Running Head: IMPROVING STROKE INTERVENTION TIMES

Quality Improvement:
Improving Stroke Intervention Times in the Emergency Department
Loyce Anne Holt
Bon Secours Memorial College of Nursing

Honor Pledge: I have neither given nor received aid, other than acknowledged, on this
assignment or test, nor have I seen anyone else do so.

IMPROVING STROKE INTERVENTION TIMES

Quality Improvement:
Improving Stroke Intervention Times in the Emergency Department
The purpose of this paper is to discuss the current quality improvement project in the St.
Marys adult emergency department (ED), improving stroke intervention times, and the proposed
plan to create a new position of code nurse. This paper will also detail how the proposed
changes can be implemented using the leadership skills discussed in Lead like Jesus and The
Student Leadership Challenge. This is a current ongoing project and the interventions have not
been initiated at this time, therefore only potential outcomes will be described in this paper.
According to the Centers for Disease Control and Prevention (CDC), strokes have been
among the top five leading causes of death over the past 80 years (Hoyert, 2012). In 1996 tissuetype plasminogen activator (t-PA) was approved for use in the treatment of ischemic strokes, but
it is only effective if used within the first three hours of the onset of symptoms (Ellmers, Clark,
& Lutsep, 2015). This limited window of treatment along with the understanding that the sooner
proper blood flow is restored the better the outcome is why the National Institute of Health
(NIH) developed guidelines for stroke intervention times. The guidelines recommend a stroke
team be established and contain recommended times that patients should be evaluated by a
physician, a computed tomography (CT) scan should be completed and interpreted, and t-PA
given, if indicated (Bock, 2011). The American Stroke Associations new campaign, Target
Stroke, details best practice strategies that will help in reducing overall intervention times
(American Stroke Association, 2014). This includes rapid triage and stroke team notification
using a single call activation system. A report by the CDC (2015) states early recognition as well
as early treatment help to reduce morbid and mortality in stroke patients, which is why St.
Marys ED is focused on improving stroke intervention times. St. Marys ED uses an overhead

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broadcast code stroke, that is heard throughout the entire hospital, to alert the stroke team.
Currently the team consists of an ED nurse, an ED physician, a hospitalist, a neurologist, CT
personnel, and a chaplain.
The ED records data from each stroke patient from the time they come in the door until
the time they are transferred out and is used for quality improvement. The current data provides
an evaluation of the last 12 months and shows that the ED consistently meets the goal of door to
calling a code stroke in less than 15 minutes, door to CT being completed in less than 25
minutes, and door to CT being resulted in less than 45 minutes. However, the goal of door to
being seen by a physician in less than 10 minutes and door to labs collected in less than 25
minutes have never been achieved. In addition, the NIH guidelines for neurological assessment
consist of a baseline check using NIH stroke scale be done within 15 minutes, then neurological
checks every 15 minutes for two hours, then every 30 minutes for 6 hours, have not been
achieved. The goal of door to t-PA time in less than 60 minutes is inconsistent, some months the
team is able to meet the goal and other months they have not.
The importance of the goals of rapid treatment for patients experiencing an acute stroke is
to improve patient outcomes (Ellmers, Clark, & Lutsep, 2015). In order to improve these
intervention times and the overall outcome of the patient, St. Marys ED has proposed the
implementation of a code response nurse (CRN). The primary function of this nurse would be to
ensure that all process and protocols are followed appropriately during a code (Shinault, 2015).
When a code stroke is called, the CRNs job is to ensure that appropriate care is initiated,
including peripheral IV placement, interventions, and notification of appropriate inpatient unit
for transfer. The CRN would also act as a float nurse when not responding to one of the many

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different codes in the ED, such as code stroke, code sepsis, code STEMI, code ICE, or code
white.
As a manager, changing the process of critical time sensitive situations such as a code
stroke can be stressful to the staff, but using the practices taught in becoming an exemplary
leader and Lead like Jesus, can make the change smooth. According to Blanchard and Hodges
(2005), leadership is a spiritual matter of the heart, and should be for the benefit of others, not for
ones own self-interest. Therefore, as a leader I understand that improving stroke intervention
times is done for the benefit of the patient, not to improve the numbers so that the department
looks good. The heart of a servant leader goes together with the head of a servant leader. After
you understand your motivation for leading others, you should also reflect on your own beliefs
and values (Blanchard & Hodges, 2005). Kouzes and Posner (2014) also teach that the first step
in becoming an exemplary leader is to clarify your values and model the way. As a leader, I
recognize that I value positivity and constructive feedback from peers and coworkers. I also
understand that I cannot enable change by myself and therefore, I start the process of introducing
the new CRN role in the department by creating a team. The team will help with training
everyone on the new role and providing immediate feedback after a code in order to improve as
we go. The team provides different experiences and points of views from each member, all
working toward a common goal, which is the premise behind the leadership practice of challenge
the process. This team not only provides different perspectives, fosters collaboration, and
enables others to act; it also creates a climate of trust within the department. According to
Kouzes and Posner (2014), a leader that relinquishes control and places trust in their team creates
a sense of empowerment and in return gains the trust of team. This trust from the team will
facilitate trust from the department as this and new quality improvement projects are developed.

