Triage, Treatment, and Transfer: Evidence-Based Clinical Practice Recommendations and Models of Nursing Care for the First 72 Hours of Admission to Hospital for Acute Stroke

Key processes relevant to emergency nurses that are tied to timely assessment, triage, and rapid management of acute stroke in the emergency department are outlined in the table. As urgent administration of thrombolysis provided ≤4.5 hours from symptom onset is one of the few proven interventions for stroke,⁴ the aim of rapid triage is to commence immediate assessment of suitability for this treatment. It has been estimated that each 15 minutes decrease in treatment delay results in 1 month of additional disability-free life after a stroke.²⁰ However, triage times²¹ and process²² on arrival in the emergency department remain variable.

The use of a Code Stroke alert system has been shown to improve time to diagnosis and treatment and reduce intravenous r-tPA door-to-needle times.^17–19 Recently, the use of stroke team models led by appropriately trained advanced practice nurses have been shown to be efficient, accurate, and safe at identifying and treating patients with r-tPA.^23–26 These teams capitalize on the 24-hour-a-day nature of nursing providing around the clock on-site expert input for both Code Stroke calls and ongoing acute stroke patient management. Code Stroke advanced practice nurses oversee the diagnostic work up, interpretation of neuroimaging, review of laboratory work, and communicate remotely to physicians about their estimation of suitability for r-tPA treatment. This model of care enables rapid decision making that may significantly reduce door-to-needle times. Advanced practice nurse–led teams offer a method to safely extend vascular neurologist services when an in-house neurologist is unavailable 24 hours a day^23–25 and to augment telemedicine services (Table 1).²⁶

Organized SU care significantly reduces death and disability³ and improves processes of care³⁰ as grouping patients together by clinical specialty is associated with improved outcomes.³¹ However, overall access to SUs is variable and suboptimal, for example, 23% (Canada),¹¹ 58% (Australia)¹⁰; and SU staffing, structure, and organization may vary considerably. Timeliness of SU access also may be a critical factor.^32,33 Extended waiting time in emergency departments for non–stroke-specific conditions is associated with poorer outcomes and higher inpatient mortality.³⁴ Although data are limited, better outcomes have been reported in patients with stroke with shorter admission times (>6 hours compared with within 3 hours),³² and earlier admission to SU (within 2 days) has been associated with fewer complications.³³ Hence, any unnecessary delays in transfer to a SU likely may compromise patient outcomes, especially for patients requiring complex stroke care and those needing close nursing surveillance. Key nursing elements and models of care that facilitate rapid admission to the SU include prenotification of incoming stroke to the stroke team³⁵ and use of protocols to ensure that patients are admitted directly to the SU.³² The effect of admission to a short-stay ward before transfer to a dedicated SU is unknown and requires further research (Table 2).

Significant variability exists in the nursing qualifications, education/training, and services offered in hospitals throughout the world³⁷ and this variability is likely also to be reflected in SUs. Local policies and procedures, often underpinned by nursing care safety concerns (lack of nursing staff, lack of nursing staff with necessary skill mix) may impede direct admission to SUs for the entire hospital admission. For example, in some hospitals, an admission to an intensive care unit or high dependency unit is required⁶ after thrombolysis administration or for those patients requiring more complex care including cardiac monitoring or acute blood pressure (BP) management. Specifically, in the United States, SUs commonly are set up as general care wards with a few dedicated beds and rarely are r-tPA–treated patients admitted to SUs directly, without first spending 24 hours in an intensive care unit. In contrast, in Australia and Europe, r-tPA patients often are admitted directly to SUs that offer an ability to provide close monitoring of these patients. Recent evidence from the USA suggests that an intensive care unit admission solely for monitoring patients post–r-tPA may be unwarranted and unnecessarily expensive and that these patients safely can be managed in a SU when nurses have undertaken specialized education and training.³⁸ Furthermore, admission directly to a SU for r-tPA patients improves continuity of care and the opportunity to provide early and consistent education about the stroke event, stroke recovery, and strategies for stroke prevention.

