadership collaboraon, standardizaon (e.g. clinical pracce guidelines), direcng department /services, integraon of services, inadequate policies and procedures, non-compliance with policies and procedures, performance improvement, medical staff organizaon, nursing leadership
Figure 4. Top three categories and subcategories for sentinel events from root cause analysis. EMS Z emergency medical service. Adapted from Sentinel event data: Root causes by event type 2004-3Q 2015. Accessed at www.jointcommision.org/sentinel-event-statistics. 202
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Stroke Paent Family, Friend or By-stander EMS Team and Hospital Triage Team Pre hospital dispatcher EMS Team: Paramedic and or emergency medical technician (EMT) Emergency department triage nurse Emergency Department Team Emergency Medicine Physician team: Aending, Resident or mid- level provider (physician assistant or advanced pracce nurse) Primary nurse Scribe Nurse Nurse assistant Pharmacist Registraon Transport Radiology Team Radiology Aending, Resident or Fellow Radiology Technologist
Neurology or Neurosurgery Team Neurology or Neurosurgery Aending, Resident or Fellow
Interventional radiology (IR) is considered for patients who present for care outside of the t-PA window or are ineligible for t-PA, as well as patients who have received t-PA and may need further intervention. Stroke patients who have a delayed presentation to the hospital and are outside the window for t-PA and the interventional window may be admitted to the hospital for intermediate care. Observation stroke care may be considered for lowrisk transient ischemic event patients waiting for magnetic resonance imaging (MRA)/magnetic resonance angiogram (MRA). Neurology teams may follow these patients while they are in observation status. The AHA/ASA recommends that stroke patients be transferred to stroke center for stroke care. Certification of stroke centers is done by external or state health departments. Criteria to be designated a Stroke Center is rigorous and encompasses patient management, data collection, and continuous quality improvement (Jauch et al., 2013). WHEN ACUTE STROKE OCCURS IN A PROCEDURE AREA OR ON AN INPATIENT UNIT
Intervenonal Radiology Intervenonist Intervenonal Radiology Nurse Intervenonal Radiology Technologist
Figure 5. Stoke Team members.
set of clinical guidelines or protocols specific to your institution. In the emergency department, a standardized process and clinical pathway optimizes the patient’s treatment decisions and outcomes. Emergency Department Stroke Process The Acute Stroke Page from the ED is a physician-tophysician page. This brings the stroke team to the patient’s bedside in the emergency department; it notifies the ED radiologist and the ED radiology technician to clear the table and hold the table for the stroke patient. It also alerts the ED pharmacist to obtain the t-PA from the pharmacy or automated medication dispenser. During the time, the specialty teams are preparing for the patient: the ED team begins the assessment process, identifying the last known well time, the patient’s signs and symptoms, and transports the patient to the CT scan. The CT scan is the critical screen for t-PA. ED TEAM HANDOFF: WHICH WAY DO WE GO? The neuroscience intensive care unit receives all stroke patients who received t-PA and all critically ill stroke patients including most hemorrhagic stroke patients. Ischemic stroke is 10 times more frequent than hemorrhagic stroke, yet hemorrhagic stroke is associated with a considerable increase in mortality within the first 3 months after stroke (Andersen et al., 2009). VOLUME 35 ISSUE 3
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Nurses throughout the hospital should recognize stroke signs, symptoms, and assess patient’s risk factors for a stroke event. It is important to know your hospital’s stroke notification process for inpatients. The nurse must understand that stroke care is time sensitive and follow protocol for getting specialty stroke care to the bedside. Facility protocols will help determine the sequence of events. When a patient who is undergoing a procedure in the radiology department suffers a possible stroke, the radiology nurse should know what protocols and procedures are to be followed in that particular modality. For the diagnostic imaging area, it may mean transferring the outpatient to the ED as soon as possible or if the event occurs in the IR setting, it might mean taking the patient to CT as soon as possible in addition to notifying the Stroke Team or starting treatment in the IR area. Each facility’s procedures will dictate the course of action. Regardless, the radiology nurse should be familiar with the stroke assessment scales to be better able to inform the receiving area nurse and physician of the event. If t-PA is to be started in the IR setting, the nurse will need to know the procedure to obtain the medication if it is not readily available there. Know your facilities resources and best practice for the administration of t-PA. Inpatient stroke teams often have a critical care nurse who is familiar with the administration of t-PA as it is a high-risk medication that requires intensive care unit (ICU)-level patient monitoring. Your facility protocols will have guidance
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for patient transfer and handoff to the appropriate care teams. Stroke patients are high-risk patients, and untoward events may occur during the continuum of care. Hospital best practice should be built on the best evidence available to maximize patient’s functional recovery and limit disability from stroke. CONCLUSION Care of the acute stroke patient begins with identifying these patients in the community, in the emergency department, and within our hospitals. These high-risk patients require multidisciplinary teams who merge together at different points in the patient’s continuum of care. Excellent communication, protocols, and clinical pathways/guidelines specific to your hospital will guide teams to navigate and optimize stroke patient outcomes. Acknowledgment The author would like to thank John J. O’Reilly, BSN, RN, and Robert Fine, MS, RN, for their review and comments regarding this article.
