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					Improving the care
of stroke patients
                                        Using an evidence-based quality
                                                 improvement initiative
                                                    enhances outcomes
                                                    for stroke patients.

                                                                           By Kathy Morrison, MSN, RN, CNRN

                                                                      EACH     YEAR, about 795,000 new or recur-
                                                                      rent strokes occur in the United States,
                                                                      killing about 150,000 people. This averages
                                                                      out to one stroke every 40 seconds and
                                                                      one stroke death every 3 to 4 minutes.
                                                                          Perhaps even more alarming, the inci-
                                                                      dence of transient ischemic attack (TIA)—
                                                                      a warning sign of impending stroke—ex-
                                                                      ceeds that of stroke. About 15% of strokes
                                                                      occur within 90 days of a TIA. (See Stroke:
                                                                      A crisis for the brain and body.)
                                                                          Improving treatment and outcomes for
                                                                      stroke patients is imperative. Fortunately,
                                                                      evidence-based guidelines are available to
                                                                      help healthcare providers do just that. Our
                                                                      facility has enhanced stroke care by taking
                                                                      part in Get With The Guidelines—Stroke
                                                                      (GWTG—Stroke). Launched in 2004 to im-
                                                                      prove acute stroke treatment and prevent
                                                                      ischemic strokes, this initiative is part of
                                                                      the American Stroke Treatment Program,
                                            1.6 contact
                                                                      created by the American Stroke Association
                                               hours                  (ASA) and the multidisciplinary Brain At-
                                                                      tack Coalition (BAC).
                                LEARNING OBJECTIVES
                                                                      Understanding GWTG
                                1. Describe the types of stroke and   GWTG-Stroke helps healthcare facilities
                                   risk factors for stroke.           ensure continuous quality improvement of
                                2. Discuss how to use evidence-       stroke treatment by aligning clinical care
                                   based practices to improve         with evidence-based practice guidelines. It
                                   the quality of care for stroke     focuses on quick diagnosis and treatment
                                   patients.                          using protocols to ensure appropriate care
                                3. Explain appropriate manage-        and discharge of stroke patients. GWTG
                                   ment of patients with stroke.      is available for implementation at both
                                                                      acute-care and rehab hospitals, and thou-

American Nurse Today   September 2008
                                                                                 Hemorrhagic stroke occurs when a blood vessel ruptures
 Stroke: A crisis for the brain and body                                     and blood leaks into brain structures. Its most common under-
 Although a stroke occurs in the brain, it can affect the entire             lying cause is hypertension. Less often, it results from rupture
 body. Disabilities caused by stroke range from mild to severe               of an aneurysm or arteriovenous malformation.
 and may include paralysis, cognitive and speech problems,                   Risk factors for stroke
 and difficulty performing activities of daily living.                       Some risk factors, such as lifestyle habits, can be controlled,
    When considered separately from other cardiovascular dis-                modified, or prevented. Others, such as heredity or natural
 eases, stroke ranks as the third leading cause of death. Among              processes, can’t be changed. If all the modifiable risk factors
 neurologic conditions, it’s the leading cause of long-term dis-             below were controlled, 80% of strokes could be prevented.
 ability. Only 50% to 75% of stroke survivors regain functional                 Modifiable risk factors include the following:
 independence.                                                               • Hypertension, the most important modifiable risk factor.
 Categorizing stroke                                                            The higher the blood pressure, the higher the risk of stroke.
 Strokes occur in two basic types—ischemic and hemorrhagic.                     Controlling hypertension reduces the stroke risk.
