Triage, Treatment, and Transfer

Abstract

e18 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 therapy 2 stroke unit (SU) care 3 and thrombolysis. 4 International clinical guidelines for stroke provide key recommendations to guide clinical practice 5-8 ; 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 times 21 and process 22 on arrival in the emergency department remain variable. The use of a Code Stroke alert system has been shown to improve time to diagnosis and treatment and reduce intravenous r-tPA door-to-needle times. 17-19 Recently, the use of stroke team models led by appropriately trained advanced practice nurses have been shown to be efficient, accurate, and safe at identifying and treating patients with r-tPA. 23-26 These teams capitalize on the 24-hour-a-day nature of nursing providing around the clock on-site expert input for both Code Stroke calls and ongoing acute stroke patient management. Code Stroke advanced practice nurses oversee the diagnostic work up, interpretation of neuroimaging, review of laboratory work, and communicate remotely to physicians about their estimation of suitability for r-tPA treatment. This model of care enables rapid decision making that may significantly reduce door-to-needle times. Advanced practice nurse-led teams offer a method to safely extend vascular neurologist services when an in-house neurologist is unavailable 24 hours a day 23-25 and to augment telemedicine services (Table 1). 26