Nurses Activate Inpatient Stroke Alerts Faster than Physicians and ...

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

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

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

• Reached out to:
Introduction
• 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

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

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

• Statistics:
Methods
- 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

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]

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]

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

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

Conclusions
• The majority of stroke alert calls from stroke-
educated, 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

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

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?

Limitations
• We do not have a comparison group of un-
educated nursing staff
• We do not know how many patients with
stroke did not have stroke team activation by
nurses or physicians

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