Feature article

Stroke Nurse Certification: Optimizing Stroke Care Through Staff Education

Although stroke has declined from third to the fifth leading cause of death in the United States, it continues to be the leading cause of disability, costing the healthcare system billions of dollars and contributing to poor quality of life.1,2

The primary method for improving stroke outcomes, according to standards set by The Joint Commission (TJC), is closing known evidence-practice gaps, reducing variability, and decreasing time to early treatment.3 It is here where nurses are well placed and well qualified to assume leadership roles in key protocols that advance rapid identification, triage and initial assessments of patients during the first 72 hours through post-discharge.3

Continuous evolution of stroke care, standards, and guidelines for neurological assessments, interpreting diagnostic imaging, limiting complications of stroke, and more, has led to over 4,000 nurses earning the Stroke Certified Registered Nurse (SCRN®) credential from the American Board of Neuroscience.4 Regardless of advanced certifications, expanding specialist education has already become mandatory in many healthcare facilities, particularly for hospitals seeking Primary Stroke Center or Comprehensive Stroke Center certification.4,5,6

According to TJC certification requirements, eight hours of stroke education each year is required for the core stroke nursing team, as well as for other nurses caring for stroke patients in the stroke unit, intensive care unit (ICU), neuro-ICU, catheterization lab, and more.5 Additionally, emergency department nurses must earn two hours of cerebrovascular disease education annually.5  

The evolving role of modern stroke nurse care

Certification as a Primary Stroke Center or Comprehensive Stroke Center requires hospitals to meet a variety of performance standards set by TJC. As stroke care evolves and becomes increasingly complex, nurses with advanced knowledge, training, and certifications are taking on highly visible roles in new nurse-led strategies.

When a patient with acute neurologic impairment arrives at the emergency department, the phrase “time is brain” guides and reminds the triage nurse that prompt action is imperative for saving brain tissue.7 The primary focus of nurse-led stroke triage includes facilitating speedy access to and interpretation of diagnostic imaging in order to meet the 60-minute door-to-needle goal for thrombolytic treatment. That treatment can be administration of a clot-busting agent like tissue plasminogen acitvator (tPA) or coordination of mechanical thrombectomy procedures.7,8 Understanding the time-sensitive nature of evaluating a stroke patient in the context of inclusion and exclusion criteria for intervention requires nurses have knowledge of timelines and patient status.7

For example, guidelines recommend that eligible patients receive tPA therapy within 3 hours of stroke symptom onset.7 In addition, there is now a longer treatment window for tPA administration of up to 4.5 hours that has been formally tested for patients meeting certain criteria.8 At the same time, stroke nurses must be informed on various time frames and criteria for mechanical thrombectomy, which has become a standard alternative intervention for certain acute ischemic stroke patients.7

Selecting patients for the right ischemic stroke intervention is highly dependent on stroke nurse facilitation of timely acquisition and interpretation of diagnostic imaging.9 It is essential to initiate a computed tomography (CT) scan or magnetic resonance imaging (MRI) within 25 minutes of a patient’s arrival while interpretation must be complete within 45 minutes of arrival.8 Additionally, timely CT angiography and perfusion studies can identify salvageable tissue to which endovascular interventions can restore blood flow and reverse or limit any disability a patient may experience during recovery.7

As the role of nurses, nurse leaders, and other advanced practice nurse roles evolve with the complexities of stroke care delivery, healthcare facilities are implementing strategies to expand access to stroke care education that is having an impact.

Stroke competency initiative increases evidence-based adherence

Success in improving stroke patient care by nursing staff was reported in a study that implemented a tailored, multifaceted education program designed to increase nurses' knowledge as well as adherence to evidence-based treatment.10

Outcomes included improvements in both nursing adherence and knowledge.10 Nurses with advanced certifications scored significantly higher on the stroke knowledge assessment before the program began, but not after or during the follow-up.10 This was attributed to non-certified nurses having gained knowledge during the educational initiative.10  

Overall years of experience also had an impact on results.10 Nurses with more experience had significantly higher scores on portions of the stroke knowledge assessment only at the follow-up time point, which was attributed to the fact that more experience allows for more years of practice to gain more total knowledge.10

