Debbie Summers

Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose— The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods— Members of the writing committee were appointed by the American Stroke Association Stroke Council’s Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council’s Level of Evidence grading algorithm. Results— The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. Conclusions— Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement From the American Heart Association

Ischemic stroke represents 87% of all strokes.1 As worldwide initiatives move forward with stroke care, healthcare providers and institutions will be called on to deliver the most current evidence-based care. The American Heart Association/American Stroke Association (AHA/ASA) charged a panel of healthcare professionals from several disciplines with developing a practical, comprehensive overview of care for the patient with acute ischemic stroke (AIS). This article focuses on educating nursing and allied healthcare professionals about the roles and responsibilities of those who care for patients with AIS. Nurses play a pivotal role in all phases of care of the stroke patient. For the purposes of this article, the writing panel has defined 2 phases of stroke care: (1) The emergency or hyperacute care phase,2,3 which includes the prehospital setting and the emergency department (ED), and (2) the acute care phase, which includes critical care units, intermediate care units, stroke units, and general medical units. Stroke is a complex disease that requires the efforts and skills of all members of the multidisciplinary team. Nurses are often responsible for the coordination of care throughout the continuum.4–9 Coordinated care of the AIS patient results in improved outcomes, decreased lengths of stay, and decreased costs.10 In developing this comprehensive overview, the writing panel applied the rules of evidence and formulation of strength of evidence (recommendations) used by other AHA writing groups11 (Table 1). We also cross-reference other AHA guidelines as appropriate. Table 1. Applying Classification of Recommendations and Levels of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. …

Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Background— Stroke is a major cause of disability and death. The Brain Attack Coalition has proposed establishment of primary and comprehensive stroke centers to provide appropriate care to stroke patients who require basic and more advanced interventions, respectively. Primary stroke centers have been designated by The Joint Commission since 2003, as well as by various states. The designation of comprehensive stroke centers (CSCs) is now being considered. To assist in this process, we propose a set of metrics and related data that CSCs should track to monitor the quality of care that they provide and to facilitate quality improvement. Methods and Results— We analyzed available guideline statements, reviews, and other literature to identify the major features that distinguish CSCs from primary stroke centers, drafted a set of metrics and related data elements to measure the key components of these aspects of stroke care, and then revised these through an iterative process to reach a consensus. We propose a set of metrics and related data elements that cover the major aspects of specialized care for patients with ischemic cerebrovascular disease and nontraumatic subarachnoid and intracerebral hemorrhages at CSCs. Conclusions— The metrics that we propose are intended to provide a framework for standardized data collection at CSCs to facilitate local quality improvement efforts and to allow for analysis of pooled data from different CSCs that may lead to development of national performance standards for CSCs in the future.

Interactions Within Stroke Systems of Care A Policy Statement From the American Heart Association/American Stroke Association

In the United States and other parts of the world, various cities, states, and regions are developing multitiered systems for the care of patients with acute stroke. These systems often involve a range of healthcare components supported by various rules and regulations. The present policy statement will put forth concepts and elements for stroke systems of care that are intended to optimize patient care and management processes and improve patient outcomes, are practical to implement, and are supported by existing clinical data or expert consensus opinion. We will also make policy recommendations for the key elements of a stroke system of care. The public health implications of stroke care in the United States and worldwide are profound. Stroke is currently the fourth-leading cause of death in the United States and a major cause of long-term disability. Advancing age is a major risk factor for stroke, and the demographics of the US population and elsewhere reflect a continued growth of the aging population, with a resulting increase in the absolute incidence and prevalence of stroke.1 Improved stroke systems of care can ensure proper treatment of these patients and a reduction in death and disability. This is consistent with current American Heart Association and Centers for Disease Control and Prevention Healthy People 2020 public health goals and initiatives.2 There are several new care paradigms and technologies that are emerging as important elements of a stroke system of care. These include the development and proliferation of various levels of stroke centers; the expanded use of telemedicine technologies; advanced medical, endovascular, and surgical interventions; and comprehensive rehabilitation strategies and programs. Prehospital care and triage and the efficient transfer of patients between hospitals are also key components of stroke systems. The present …

Dysphagia Screening: State of the Art Invitational Conference Proceeding From the State-of-the-Art Nursing Symposium, International Stroke Conference 2012

Dysphagia screening is a recurring topic of discussion in stroke care and other acute and chronic conditions that can affect swallowing. Many would agree with Wolf and Rudd that “[s]wallowing screening is so obviously important that a trial is not needed, but the hard evidence that screening saves lives is absent.”1 Paradoxically, the 2010 Joint Commission retired the dysphagia screening performance standard for acute stroke because the National Quality Forum could not endorse it, stating that there are no standards for what constitutes a valid dysphagia screening tool, and no clinical trials have been completed that identify the optimal swallow screening.2 Consequently, dysphagia screening was removed from the “Get With The Guidelines” stroke guidelines. This has led to concern among multidisciplinary stroke professionals that dysphagia screening will be entirely omitted from stroke care, leading to worsening outcomes among stroke patients at risk for swallowing problems. An invitational symposium was held January 31, 2012, at the State-of-the-Art Nursing Symposium in New Orleans, LA, to explore the issues and state of the science in dysphagia screening. The present report serves as a conference proceeding that aims to (1) educate multidisciplinary stroke professionals about the important issues related to identifying valid and reliable dysphagia screening tools, (2) identify the strengths and limitations of currently available dysphagia screenings, (3) describe how facilities may make cogent decisions about dysphagia screening selection, based on their specific needs, and (4) provide an example for establishing a dysphagia screening in a stroke care unit. As part of the discussion during the symposium, several expert recommendations were made regarding dysphagia screening in stroke care, which are also presented here. We will begin the report, as we will end, with this caveat: Because dysphagia screening is not a “one size fits all” process, neither the symposium nor the …

Patient-Centered Decision Support in Acute Ischemic Stroke: Qualitative Study of Patients' and Providers' Perspectives.

