Vol. 4 Issue 25
Evidence into Practice
An interdisciplinary team approach to the care of stroke patients
To ensure veterans receive timely evaluation and evidence-based therapies, the Michael E. DeBakey VA Medical Center (MEDVAMC) delivers patient-centered interdisciplinary team care to veteran's who suffer strokes. Each year in the U.S., about 700,000 people experience a new or recurrent stroke (Thom, et al, 2006). Unfortunately, these events lead to deaths and long-term disability.
In 2006, the estimated national cost of stroke is expected to exceed $58 billion of which healthcare expenditures will account for about 64 percent or $38 billion (Thom, et al, 2006). Stroke affects approximately 17,000 veterans each year and costs the Veterans Health Care system on average $18,000 per patient. According to the Department of Veterans Affairs, the importance of stroke within the VA is emphasized by the fact that stroke patients account for more than 10 percent of the VA's complex caseload. In addition to the absolute burden of stroke, many elderly veterans are at high risk of stroke.
Centering on Stroke
At the MEDVAMC, more than 300 stroke patients are cared for annually. In response to this serious healthcare issue, the facility established a stroke center to ensure veterans receive evidence-based stroke care. Just as in MI, the first hours of the event are a crucial time period in which evidence-based interventions can be initiated that improve stroke survival and outcomes.
Current practice guidelines recommend individuals with symptoms be transported immediately to a stroke-qualified facility for rapid workup. The MEDVAMC Stroke Center is such a facility with a dedicated in-house stroke care team. The emergency department works closely with Emergency Medical Services (EMS) to ensure veterans with stroke symptoms are transported immediately for evaluation and treatment. To facilitate rapid assessment and diagnostic testing in the event thrombolytic therapy is needed, a dedicated phone line is utilized to notify ED staff when EMS is in route.
A multidisciplinary team comprised of ED nurses and physicians, a neurologist, and radiology and laboratory specialists are available 24/7 to provide immediate diagnosis and emergent treatment of veterans who present to the ED with stroke symptoms. Nursing care for veterans with stroke follows a continuum that generally begins in the ED with subsequent care provided in the stroke unit. Here, nurses provide daily assessment, teaching and discharge planning.
Once stabilized patients are evaluated by a rehabilitation nurse practitioner for inpatient rehabilitation or discharge home. The neurology nurse case manager and social worker collaborate closely to ensure smooth transition from an inpatient to outpatient setting.
After discharge, veterans receive follow-up care in stroke specialty clinics; one new initiative is the nurse-lead STOP (Self-management TO Prevent) Stroke Clinic. A neurology nurse practitioner, nurse practitioner faculty and nurse practitioner students staff this hybrid specialty clinic. The focus of the clinic is secondary prevention interventions for veterans who have experienced stroke or transient ischemic attack (TIA).
Arrival at the ED
Nurses play a critical roll as the first point of contact for veterans presenting to the ED. When a veteran presents with signs and symptoms of stroke, the ED nurses activate the stroke code protocol. Vital to ED procedure is rapid assessment and activation of the stroke team.
The nurse must first determine when stroke symptoms began; this information is key in determining the course of care. The only approved treatment for ischemic stroke, recombinant tissue plasminogen activator (rtPA), is effective only if administered within 3 hours of symptoms onset. Patients arriving within this time window are rapidly triaged using stroke code protocols to ensure eligible patients receive thrombolytic therapy. Although veterans with hemorrhagic stroke are not candidates for rtPA, immediate evaluation and treatment may improve mortality.
Time lost is brain lost and ED nurses work as a team to quickly complete history, physical assessment, ECG, IV access and blood collection in preparation for timely transport to the CT scan. The goal is to complete these nursing interventions rapidly based on stroke code target times as outlined in the Table. Nurses also determine the severity of stroke symptoms using the NIH Stroke Scale (NIHSS). All ED nurses at the MEDVAMC are NIHSS-certified.
Stroke Unit Care
Upon admission to the stroke unit, nurses continue to monitor and assess stroke patients for acute complications that may occur. Frequent neurological and vital sign assessments are important in the immediate post-stroke period to ensure blood flow and oxygenation of the brain. Nurses monitor patients to prevent hypoxia, hypotension and elevated body temperature, as these events compound the ischemic insult to the brain and worsen recovery outcomes.
Hypertension is common in conjunction with stroke and is managed conservatively. Antihypertensive medications are not recommended unless systolic blood pressure (SBP) is >220 mm Hg or diastolic blood pressure (DBP) is >120 mm Hg. If rtPA was given, target SBP is 185 mm Hg and DBP <100 mm Hg.
Nurses in the stroke unit also know the importance of maintaining normal blood glucose levels. Hyperglycemia during the post-stroke period recently has been linked to increased mortality and morbidity.
Nurses in the stroke unit provide daily assessments focused on stroke sequelae: mobility, swallowing and prevention of deep vein thrombosis. The nurse case manager conducts physical and psychosocial assessments for proactive discharge planning and tracks improvements in stroke severity using the NIHSS.
Patient education is an important part of daily nursing interventions on the stroke unit. Education materials are easily accessible via a Web-based system that can be automatically printed at the nursing station for review with the veterans.
A collaborative care model is employed where the patient and provider partner in the management of risk factors for stroke and TIA. The STOP Stroke Clinic provides a system through which evidence-based interventions can be implemented using three essential care delivery areas: clinical management, patient education and patient self-management.
This comprehensive care delivery process will be facilitated by a computerized template based tool (the STOP Stroke Tool) that prompts providers' interventions based on current evidence-based practices, automates guideline-adherent documentation and facilitates outcomes data collection at the point of care. Current nursing research is under way to measure the effectiveness of this tool in facilitating secondary prevention guidelines and patient self-management counseling.
A specific aim of the Stop STROKE Clinic is to foster excellence in nursing education and research. In this pursuit, a unique affiliation has been established between the center and Prairie View A&M University College of Nursing. Faculty and students combine graduate course work, faculty practice and clinical rotations to provide health services and counseling to post-stroke patients and their families.
Members of the interdisciplinary Stroke Team conduct pedagogical lectures on epidemiology, risk factors and risk reduction; cardiovascular disease, stroke and TIA; acute and secondary stroke management; and chronic disease self-management (CDSM) training. Students enrolled in the senior graduate courses "Chronic Disease Self-Management" and "Management of Chronic Diseases" complete clinical practicums in the STOP Stroke Clinic and help lead a 6-week CDSM course at the medical center.
Students readily demonstrate competencies in translation of evidence-based practice by immediate implementation of guideline-based care into practice. Unique teaching strategies implemented by this partnership are:
role modeling of interdisciplinary team care;
clinical use of research instruments;
documentation using a computerized medical record with a guideline decision support tool; and
individual and group counseling sessions.
Through these innovative nursing practices, the nurses at the MEDVAMC Stroke Center are demonstrating excellence in care and interdisciplinary team practice. These processes serve as a model for the translation of evidence into practice for the care of veterans with stroke.
Thom, T., et al. (2006). Heart disease and stroke statistics–2006 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 113(6), e85-151.
Jane Anderson is associate director of the stroke center and Karen Stonecypher is case manager of the neurology care line, both at the Michael E. DeBakey VA Medical Center. Pamela Willson is director of the family nurse practitioner program at Prairie View A&M University, College of Nursing.