Implementation of Evidence Into Practice Development of a Tool to Improve Emergency Nursing Care of...

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Implementation of evidence into practice:Development of a tool to improve emergency

nursing care of acute stroke

ARTICLE in AUSTRALASIAN EMERGENCY NURSING JOURNAL AUGUST 2009

DOI: 10.1016/j.aenj.2009.03.005

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Australasian Emergency Nursing Journal (2009) 12, 110119

a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a e n j

DISCUSSION PAPER

Implementation of evidence into practice:Development of a tool to improve emergencynursing care of acute stroke

Bree McGillivray, RN, BN, GCertEmergNurs a,Julie Considine, RN, RM, BN, GDipNurs(AcuteCare), MNurs, PhD, FRCNA b,

a The Northern Hospital, 185 Cooper St, Epping, 3076, Victoria, Australiab Deakin University-Northern Health Clinical Partnership, c/- School of Nursing,

Deakin University, 221 Burwood Hwy, Burwood, 3125, Victoria, Australia

Received 24 October 2008; received in revised form 12 March 2009; accepted 20 March 2009

KEYWORDSEmergency nursing;

Stroke;Evidence-basedmedicine;Guideline

Summary

Background: Stroke is an increasing global health issue that places considerable burden on

society and health care services. An important part of acute stroke management and decreasing

stroke-related mortality is preventing complications within the first 2448hours. The current

climate of prolonged time spent in the Emergency Department (ED) means that many aspects

of stroke management are now the responsibility of emergency nurses.

Aims:The aims of this paper are to: i) examine the evidence related to nursing care of acute

stroke, ii) identify evidence-based elements of stroke care with most applicability to emergency

nursing and iii) use evidence-based stroke care recommendations to develop a guideline for the

emergency nursing management of acute stroke.

Results:Emergency nursing care of acute stroke should focus on optimal triage decisions, phys-

iological surveillance, fluid management, risk management, and early referral to specialists.

Conclusions:The role of emergency nurses in stroke care will increase and it is important that

emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes.

Guidelines and decision support tools for use in emergency nursing must be practical and have

high levels of clinical utility for maximum uptake in a busy clinical environment.

2009 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rightsreserved.

Corresponding author. Tel.: +61 3 8405 8600.E-mail addresses: [email protected](B. McGillivray),[email protected](J. Considine).

1574-6267/$ see front matter 2009 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.aenj.2009.03.005

Copyright Agency Limited (CAL) licenced copy
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Implementation of evidence into practice: Development of a tool to improve emergency nursing care of acute stroke 111

Introduction

Stroke is an increasing global health issue that places consid-erable burden on society and health care services. Althoughthe incidence of stroke is decreasing due to increased aware-ness and modification of risk factors such as hypertensionand smoking, the absolute number of strokes continues torise as a result of an ageing population and increased life

expectancy.1

Global stroke data shows that 15 million peo-ple suffer a stroke very year, 5 million people die annuallyfrom stroke and 5 million people are left with permanentdisability as a result of stroke.1 Burden of disease is pro-jected to rise from 38 million disability adjusted life yearsin 1990 to 61 million disability adjusted life years in 2020.1

These worldwide trends of increasing incidence of strokeare also evident in Australia. Every year 48,000 Australianshave a stroke and 9,000 Australians die within 1 month ofstroke.2 Further, an additional one third of patients withstroke die within 12 months2 and in the next 10 years morethan half a million people in Australia will suffer a stroke.3

Of patients suffering stroke, 70% have a first ever strokeand 30% will have another stroke within one year.2 In addi-

tion, stroke is a leading cause of disability and health systemdemands in Australia.2,3 During 2005/06 Victorian public hos-pitals managed almost 12,000 episodes of stroke2 and it ispredicted that the incidence of acute stroke will continueto increase by 2.7% annually.2

