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discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/228850702

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

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DISCUSSION PAPER

Implementation of evidence into practice:

Development of a tool to improve emergency
nursing 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, Australia
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

KEYWORDS
Emergency nursing;
Stroke;
Evidence-based
medicine;
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 rst 2448 hours. 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, physiological surveillance, uid 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 rights
reserved.

Corresponding author. Tel.: +61 3 8405 8600.

E-mail addresses: bree.mcgillivray@nh.org.au (B. McGillivray), julie.considine@deakin.edu.au (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

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

Introduction
Stroke is an increasing global health issue that places considerable burden on society and health care services. Although
the incidence of stroke is decreasing due to increased awareness and modication of risk factors such as hypertension
and smoking, the absolute number of strokes continues to
rise as a result of an ageing population and increased life
expectancy.1 Global stroke data shows that 15 million people suffer a stroke very year, 5 million people die annually
from stroke and 5 million people are left with permanent
disability as a result of stroke.1 Burden of disease is projected to rise from 38 million disability adjusted life years
in 1990 to 61 million disability adjusted life years in 2020.1
These worldwide trends of increasing incidence of stroke
are also evident in Australia. Every year 48,000 Australians
have a stroke and 9,000 Australians die within 1 month of
stroke.2 Further, an additional one third of patients with
stroke die within 12 months2 and in the next 10 years more
than half a million people in Australia will suffer a stroke.3
Of patients suffering stroke, 70% have a rst ever stroke
and 30% will have another stroke within one year.2 In addition, stroke is a leading cause of disability and health system
demands in Australia.2,3 During 2005/06 Victorian public hospitals managed almost 12,000 episodes of stroke2 and it is
predicted that the incidence of acute stroke will continue
to increase by 2.7% annually.2
Many guidelines relating to the Emergency Department
(ED) management of acute stroke focus on rapid identication of patients eligible for thrombolysis (rt-PA) and
timely administration in patients who meet the specic criteria for this treatment.2,4,5 Thrombolysis is benecial in
selected patients with acute ischaemic stroke when used
within 3 hours of symptom onset and more recent studies suggesting that thrombolysis can be safely used up to
4.5 hours after symptom onset.612 The recent national audit
of stroke services in Australia4 showed that of 1944 patients
with acute ischaemic stroke, only 795 patients arrived within
three hours and only 56 of the eligible patients received IV
thrombolysis (7%).4 Capacity to treat acute ischaemic stroke
was greater in Category A hospitals (immediate access to CT
scanning, access to HDU and on-site neurosurgery, and geographically located stroke unit) who had a 6% thrombolysis
rate compared with 1% in Category B hospitals (immediate access to CT scanning, access to HDU, geographically
located stroke unit but no on-site neurosurgery).4 In addition, management by a specialist multidisciplinary team
is a key factor in improving outcomes for patient with
acute stroke.2,5 Although, it is well known that patients who
receive stroke unit care have lower mortality rates and are
more likely live independently,2,13 41% of the hospitals that
contributed to the audit of acute stroke services did not
have a stroke unit.14 The ndings of the national audit of
stroke services highlighting signicant and widespread barriers to evidence-based stroke care and signicant variation
between organisations in terms of resources, facilities and
treatments offered for acute stroke.
Access block is delay in admission to an inpatient bed
for patients in the ED requiring hospital admission15 and
ED length of stay is a key inuence on hospital length of
stay.16 Access block results in prolonged periods of time in
the ED15 and is a common issue for patients requiring hospi-

