Evidence-Based Clinical Practice of Nursing Care for First 72 Hours

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State-of-the-Science Nursing Review
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
Sandy Middleton, PhD, RN; Rohan Grimley, MBBS(Hons), BSc(Med), FRACP;
Anne W. Alexandrov, PhD, RN, NVRN-BC, ANVP-BC
S
troke is a medical emergency and care provided in the
first hours is critical in shaping patients’ long-term recovery and prognosis.1 There is robust evidence demonstrating
significant reductions in death and disability with early interventions in acute stroke care, including antiplatelet therapy2
stroke unit (SU) care3 and thrombolysis.4 International clinical guidelines for stroke provide key recommendations to
guide clinical practice5–8; however, uptake of evidence-based
care is variable and often less than optimal.9–14 For example,
among patients with ischemic stroke, rates for treatment with
intravenous recombinant tissue-type plasminogen activator
(r-tPA) are relatively low in the USA (5%)9 and Australia
(7%),10 compared with Canada (12%)11 and some European
centers (14%).15
Nurses play a pivotal role in rapid identification and triage
of patients with acute stroke, initial assessment, and coordinating the timely flow of patients with acute stroke through the
health system. Nurses enable delivery of relevant time critical
treatments, and rapid transfer to acute SUs for ongoing assessment and provision of further treatment.
The purpose of this article is to highlight nursing’s essential contribution to the expedient delivery of acute stroke care
by providing evidence-based recommendations for clinical
practice processes of care and models of care where nurses
have a pivotal role during the first 72 hours from arrival at the
emergency department through to SU care. A more detailed
comprehensive overview of nursing and interdisciplinary care
for patients with acute ischemic stroke extending beyond the
first 72 hours has been published previously.16
Where available in existing guidelines, the class and level
of evidence for recommendations shown in tables have been
provided using the American Heart Association taxonomy.6
As there is a dearth of evidence from high-quality stroke nursing research, not all the recommendations described in this
article have been evaluated using randomized controlled trials.
Therefore, we have included examples of clinical models and
systems for which lower levels of evidence suggest improvement in patient outcomes or a reduction in barriers to rapid
assessment and management of stroke.17–19 Furthermore, we
also have included models of care that emphasize the multidisciplinary team, as examination of nursing care in isolation from care provided by other health professionals does not
reflect current evidence-based practice. Where no rigorous
evidence exists for a recommendation, we have labeled it a
good practice point.7 Finally, opportunities for future research
are identified in an effort to direct the growth of acute stroke
nursing research.
Triage and Rapid Management
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 day23–25 and to augment telemedicine services (Table 1).26
Received December 4, 2014; final revision received December 4, 2014; accepted December 5, 2014.
From the Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University, St Vincent’s Hospital, Darlinghurst,
NSW, Australia (S.M.); Sunshine Coast Hospital and Health Service/Sunshine Coast Clinical School, The University of Queensland, Nambour, Queensland,
Australia (R.G.); Centre for Research, College of Nursing, University of Tennessee Health Science Center-Memphis (A.W.A.); and Australian Catholic
University, NSW, Australia (A.W.A.).
Correspondence to Sandy Middleton, PhD, RN, Nursing Research Institute, St Vincent’s Health Australia (Sydney) and Australian Catholic University,
Executive Suite, Level 5 DeLacy Bldg, St Vincent’s Hospital, Victoria Rd, Darlinghurst 2010, NSW, Australia. E-mail [email protected]
(Stroke. 2015;46:e18-e25. DOI: 10.1161/STROKEAHA.114.006139.)