Emerging evidence from the UK has demonstrated improved quality of care and lower mortality in SUs with staffing ratios of ≥3.0 registered nurses/10 beds. The study also found that patients admitted to a SU with 1.5 registered nurses/10 beds on a weekend had a significantly higher adjusted 30-day mortality rate (15.2%) when compared with patients admitted to a SU with a weekend ratio of 3.0 registered nurses/10 beds (11.2%).³⁹

Nurses play a pivotal role in the ongoing monitoring and treatment of patients in the first 72 hours of acute stroke. Adherence to evidence-based processes of stroke care improves patient outcomes^13,30 and many of these are initiated, administered, or co-ordinated by nurses.⁴⁰ The use of clinical pathways and stroke care protocols also improve adherence to evidence-based care^41,42 and patient outcomes.⁴³ The use of specialized stroke clinical co-ordinators to implement change also can improve SU access, aspirin administration within 24 hours, use of care plans, increased allied health assessments, and result in more patients discharged to home.³⁶

For all patients with stroke, but particularly after administration of r-tPA, and those with acute intracerebral hemorrhage (ICH), close and accurate BP monitoring is required. Noninvasive automatic oscillometric BP monitors commonly are used but are not recommended for use in patients with atrial fibrillation because of significant beat-to-beat variability. In this situation, manual sphygmomanometers should be considered recording the average of 3 consecutive systolic and diastolic measurements.^44,45 Importantly, noninvasive oscillometric BP monitors only accurately measure the mean arterial pressure and then algorithmically derive a systolic and diastolic pressure.^46,47 As current stroke BP management guidelines are not based on mean arterial pressure ranges, more research is warranted to refine the use of derived values from these devices in patients with acute stroke. Goals for BP levels are outlined in the table. In the case of ICH, aggressive BP lowering seems to be safe with potential small improvements in outcome.⁴⁸

Accurate and frequent neurological observation assists in early identification and subsequent management of deterioration.⁶ The Glasgow Coma Score is not recommended for ongoing monitoring of patients with ischemic stroke and has been shown to produce a normal score of 15 when the National Institutes of Health Stroke Scale in the same patient reflects significant disability.⁴⁹ The National Institutes of Health Stroke Scale is recommended as a method to quantify stroke disability and can be validly and reliably performed by nurse.⁵⁰ Using the full National Institutes of Health Stroke Scale more accurately reflects the vascular territory involved rather than use of a cut down version of the National Institutes of Health Stroke Scale, which involves an arbitrary selection of assessments that may not be related to the presenting stroke deficit.⁴⁹

Evidence of the impact of a nurse-led multidisciplinary intervention on outcomes in acute stroke was provided by the Quality in Acute Stroke Care (QASC) Trial.⁴³ Results demonstrated that supported implementation of 3 clinical protocols for the management of fever, hyperglycemia, and swallowing dysfunction (fever, sugar, swallowing clinical protocols) in the first 72 hours of stroke significantly decreased death and dependency by 16% and also significantly reduced temperature, blood glucose level and improved swallowing management. Specifically, the fever, sugar, swallowing protocols consisted of 4 to 6 hourly monitoring of temperature with treatment of temperature >37.5°C with antipyretics; monitoring of glucose levels sixth hourly and treatment of elevated glucose >198 mg/dL (11 mol/L) with insulin; and either a swallowing screen by nurses within 24 hours of admission with referral to speech-language pathologist for those who fail the screen or a swallowing assessment by a speech-language pathologist. This is one of the few trials in stroke nursing care demonstrating that evidence-based nursing care can reduce death and dependency,^13,43 and results from this trial reinforce the potential that nursing quality improvement initiatives can have dramatic impact on patient outcomes.