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111

tal admission via the ED, including patients with stroke. An

important part of acute stroke management and decreasing
stroke-related mortality is preventing complications within
the rst 2448 hours.1720 The current climate of prolonged
time spent in the ED means that many aspects of stroke management are now the responsibility of emergency nurses.
A guideline for the emergency nursing management
of stroke was developed in June 2007 and then revised
in January 2009. Initial guideline development occurred
in response to three major factors: i) the numbers of
patients with acute stroke are increasing therefore stroke
will become a more common EDs presentation, ii) there were
observations of variability in stroke management in the ED
at TNH, and iii) evidence-based emergency nursing management of acute stroke was one way of overcoming some of
the limitations to organisational stroke care that are highlighted later in this paper and optimising patient outcomes
following stroke.
The aim of this paper is threefold. First, the local context
of acute stroke care at Northern Health will be described.
Second, the evidence related to nursing care of acute stroke
will examined and the elements of stroke care that had
the most applicability to emergency nursing management of
acute stroke will be identied. Finally, the process of using
evidence related to stroke care for development of a guideline for the emergency nursing management of acute stroke
at Northern Health, The Northern Hospital will be outlined.
The focus of this paper, however, is the emergency nursing care of acute stroke. As a result, the discussion will be
concentrated on issues that are under the direct inuence
of emergency nurses: issues surrounding implementation of
thrombolysis for acute ischaemic stroke in centres that do
not currently offer this treatment option will not be discussed in this paper.

Local context
Northern Health provides health care services to over
700,000 people living in Melbournes northern suburbs and
semi-rural regions beyond the city fringe. Northern Health
manages 613 beds and provides care in acute, sub-acute
and community settings over ve campuses. At Northern
Health, acute stroke care is provided at The Northern Hospital (TNH), a 300 bed facility designated as a Category B
hospital by the National Stroke Audit.4 This means that The
Northern Hospital has immediate access to CT scanning,
access to high dependency unit, a geographically located
stroke unit but no on-site neurosurgery.
During 2006/07, the ED at The Northern Hospital, Northern Health (TNH) managed 265 patients with stroke:a their
average age was 71 years, 51% arrived by ambulance and
18% required an interpreter. The median ED length of stay
for admitted patients was 11.4 hours (IQR 7.9 - 14.3). Inpatient data shows that during 2007 there were 172 separations
for acute stroke with a total of 1557 bed days and average
length of hospital stay of 9.1 days. The majority of patients

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

specied as haemorrhage or infarction: n = 214) I610 I619 (Intracerebral haemorrhage: n = 48)I630 I639 (Cerebral infarction: n =
3)I629 (Intracerebral haemorrhage unspecied)

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B. McGillivray, J. Considine

(90%) were living at home prior to admission4 suggesting

reasonable functional status prior to stroke.
Thrombolysis is not currently offered as a treatment
option for management of acute ischaemic stroke due to
organisational infrastructure limitations: lack of specialist neurology and neurosurgical services, limited specialist
neuro-imaging capabilities, limitations to high dependency
unit facilities offered by critical care department, lack of
high dependency unit capability on current stroke unit, and
absence of core group of specialist stroke nurses/stroke liaison nurses. Pre-hospital triage of patients with stroke by
paramedics tends to result in transport of patients who may
be eligible for thrombolysis (younger, shorter duration of
symptoms) to neighbouring centres with specialist stroke
services that do offer thrombolysis as a management option
for acute ischaemic stroke. Despite limitations to offering
thrombolysis, patients with acute stroke managed at TNH
had a number of outcomes that were superior to those
reported at national level.21 For example, in hospital mortality rate was 8% at TNH compared with the national rate of
13%, and average length of stay for discharged patients was
5.6 days which was considerably shorter than the national
rate of 11 days.21 The proportion of patients who were independent at discharge was 45% which was comparable to the
national rate of 49%.21

Review of current guidelines

There are a number of guidelines for the management of
acute stroke. Most address emergency care in terms of
investigations, particularly neuro-imaging and assessment
for thrombolysis however few specically address emergency nursing management of patients with acute stroke. In
the section to follow, recommendations from existing guidelines for the management of acute stroke that relate directly
to nursing care will be examined and their applicability to
emergency nursing will be discussed. Gaps in current recommendations for emergency nursing care for acute stroke will
also be highlighted. The guidelines included in this review
were limited to evidence based guidelines less than 10 years
old. 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 triage
decisions are a key determinant of the trajectory of care for

