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Ischemic stroke remains the fifth leading cause of death in the United States. Nurses play a pivotal role in the care of patients throughout the continuum. With the advances in stroke care, including mechanical thrombectomy, the American Heart Association/American Stroke Association charged the writing panel to complement the 2009 clinical practice guideline, “Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient,” with current evidence-based nursing care. This update is 1 of a 3-part series focusing on emergency medical services/emergency care, endovascular/intensive care unit care, and postacute care. The aim of this scientific statement is to review and present current evidence, complications, best practices, and clinical practice strategies to provide current comprehensive scientific information for nursing care in the neuroendovascular area and intensive care unit in conjunction with medical treatments, including intravenous thrombolysis and mechanical thrombectomy.

Background: Stroke coordinators (SC) are key stroke program personnel. However, little is known about the SC role or barriers to practice. We designed a role study to better understand barriers to SCs practice and contributors to burnout and and turnover. Methods: a role survey was developed using Dillman’s Tailored Design Methods and addressed orientation to role, mentoring and barriers to practice. The voluntary survey was distributed by email through three stroke organizations in Illinois and targeted SCs and advanced practice nurses (APN) with stroke program responsibilities. Results: 40 participants from 33 different facilities responded to the role survey. 65% of respondents identified as SC, 30% as stroke program manager/director, 20% as an APN. 17% had worked at other facilities previously as a stroke coordinator or similar role. 46% of respondents reported not having adequate resources to perform duties as stroke coordinator. Top reported moderate or extreme barriers to success in the role were lack of time (78%), lack of role clarity by supervisor (32%), lack of role definition as stroke coordinator (30%), lack of mentorship (27%), lack of on-the-job training (22%), and lack of formal education (19%). SCs and APNs with program coordination responsibilities report to a variety of different supervisor roles, including nursing management (38%), quality department (27%), other hospital administration (14%), service line management (8%), a physician (5%), other (6%). 70% of respondents reported they had not been mentored by anyone at their facility once hired into the role and 16% of coordinators reported they were considering leaving their position in the next year. Conclusions: While stroke coordinators and APNs with programmatic oversight are viewed as integral to program success, many are struggling with lack of role clarity, time management, adequate resources, and lack of mentorship. These factors may be contributing to turnover and burnout.

Objective: To reduce the hospital-acquired pneumonia rate in stroke patients. Background: The hospital-acquired pneumonia rate for stroke patients at our institution was 6.2% in 2014. This is the 39th percentile for the Joint Commission Comprehensive Stroke Centers in the University HealthSystem Consortium. Our goal was to achieve top decile performance by reducing our hospital-acquired pneumonia rate for stroke patients to 3.0%. Methods: A multidisciplinary team was assembled with representation from administration, coding, nursing, resident physicians, and attending physicians from stroke, neurocritical care and infectious disease. The team analyzed benchmarking data and decided to use chart review to validate the data. The team decided to use the CDC’s definition and clinical criteria for hospital-acquired pneumonia. Further chart review was performed to find information on swallow evaluations, incentive spirometer use, oral care, and head of bed elevation. A coding manager reviewed the documentation and the coding decision for each patient. After results were presented, the team decided on a course of action. Results: Review of stroke patients with hospital-acquired pneumonia showed 44% of the patients coded with pneumonia did not meet the clinical definition on physician review. When reviewed by a coding manager, all coding was found to be correct based on the documentation in the chart. To solve this documentation problem, attending physicians discharging stroke patients were informed of these results about unclear pneumonia documentation and were asked to clarify documentation if the diagnosis was not appropriate. After this change, the hospital acquired pneumonia rate in stroke patients fell from 6.2% prior to the changes from April 2014 to March 2015 to 1.9% after the changes were implemented from April to June 2015. Conclusion: Our facility was able to reduce the rate of hospital-acquired pneumonia in stroke patients from 6.2% to 1.2% through a multidisciplinary approach to achieve more accurate documentation and coding. The widespread over-documentation showed it is clinically difficult to make a diagnosis of pneumonia in this population. Therefore, the rate of hospital-acquired pneumonia is not a valid measure of quality of care.

Thank you for your thoughtful review. We appreciate the additional nursing consideration points related to the care of the patient after decompressive craniectomy (DC). Both points highlight the importance of considering nursing care implications when evaluating medical therapy and measuring complications associated with any therapy. In our extensive review of the literature on complications associated with DC and care priorities after DC, train of 4 monitoring …

Introduction The American Heart Association’s quality improvement initiative, Target Stroke, is designed to reduce door-to-needle (DTN) times for IV r-tPA to improve patient outcomes. One of the quality indicators is time-to-CT scan and interpretation. Although, we were already meeting the recommended target, we sought to further enhance efficiency of this process in our institution. Method We performed a retrospective chart review of patients with CT Brain Acute Stroke protocol orders from January to December 2010, which represents a one-year period after instituting changes to our CT protocol. Some of the changes included: improved emergency medical service communication, streamlined patient registration and emergency department (ED) training on time-sensitive stroke care elements. CT scan times were analyzed based on time ordered, time of completion, and radiology interpretation. Our review included DTN for IV r-tPA administration for acute stroke patients during the same time period. Results Of the 571 acute stroke patients admitted through the ED during the study period, 12% received IV r-tPA. Of these, 79% received IV r-tPA within 60 minutes, with a mean (±SD) DTN time of 52 (±27) minutes. The relative efficiency of thrombolysis was attributed in part due to our fast-track CT head protocol process. The mean time from CT order to completion was 12 minutes and CT completion to verbal reporting to the ordering physician was 6 minutes. Conclusion Using a multi-disciplinary approach for quality improvement in CT acquisition and interpretation times, we were able to enhance the efficiency of our overall DTN time. We believe that our protocol is easily adaptable in any Neurointensivist led stroke service, and would benefit patients on a national level to allow for more rapid administration of IV r-tPA by reducing delays in the CT head protocol. Developing a strong infrastructure that is hard-wired and part of the institutional culture resulted in decreased CT times along with 79% of stroke patients receiving r-tPA in less than 60 minutes. Are efforts have paid off; our hospital has been designated on the Target Stroke Honor Roll.