© 2015 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.006139
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Middleton et al Best Practice and Models of Stroke Nursing Care e19
Table 1. Triage: Key Nursing Elements for Timely Assessment, Triage, and Rapid Management of Acute Stroke in ED
The use of evidence-based rapid stroke screening tools at triage such as the Los Angeles prehospital stroke screen, the Cincinnati Prehospital Stroke Scale (FAST),27
or Recognition of Stroke in the Emergency Room Scale28 (class I: level of evidence B)6
Assignment of a high-severity triage category, to be seen within <10 min of ED arrival,6 using a standardized triage system such as the Emergency Severity Index
(GPP)
Systems to urgently notify the hospital stroke team such as hospital prenotification and initiation of Code Stroke (see below; class I: level of evidence B) aiming for
rapid brain imaging (class I: level of evidence A), assessment for suitability for r-tPA and thrombolytic administration where indicated (class I: level of evidence A) with
a door-to-needle time of <60 min (class I: level of evidence A)6
Code Stroke alerts including (1) prenotification: ambulance to the ED or directly to stroke team and ED notification to stroke team, (2) rapid assessment of airway,
breathing, circulation, and disability, with assignment of triage category to be seen in <10 min, (3) rapid patient registration or use of a preregistration alias, (4)
priority use of CT scanner, (5) immediate intravenous access, with blood drawn for standard laboratory tests, (6) immediate transfer to CT directly from ambulance
after obtaining a brief but thorough history including time last seen normal, anticoagulant use, and medical–surgical history pertinent to thrombolysis risks, (7) rapid
imaging interpretation by stroke team and completion of the NIHSS, (8) rapid control of arterial blood pressure as indicated by r-tPA treatment criteria, with infusion kit
brought to CT to expedite treatment, and (9) r-tPA bolus and infusion initiated on CT scanning bed when possible (class I: level of evidence C)17,18
Assessment of initial stroke severity using the NIHSS on arrival in ED and before and after treatment with r-tPA (class I: level of evidence B)6,29
Rapid imaging of the brain (class I: level of evidence A)6 with either noncontrast CT or MRI within 25 min of arrival to the ED with r-tPA administration commenced
before the use of additional imaging sequences (ie, CT angiography; GPP)
CT indicates computed tomography; ED, emergency department; FAST, Face, Arm, Speech, Time; GPP, good practice point; NIHSS, National Institutes of Health Stroke
Scale; and r-tPA, recombinant tissue-type plasminogen activator.
Transfer
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 shortstay 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
Monitoring and Treatment
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
Table 2. Transfer: Key Nursing Elements for Rapid Transfer of
Patients With Acute Stroke From the ED to the SU
All patients should be cared for in a dedicated SU (class I: level of evidence A)3,6
Rapid transfer to the SU from the ED is optimal32,33 (GPP)
Prenotification of the stroke team may facilitate rapid transfer to the SU on
admission (GPP)35
The use of stroke protocols may facilitate rapid transfer to the SU on
admission (GPP)32
Formal appointment of a stroke coordinator may streamline stroke system
processes and strengthen quality improvement of stroke services (class I: level
of evidence C)36
ED indicates emergency department; GPP, good practice point; and SU,
stroke unit.
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e20 Stroke February 2015
Table 3. Key Nursing Elements for Monitoring and Treatment in First 72 Hours of Acute Stroke
Monitoring
Neurological assessment with the National Institutes of Health Stroke Scale to determine deterioration or improvement in neurological condition (GPP)6
Continuous oxygen saturation monitoring to identify hypoxia and early development of complications (eg, aspiration; GPP)6
Cardiac monitoring for at least the first 24 h to determine possible stroke pathogenic mechanism (eg, atrial fibrillation) and monitor for possible arrhythmias (class I:
level of evidence B)6
BP monitoring every 15 min for 2 h, then every 30 min for 6 h, and then every hour for 16 h in patients undergoing reperfusion therapy (GPP); ongoing BP
assessment to manage titration of antihypertensive medications and identify patients for improved stroke risk factor management6
Temperature monitoring at least every 4 h (class I: level of evidence B) to determine the need for treatment of hyperthermia8,43
Glucose monitoring on arrival to ED and every 6 h thereafter for the initial 72 h of care to determine the need for implementation of glucose control measures (GPP)
(class I: level of evidence B)43
Dysphagia screening using a valid and reliable tool by a trained non–SLP or swallowing assessment by a SLP should occur before administration of food, drink,
or oral medications60 (class I: level of evidence B)6 within 4 to 24 h of hospitalization.63,64 Referral to SLP for those failing the screen for formal swallowing
assessment (class I: level of evidence B).43,60 The presence of a gag reflex does not constitute an adequate dysphagia screen as this does not indicate safety with
swallowing6
Fluid balance monitoring is recommended to identify dehydration and concurrent conditions seen in vascular patients (ie, renal insufficiency associated with longstanding hypertension, congestive heart failure, or left ventricular dysfunction (class I: level of evidence C)
Comprehensive nursing care assessment within 4 h of stroke unit admission for nutritional and hydration needs, positioning and mobilization needs, bladder control
and incontinence management, pressure ulcer risk, cognitive and language capacity, hearing and visual needs, and family/carer needs (GPP)5
Treatment
The use of appropriately educated and credentialed advanced practice nurses where available to initiate standardized diagnostic protocols (ie, ordering and
interpreting standardized laboratory tests and neuroimaging; GPP) and administer intravenous r-tPA (class IIb: level of evidence B)25
Airway and breathing support as required (class I: level of evidence C) with provision of oxygen for hypoxic patients (<94% oxygen saturation; class I: level of