 Ischemic stroke, accounting for 80% to 85% of strokes, results              • High cholesterol. While high blood cholesterol raises the risk
 from reduced or interrupted blood supply to the brain. With-                   of stroke, treatment with statin drugs may reduce risk by
 out adequate blood flow, tissue death occurs in the region                     about 30%.
 served by the blocked vessel.                                               • Diabetes mellitus. Diabetes is an independent risk factor for
    Ischemic stroke is subdivided into several types based on                   stroke. Controlling diabetes significantly reduces risk.
 the underlying cause (as shown in the pie chart below).                     • Smoking. Smokers have twice the risk of ischemic stroke
 • Large-vessel thrombotic and embolic strokes result from                      and two to four times the risk of hemorrhagic stroke.
    hypoperfusion, hypertension, and arteriogenic emboli from                   Smoking cessation reduces risk.
    large arteries to distal branches.                                       • Alcohol intake. Heavy intake (five or more drinks per day)
 • Small-vessel thrombotic stroke (lacunar stroke) typically                    increases the risk of stroke. Light to moderate intake (two
    stems from plaque, diabetes mellitus, or hypertension.                      drinks per day for men and one drink per day for women)
 • Cardioembolic stroke results from atrial fibrillation, valve                 decreases the risk—although experts don’t recommend
    disease, or ventricular thrombi.                                            anyone take up drinking to prevent stroke.
 • Other types of ischemic stroke are caused by prothrombic                  • Sedentary lifestyle. A low activity level increases the risk of
    states, arterial dissection, arteritis, and drug abuse.                     stroke. An active lifestyle lowers risk, with intensive activity
 • For the remaining 30% of ischemic strokes, the cause isn’t                   providing more benefits than light to moderate activity.
    known. These strokes are termed cryptogenic.                             • Obesity and increased abdominal fat. Abdominal obesity, as
                                                                                indicated by increased waist circumference (greater than
                   Ischemic stroke subtypes                                     40" [102 cm] in men and 35" [88 cm] in women) increases
                                                                                risk of stroke.
                                                                             • Atrial fibrillation. This arrhythmia is associated with a three-
                                 5%                                             to fourfold increase in stroke risk. Antithrombotic therapy
                                                                                reduces the risk.
                                                                                 Nonmodifiable risk factors include the following:
              20%                                  30%                       •   Age. Stroke incidence rises dramatically with age, doubling
        Cardioembolic stroke                   Unknown causes                    for each decade after 55 years.
                                                                             •   Gender. Men have a higher stroke incidence until age 85,
                                                                                 when women may have a slightly higher incidence. At all
                                                                                 ages, strokes kill more women than men.
                                                                             •   Race and ethnicity. African Americans have a 38% or higher
              20%                                                                stroke incidence than European Americans, possibly from a
       Large-vessel thrombotic                                                   higher prevalence of other risk factors (such as hyperten-
         and embolic stroke                 25%                                  sion). Hispanic Americans have a higher risk than European
                                     Small-vessel thrombotic                     Americans but a lower risk than African Americans.
                                             stroke                          •   Family history of cerebrovascular or cardiovascular disease.
                                                                                 Having parents, grandparents, or siblings who’ve had a
                                                                                 stroke increases a person’s risk. Also, some rare genetic dis-
                                                                                 orders are associated with stroke.

sands of healthcare facilities now                      stroke center—a hospital-based cen-          provides evidence-based care as ap-
participate.                                            ter that stabilizes and provides emer-       propriate.
   Many facilities become familiar                      gent care to acute stroke patients,             However, a facility doesn’t have
with GWTG when pursuing Joint                           transfers patients to a comprehensive        to be a primary stroke center to use
Commission certification as a primary                   stroke center, or admits them and            GWTG. Even if your facility doesn’t

                                                                                                    September 2008       American Nurse Today
plan to become a primary stroke
center or implement GWTG, our
                                              Resources for improving stroke care
hospital’s experience with the pro-           Healthcare facilities and professionals interested in improving the care of stroke pa-
gram can help you and your col-               tients can get valuable information from the websites of the American Stroke Treat-
leagues learn how to use evidence-            ment Program (ASTP) and the American Stroke Association (ASA). Resources avail-
based practice guidelines to                  able on these websites include:
                                              • primary and secondary stroke prevention guidelines
improve the quality of stroke care.