Many guidelines relating to the Emergency Department(ED) management of acute stroke focus on rapid identi-fication of patients eligible for thrombolysis (rt-PA) andtimely administration in patients who meet the specific cri-teria for this treatment.2,4,5 Thrombolysis is beneficial inselected patients with acute ischaemic stroke when usedwithin 3 hours of symptom onset and more recent stud-ies suggesting that thrombolysis can be safely used up to

4.5hours after symptom onset.612

The recent national auditof stroke services in Australia4 showed that of 1944 patientswith acute ischaemic stroke, only 795 patients arrived withinthree hours and only 56 of the eligible patients received IVthrombolysis (7%).4 Capacity to treat acute ischaemic strokewas greater in Category A hospitals (immediate access to CTscanning, access to HDU and on-site neurosurgery, and geo-graphically located stroke unit) who had a 6% thrombolysisrate compared with 1% in Category B hospitals (immedi-ate access to CT scanning, access to HDU, geographicallylocated stroke unit but no on-site neurosurgery).4 In addi-tion, management by a specialist multidisciplinary teamis a key factor in improving outcomes for patient withacute stroke.2,5 Although, it is well known that patients who

receive stroke unit care have lower mortality rates and aremore likely live independently,2,13 41% of the hospitals thatcontributed to the audit of acute stroke services did nothave a stroke unit.14 The findings of the national audit ofstroke services highlighting significant and widespread bar-riers to evidence-based stroke care and significant variationbetween organisations in terms of resources, facilities andtreatments offered for acute stroke.

Access block is delay in admission to an inpatient bedfor patients in the ED requiring hospital admission15 andED length of stay is a key influence on hospital length ofstay.16 Access block results in prolonged periods of time inthe ED15 and is a common issue for patients requiring hospi-

tal admission via the ED, including patients with stroke. Animportant part of acute stroke management and decreasingstroke-related mortality is preventing complications withinthe first 2448 hours.1720 The current climate of prolongedtime spent in the ED means that many aspects of stroke man-agement are now the responsibility of emergency nurses.

A guideline for the emergency nursing managementof stroke was developed in June 2007 and then revised

in January 2009. Initial guideline development occurredin response to three major factors: i) the numbers ofpatients with acute stroke are increasing therefore strokewill become a more common EDspresentation, ii) there wereobservations of variability in stroke management in the EDat TNH, and iii) evidence-based emergency nursing manage-ment of acute stroke was one way of overcoming some ofthe limitations to organisational stroke care that are high-lighted later in this paper and optimising patient outcomesfollowing stroke.

The aim of this paper is threefold. First, the local contextof acute stroke care at Northern Health will be described.Second, the evidence related to nursing care of acute strokewill examined and the elements of stroke care that had

the most applicability to emergency nursing management ofacute stroke will be identified. Finally, the process of usingevidence related to stroke care for development of a guide-line for the emergency nursing management of acute strokeat Northern Health, The Northern Hospital will be outlined.The focus of this paper, however, is the emergency nurs-ing care of acute stroke. As a result, the discussion will beconcentrated on issues that are under the direct influenceof emergency nurses: issues surrounding implementation ofthrombolysis for acute ischaemic stroke in centres that donot currently offer this treatment option will not be dis-cussed in this paper.

Local context

Northern Health provides health care services to over700,000 people living in Melbournes northern suburbs andsemi-rural regions beyond the city fringe. Northern Healthmanages 613 beds and provides care in acute, sub-acuteand community settings over five campuses. At NorthernHealth, acute stroke care is provided at The Northern Hos-pital (TNH), a 300 bed facility designated as a Category Bhospital by the National Stroke Audit.4 This means that TheNorthern Hospital has immediate access to CT scanning,access to high dependency unit, a geographically locatedstroke unit but no on-site neurosurgery.

