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, CE 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 Other reduces the risk. causes 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 www.strokeassociation.org/presenter.jhtml?identifier= • availability of neuroimaging 24 3039761. The ASA website is www.strokeassociation.org/presenter.jhtml?identifier 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 edition). 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 Source: www.stroke-site.org/guidelines/tpa_guidelines.html 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. * CE POST-TEST 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 www.AmericanNurseToday.com/ce. 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 NursingWorld.org: http://nursingworld.org/ce/journal September 2008 American Nurse Today Selected references Adams, R.J., Albers, G., Alberts, M.J., Be- American Heart Association. Heart disease clinical practice. www.aann.org/pubs/ 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 circ.ahajournals.org/cgi/reprint/CIRCULA 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 www.heart.org/HEARTORG/Healthcare 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 www.AmericanNurseToday.com. nals.org/cgi/reprint/STROKEAHA.107.181486. 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.