evidence C)6; routine oxygen for nonhypoxic patients is not recommended (class III: level of evidence B)6
Thrombolysis: Delivery of prompt intravenous r-tPA treatment for eligible patients with ischemic stroke ≤4.5 h from symptom onset (class I: level of evidence A)65
with a door-to-needle time (time of bolus administration) target of <60 minutes6 (class I: level of evidence B)
Hypertension management: Goals for target BP are uncertain.6 However, the following are recommended
Prethrombolysis (potentially eligible patients): SBP <185 mm Hg and DBP <110 mm Hg (class I: level of evidence B)6
Post–r-tPA bolus: target <180 mm Hg SBP, <105 mm Hg DBP6
Nonthrombolysed ischemic stroke: a reasonable approach is BP lowering by 15% during the first 24 h after stroke. Withhold medications unless SBP >220 mm Hg
or DBP >120 mm Hg (class I: level of evidence C),6 or there are signs of cardiac decompensation because of left ventricular afterload (GPP)
ICH: Intensive BP lowering is safe and feasible.48,66 BP lowering within 6 h of ICH onset to a target systolic BP of <140 mm Hg may improve functional outcome at
3 mo after stroke as compared with a traditional BP-lowering target of <180 mm Hg (class I: level of evidence B)48
Subarachnoid hemorrhage: Reduction of systolic BP to a target of 90/160 mm Hg67 until the aneurysm has been occluded by endovascular or surgical
means (GPP)
Ongoing monitoring and reporting of BP control throughout hospitalization to identify patients in need of medication additions or dose adjustments (GPP)
Temperature: Treatment of temperature >37.5°C with antipyretics (class I: level of evidence B)8,43; evidence supporting induced hypothermia is currently lacking
(class IIb: level of evidence B)6
Hyperglycemia: Maintenance of glucose levels of 140–180 mg/dL (7.8–10 mmol/L; class IIa: level of evidence C).6,43 Avoidance of hypoglycemia (blood glucose
<60 mg/dL [3.3 mmol/L]; class I: level of evidence C)6
The use of standardized evidence-based stroke care protocols/pathways to inform care (class I: level of evidence B)6
Preparation for endovascular interventions for patients undergoing mechanical thrombectomy, noting emerging evidence that thrombectomy within 6 h of stroke
onset caused by proximal occlusion of anterior circulation, improves functional independence at 3-mo (class I: level of evidence B)6,6a
Head positioning: There is no large trial data to date examining the best head position after stroke, although these are underway. There is some evidence to support
improved blood flow when lying flat (0°) for large artery ischemic strokes, including those with fluctuating clinical presentation68,69 (class IIb: level of evidence C);
however, these findings cannot be generalized to patients with small vessel occlusions presenting with relatively minor symptoms who may best be served by early
mobilization; ICH patients at risk for increased intracranial pressure may benefit from head of bed elevation to 30° (GPP)
Palliative care: Identification of patient goals and commencement of relevant discussions for patients with poor prognosis (GPP)6
Education for stroke survivors and their caregivers/family (GPP)6
Caregiver support for those overseeing the needs of stroke survivors, including provision of accurate information about stroke, emotional and practical support, and
identification of important community resources/agencies (GPP)7
Rehabilitation: Early assessment and commencement of rehabilitation where relevant (GPP)52,70,71
Prevention of complications
Antiplatelets: Administration of antiplatelet medications within 48 h of stroke (class I: level of evidence A)2,6 after swallowing screen or swallowing assessment
undertaken6; antiplatelet agents should be withheld for 24 h in r-tPA–treated patients (class III: level of evidence C).6 If the patient is unable to swallow, aspirin or
other medication may be administered rectally72
(Continued)
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Middleton et al Best Practice and Models of Stroke Nursing Care e21
Table 3. Continued
Anticoagulants: The use of anticoagulation to prevent recurrent stroke or improve outcomes is not recommended in noncardioembolic ischemic stroke (class III:
level of evidence A).6 Anticoagulation is recommended for the primary and secondary prevention of patients with cardioembolic ischemic stroke (class I: level of
evidence A); however, the best timing for initiation of anticoagulation after an acute stroke event remains unknown
VTE: The use of anticoagulation provides superior VTE prophylaxis in patients with acute ischemic stroke (class I: level of evidence A). The use of intermittent
pneumatic compression for immobile patients reduces the risk of VTE and possibly death (class I: level of evidence B).53 Routine use of antiembolic stockings is not
recommended.54,55
Incontinence: Routine use of indwelling urinary catheters is not recommended because of infection risk (class III: level of evidence C)6,7
Early mobilization: Within the first 24 h for neurologically and hemodynamically stable patients is safe and feasible (class IIa: level of evidence B).70 Early
mobilization (within 52 h) is associated with fewer complications.71 Patients with stable neurological and hemodynamic presentation can be mobilized to out of bed
chair sitting even if level of consciousness is depressed (ie, stupor, obtundation, and lethargy; class IIa: level of evidence C)73
Hydration: Euvolemia should be maintained. The use of volume expanders to achieve hemodilution is not recommended in ischemic stroke (class III: level of
evidence A). Treatment of hypovolemia should include the use of isotonic intravenous normal saline (class I: level of evidence C)6
Nutrition: Ensure adequate nutrition. The use of nasoenteric tube feeding in patients unable to swallow for the first 2 to 3 weeks after stroke is preferred over use of
PEG tube feeding (class IIa: level of evidence B); for patients unable to safely swallow and those incapable of meeting their nutrition and hydration needs, consider
initiating nasoenteric feeding within 24 h (GPP).5 Verification of feeding tube placement should be done by radiographic methods74
Oral hygiene: Oral hygiene should be provided to reduce the risk of aspiration pneumonia (GPP).6,7,75 At least 3×/d and immediately after meals are recommended
(GPP).