                                              • program capacity assessment criteria tool to analyze current programs and
                                                 track follow-up
Recommendations for primary                   • prehospital checklist
stroke centers                                • stroke scales for patient assessment
BAC recommendations for facilities            • samples of hospital process documentation
pursuing designation as a primary             • implementation tips, including how to overcome common barriers
stroke center include:                        • patient education materials
• establishing criteria for emer-             • professional educational resources.
   gency response                                 The ASTP website is
• availability of neuroimaging 24             3039761. The ASA website is
   hours a day, 7 days a week                 =3002728.
• laboratory, neurology, and neu-                 Also, ASA’s field staff can offer suggestions and insights about successful ini-
   rosurgery support                          tiatives at other healthcare facilities. (Consulting with ASA’s physician expert
• administrative support                      helped our facility reach 85% compliance with the Joint Commission’s lipid evalu-
• appropriate staff education                 ation performance measure for stroke patients.) Another excellent resource is the
• outcomes tracking.                          Joint Commission’s publication Disease-Specific Care Certification Manual (second
Improving the infrastructure,
evaluating treatment
Having a primary stroke center im-          BAC, and the Joint Commission. (See           sponsored conference, “Improving
proves the infrastructure through           Resources for improving stroke care.)         Stroke Care at Your Hospital,”
which a facility delivers care, pro-           To become certified as a primary           which featured a workshop on
motes quick diagnosis and treat-            stroke center, a facility takes these         GWTG. Also, GWTG staff came to
ment, and emphasizes proven treat-          steps:                                        our hospital and presented the pro-
ments. At many primary stroke               • identifies internal program cham-           gram to our nursing and clinical
centers, treatment is measured and             pions to develop, lead, and mo-            systems administrators.
evaluated using GWTG electronic                bilize teams
tools that offer patient-specific           • builds a multidisciplinary team to          Performance measure review
guideline information. These inter-            implement treatment                        The stroke subcommittee conduct-
active tools allow each facility to         • assesses current treatment and              ed a review of the performance
track its adherence to the guide-              identifies areas for improvement           measures affecting outcomes in
lines—both individually and against         • refines processes                           stroke patients, listed in the Joint
national benchmarks over time.              • implements needed changes                   Commission’s Disease-Specific Care
They also generate automated pa-            • continues to pursue excellence.             Certification Manual (second edi-
tient education materials and, with                                                       tion). These measures include:
permission, send data to the Joint          Our journey to certification                  • initiating deep-vein thrombosis
Commission or other third parties.          In March 2004, the Neuroscience                  prophylaxis
                                            Service Line at our 590-bed facility          • giving antithrombotics within 48
Certification criteria                      decided we were ready to pursue                  hours of hospitalization
In 2003, ASA and the Joint Commis-          certification as a primary stroke             • prescribing antithrombotics at
sion collaborated to develop the            center. A program coordinator was                discharge
voluntary primary stroke center cer-        designated, and a stroke subcom-              • providing anticoagulant therapy
tification program, which allows            mittee was formed from our multi-                to patients with atrial fibrillation
consumers and emergency medical             disciplinary Neuroscience Care                • considering tissue plasminogen
service professionals to identify           Management Team to prepare the                   activator (tPA) therapy (see Deter-
healthcare facilities equipped to treat     application for certification.                   mining eligibility for tPA therapy)
acute stroke according to nationally           To gain an overview of the certi-          • treating low-density lipoproteins
recognized standards. Certification         fication process, stroke subcommit-              greater than 100 mg/dL
criteria were developed by ASA,             tee members attended an ASA-                  • screening the patient for dysphagia

American Nurse Today       September 2008
• providing stroke education to the
    patient and family
                                          Determining eligibility for tPA therapy
• providing smoking cessation ma-         Patients with apparent ischemic stroke confirmed by absence of hemorrhage on
    terials to the patient and family     computed tomography (CT) scan should be evaluated immediately to determine
• considering a rehabilitation plan.      eligibility for tissue plasminogen activator (tPA) therapy. The American Heart Asso-
    Note: Joint Commission changed        ciation and American Stroke Association recommend I.V. tPA therapy within 3
                                          hours of stroke onset in eligible patients. (Because of the bleeding risk, patients
the reporting requirements in 2010
                                          with hemorrhagic stroke aren’t eligible.) A 2008 a study demonstrated that a select
to include only 8 of the 10 meas-         group of patients could be eligible for IV tPA up to 4.5 hours from onset. This group
ures as endorsed by the National          excludes age > 80, patients on warfarin, those with NIHSS >25, and patients with a
Quality Forum (NQF). Dysphagia            history of stroke and diabetes.