Table 1

patients with actual or potential acute stroke. As thrombolysis is a time critical intervention in acute stroke,612 a key
priority of ED triage is to facilitate rapid assessment and
identication of patients who may be eligible for thrombolysis or transfer for thrombolysis. Although many of the
guidelines reviewed refer to stroke as a medical emergency 5,8,25 however specic recommendations about ED
triage of patients with actual or potential acute stroke are
absent. There are no references to triage category allocation or risk stratication by triage nurses. The American
Heart Association/American Stroke Association guidelines
(2007)22 recommend that patients with suspected acute
stroke should be triaged with the same priority as patients
with acute myocardial infarction or serious trauma, regardless of the severity of the decits (p. 1663). In addition,
the National Institute of Neurological Disorders recommends
a door to doctor time of less than 10 minutes.26,27 In Australia, all of these recommendations equate to Category 2
of the Australasian Triage Scale28 and this is reected in the
stroke guideline.
In terms of potential for stroke, some guidelines do contain detailed information about risk factor stratication
for TIA5 however these recommendations about TIA are
not related to the ED triage process. For the purposes of
the stroke guideline, the ABCD risk stratication scoring
system29 was used to ag patients who may present with
TIA who are at high risk of stroke. Features of this scoring system include age, blood pressure, clinical history and
duration of symptoms and more recently diabetes has added
as a signicant risk factor for stroke in patients with TIA.30
The ABCD2 score was included in the 2009 stroke guideline
update.30

Immediate evaluation
In terms of immediate evaluation and early diagnosis, both
of which occur in the ED, many guidelines focus on stroke
scale scoring, brain imaging and mobilisation of stroke team
or specialised stroke personnel.22 American Heart Association/American Stroke Association guidelines (2007)22 state
that complete evaluation and treatment decisions should
occur within 60 minutes of the patients arrival in the ED.
Recommendations regarding brain imaging are varied. For
example, National Institute of Neurological Disorders recommends that head CT is performed within 25 minutes and
interpreted within 45 minutes of arrival in ED23,26,27 however
the Royal College of Physicians state that imaging should

Guidelines included in review.

Victorian Department of Human Services (2007). Stroke Care Strategy for Victoria2
National Stroke Foundation (2007). National guidelines for acute stroke management. Melbourne, National Stroke
Foundation5
American Heart Association/American Stroke Association (2007). Guidelines for the Early Management of Adults
with Ischemic Stroke22
Institute for Clinical Systems Improvement. (2008). Health Care Guideline: Diagnosis and Initial Treatment of
Ischemic Stroke23
European Stroke Organisation (2008). Guidelines for management of ischaemic stroke and transient ischaemic
attack 200824
Royal College of Physicians (2004). National clinical guidelines for stroke25

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Australia
Australia
USA
USA
Europe
UK

Implementation of evidence into practice: Development of a tool to improve emergency nursing care of acute stroke
occur within 24 hours of symptom onset25 but urgent brain
imaging should occur if the patient: i) is anticoagulated or
has a known bleeding tendency, ii) has a decreased conscious
state, iii) has progressive or variable symptoms, neck stiffness, fever or severe headache, or iv) if thrombolysis or early
anticoagulation are treatment options.25 Both the National
Stroke Foundation5 and The European Stroke Organisation24
recommend urgent brain CT for acute stroke and the
National Stroke Foundation5 denes urgent as as soon
as possible, but certainly less than 24 hours (p. vi). The
national audit of acute stroke services also used a 24 hour
benchmark.4 Observations of usual practice at TNH suggest CT is performed early in the ED episode of care for
the majority of patients with acute stroke. As ordering CT
scans is beyond the scope of emergency nursing practice, the
stroke guideline refers to nurses checking that the patient
has had a brain CT prior to leaving the ED for two reasons.
First, emergency nurses checking that investigations have
been performed prior to the patient leaving the ED adds an
additional safeguard that CT scan has been performed while
in ED. Second, emergency nurses tend to be responsible for
patient transfer to inpatient units so the guideline acts as
a prompt to ensure the CT scans accompany the patient to
inpatient areas.