Linking evidence-based guidelines to practice increases confidence

One primary stroke center seeking to promote a culture of evidence-based practice designed and implemented a nursing education intervention using a combination of poster presentations and supplemental materials.11 This program increased nurses’ confidence in the use of standardized order sets at the point of care and supported the desired evidence-based culture within the stroke center.11

Desired outcomes included a significant increase in perceived confidence scores among emergency department staff.11 Registered nurses (RNs) reported a significantly higher self-perceived likelihood of performing an ordered nursing intervention when they were confident that the order was evidence-based compared to before when they were unsure the order was evidence-based.11 In addition, RNs reported increased confidence in their ability to explain the path from evidence to bedside nursing care.11

Improving the effectiveness of stroke care protocols to achieve and maintain TJC certifications is seeing substantial success with the implementation of various nurse-focused strategies. A few methods showing substantial promise for patient outcomes include switching from physician-led to nurse-led protocols, and instituting comprehensive inpatient monitoring protocols and nurse case managers.

Knowing the stroke code

Guided by the “time is brain” phrase, one stroke center team decided to improve their process metrics by transitioning from a typical physician-driven stroke evaluation process to a nurse-led protocol.12 Nurses were trained to identify stroke symptoms and an alert process using stroke codes was designed for activation by the triage nurse greeting the patient upon arrival at the emergency department.12

Results of the stroke code initiative were reported as a retrospective analysis showing both process and patient outcomes improved, including overall stroke team paging improving by 39 percent.12 Paging team members within 15 minutes of patient arrival more than doubled and increased from 33 percent to 71 percent.12 The 45-minute CT scan order-to-complete metric improved to 98 percent from 94.12 Patients treated with tPA increased from one percent to four, and the door-to-endovascular procedure time to thrombectomy was reduced by 47 minutes.12

Nurse-led protocols improve adherence, long-term survival

Three nurse-led protocols designed to increase adherence of inpatient monitoring for dysphagia, fever, and hyperglycemia were put into practice and evaluated as part of a blinded retrospective medical record audit of 19 stroke units.1,13

For the patients assigned to the intervention group, the increased frequency and quality of monitoring meant that deteriorating conditions were identified sooner and initiation of interventions occurred earlier in the progression timeline.1,13 Outcomes at 90 days revealed a 15 percent decrease in death and disability.1 At about four years, researchers followed up and found long-term survival had increased by more than 20 percent.13

Nurse-led management reduces door-to-treatment time

Despite its efficacy, many ischemic stroke patients do not receive thrombolytic treatment because of delays in rapid identification, assessment, and diagnostic imaging by emergency department staff.14 A prospective, single-blind, randomized controlled study was implemented by one healthcare facility to evaluate the benefits of nurse case management in reducing their hospital door-to-needle time.14

Results of this study revealed a 20-minute reduction in the timeline to treatment that improved early neurologic recovery.14 Additionally, investigators confirmed the substantial role that nurse case management played in streamlining each step of the hospital’s stroke protocol, including reducing the time to reach the CT scanner, facilitating CT diagnostic interpretation, collecting data required for tPA administration decision-making, and increasing monitoring of clinical and vital signs throughout treatment.14

Transitional care planning closes the gaps

A large part of Comprehensive Stroke Center certification is supporting the patient’s ability to care for themselves through transitions such as discharge planning and family readiness.15 Standards for transitional care were developed in part based on the TJC’s Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient consensus statement.15

Because gaps in care still exist despite care delivery improvements made during the first 72 hours, Centers for Medicare & Medical Services, the National Quality Forum, and the Institute of Medicine requested sustainable transition of care models encompassing community-based services, patients and their families, post-acute healthcare systems, and primary care physicians.15

Nurse navigation improves transitional care outcomes

A literature review identified several stroke transitional care areas at high-risk, including discharge education, medication compliance, and risk factor modification.15 To address these challenges, a dual-phase observational longitudinal study that looked at 100 ischemic stroke patients enrolled in a Stroke Nurse Navigation Program (SNNP) was implemented.15 Goals included determining the impact this type of protocol could have on concurrent chart reviews of The Joint Commission Primary Stroke Center core measures (Phase I) and patient compliance at postdischarge (Phase II).15