screening and smoking cessation               According to guidelines from the Brain Attack Coalition’s tPA Stroke Study
were removed. However, organiza-          Group, patients can receive tPA only if they:
tions must continue to track and re-      • are age 18 or older
port the common complication of           • have been diagnosed with ischemic stroke causing a measurable neurologic
aspiration pneumonia and their ini-           deficit
tiatives to limit this. So dysphagia      • experienced symptom onset less than 180 minutes before tPA therapy would
screening is still important, but not         start.
a directly reportable measure.                Contraindications for tPA therapy include:
    For this review, a spreadsheet        •   evidence of intracranial hemorrhage on pretreatment CT scan
was created that covered all 450          •   clinical presentation that suggests subarachnoid hemorrhage, even with a nor-
stroke patients treated from July             mal CT scan
2003 through June 2004; it was or-        •   active internal bleeding
ganized according to each perform-        •   known bleeding disorder (for instance, platelet count below 100,000/mm3)
ance measure. Although the initial        •   heparin administration within 48 hours and activated partial thromboplastin
database was time-consuming to                time greater than the upper limit of normal
develop, the effort paid off by pro-      •   current oral anticoagulant use, or recent use with a prothrombin time longer
viding a crucial overall picture of           than 15 seconds
                                          •   within 3 months of intracranial surgery, serious head trauma, or previous stroke
the stroke patient population.
                                          •   on repeated measurements, systolic pressure above 185 mm Hg or diastolic
    Before the database was created,
                                              pressure above 110 mm Hg at the time therapy is to begin and the patient
our facility could track stroke pa-
                                              needs aggressive treatment to reduce blood pressure to within these limits
tients only through an annual retro-      •   history of intracranial hemorrhage
spective chart review of a represen-      •   known arteriovenous malformation or aneurysm.
tative sampling of stroke cases. Now      •   stroke symptoms that are minor or improving rapidly
that we’re using GWTG, we have            •   major surgery or serious trauma excluding head trauma in the past 14 days
concurrent data on each stroke and        •   history of GI or urinary tract hemorrhage in the past 21 days
TIA patient as he or she is admitted,     •   recent arterial puncture at a noncompressible site
which allows more timely documen-         •   recent lumbar puncture
tation of areas that need improve-        •   abnormal blood glucose level (below 50 or above 400 mg/dl)
ment. Largely because of this per-        •   post–myocardial infarction pericarditis
formance measure reporting, our           •   seizure occurring at the time of stroke symptom onset.
2-year recertification visit by the
Joint Commission was a breeze.
    Our primary stroke center coor-
dinator saw every patient with sus-
pected stroke or TIA who was ad-        stroke center—and we were award-                        tion site visit was conducted with the
mitted to the hospital, gathering       ed certification. In October 2006,                      tracer methodology. Care processes
data for the new database and           the Commission made its unan-                           are evaluated by following a stroke
mentoring the nursing staff in per-     nounced 2-year site visit. During                       patient’s path through the hospital
formance measures and standards.        both visits, surveyors created a col-                   system. For example, first the emer-
                                        laborative rather than investigative                    gency department, then the CT, lab,
Implementation and site visits          atmosphere, and supported our ef-                       ICU, therapy, and care coordination.
Our target date for implementing        forts by making suggestions and
GWTG was July 2004. In November         sharing ideas gained from other                         Pinpointing areas for
2004, the Joint Commission con-         successful primary stroke centers.                      improvement
ducted its site visit of our primary       In 2008, the successful re-certifica-                Before we implemented GWTG, our

                                                                                              September 2008     American Nurse Today
                                                  Thanks to our database, we can
facility complied with only six of                now report on risk factors specific
the 10 performance measures
for stroke patients; in 2009, we                  to our stroke patients.
achieved compliance with all 10.