IMPROVING STROKE INTERVENTION TIMES

The practice of modeling the way and the hands of the servant leader are similar, they are
about aligning your values and your actions (Blanchard & Hodges, 2005). The role of CRN has
a clear job description that includes additional training for stroke certification and sepsis
credentialing. I believe it is important to lead by example, if I expect others to do something,
then as a leader, I should be willing to do the same. Hence, I would also obtain these additional
certifications and would therefore be able provide support when needed. Inspiring a shared
vision is also an important practice of a leader. In order to inspire the team and the department, I
would remind everyone that we all have the common goal of serving others to the best of our
ability during their time of need. As a leader, displaying optimism and hope attracts and inspires
followers (Kouzes & Posner, 2014).
I always try to remain positive whether it is for my patients or my coworkers, by
displaying a positive attitude, I hope to inspire others around them to remain positive as well.
However, we all know that in during times of stress, remaining positive can be difficult and
many times the negative attitudes are contagious, which is way the habits of the servant leader
are important. According to Blanchard and Hodges (2005), in order to lead like Jesus, we must
first develop his habits. The habit of solitude is not often practiced in todays busy world, but I
believe it can be the best way to center myself during a busy day. As a leader I would encourage
the CRN to find a quiet place to decompress and reflect after the code is done, this may mean
allowing them to go to the chapel or giving up an office for 10 minutes. A leader should
understand that the job of a nurse is difficult and should provide encouragement to the team as
well as individuals and provide assistance when needed. This new process and role of the CRN
can be a difficult adjustment for staff, so as a leader I would applaud accomplishments, no matter
how small, and recognize individuals that go above-and-beyond, in order to encourage staff.

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Following the implementation of the CRN, I would continue to review the data for stroke
intervention times in order to determine the effectiveness. As this is still in the planning stages at
St. Marys ED, there are no outcomes to evaluate. During my research, I did not find any articles
that discussed a CRN, only a code team. One article states that the role or the stroke nurse and
the ED nurse within the stroke team, need to be defined in order to prevent omissions in care and
save valuable time (Ellmers, Clark, & Lutsep, 2015). The creation of the CRN in St. Marys ED
provides clear definition of the role of CRN, which is different from the role of the primary
nurse. Another article by Garcia-Santibanez , et al. (2015), states that the role of the stroke team
diminstrated significant improvement in CT and t-PA time. Therefore, based on this data adding
the rold of CRN to the stroke team can only improve target intervention times and the overall
goal of patient outcomes.

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References
American Stroke Association. (2014, October). American Stroke Association. Retrieved from
Target: Stroke Phase II: http://www.strokeassociation.org/idc/groups/heartpublic/@wcm/@gwtg/documents/downloadable/ucm_470730.pdf
Blanchard, K., & Hodges, P. (2005). Lead Like Jesus. Nashville: Thomas Nelson, Inc.
Bock, B. F. (2011, May 17). National Institute of Neurological Disorders and Stroke. Retrieved
from National Institutes of Health:
http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/bock.htm
Centers for Disease Control and Prevention. (2015). Stroke Facts. Retrieved from
http://www.cdc.gov/stroke/facts.htm
Ellmers, K., Clark, W. M., & Lutsep, H. L. (2015, October 12). Stroke Team Creation and
Primary Stroke Center Certification. Retrieved from Medscape:
http://emedicine.medscape.com/article/1162677-overview#showall
Garcia-Santibanez , R., Liang, J., Walker A, A., Matos-Diaz, I., Kahkeshani , K., & Boniece, I.
(2015). Comparison of Stroke Codes in the Emergency Room and Inpatient Setting.
Journal of Stroke and Cardiovascular Diseases, 24(8).
doi:10.1016/j.jstrokecerebrovasdis.2015.05.010
Hoyert, D. (2012, March 13). 75 Years of Mortality in the United States, 19352010. Retrieved
October 15, 2015.
Kouzes, J. M., & Posner, B. Z. (2014). The Student Leadership Challenge: Five practices to
becoming an exemplary leader. San Francisco: The Leadership Challenge.
Shinault, C. (2015, September 22). Quality Improvement: Code Response Nurse. (A. Holt,
Interviewer)

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