During 2006/07, the ED at The Northern Hospital, North-ern Health (TNH) managed 265 patients with stroke:a theiraverage age was 71 years, 51% arrived by ambulance and18% required an interpreter. The median ED length of stayfor admitted patients was 11.4 hours (IQR 7.9 - 14.3). Inpa-tient data shows that during 2007 there were 172 separationsfor acute stroke with a total of 1557 bed days and averagelength of hospital stay of 9.1 days. The majority of patients

a ED definition of stroke using IDC-10 codes:I64 (Stroke not

specified as haemorrhage or infarction: n = 214) I610 I619 (Intrac-

erebral haemorrhage: n = 48)I630 I639 (Cerebral infarction: n =

3)I629 (Intracerebral haemorrhage unspecified)

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112 B. McGillivray, J. Considine

(90%) were living at home prior to admission 4 suggestingreasonable functional status prior to stroke.

Thrombolysis is not currently offered as a treatmentoption for management of acute ischaemic stroke due toorganisational infrastructure limitations: lack of special-ist neurology and neurosurgical services, limited specialistneuro-imaging capabilities, limitations to high dependencyunit facilities offered by critical care department, lack of

high dependency unit capability on current stroke unit, andabsence of core group of specialist stroke nurses/stroke liai-son nurses. Pre-hospital triage of patients with stroke byparamedics tends to result in transport of patients who maybe eligible for thrombolysis (younger, shorter duration ofsymptoms) to neighbouring centres with specialist strokeservices that do offer thrombolysis as a management optionfor acute ischaemic stroke. Despite limitations to offeringthrombolysis, patients with acute stroke managed at TNHhad a number of outcomes that were superior to thosereported at national level.21 For example, in hospital mor-tality rate was 8% at TNH compared with the national rate of13%, and average length of stay for discharged patients was5.6 days which was considerably shorter than the nationalrate of 11 days.21 The proportion of patients who were inde-pendent at discharge was 45% which was comparable to thenational rate of 49%.21

Review of current guidelines

There are a number of guidelines for the management ofacute stroke. Most address emergency care in terms ofinvestigations, particularly neuro-imaging and assessmentfor thrombolysis however few specifically address emer-gency nursing management of patients with acute stroke. Inthe section to follow, recommendations from existing guide-lines for the management of acute stroke that relate directly

to nursing care will be examined and their applicability toemergency nursing will be discussed. Gaps in current recom-mendations for emergency nursing care for acute stroke willalso be highlighted. The guidelines included in this reviewwere limited to evidence based guidelines less than 10 yearsold. Previous versions of current guidelines were omitted.The guidelines included in this review are listed in Table 1.

Triage

Triage is the point at which emergency care begins and triagedecisions are a key determinant of the trajectory of care for

patients with actual or potential acute stroke. As thrombol-ysis is a time critical intervention in acute stroke,612 akeypriority of ED triage is to facilitate rapid assessment andidentification of patients who may be eligible for throm-bolysis or transfer for thrombolysis. Although many of theguidelines reviewed refer to stroke as a medical emer-gency 5,8,25 however specific recommendations about EDtriage of patients with actual or potential acute stroke are

absent. There are no references to triage category alloca-tion or risk stratification by triage nurses. The AmericanHeart Association/American Stroke Association guidelines(2007)22 recommend that patients with suspected acutestroke should be triaged with the same priority as patientswith acute myocardial infarction or serious trauma, regard-less of the severity of the deficits (p. 1663). In addition,the National Institute of Neurological Disorders recommendsa door to doctor time of less than 10 minutes.26,27 In Aus-tralia, all of these recommendations equate to Category 2of the Australasian Triage Scale28 and this is reflected in thestroke guideline.

In terms of potential for stroke, some guidelines do con-tain detailed information about risk factor stratification

for TIA5 however these recommendations about TIA arenot related to the ED triage process. For the purposes ofthe stroke guideline, the ABCD risk stratification scoringsystem29 was used to flag patients who may present withTIA who are at high risk of stroke. Features of this scor-ing system include age, blood pressure, clinical history andduration of symptoms and more recently diabetes has addedas a significant risk factor for stroke in patients with TIA.30

The ABCD2 score was included in the 2009 stroke guidelineupdate.30

Immediate evaluation

In terms of immediate evaluation and early diagnosis, bothof which occur in the ED, many guidelines focus on strokescale scoring, brain imaging and mobilisation of stroke teamor specialised stroke personnel.22 American Heart Associa-tion/American Stroke Association guidelines (2007)22 statethat complete evaluation and treatment decisions shouldoccur within 60 minutes of the patients arrival in the ED.Recommendations regarding brain imaging are varied. Forexample, National Institute of Neurological Disorders rec-ommends that head CT is performed within 25 minutes andinterpreted within 45 minutes of arrival in ED23,26,27 howeverthe Royal College of Physicians state that imaging should

Table 1 Guidelines included in review.