(We continue to be challenged in           ing this data gave us much greater         we know what percentage are dia-
documenting that patient and family        credibility than if we’d simply told       betic, and we’re managing their
education has been completed.) Us-         the pharmacy we thought it was             care partly by tracking their hemo-
ing the GWTG database, we can              taking too long to start administer-       globin A1C values (which reflect
produce reports that compare our           ing tPA. In response, the pharmacy         long-term blood glucose control).
performance against that of other fa-      staff reviewed—and improved—               Multidisciplinary team meetings and
cilities. We’ve found this is a power-     their own process, which has en-           physician department meetings
ful way to pinpoint areas that need        abled us to cut a few more minutes         brought these values to the atten-
improvement and motivate staff to          off door-to-needle time. From July         tion of physicians, and we’re now
implement required changes.                2005 through June 2006, we                 seeing tighter blood glucose con-
    We’re also using the database to       dropped below the benchmark of             trol. We’re also able to track man-
track door-to-computed tomogra-            60 minutes for the first time, and we      agement of patients with hyperten-
phy (CT) time—the interval from            have maintained an average door-           sion, the leading cause of stroke.
the patient’s arrival in the emer-         to-needle time of 58 minutes.              Because we can share these data
gency department (ED) to comple-                                                      with physicians and other staff,
tion of the CT scan. (Previously,          Developing a dysphagia                     we’re seeing more consistent man-
we’d used a smaller database that          screening tool                             agement. Before we implemented
lacked benchmarking capabilities.)         The GWTG database also helped us           GWTG, these quality measures
While we’ve always had good door-          develop and improve a dysphagia            were impossible to track and trend.
to-CT times for acute stroke pa-           screening tool. Before we had this
tients (22 minutes in 2004, com-           tool, our speech therapists were           Eliminating outdated practices
pared to the national benchmark of         screening only about 50% of stroke         Using GWTG has led us to eliminate
25 minutes), our ED nurses saw             patients for dysphagia (a risk factor      some outdated practices. ASA’s sci-
room for improvement. To boost             for aspiration pneumonia). With            entific statement “Guidelines for the
motivation, they devised a quarterly       guidance from our monthly GWTG             early management of patients with
contest in which the nurse with the        teleconferences, we were able to           ischemic stroke” provides treatment
shortest door-to-CT time got a gift        conduct a literature search that           recommendations, along with clinical
certificate to the hospital gift shop.     helped us develop a customized             evidence to back each recommenda-
Using this strategy shaved another 4       dysphagia screening tool identifying       tion. These guidelines state that:
minutes off our door-to-CT time over       patients at risk for aspiration. We put    • anti-embolism support stockings
the next year. Between July 2005           at-risk patients on a controlled diet          have no proven value to stroke
and June 2006, we shaved off anoth-        and instructed them on safe swal-              patients
er 2 minutes by changing the proce-        lowing methods or, if needed, we           • routine anticoagulation in pa-
dure so that stroke patients are tak-      used an alternative feeding method.            tients with acute ischemic stroke
en straight from the EMS vehicle to           As a result, our dysphagia                  isn’t recommended
the CT area. And in 2008, by provid-       screening compliance rose to 88%           • the patient’s swallowing reflex
ing education to the EMS profession-       and the incidence of aspiration                must be assessed before he or she
als, we reduced this further. Our cur-     pneumonia fell by about 50% from               can receive anything by mouth.
rent door-to-CT time is 13 minutes.        July 2005 through June 2006, and               With this scientific statement in
Of course, time saved means pa-            has remained low. Being able to re-        hand, we convinced our physician-
tients get the treatment they need         port this statistic to the staff and ad-   leaders and interdisciplinary team
faster, which helps save lives and re-     ministration gave us the chance to         to change their admission orders.