Background—National guidelines endorse recombinant tissue-type plasminogen activator (r-tPA) in eligible patients with acute ischemic stroke to improve patients’ functional recovery. However, 23% to 40% of ideal candidates with acute ischemic stroke for reperfusion are not treated, perhaps because of the difficulty in explaining the benefits and risks of r-tPA within the frenetic pace of emergency department care. To support better knowledge transfer and creation of a shared decision-making tool, we conducted qualitative interviews to define the information needs and preferred presentation format for stroke survivors, caregivers, and clinicians considering r-tPA treatment. Methods and Results—A multidisciplinary team used qualitative research methods to identify informational needs and strategies for describing the benefits and risks of r-tPA in a clinical setting. Through focus groups (n=10) of stroke survivors (n=39) and caregivers (n=24) and individual interviews with emergency physicians (n=23) and advanced practice nurses (n=20), several themes emerged. Survivors and caregivers preferred a broader definition of a good outcome (independence, rather than no significant disability), simpler graphs as compared with detailed pictographs, and presentation of both population and individualized benefits (framed positively) and risk of receiving r-tPA. Some physicians expressed skepticism with the data and the ability to present risk/benefit information emergently, whereas other physicians and most advanced practice nurses thought such information would improve care. Physicians stressed the importance of presenting the risk of thrombolytic-related intracranial hemorrhage. Conclusions—This study suggests that a positively framed risk–benefit tool with graphical presentations of general and patient-specific risk estimates could support patients and providers in considering r-tPA for acute ischemic stroke. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01864928.

Update on Transient Ischemic Attack Nursing Care

Considered a medical emergency, a transient ischemic attack (TIA) resulting from a focal ischemia in the brain or retina signals a sudden neurological deficit with patient symptoms typically lasting only 1 to 2 hours.1,2 The 90-day risk of stroke after a TIA is reported as high as 17% with the highest risk occurring in the first week.3,4 Approximately 240 000 US adults each year experience a TIA.5 The true prevalence of TIAs seems under-reported because patients fail to report their symptoms to healthcare providers.6,7 Evidence supports when an individual is at risk for TIA or one is suspected, immediate action is required. Nurses play a pivotal role in all phases of patient care. Also, they frequently are on the front line regarding TIA and stroke education of patients/families, recognition of signs/symptoms, assessment and evaluation of modifiable risk factors, and long-term management of TIA.7–9 The purpose of this article is to provide an update of the most salient aspects of evidence-based TIA nursing care. Nurses especially with advance practice training have a unique role in the initial evaluation (eg, identifying symptoms, eliminating mimics, triaging TIA referrals or early access to initial evaluation, assessing risk of acute and long-term complications), diagnosis, management, and patient/family education.7,9 Evidence resulting from a 5-year prospective study reveals key clinical characteristics associated with an impending stroke which include first diagnosis of TIA, increased age, deficits lasting >10 minutes, history of gait disturbance, dysarthria, elevated blood pressure …

The Stroke Center Handbook : Organizing Care for Better Outcomes

1. Setting the Goal for the Stroke Center 2. Stroke Center Organization 3. Regional Stroke Networks 4. Imaging for Diagnosis and Selection of Therapy 5. Acute Stroke Interventions 6. Issues in Acute Management 7. Prevention of Complications 8. Secondary Prevention of Stroke 9. Stroke Rehabilitation Appendix: Clinical Scales and Tools

Secondary prevention of stroke

The Heart and Stroke Foundation of Canada has estimated that there are approximately 400,000 individuals living with the effects of stroke (Statistics Canada, 2011). While there is disagreement among studies assessing the relative cost associated with secondary compared to first-ever stroke, recurrent strokes appear to contribute a disproportionate share to the overall national burden of stroke, principally due to costs associated with long-term disability (e.g. nursing home care and re-hospitalization). The secondary prevention of stroke includes strategies used to reduce the risk of stroke recurrence among patients who had previously presented with a stroke or TIA. Management strategies, which should be specific to the underlying etiology, include risk factor modification, the use of antithrombotic or anticoagulant drugs, carotid surgery, endovascular treatments. The present review provides information on risk factor management programs, management of hypertension, diabetes, hyperlipidemia, the role of infection, lifestyle modification (diet, smoking, use of alcohol, physical activity) as well as treatment for atherosclerosis and cardiac abnormalities (e.g. atrial fibrillation) and reperfusion techniques. The review may be downloaded in a single document or in single sections corresponding to the topic areas listed above. 8 Secondary Prevention of Stroke Katherine Salter PhD (cand.), Robert Teasell MD, Norine Foley MSc, Adam Hopfgartner MSc (cand.), Jennifer Mandzia MD, Shannon Janzen MSc, Danielle Rice BA, Mark Speechley PhD