Findings for Phase I found concurrent chart reviews increased stroke performance measures compliance.15 Measurement was based on three main criteria, including completing a dysphagia screening before oral intake, providing individualized patient stroke education before discharge, and continued treatment with a statin medication upon discharge.15

Results found in Phase II of the SNNP study included a three percent decrease in the rate of neurovascular emergency department visits and/or readmissions, an increase of more than 98 percent in medication compliance, a 100 percent increase in follow-up medical appointments, and a quality of life improvement in daily living activities through 12 months post-discharge.15

Coordinated early supported discharge reduces death, dependency

Early supported discharge (ESD) services provided by a coordinated multidisciplinary team (stroke care nurse working together with therapists and physicians) were found to reduce long-term dependency, admission to institutional care, and the length of hospital stay for patients with mild to moderate disability.16,17 Hospital stays decreased by an average of six days, and at the end of the three to six month follow-up period, there was the equivalanet of five fewer adverse outcomes, such as death or dependency, per 100 patients.16

To ensure high-quality care delivery post-discharge, it is considered a best practice for an ESD nurse team member to have specialist stroke care knowledge that allows them to treat the patient holistically, i.e., integrate essential basic nursing needs such as wound care with rehabilitation-specific needs.17

 

REFERENCES:

  1. Acute Ischemic Stroke: The Golden Hour. Nursing2019 Critical Care https://journals.lww.com/nursingcriticalcare/Fulltext/2016/05000/Acute_ischemic_stroke__The_golden_hour.7.aspx?sid=ada0eab2-aa09-4d0e-8c34-89178741ec5e Accessed 1/10/2019
  2. Heart Disease and Stroke Statistics 2018 At-a-Glance. American Heart Association https://www.heart.org/-/media/data-import/downloadables/heart-disease-and-stroke-statistics-2018---at-a-glance-ucm_498848.pdf Accessed 1/10/2019
  3. Triage, Treatment, and Transfer: Evidence-Based Clinical Practice Recommendations and Models of Nursing Care for the First 72 Hours of Admission to Hospital for Acute Stroke. AHA Journals https://www.ahajournals.org/doi/10.1161/STROKEAHA.114.006139 Accessed 1/10/2019
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  5. Education - Staff Requirements for Comprehensive Stroke Certification. The Joint Commission https://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId=1504&StandardsFAQChapterId=222&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword= Accessed 1/10/2019
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  10. Implementation of a Stroke Competency Program to Improve Nurses’ Knowledge of and Adherence to Stroke Guidelines. Journal of Neuroscience Nursing https://www.nursingcenter.com/cearticle?an=01376517-201612000-00008&Journal_ID=828525&Issue_ID=3872209 Accessed 1/10/2019
  11. Promoting Evidence-Based Practice at a Primary Stroke Center: A Nurse Education Strategy. Dimensions of Critical Care Nursing  https://insights.ovid.com/pubmed?pmid=28570379 Accessed 1/10/2019
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  13. QASC Trial (Quality in Acute Stroke Care) Follow-Up: Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention. AHA Stroke Journal https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.116.016038?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed Accessed 1/10/2019
  14. The Early Outcomes of Nurse Case Management in Patients with Acute Ischemic Stroke Treated with Intravenous Recombinant Tissue Plasminogen Activator: A Prospective Randomized Controlled Trial. Neurology Research International https://www.hindawi.com/journals/nri/2018/1717843/ Accessed 1/10/2019
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  16. Early supported discharge services for people with acute stroke. Cochrane Systematic Review - Intervention https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000443.pub4/full Accessed 1/10/2019
  17. Nurse Staffing of Stroke Early Supported Discharge Teams: A Position Statement for Guidance of Service Developments. National Stroke Nursing Forum https://www.uclan.ac.uk/research/explore/groups/assets/nsnf_final_esd_position_statement.pdf Accessed 1/10/2019