duce disability.                           dramatically demonstrate the extent        Consequently, our clinicians stopped
    Our ED staff also recognized the       to which process improvement af-           ordering anti-embolism stockings
need to shorten door-to-needle             fects patient outcomes.                    for deep-vein thrombosis prophy-
time—the interval from the patient’s                                                  laxis; instead, we’re using sequen-
arrival in the ED to the beginning of      Improving risk factor                      tial pneumatic compression devices.
tPA administration. We developed a         identification                             A study published in Lancet in 2009
performance improvement initiative         Thanks to our database, we can             provided further evidence that us-
to track this time and presented the       now report on risk factors specific        ing these stockings in stroke pa-
tracking data to the pharmacy. Hav-        to our stroke patients. For instance,      tients may be harmful. Patients with

American Nurse Today      September 2008
sensory deficit may not report ill-fit-          can be used as an early predictor                 The GWTG experience has helped
ting application, resulting in blisters          of discharge disposition. An initial           our nurses become more engaged
and other skin problems. They also               NIHSS score below 10 is linked to a            in the delivery of high-quality care
stopped ordering heparin drips for               favorable outcome in 60% to 70%                to stroke patients. They now fully
virtually all ischemic stroke patients.          of ischemic stroke patients at 1 year          appreciate the extent to which
And we no longer administer med-                 after the stroke; a score above 20             nursing care can give these patients
ications orally (or allow any other              portends a favorable outcome in                the best chance for recovery. In
type of oral intake) to patients with            only 4% to 16% of these patients.              fact, our nursing staff has become
suspected dysphagia; previously,                 One study found that an initial                so committed to providing high-
our clinicians ordered that these pa-            NIHSS score of 5 or lower indicates            quality stroke care that member-
tients be kept “NPO except meds.”                probable discharge to home, scores             ship in the local chapter of the
                                                 between 6 and 13 (moderate                     American Association of Neuro-
Predicting patient disposition                   stroke) indicate probable discharge            science Nurses has tripled in the
At our primary stroke center, dis-               to an acute rehabilitation program,            past 2 years, and more of our nurs-
charge planning starts on admission              and scores above 13 (severe stroke)            es are seeking certification as neu-
with assessment of the patient’s                 will likely necessitate placing the            roscience registered nurses.
preadmission functional level. Ap-               patient in an ECF.
proximately 50% of our stroke pa-                                                               Pride, purpose, and benefits
tients are able to return home direct-           Garnering awards and                           for all
ly from the acute care department;               recognition                                    Our hospital staff is proud that the
20% to 25% are discharged to the                 Our facility has received three lev-           facility is a certified primary stroke
acute rehabilitation unit; 8% don’t              els of GWTG recognition—the                    center providing evidence-based
survive the stroke, and the remain-              bronze, silver, and gold Perform-              care. What’s more, the process of
ing 17% to 22% require placement                 ance Awards. When the hospital                 obtaining certification has improved
in an extended-care facility (ECF).              newsletter published these awards,             our teamwork. Using a quality im-
Predicting disposition on the first              our stroke program gained an iden-             provement program and a powerful
hospital day can reduce stroke care              tity within the hospital. Now when             database has given us a deep sense
costs by allowing an early start to              the hospital needs examples of per-            of purpose and accomplishment,
the time-consuming process of se-                formance improvement or evi-                   and being recognized as a quality-
curing an ECF bed.                               dence-based practice, it includes              based program has had a dramatic
    For guidance in predicting dis-              stroke program data. Our facility’s            impact within our facility.
position and planning discharges,                successful Magnet™ recertification                 Our experience with GWTG
we turned to the National Institutes             application in 2006 also prominent-            shows that patients, staff, and the en-
of Health Stroke Scale (NIHSS)—a                 ly featured our stroke program.                tire hospital benefit when scientific
quantitative measure of stroke-                      We’ve gained regional and state            research and evidence inform the
related neurologic deficit. Although             recognition, too. Our facility has             care of stroke patients. Through
initially used to determine a pa-                hosted many on-site visits and                 GWTG, our stroke treatment has
tient’s candidacy for stroke research            countless teleconferences with oth-            gained an outstanding reputation, and
trials, NIHSS has been found to reli-            er hospitals seeking to improve                our staff take great pride in knowing
ably indicate prognosis and thus                 their stroke care.                             we’re providing excellent care.       *

  Improving the care of stroke patients                                  Provider accreditation
                                                                         The American Nurses Association Center for Continuing Educa-
  Instructions                                                           tion and Professional Development is accredited as a provider of
  To take the post-test for this article and earn contact hour credit,   continuing nursing education by the American Nurses Creden-
  please go to Once you’ve                tialing Center’s Commission on Accreditation.