Victorian Department of Human Services (2007). Stroke Care Strategy for Victoria2 Australia

National Stroke Foundation (2007). National guidelines for acute stroke management. Melbourne, National Stroke

Foundation5Australia

American Heart Association/American Stroke Association (2007). Guidelines for the Early Management of Adults

with Ischemic Stroke22USA

Institute for Clinical Systems Improvement. (2008). Health Care Guideline: Diagnosis and Initial Treatment of

Ischemic Stroke23USA

European Stroke Organisation (2008). Guidelines for management of ischaemic stroke and transient ischaemic

attack 200824Europe

Royal College of Physicians (2004). National clinical guidelines for stroke 25 UK

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occur within 24 hours of symptom onset25 but urgent brainimaging should occur if the patient: i) is anticoagulated orhas a known bleeding tendency, ii) has a decreased consciousstate, iii) has progressive or variable symptoms, neck stiff-ness, fever or severe headache, or iv) if thrombolysis or earlyanticoagulation are treatment options.25 Both the NationalStroke Foundation5 and The European Stroke Organisation24

recommend urgent brain CT for acute stroke and the

National Stroke Foundation5 defines urgent as as soonas possible, but certainly less than 24 hours (p. vi). Thenational audit of acute stroke services also used a 24 hourbenchmark.4 Observations of usual practice at TNH sug-gest CT is performed early in the ED episode of care forthe majority of patients with acute stroke. As ordering CTscans is beyond the scope of emergency nursing practice, thestroke guideline refers to nurses checking that the patienthas had a brain CT prior to leaving the ED for two reasons.First, emergency nurses checking that investigations havebeen performed prior to the patient leaving the ED adds anadditional safeguard that CT scan has been performed whilein ED. Second, emergency nurses tend to be responsible forpatient transfer to inpatient units so the guideline acts asa prompt to ensure the CT scans accompany the patient toinpatient areas.

Initial assessment

Emergency nurses play a key role in decreasing stroke-related mortality by prevention of complications in the first2448hours after stroke.1720 The initial assessment ofallED patients (following triage) is undertaken using a pri-mary survey approach: airway, breathing, circulation anddisability. Airway assessment includes crude assessment of

conscious state, ability to speak and, for all patients withactual or potential stroke, nil orally status. Airway supportby endotracheal intubation may be indicated in patientswith decreased conscious state.22,31 Impaired swallowing isassociated with increased mortality following stroke32 sopatients with stroke should remain nil orally until ability toswallow safely has been formally assessed. Specific recom-mendations about nil orally status in the stroke guidelineare important because decisions regarding oral intake areusually nursing decisions.

Assessment of breathing typically involves assessmentof respiratory rate, respiratory effort, oxygen saturationand chest auscultation. Assessment of oxygen saturationis important as patients with acute stroke are known to

have lower a oxygen saturation than matched controls33

and hypoxia increases cerebral injury following stroke.8,17

Supplemental oxygen is indicated if peripheral oxygen satu-ration is less than 92%22,34 to 95%.23 The use of supplementaloxygen in non-hypoxic patients with stroke is not recom-mended as there is no evidence of survival benefit fromoxygen use in non-hypoxic patients with stroke and someevidence to suggest that hyperoxia may increase cerebralinjury.17,22 Given that the majority of oxygen administrationdecisions are made independently by emergency nurses35,36

and the routine use of oxygen in acute stroke may be harm-ful, it was important to made a statement about oxygenmanagement in the stroke guideline.