Initial assessment
Emergency nurses play a key role in decreasing strokerelated mortality by prevention of complications in the rst
2448 hours after stroke.1720 The initial assessment of all
ED patients (following triage) is undertaken using a primary survey approach: airway, breathing, circulation and
disability. Airway assessment includes crude assessment of
conscious state, ability to speak and, for all patients with
actual or potential stroke, nil orally status. Airway support
by endotracheal intubation may be indicated in patients
with decreased conscious state.22,31 Impaired swallowing is
associated with increased mortality following stroke32 so
patients with stroke should remain nil orally until ability to
swallow safely has been formally assessed. Specic recommendations about nil orally status in the stroke guideline
are important because decisions regarding oral intake are
usually nursing decisions.
Assessment of breathing typically involves assessment
of respiratory rate, respiratory effort, oxygen saturation
and chest auscultation. Assessment of oxygen saturation
is 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 saturation is less than 92%22,34 to 95%.23 The use of supplemental
oxygen in non-hypoxic patients with stroke is not recommended as there is no evidence of survival benet from
oxygen use in non-hypoxic patients with stroke and some
evidence to suggest that hyperoxia may increase cerebral
injury.17,22 Given that the majority of oxygen administration
decisions are made independently by emergency nurses35,36
and the routine use of oxygen in acute stroke may be harmful, it was important to made a statement about oxygen
management in the stroke guideline.

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113

Assessment of circulation typically comprises assessment of heart rate, blood pressure and cardiac rhythm by
cardiac monitoring and 12 lead ECG. Blood pressure monitoring is essential to the management of acute stroke.
Hypotension will reduce cerebral perfusion and potentially
increase infarct size so should be treated aggressively with
intravenous uids and/or medications.22,32 Hypertension
is common following acute stroke and is a physiological response to optimise cerebral perfusion pressure in
the setting of cerebral ischaemia and increased intracranial pressure.31 Aggressive blood pressure reduction is not
recommended as this may further compromise cerebral
perfusion.17,31,32,37 However other causes for hypertension,
such as pain, vomiting or urinary retention should be considered and if present, treated appropriately.31,38 Again,
identication and management of issues such as pain,
vomiting and urinary retention are typically nursing responsibilities.
Some guidelines recommend cautious treatment of
severe hypertension (systolic blood pressure greater than
220 mmHg or diastolic blood pressure greater than 120
mmHg) using intravenous medications that can be accurately
titrated8,23,31,32 however there is no high level evidence to
support this approach in patients with stroke.31 The use of
oral or sublingual agents is not recommended as their use
cause rapid and uncontrolled blood pressure reduction.31
Patients with hypertension and who are eligible for thrombolysis may have blood pressure lowered to 185 mmHg
systolic and 110 mmHg diastolic before thrombolysis.22
TNH has a local ED policy for reportable blood pressure
parameters that applies to all patients and a hospital wide
policy for reportable blood pressure parameters in patients
who have suffered a stroke.34,39 It was important that the
stroke guideline was aligned to these existing policies.
Electrocardiography (ECG) is indicated in patients with
acute stroke to identify sources of cardiogenic emboli
such as atrial brillation or recent AMI and signs of
pre-existing cardiac disease.31,37,40 ECG abnormalities are
present in up to 60% of patients with cerebral infarction and 50% of patients with intracerebral haemorrhage.41
ECG changes such as T wave inversion can occur in as
many as 75% of patients with acute stroke and cardiac
arrhythmias can occur as a result in increased sympathetic
tone, decreased parasympathetic tone and catecholamine
release.32 Some guidelines advocate cardiac monitoring for
rst 24 hours after ischaemic stroke in order to screen for
atrial brillation.22 It is therefore not surprising that 12
lead ECG +/ cardiac monitoring are featured in the stroke
guideline.
Hyperthermia in the early phase of acute stroke increases
mortality and infarct size17,18,32 so temperature monitoring
and active management of hyperthermia is an important
part of ED stroke care. A meta-analysis of hyperthermia and
stroke outcomes by Hajat et al.42 showed that patients who
were febrile following stroke had a 19% increase in mortality.
This meta-analysis42 highlights the importance of temperature monitoring and temperature control in patients with
acute stroke while they are in the ED. Key issues for emergency nurses include consideration and treatment of causes
of hyperthermia (such as infection, or thromboembolism)
and possibly administration of anti-pyretic medications in
febrile patients with acute stroke.8,22 Inclusion of infor-