  successfully passed the post-test and completed the evaluation         ANA is approved by the California Board of Registered Nursing,
  form, simply use your Visa or MasterCard to pay the processing         Provider Number 6178.
  fee. (Online: ANA members $15; nonmembers $20.) You’ll then be         Contact hours: 1.6. Expiration: 12/31/2013.
  able to print out your certificate immediately.
                                                                         Purpose/goal: To provide registered nurses with information on
                                                                         how to use evidence-based practices to improve the quality of
                                                                         care for stroke patients.

Click Here to Register and Take Test at                                                             September 2008      American Nurse Today
Selected references
Adams, R.J., Albers, G., Alberts, M.J., Be-     American Heart Association. Heart disease       clinical practice.
navente, O., et al. Update to the AHA/ASA       and stroke statistics. Available at: http://    guidelines.html. Accessed February 12, 2007.
recommendations for the prevention of stroke        Sacco R, Adams R, Albers G, et al. American
in patients with stroke and transient is-       TIONAHA.109.192667. Accessed September          Heart Association/American Stroke Association
chemic attack. Stroke, 2008; 39:1647-1652.      20, 2010.                                       guideline: guidelines for prevention of stroke
Adams H, del Zoppo G, Alberts M, et al.         American Stroke Association. Get with the       in patients with ischemic stroke or transient is-
Guidelines for the early management of          guidelines—stroke. Available at: http://        chemic attack. Stroke. 2006;37:577-617.
adults with ischemic stroke. A guideline               Sigel B, Edelstein AL, Savitch L, Hasty JH.
from the American Heart Association/Ameri-      Professional/GetWithTheGuidelinesHFStroke/      The CLOTS Trials Collaboration. Effective-
can Stroke Association Stroke Council, Clini-   GetWithTheGuidelinesStrokeHomePage/             ness of thigh-length graduated compression-
cal Cardiology Council, Cardiovascular Radi-    Get-With-The-Guidelines-Stroke-Home-Page        stockings to reduce the risk of deep vein
ology and Intervention Council, and the         _UCM_306098_SubHomePage.jsp. Accessed           thrombosis after stroke (CLOTS trial 1): a
Atherosclerotic Peripheral Vascular Disease     September 20, 2010.del Zoppo, G., Saver, J.,    multicentre, randomised controlled trial.
and Quality of Care Outcomes in Research        Jauch, E. & Adams, H. Expansion of the time     Lancet June2009; 373: 1958–65.
Interdisciplinary Working Groups. Stroke.       window for treatment of acute ischemic
                                                stroke with intravenous tissue plasminogen      For a complete list of selected references, vis-
2007;38:1655-1711. http://stroke.ahajour-
                                                activator: a science advisory from the Ameri-   it
Accessed September 11, 2008.                    can Heart Association/American Stroke Asso-
                                                ciation. Stroke 2009;40;2945-2948.              Kathy Morrison is Stroke Program Manager at Penn
American Association of Neuroscience Nurs-                                                      State Hershey Medical Center in Hershey, PA. She
es (2008). Guide to the care of the hospital-   Pugh S, Mathiesen C, Meighan M, Summers         also leads seminars on the topic of excellent stroke
ized patient with ischemic stroke. AANN ref-    D. Guide to the care of the patient with is-    care. Previously, she was Stroke Program Coordinator
erence series for clinical practice.            chemic stroke; AANN reference series for        at Lancaster General Hospital in Lancaster, PA.

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