Assessment of circulation typically comprises assess-ment of heart rate, blood pressure and cardiac rhythm bycardiac monitoring and 12 lead ECG. Blood pressure mon-itoring is essential to the management of acute stroke.Hypotension will reduce cerebral perfusion and potentiallyincrease infarct size so should be treated aggressively withintravenous fluids and/or medications.22,32 Hypertensionis common following acute stroke and is a physiologi-

cal response to optimise cerebral perfusion pressure inthe setting of cerebral ischaemia and increased intracra-nial pressure.31 Aggressive blood pressure reduction is notrecommended as this may further compromise cerebralperfusion.17,31,32,37 However other causes for hypertension,such as pain, vomiting or urinary retention should be con-sidered and if present, treated appropriately.31,38 Again,identification and management of issues such as pain,vomiting and urinary retention are typically nursing respon-sibilities.

Some guidelines recommend cautious treatment ofsevere hypertension (systolic blood pressure greater than220mmHg or diastolic blood pressure greater than 120mmHg) using intravenous medications that can be accurately

titrated8,23,31,32 however there is no high level evidence tosupport this approach in patients with stroke.31 The use oforal or sublingual agents is not recommended as their usecause rapid and uncontrolled blood pressure reduction.31

Patients with hypertension and who are eligible for throm-bolysis may have blood pressure lowered to 185mmHgsystolic and 110 mmHg diastolic before thrombolysis.22

TNH has a local ED policy for reportable blood pressureparameters that applies to all patients and a hospital widepolicy for reportable blood pressure parameters in patientswho have suffered a stroke.34,39 It was important that thestroke guideline was aligned to these existing policies.

Electrocardiography (ECG) is indicated in patients with

acute stroke to identify sources of cardiogenic embolisuch as atrial fibrillation or recent AMI and signs ofpre-existing cardiac disease.31,37,40 ECG abnormalities arepresent in up to 60% of patients with cerebral infarc-tion and 50% of patients with intracerebral haemorrhage.41

ECG changes such as T wave inversion can occur in asmany as 75% of patients with acute stroke and cardiacarrhythmias can occur as a result in increased sympathetictone, decreased parasympathetic tone and catecholaminerelease.32 Some guidelines advocate cardiac monitoring forfirst 24 hours after ischaemic stroke in order to screen foratrial fibrillation.22 It is therefore not surprising that 12lead ECG +/ cardiac monitoring are featured in the strokeguideline.

Hyperthermia in the early phase of acute stroke increasesmortality and infarct size17,18,32 so temperature monitoringand active management of hyperthermia is an importantpart of ED stroke care. A meta-analysis of hyperthermia andstroke outcomes by Hajat et al.42 showed that patients whowere febrile following stroke had a 19% increase in mortality.This meta-analysis42 highlights the importance of tempera-ture monitoring and temperature control in patients withacute stroke while they are in the ED. Key issues for emer-gency nurses include consideration and treatment of causesof hyperthermia (such as infection, or thromboembolism)and possibly administration of anti-pyretic medications infebrile patients with acute stroke.8,22 Inclusion of infor-

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mation related to consequences of hyperthermia was animportant element of the stroke guideline.

Glycaemic control is an important aspect of manage-ment of serious illness. Blood glucose levels should beassessed in patients with actual or potential stroke fora number of reasons. First, it is important to excludehypoglycaemia as an easily treated cause for signs andsymptoms that may mimic stroke.31,40 Second, diabetes is

a significant risk factor for stroke4,5

and many patientswith Type II diabetes are undiagnosed.43 Third, hypergly-caemia is associated with increased cerebral infarct sizeand poor patient outcomes.8,17,32 Blood glucose levels over8 mmol/L is predictive of mortality following stroke, evenwhen adjusted for age, stroke severity, and stroke type.44

Hyperglycaemia following stroke is also associated withdecreased functional outcome 8,17,18,32,44 so blood glucosemonitoring and active management of hyperglycaemia inthe ED may have significant impact on patients outcomesfollowing acute stroke. Given that blood glucose monitor-ing is a nursing responsibility and that hyperglycaemia has astrong association with poor outcomes, information relatedto frequency of blood glucose monitoring and reportable

parameters was an important element of the stroke guide-line.