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B. McGillivray, J. Considine

mation related to consequences of hyperthermia was an

important element of the stroke guideline.
Glycaemic control is an important aspect of management of serious illness. Blood glucose levels should be
assessed in patients with actual or potential stroke for
a number of reasons. First, it is important to exclude
hypoglycaemia as an easily treated cause for signs and
symptoms that may mimic stroke.31,40 Second, diabetes is
a signicant risk factor for stroke4,5 and many patients
with Type II diabetes are undiagnosed.43 Third, hyperglycaemia is associated with increased cerebral infarct size
and poor patient outcomes.8,17,32 Blood glucose levels over
8 mmol/L is predictive of mortality following stroke, even
when adjusted for age, stroke severity, and stroke type.44
Hyperglycaemia following stroke is also associated with
decreased functional outcome 8,17,18,32,44 so blood glucose
monitoring and active management of hyperglycaemia in
the ED may have signicant impact on patients outcomes
following acute stroke. Given that blood glucose monitoring is a nursing responsibility and that hyperglycaemia has a
strong association with poor outcomes, information related
to frequency of blood glucose monitoring and reportable
parameters was an important element of the stroke guideline.

Stroke unit/specialist referral and assessment

A key factor in the ED management of acute stroke is specialist referral to stroke units and allied health personnel. Acute
stroke care should be provided by stroke units that are led
by a physician and supported by an interdisciplinary team.2
There is high level evidence that standardised stroke care
in 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 the
rst 24 to 48 hours following acute stroke. Dysphagia occurs
in up to 50% of patients with acute stroke and is associated
with complications such as aspiration, pneumonia, dehydration and malnutrition.5 Dysphagia screening by trained
personnel within 24 hours of admission should occur before
patients are given food or uids.5,22 Patients who fail dysphagia screening should be referred to a speech pathologist for a
comprehensive assessment5 so ED referral to speech pathology is a key component of stroke care in patients whose
transfer to inpatient stroke unit is delayed.
Dietician assessment of hydration and nutrition is an
important part of acute stroke care. Dehydration is common
after stroke due to nil orally status until swallow assessment is complete, impaired swallowing and immobility5 and
poor nutritional status in patients with stroke is associated
with increased morbidity and mortality.18,22 Dehydration and
malnutrition are associated with an increase in poor outcomes following acute stroke.5 All patients with acute stroke
should be screened for malnutrition and patients at risk
of malnutrition (including patients with dysphagia) should
have dietician assessment within 48 hours for ongoing management planing.5 Although uncommon, some patients are
in the ED for 48 hours so dietician referral may be part of
emergency nursing care. Further, there may also be a need