Maintenance of glucose levels of 140 to 180 mg/dL (7.8–10 mmol/L) is recommended.⁶ Hyperglycemic management is important not just for diabetic patients, as patients with hyperglycemic stroke not known to have diabetes mellitus (glucose 108–144 mg/dL [6–8 mmol/L]) have a 3-fold higher risk of death when compared with patients with euglycemic stroke not known to have diabetes mellitus.⁵¹ Hence, glucose monitoring for all patients with stroke is crucial and often overlooked.¹³

Nurses have a critical role in implementing important clinical processes of care at the bedside, many of which have demonstrated association with improved outcomes.^13,30 These are outlined more fully in the table and include assessment procedures, early mobilization; avoidance of urinary catheterization; treatment of hypoxia, hyperglycemia, and suspected infection; and ongoing rehabilitation policies (eg, co-ordinated multidisciplinary team care and early assessment for discharge).⁵² The use of intermittent pneumatic compression,⁵³ but not compression stockings,^54,55 has been shown to reduce the risk of deep venous thrombosis and possibly improve survival in immobile patients after stroke.

Dysphagia is a significant problem after stroke experienced by 42% to 67% of patients within 3 days of stroke.⁵⁶ Patients with dysphagia have a 3-fold increased risk of pneumonia⁵⁷ and should be nil by mouth until their swallowing ability has been determined.⁶ Dysphagia screening should be performed using a validated,⁷ evidence-based tool⁶ and can safely be undertaken by nurses.⁵⁸ A dysphagia screen is defined as a pass/fail procedure to identify an individual who may need a complete dysphagia assessment.⁵⁹ Patients who fail a swallow screen should be referred to a speech-language pathologist for a full dysphagia assessment.⁶⁰

Determination of stroke pathogenic mechanism is a key area of focus during SU care and guides subsequent secondary prevention therapies. Identification of atrial fibrillation requires either serial ECGs or telemetric cardiac monitoring.⁶¹ Nurses play a vital role in overseeing this aspect of care through inquiry about stroke risk factors and mechanism, reviewing diagnostic test results, and providing advice on secondary prevention measures to prevent future stroke.

In addition, nurses are responsible for educating patients and family members/carers about their stroke care, including the pathogenesis of stroke, treatment provided, personal risk factors, medications, stroke signs and symptoms, use of emergency medical services, and strategies to reduce further stroke risk. Despite this, recent data show that patients and family members/carers poorly retain information taught to them in the hospital about stroke (Table 3).⁶²

A summary of key nursing–supported factors guiding stroke care in the first 72 hours is shown in Table 4.⁷⁷

The clear priority for improving stroke care outcomes is closing known evidence-practice gaps by improving timely access to early interventions with demonstrated efficacy. Nurses play a crucial role in stroke care and they are well placed to take a leadership role in implementing evidence-based care within the multidisciplinary stroke team.^40,78 The internationally emerging roles of the stroke advanced practice nurse and stroke nurse practitioner hold great promise for the development of new nurse-led models of stroke nursing care, including stroke telemedicine services which could be augmented by inclusion of these nursing roles.²⁶

The future for SUs to involve critical care is worthy of consideration where nurses have the appropriate qualifications and experience to undertake complex nursing care such as care of ventilated patients, administration of intravenous insulin, co-ordination of r-tPA administration, post-tPA recovery, and care of the unstable stroke patient.⁶

Quality monitoring and improvement activities are recommended to ascertain adherence to nationally accepted clinical practice guidelines.⁶ Routine collection of quality data in the form of local or national audit^10,11,14,79 or stroke clinical registries^80,81 to measure adherence to important stroke processes of care is imperative. The use of these data to drive continuous quality improvement in stroke care can benefit patients.⁸² Recently clinical performance measures for acute ischemic stroke have been published by the American Heart Association and American Stroke Association.⁸³

Acute stroke nursing research is in its infancy. Encouragingly, there are an increasing number of trials underway exploring vital questions for acute stroke care nursing.^84–88 Nurse researchers also have a pivotal role in conducting implementation research, that is, examination of methods to increase evidence uptake by clinicians.^43,84 Future rigorous clinical and implementation research will help to address gaps in evidence and strengthen existing models of care and clinical guidelines.

We would like to thank the Australian Stroke Coalition for their support and acknowledge Erin Lalor from the National Stroke Foundation, Australia, and Cintia Martinez-Garduno from the Nursing Research Institute for their assistance with this article.