References American Stroke Association and the American Heart Association (2015). Learn more stroke warning signs and symptoms. Retrieved from http://www.strokeassociation.org/STROKE ORG/WarningSigns/Learn-More-Stroke-Warning-Signs-andSymptoms_UCM_451207_Article.jsp#.V54g5bgrLIU. American Stroke Association (2016). Target Stroke. Retrieved from http://www.strokeassociation.org/STROKEORG/Pro fessionals/Target-Stroke_UCM_314495_SubHomePage.jsp. Andersen, K.K., Olsen, T.S., Dehlendorff, C., & Kammersgaard, L.P. (2009). Hemorrhagic and ischemic strokes compared: Stroke severity, mortality, and risk factors. Stroke, 40, 2068-2072. Cheng, N.T., & Kim, A.S. (2015). Intravenous thrombolysis for acute ischemic stroke within 3 hours verses between 3 and 4.5 hours of symptom onset. The Neurohospitalist, 5(3), 101-109. del Zoppo, G.J., Saver, J.L., Jauch, E.C., & Adams, H.P. (2009). Expansion of the time window for the treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke, 40, 2945-2948. Easton, J., Saver, J., Albers, G., Alberts, M., Chaturvedi, S., Feldmann, E., et al. (2009). Definition and evaluation of transient ischemic attack: A scientific statement for healthcare professionals from the American Heart Association/ American Stroke Association Stroke Council. Stroke, 40, 2276-2293. Edlow, J.A., & Selim, M.H. (2011). Atypical presentations of acute cerebrovascular syndromes. The Lancet/Neurology, 10, 550-560.
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Emergency Nurses Association (2011). Emergency nursing scope and standards of practice: 2011 edition. Park Ridge, IL: Emergency Nurses Association. Flin, R., & Maran, N. (2004). Identifying and training non-technical skills for teams in acute medicine. Quality Safety in Health Care, 13, i80-i84. Gilboy, N., Tanabe, P., Travers, D.A., Rosenau, A.M., & Eitel, D.R. (2005). Emergency Severity Index, Version 4: Implementation handbook, AHRQ Publication No. 05-0046-2. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/research/esi. Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J., Demaerschalk, B., et al. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/ American Stoke Association. Stroke, 44, 870-947. Kothari, R., Pancioli, A., Liu, T., Brott, T., & Broderick, J. (1999). Cincinnati Prehospital Stroke Scale: reproducibility and validity. Annals of Emergency Medicine, 33(4), 373-378. Lindeke, L.L., & Sieckert, A.M. (2005). Nurse-physician workplace collaboration. OJIN: The Online Journal of Issues in Nursing, 10(1). Manuscript 4. McKinney, J.S., Mylavarapu, K., Lane, J., Roberts, V., Ohman-Strickland, P., & Merlin, M.A. (2013). Hospital prenotification of stroke patients by emergency medical services improves stroke time targets. Journal of Stroke and Cerebrovascular Diseases, 22, 113-118. Mozaffarian, D., Benjamin, E.J., Go, A.S., Arnett, D.K., Blaha, M.J., Cushman, M., et al. (2016). Heart disease and stroke statisticsd2016 update: A report from the American Heart Association. Circulation, 133, e38-e60. National Stroke Association. (n.d.). Signs and symptoms of stroke. Retrieved from www.stroke.org Powers, W.J., Derdeyn, C.P., Biller, J., Coffey, C.C., Hoh, B.L., Jauch, E.C., et al. (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46, 3020-3035. Schouten, L.M.T., Hulscher, M.E.J.L., Akkermans, R., van Everdingen, J.J.E., Grol, R.P.T.M., & Huijsman, R. (2008). Factors that influence the stroke care team’s effectiveness in reducing the length of hospital stay. Stroke, 39, 2515-2521. Summers, D., Leonard, A., Wentworth, D., Saver, J.L., Simpson, J., Spilker, J.A., et al.; the American Heart Association Council on Cardiovascular Nursing and the Stroke (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke, 40, 2911-2944. The Joint Commission. (2016). Sentinel event data: Root causes by event type 2004-2015. Retrieved from http://www. jointcommission.org/sentinel_event_statistics/ Vazirani, S., Hays, R.D., Shapiro, M.F., & Cowan, M.C. (2005). Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71-77.
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