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for prioritising patients with high risk features of dehydration or malnutrition and targeted early referral to dieticians
for patients with dysphagia or known hydration or nutrition problems. Allied health referrals from ED were ad hoc
with no systemic referral processes in place. As part of the
stroke guideline implementation, an electronic referral system (HealthPower) was activated on all ED computers and
nursing staff were educated in its use.
Many patients with acute stroke spend signicant time
in bed,5 and this is particularly true in the ED. Up to 51%
of deaths in the rst 30 days after ischaemic stroke are
due to complications of immobility and over 62% of these
complications occur in the rst week.5 Early mobilisation
(<48 hours) prevents complications related to immobility
(deep vein thrombosis, joint disorders, contractures, and
pressure injuries)18 so there may be a role for ED referral
to physiotherapy for patients with delayed transfer to the
stroke unit or inpatient care.
Early mobilisation promotes positive health outcomes for
patients with acute stroke.22 In addition to functional benets, early mobilisation decreases the risk of complications
related to immobility such as pneumonia, deep vein thrombosis, pulmonary embolism, and pressure ulcers.22 There is
also evidence that early mobilisation after stroke reduces
mortality and morbidity following stroke and improves
physiological recovery by decreasing rates of depression
and anxiety.46,47 Although the stroke guideline provides a
prompt for referral to physiotherapy, the effectiveness of
mobilisation of patients suffering acute stroke in the ED
remains unknown. The results of a current multicentre
study of very early rehabilitation in stroke (AVERT trial
Phase 3) may inform future mobilisation practices in
ED.48
Urinary and/or faecal incontinence can occur due
to stroke-related impairments such as weakness, cognitive impairments and decreased mobility.5 Incontinence
is associated with stroke-related complications such as
depression,5 can precipitate other adverse events such as
falls, or can result in prolonged recovery. Accurate assessment of the cause of incontinence is vital to ensure targeted
and appropriate interventions.5 Although assessment of continence may not occur in ED, it is important that use of
indwelling catheters as initial management of incontinence
should be avoided.5,22 Although it may be argued that continence care falls outside the scope of emergency nursing care
of acute stroke, the majority of urinary catheters in elderly
hospital patients are inserted in the ED,49 as many as 63%
of urinary catheterisations in ED are inappropriate,50 and
urinary catheters place patients at risk of nosocomial infection and sepsis.22 Emergency nurses need to be cognisant of
appropriate criteria for placement of urinary catheters and
the risks associated with this intervention.

Prevention of complications
Patients suffering acute stroke are predisposed to a number
of complications and prevention of complications is fundamental to improving outcomes following stroke. In the rst
few weeks following acute stroke, patients are at risk of
deep vein thrombosis (DVT) and pulmonary embolism (PE).
The risk of DVT following stroke is 25-50%18 and PE is the

Implementation of evidence into practice: Development of a tool to improve emergency nursing care of acute stroke
third most common cause of deaths after stroke.5 Risk factors for venous thromboembolism (VTE) include reduced
mobility, stroke severity, age, dehydration and delayed
VTE prophylaxis.5 Strategies to prevent venous thromboembolism following stroke include early mobilisation, adequate

Figure 1

hydration, antithrombotic stockings and in patients with

ischaemic stroke, anti-platelet therapy5,22 and many organisations have VTE risk assessment and prophylaxis programs
that should be implemented in the ED for patients with acute
stroke.

Emergency Department Guideline: Management of Acute Stroke.

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115

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B. McGillivray, J. Considine

Figure 1

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(Continued ).

Implementation of evidence into practice: Development of a tool to improve emergency nursing care of acute stroke
Patients with acute stroke are at signicant risk of
pressure ulcers due to increased age, immobility, incontinence, poor nutritional status, cognitive impairment and
diabetes.5,22 Pressure ulcer prevention is a fundamental
component of nursing care and pressure ulcer risk assessment, skin surveillance, frequent position changes, and use
of devices such as alternating pressure mattresses22 should
already 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 to
spatial problems, impaired mobility, cognitive impairment,
incontinence and dehydration.22 Many organisations have
well established falls screening and prevention programs and
given that nurses have played a major role in reducing falls
and falls related injuries51,52 there is no reason that falls
screening cannot occur in the ED.
Poor limb care in patients with acute stroke can result in
joint subluxation, shoulder pain, decreased functional use.53
Limb care following acute stroke is therefore an important
aspect of stroke care and should begin in the ED. Emergency
nurses have a well established role in pain assessment of
pain and so pain management using analgesic agents or nonpharmacological strategies in patients with acute stroke are
well within the scope of emergency nursing practice.