Stroke unit/specialist referral and assessment

A key factor in the ED management of acute stroke is special-ist referral to stroke units and allied health personnel. Acutestroke care should be provided by stroke units that are ledby a physician and supported by an interdisciplinary team.2

There is high level evidence that standardised stroke carein an organised stroke unit improves patient outcomes13,22,45

however the challenge for EDs is to replicate this specialist

care when there are delays in accessing inpatient beds.Allied health referrals for assessment of swallowing,hydration and nutrition, and mobility are important in thefirst 24 to 48 hours following acute stroke. Dysphagia occursin up to 50% of patients with acute stroke and is associatedwith complications such as aspiration, pneumonia, dehy-dration and malnutrition.5 Dysphagia screening by trainedpersonnel within 24 hours of admission should occur beforepatients are given food or fluids.5,22 Patients who fail dyspha-gia screening should be referred to a speech pathologist for acomprehensive assessment5 so ED referral to speech pathol-ogy is a key component of stroke care in patients whosetransfer to inpatient stroke unit is delayed.

Dietician assessment of hydration and nutrition is an

important part of acute stroke care. Dehydration is commonafter stroke due to nil orally status until swallow assess-ment is complete, impaired swallowing and immobility5 andpoor nutritional status in patients with stroke is associatedwith increased morbidity and mortality.18,22 Dehydration andmalnutrition are associated with an increase in poor out-comes following acute stroke.5 All patients with acute strokeshould be screened for malnutrition and patients at riskof malnutrition (including patients with dysphagia) shouldhave dietician assessment within 48 hours for ongoing man-agement planing.5 Although uncommon, some patients arein the ED for 48 hours so dietician referral may be part ofemergency nursing care. Further, there may also be a need

for prioritising patients with high risk features of dehydra-tion or malnutrition and targeted early referral to dieticiansfor patients with dysphagia or known hydration or nutri-tion problems. Allied health referrals from ED were ad hocwith no systemic referral processes in place. As part of thestroke guideline implementation, an electronic referral sys-tem (HealthPower) was activated on all ED computers andnursing staff were educated in its use.

Many patients with acute stroke spend significant timein bed,5 and this is particularly true in the ED. Up to 51%of deaths in the first 30 days after ischaemic stroke aredue to complications of immobility and over 62% of thesecomplications occur in the first week.5 Early mobilisation(


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third most common cause of deaths after stroke.5 Risk fac-tors for venous thromboembolism (VTE) include reducedmobility, stroke severity, age, dehydration and delayedVTE prophylaxis.5 Strategies to prevent venous thromboem-bolism following stroke include early mobilisation, adequate

hydration, antithrombotic stockings and in patients withischaemic stroke, anti-platelet therapy5,22 and many organ-isations have VTE risk assessment and prophylaxis programsthat should be implemented in the ED for patients with acutestroke.

Figure 1 Emergency Department Guideline: Management of Acute Stroke.

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Figure 1 (Continued).



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Patients with acute stroke are at significant risk ofpressure ulcers due to increased age, immobility, inconti-nence, poor nutritional status, cognitive impairment anddiabetes.5,22 Pressure ulcer prevention is a fundamentalcomponent of nursing care and pressure ulcer risk assess-ment, skin surveillance, frequent position changes, and useof devices such as alternating pressure mattresses22 shouldalready be part of emergency nursing practice for patients

with impaired mobility and other risk factors.Falls are a well known in-hospital adverse event and

patients with acute stroke are at increased risk of falls due tospatial problems, impaired mobility, cognitive impairment,incontinence and dehydration.22 Many organisations havewell established falls screening and prevention programs andgiven that nurses have played a major role in reducing fallsand falls related injuries51,52 there is no reason that fallsscreening cannot occur in the ED.

