STROKE AWARENESS: Bethany Abernethy, RN, and Theresa Kwah, MBA, BSN, RN, clinical nurse manager of the neuro floor, work near a stroke prevention educational poster.

The Joint Commission encourages medical centers treating patients experiencing an acute stroke to become recognized as Primary Stroke Centers to improve outcomes for these patients. The Joint Commission has established performance requirements that facilities must meet.¹ Because "time is brain," the purpose of these performance measures is to ensure rapid treatment of stroke to minimize neurological damage. However, even though the advantages of rapid treatment are well known, the proportion of stroke patients nationwide who receive treatment within the 2 hours is only 4 percent.²

On Nov. 3, 2008, Gaston Memorial Hospital (GMH) in Gastonia, NC, was awarded certification as a Primary Stroke Center by the Joint Commission, culminating an effort that began in July 2007. The multidisciplinary team included representatives from both the hospital and community, coming together to address a real community need: stroke prevention and treatment. To succeed, we knew stroke care had to occur across a continuum - from EMS to the hospital, to rehab, and finally back to the home.

Developing the Team

Jan Mathews, MPHA, RN, CPHQ, NEA-BC, director of Clinical Performance Improvement, spearheaded the work and gathered a team of key people who would play crucial roles. We realized stroke care would be optimized only if there was a combined effort of the hospital and community.

GMH physicians were involved in formulating the plan to deliver stroke care. Vice President of Medical Services David Huber, MD, Medical Director of Stroke Richard Fricker, MD, and Medical Director of Emergency Services Timothy Corvino, MD, and other neurologists and hospitalists provided guidance. They worked together with nurses and community representatives to develop goals and action plans focused on caring for patients experiencing stroke.

Special attention was given to the staff members who would provide care to these patients once they were admitted to the hospital. A steering committee met every month to develop stroke protocols and identify the specialized team that would be responsible for responding to stroke patients who presented at the hospital. This "Code Stroke" team includes a physician, nurses, laboratory staff, respiratory therapists, radiology staff, the shift supervisor and the stroke coordinator.

GROUP EFFORT: The "Code Stroke" team includes a physician, nurses, laboratory staff, respiratory therapists, radiology staff, the shift supervisor and the stroke coordinator.

Specialized Training

In November 2007, all nurses in the emergency department, critical care and neurology were invited to attend a 4-hour class titled "Brain Attack: A Golden Opportunity." The class covered signs and symptoms of stroke, the different types of stroke, the importance of early intervention, use of the NIH Stroke Scale, case management and discharge planning, and community awareness.

Physicians, our community outreach coordinator, the critical care clinical nurse specialist and clinicians from the ED all helped teach the class. A follow-up class was provided to certify all critical care, ED and neurology nurses in the use of the NIH Stroke Scale and familiarize them with the new stroke protocols.

NIH certification will be maintained to ensure all staff members are trained to recognize neurological changes in patients. Certain floors have been designated to care for stroke patients. They include the critical care units and neurology. Once patients are admitted to the hospital, they are placed on these units to ensure specialized care for their needs.

Putting the Plan Into Action

Since the stroke steering committee first met, many changes have occurred at GMH. A major change is in the response when a "code stroke" is recognized. Gastonia EMS, our local EMS system, immediately notifies our ED when they have a patient exhibiting signs and symptoms of stroke. Several things happen in anticipation of the patient's arrival at the hospital. Specialized ED staff are freed up to care for the patient and necessary supplies are gathered in the room where the patient will be placed. These supplies include blood sample tubes specially tagged with a green "stroke" sticker that can be easily identified in the lab.

Having also received the same notification as the ED, the lab begins to prioritize the work and someone from their department is made available to draw blood. Radiology also prepares to facilitate rapid CT scanning to identify the type of stroke quickly so medication can be given if indicated to reduce the effects of the stroke. The intensivist is notified if it is determined that the patient is a candidate for tPA. The staff also perform a baseline NIH stroke scale assessment for comparison to as time goes on. The process has been made much more efficient by the hard work of everyone involved.

Stroke Coordinator

Part of ensuring the success of the stroke program has been identifying a stroke coordinator. Anita Burris, MSN, RN, who recently was named to the position, has done a wonderful job. Anita's responsibilities include checking on each stroke patient, providing individualized education to patients, and monitoring charts to be sure that everyone is following the policy and procedures for stroke care.

Educating the Community

Efforts have been made to educate the community on the signs and symptoms of stroke as well as the need to seek treatment. Our stroke coordinator has spoken throughout the community. Both she and some of the nurses participated in a blood pressure screening at the mall, and Dr. O'Conner, one of our physicians, spoke to an audience of more than 150 people about stroke.

Several staff members have participated in health fairs to provide information to the public. In addition, every patient admitted to the hospital is given a booklet on stroke prevention and encouraged to share this with friends and loved ones.

Striving for Excellence

We first submitted our application for certification as a Primary Stroke Center in May 2008, sure we had what was needed to become a premier provider for specialized stroke care in North Carolina.

Chief Nursing Office Kathleen Harwell, MSN, MBA, RN, NEA-BC, and President and Chief Executive Officer Wayne Shovelin, FACHE, have been very supportive in our pursuit of excellence. Our biggest validation came when we learned we had achieved our goal. At GMH, our view is patients and families are the purpose of our existence; they are included in care decisions, they are safe and we care unconditionally.

With our plan to quickly identify and treat stroke patients, and our educational efforts in the community, we believe patients will receive the best stroke care available right in their own home town.

References

1. Joint Commission (2009). Stroke performance measurement. Retrieved April 21, 2009 from the World Wide Web: http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pms.htm

2. American Heart Association. (2009). Heart disease and stroke statistics - 2009 update. Circulation, 119: e21-e181.

Theresa Kwah is clinical nurse manager of HMI Neurology at Gaston Memorial Hospital, Gastonia, NC, and Donald D. Kautz is director of the Hickory Outreach Program at the University of North Carolina at Greensboro. The authors wish to acknowledge the editorial assistance of Elizabeth Tornquist with this article. The NIH Stroke Scale is in the public domain. The authors encourage all facilities to train all nurses who may care for stroke patients to use this scale.