Pressure area care: Those at high risk of developing pressure injuries should be placed on a high-specification foam mattress (class I: level of evidence A)76
Antibiotics: Patients with suspected pneumonia, sepsis, or urinary tract infections should receive antibiotics that target the relevant pathogen (class I: level of
evidence A)6
BP indicates blood pressure; DBP, diastolic BP; ED, emergency department; GPP, good practice point; ICH, intracerebral hemorrhage; PEG, percutaneous
endoscopic gastrostomy; r-tPA, recombinant tissue-type plasminogen activator; SBP, systolic BP; SLP, speech-language pathologist; SU, stroke unit; and VTE, venous
thromboembolism.
outcomes13,30 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 evidencebased care41,42 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
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e22 Stroke February 2015
Table 4. Key Nursing–Supported Factors Guiding Stroke Care in the First 72 Hours77
Rapid assessment
Stroke is an emergency and rapid assessment and treatment improves outcomes
Early identification
Early identification of acute stroke will improve access to time-dependent interventions
Prehospital services facilitate access
Organized prehospital services improve outcomes by increasing access and decreasing delays to time-dependent
acute stroke treatments
ED systems
Systems that prioritize assessment and management of acute stroke in the ED will minimize treatment delays and
maximize proportion of eligible patients receiving thrombolysis
SU access
Rapid flow of patients with acute stroke from ED to SU improves outcomes for patients with stroke
Multidisciplinary assessment and treatment
Whole of system quality improvement
Coordinated and rapid onset of specific treatments by a multidisciplinary team within SUs will improve outcomes
Quality improvement activities will improve performance within all aspects of care/system performance
ED indicates emergency department; and SU, stroke unit.
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
Discussion
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 audit10,11,14,79 or stroke clinical
registries80,81 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,
Take-Home Points
• Rapid evidence-based assessment and management
of stroke are fundamental to reducing mortality and
disability.
• Nurses have a key role to facilitate multidisciplinary
models of care and improve uptake of evidencebased stroke care.
• Nurse-led stroke research is paramount to further
inform the evidence base for nursing care.
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Middleton et al Best Practice and Models of Stroke Nursing Care e23
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.
Acknowledgments
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.
Disclosures
R. Grimley has received educational travel support from Boerhinger
Ingelheim; Anne Alexandrov is the Program Director, Neurovascular
Education & Training in Acute Stroke Management & Reperfusion
Therapies (NET SMART). The other author reports no conflicts.
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Key Words: guideline ◼ nursing ◼ stroke
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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
Sandy Middleton, Rohan Grimley and Anne W. Alexandrov
Stroke. 2015;46:e18-e25; originally published online January 6, 2015;
doi: 10.1161/STROKEAHA.114.006139
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2015 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/46/2/e18
An erratum has been published regarding this article. Please see the attached page for:
http://stroke.ahajournals.org/content/46/5/e129.full.pdf
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Correction
In the article by Middleton et al (Middleton S, Grimley R, Alexandrov AW. 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. Stroke. 2015;46:e18–e25. DOI: 10.1161/
STROKEAHA.114.006139.), which published online ahead of print January 6, 2015, and appears
in the February 2015 issue of the journal, a correction was needed.
On page e18, in the Triage and Rapid Management section, first paragraph, line 8, “It has been
estimated that each 15 minutes of treatment delay results in 1 month of additional disability-free
life after a stroke.20,” has been changed to read, “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”
The authors regret the error.
This correction has been made to the online version of the article, which is available at http://
stroke.ahajournals.org/content/46/2/e18.
(Stroke. 2015;46:e129. DOI: 10.1161/STR.0000000000000067.)
© 2015 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STR.0000000000000067
e129

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