Poor limb care in patients with acute stroke can result injoint subluxation, shoulder pain, decreased functional use.53

Limb care following acute stroke is therefore an importantaspect of stroke care and should begin in the ED. Emergencynurses have a well established role in pain assessment of

pain and so pain management using analgesic agents or non-pharmacological strategies in patients with acute stroke arewell within the scope of emergency nursing practice.

Tool development

In order to improve the emergency nursing management ofstroke, the recommendations described so far in this paperwere incorporated into a one page (double sided) summarydocument that was titled Emergency Nursing Managementof Acute Stroke. This guideline was developed in June 2007and revised in January 2009 in light of new evidence and

additional references (Fig. 1). The stroke guideline wasintended to accompany the usual ED nursing documenta-tion and act as a prompt to guide triage decision makingand also initial assessment, ongoing nursing care and spe-cialist referrals. Although elements of the Stroke guidelinemay seem reflective of usual emergency nursing practice, itis important to recognise the high levels of transient staff(casual nursing staff, graduate nurses and students) who pro-vide care for patients with acute stroke and that patientswith acute stroke currently make up a small proportion ofthe total patient census. The Stroke guideline was aimed toassist all levels of staff to provide optimal care to patientswith acute stroke.

The stroke guideline used the state-wide policy frame-

work and best available evidence to guide triage decisionmaking. Recommendations regarding initial assessmentwere based on a primary survey approach with specificrecommendations related to reportable parameters. Rec-ommendations for ongoing care focused on physiologicalmonitoring (vital signs, neurological observations and gyl-caemic control), fluid management, risk management (VTE,pressure ulcers, safe swallowing and limb care). Finallythere was also a prompt for allied health referrals.

Guideline implementation was supported by a tutorialconducted during nursing in-service education time andpromotion by local opinion leaders. In-service educationsessions were repeated over a 3 week period until all nurs-

ing staff had attended. The researchers also spent timein the clinical area reminding staff about the guidelineand the guideline was loaded on to the ED Clinical Guide-lines intranet. Evaluation of the effect of the guideline isdescribed elsewhere.54

Conclusion

The role of emergency nurses in stroke care will increaseand it is important that emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes.Expert emergency nursing care of patients with acute strokeis pivotal irrespective of whether the patient is eligible forthrombolysis and serves to potentiate the treatment effectsof rt-PA in patients meeting the inclusion criteria but willalso optimise outcomes for patients who are not candidatesfor thrombolysis. Further, suboptimal emergency nursingmanagement of acute stroke may even counter potentialbenefits of thrombolysis. Guidelines and decision supporttools for use in emergency nursing must be practical andhave high levels of clinical utility for maximum uptake in a

busy clinical environment. A simple one page summary ofevidence related to stroke care in the first 24 hours has thepotential to improve the emergency nursing care of patientswith acute stroke.

Addendum

Since development of this guideline, there have been a num-ber of initiatives related to stroke care at Northern Health.The Victorian Government has established a Stroke ClinicalNetwork and Northern Health has a Stroke Network Facili-tator dedicated to facilitating evidence-based stroke care.The stroke unit at TNH has undergone a review and co-

location of patients with stroke and reducing the numbersof patients with stroke on outlying medical units are key pri-ority areas. A stroke nurse practitioner candidate has beenappointed and this role is under development and there aremulti-disciplinary and multi-speciality discussions regardingthe infrastructure requirements for safe delivery of throm-bolysis for acute ischaemic stroke.

Disclosures

JC was responsible for study conception and design. JC andBM were responsible for obtaining funding. BM was respon-sible for data acquisition and JC conducted data analysis.JC and BM were responsible for drafting this article and allauthors provided critical revision of the manuscript. Thereare no conflicts of interests. JC accepts responsibility forthe manuscript.

Acknowledgements

This study was supported by a National Institute of Clini-cal Studies (NICS) Emergency Care Nursing Grant. NICS is aninstitute of the National Health and Medical Research Coun-cil (NHMRC), Australias peak body for supporting health andmedical research.

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