Nurses Activate Inpatient Stroke Alerts Faster than Physicians and are Equally Competent at Identifying Stroke Patients versus Stroke Mimics
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- Jonas Leonard
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1 Nurses Activate Inpatient Stroke Alerts Faster than Physicians and are Equally Competent at Identifying Stroke Patients versus Stroke Mimics February 1, 2012 Pravin George,DO Christopher Newey, DO MS Dolora Wisco, MD Julie McNeil, RN AD CEN Michelle Winfield, RN BSN James M Gebel Jr MD MS FAHA
2 Introduction The in hospital stroke team stroke alert is activated by Physicians or Nurses when acute stroke is suspected In-patient strokes represent an excellent treatment opportunity Over-Triaging of stroke alerts can overwhelm acute stroke team resources
3 Introduction Our stroke nurse, coordinator and physicians collaborated to design and implement an educational initiative Focus was to improve quality and timeliness of acute stroke identification and stroke alert activation in high risk units - Focus was on non-neurological floor and ICU nurses
4 Introduction Reached out to: Non-Neurological Floor Nurse Managers Medical Emergency Team Managers Non-Neurological Floor Nurse Educators Nursing ACLS Instructors Focused stroke education on Patient s Assessment relating to acute strokes Importance of the Last Known Well time Time-to-treatment considerations Encouraged and empowered nursing to activate stroke alerts immediately Acknowledged nursing on an individual basis
5 Hypothesis Educated non-neurological nurses activating the stroke alert system will identify as great a proportion of acute strokes (as opposed to stroke mimics) as physicians in the same units Educated non-neurological nurses will activate the stroke alert system as fast as physicians in the same units
6 Methods Retrospectively analyzed prospectively collected consecutive inpatient stroke alert calls for a 1 year period - Neurological floors were excluded Person activating the stroke alert was identified via the EMR review Final diagnosis of stroke vs. non-stroke or stroke mimic designated by final discharge diagnosis
7 Methods Statistics: - proportion of patients with true stroke vs. mimic was compared via Chi-Square analysis - Time from symptoms to stroke alert activation compared with Wilcoxon Rank Sum test - Stratified by Physician vs. Nurse
8 Results (Accuracy of Dx) Nurses activated 59/93 (63%) of stroke alert calls Physicians activated 34/93 (37%) of the stroke alert calls 59% (37/59) of the nursing activated stroke alert call patients had final dx of stroke as compared to 63% (20/34) of physician activated calls [p=.71]
9 Results 60% (56/93) of the stroke alert calls came from the Cardiology and Cardiothoracic Surgery units Accuracy of stroke diagnosis of nurse activated calls from the cardiology/cts units was 67% as compared to 53% for other non-neurological units [p=.323]
10 Results (Time to activation) Nurses activated stroke alert calls a median of 2 hours [25th, 75th %ile 0.5hr, 6hrs] from last known well time Physicians activated stroke alert calls a median of 4.9 hours [25th, 75th %ile 1.3, 21.3 hrs] p=.0096 Wilcoxon rank sum
![5hr, 6hrs] from last known well time Physicians activated stroke](/docs-images/41/5142844/images/page_10.jpg "alert calls a median of 4.9 hours [25th, 75th %ile 1.3, 21.")
11 Results (Time to activation) Nurses activated stroke alert within 3 hours 64% of the time as compared to physicians 38% of the time p =.015 Nurses activated stroke alert within 4.5 hours 73% of the time as compared to physicians 50% of the time p =.026
12 Conclusions The majority of stroke alert calls from strokeeducated, non-neurological unit nurses are for patients with real strokes as opposed to stroke mimics The same is true for the physicians in these units
13 Conclusions Non-neurological unit nurses educated on acute stroke recognition call the acute stroke team at least twice as fast as physicians a majority of the time in these units Nurses generally have more frequent patient contact and therefore an earlier opportunity to promptly recognize acute stroke and activate the stroke team
14 Conclusions We hypothesize that formal stroke education of nursing staff may improve rapid recognition, definitive treatment, and outcomes of acute stroke patients Time is Brain 2 Hours vs. 4.9 hours IV tpa?
15 Limitations We do not have a comparison group of uneducated nursing staff We do not know how many patients with stroke did not have stroke team activation by nurses or physicians
16 Acknowledgments We wish to gratefully acknowledge the extensive time and effort put forth by our stroke team nurse (Julie McNeil, RN AD CEN) and stroke center coordinator (Michelle Winfield, RN BSN) to design and implement the formal stroke education program utilized at our institution
17
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