Tool development
In order to improve the emergency nursing management of
stroke, the recommendations described so far in this paper
were incorporated into a one page (double sided) summary
document that was titled Emergency Nursing Management
of Acute Stroke. This guideline was developed in June 2007
and revised in January 2009 in light of new evidence and
additional references (Fig. 1). The stroke guideline was
intended to accompany the usual ED nursing documentation and act as a prompt to guide triage decision making
and also initial assessment, ongoing nursing care and specialist referrals. Although elements of the Stroke guideline
may seem reective of usual emergency nursing practice, it
is important to recognise the high levels of transient staff
(casual nursing staff, graduate nurses and students) who provide care for patients with acute stroke and that patients
with acute stroke currently make up a small proportion of
the total patient census. The Stroke guideline was aimed to
assist all levels of staff to provide optimal care to patients
with acute stroke.
The stroke guideline used the state-wide policy framework and best available evidence to guide triage decision
making. Recommendations regarding initial assessment
were based on a primary survey approach with specic
recommendations related to reportable parameters. Recommendations for ongoing care focused on physiological
monitoring (vital signs, neurological observations and gylcaemic control), uid management, risk management (VTE,
pressure ulcers, safe swallowing and limb care). Finally
there was also a prompt for allied health referrals.
Guideline implementation was supported by a tutorial
conducted during nursing in-service education time and
promotion by local opinion leaders. In-service education
sessions were repeated over a 3 week period until all nurs-

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117

ing staff had attended. The researchers also spent time

in the clinical area reminding staff about the guideline
and the guideline was loaded on to the ED Clinical Guidelines intranet. Evaluation of the effect of the guideline is
described elsewhere.54

Conclusion
The role of emergency nurses in stroke care will increase
and it is important that emergency nurses deliver evidencebased stroke care in order to optimise patient outcomes.
Expert emergency nursing care of patients with acute stroke
is pivotal irrespective of whether the patient is eligible for
thrombolysis and serves to potentiate the treatment effects
of rt-PA in patients meeting the inclusion criteria but will
also optimise outcomes for patients who are not candidates
for thrombolysis. Further, suboptimal emergency nursing
management of acute stroke may even counter potential
benets of thrombolysis. 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. A simple one page summary of
evidence related to stroke care in the rst 24 hours has the
potential to improve the emergency nursing care of patients
with acute stroke.

Addendum
Since development of this guideline, there have been a number of initiatives related to stroke care at Northern Health.
The Victorian Government has established a Stroke Clinical
Network and Northern Health has a Stroke Network Facilitator dedicated to facilitating evidence-based stroke care.
The stroke unit at TNH has undergone a review and colocation of patients with stroke and reducing the numbers
of patients with stroke on outlying medical units are key priority areas. A stroke nurse practitioner candidate has been
appointed and this role is under development and there are
multi-disciplinary and multi-speciality discussions regarding
the infrastructure requirements for safe delivery of thrombolysis for acute ischaemic stroke.

Disclosures
JC was responsible for study conception and design. JC and
BM were responsible for obtaining funding. BM was responsible for data acquisition and JC conducted data analysis.
JC and BM were responsible for drafting this article and all
authors provided critical revision of the manuscript. There
are no conicts of interests. JC accepts responsibility for
the manuscript.

Acknowledgements
This study was supported by a National Institute of Clinical Studies (NICS) Emergency Care Nursing Grant. NICS is an
institute of the National Health and Medical Research Council (NHMRC), Australias peak body for supporting health and
medical research.

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