See

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

CITATIONS READS

2 123

5 AUTHORS, INCLUDING:

Julie Considine
Deakin University
155 PUBLICATIONS 761 CITATIONS

SEE PROFILE

Available from: Julie Considine

Retrieved on: 21 October 2015
Australasian Emergency Nursing Journal (2009) 12, 110119

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

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
b
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 Summary
Background: Stroke is an increasing global health issue that places considerable burden on
Emergency nursing;
society and health care services. An important part of acute stroke management and decreasing
Stroke;
stroke-related mortality is preventing complications within the rst 2448 hours. The current
Evidence-based
climate of prolonged time spent in the Emergency Department (ED) means that many aspects
medicine;
of stroke management are now the responsibility of emergency nurses.
Guideline
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, 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

Copyright Agency Limited (CAL) licenced copy

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 consid-
erable burden on society and health care services. Although
the incidence of stroke is decreasing due to increased aware-
ness 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 peo-
ple 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 pro-
jected 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 addi-
tion, stroke is a leading cause of disability and health system
demands in Australia.2,3 During 2005/06 Victorian public hos-
pitals 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 identi-
cation of patients eligible for thrombolysis (rt-PA) and
timely administration in patients who meet the specic cri-
teria 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 stud-
ies 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 geo-
graphically located stroke unit) who had a 6% thrombolysis
rate compared with 1% in Category B hospitals (immedi-
ate access to CT scanning, access to HDU, geographically
located stroke unit but no on-site neurosurgery).4 In addi-
tion, 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 bar-
riers 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-
Copyright Agency Limited (CAL) licenced copy
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 man-
agement 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 manage-
ment of acute stroke was one way of overcoming some of
the limitations to organisational stroke care that are high-
lighted 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 guide-
line 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 nurs-
ing 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 dis-
cussed 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 Hos-
pital (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, North-
ern 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). Inpa-
tient 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 (Intrac-
erebral haemorrhage: n = 48)I630 I639 (Cerebral infarction: n =
3)I629 (Intracerebral haemorrhage unspecied)
112
(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 special-
ist 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 liai-
son 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 mor-
tality 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 inde-
pendent 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 emer-
gency nursing management of patients with acute stroke. In
the 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 to
emergency nursing will be discussed. Gaps in current recom-
mendations 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 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
Copyright Agency Limited (CAL) licenced copy
B. McGillivray, J. Considine
patients with actual or potential acute stroke. As thrombol-
ysis 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 throm-
bolysis or transfer for thrombolysis. Although many of the
guidelines reviewed refer to stroke as a medical emer-
gency 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 alloca-
tion 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, regard-
less 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 Aus-
tralia, 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 con-
tain 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 scor-
ing 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 Associa-
tion/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 rec-
ommends 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
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 stiff-
ness, 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 sug-
gest 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 stroke-
related 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 pri-
mary 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 recom-
mendations 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 satu-
ration is less than 92%22,34 to 95%.23 The use of supplemental
oxygen in non-hypoxic patients with stroke is not recom-
mended 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 harm-
ful, it was important to made a statement about oxygen
management in the stroke guideline.
Copyright Agency Limited (CAL) licenced copy
113
Assessment of circulation typically comprises assess-
ment of heart rate, blood pressure and cardiac rhythm by
cardiac monitoring and 12 lead ECG. Blood pressure mon-
itoring 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 physiologi-
cal response to optimise cerebral perfusion pressure in
the setting of cerebral ischaemia and increased intracra-
nial 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 con-
sidered and if present, treated appropriately.31,38 Again,
identication and management of issues such as pain,
vomiting and urinary retention are typically nursing respon-
sibilities.
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 throm-
bolysis 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 infarc-
tion 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 tempera-
ture monitoring and temperature control in patients with
acute stroke while they are in the ED. Key issues for emer-
gency 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-
114
mation related to consequences of hyperthermia was an
important element of the stroke guideline.
Glycaemic control is an important aspect of manage-
ment 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, hypergly-
caemia 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 monitor-
ing 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 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. 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, dehy-
dration 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 dyspha-
gia screening should be referred to a speech pathologist for a
comprehensive assessment5 so ED referral to speech pathol-
ogy 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 assess-
ment 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 out-
comes 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 man-
agement 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
Copyright Agency Limited (CAL) licenced copy
B. McGillivray, J. Considine
for prioritising patients with high risk features of dehydra-
tion or malnutrition and targeted early referral to dieticians
for patients with dysphagia or known hydration or nutri-
tion 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 sys-
tem (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 ben-
ets, early mobilisation decreases the risk of complications
related to immobility such as pneumonia, deep vein throm-
bosis, 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, cogni-
tive 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 assess-
ment of the cause of incontinence is vital to ensure targeted
and appropriate interventions.5 Although assessment of con-
tinence 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 conti-
nence 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 infec-
tion 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 funda-
mental 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 115

third most common cause of deaths after stroke.5 Risk fac-
tors for venous thromboembolism (VTE) include reduced
mobility, stroke severity, age, dehydration and delayed
VTE prophylaxis.5 Strategies to prevent venous thromboem-
bolism following stroke include early mobilisation, adequate
hydration, antithrombotic stockings and in patients with
ischaemic stroke, anti-platelet therapy5,22 and many organ-
isations have VTE risk assessment and prophylaxis programs
that should be implemented in the ED for patients with acute
stroke.

Figure 1 Emergency Department Guideline: Management of Acute Stroke.

Copyright Agency Limited (CAL) licenced copy

116 B. McGillivray, J. Considine

Figure 1 (Continued ).

Copyright Agency Limited (CAL) licenced copy

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, inconti-
nence, poor nutritional status, cognitive impairment and
diabetes.5,22 Pressure ulcer prevention is a fundamental
component of nursing care and pressure ulcer risk assess-
ment, 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 non-
pharmacological 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 documenta-
tion and act as a prompt to guide triage decision making
and also initial assessment, ongoing nursing care and spe-
cialist 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 pro-
vide 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 frame-
work 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. Rec-
ommendations for ongoing care focused on physiological
monitoring (vital signs, neurological observations and gyl-
caemic 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-
Copyright Agency Limited (CAL) licenced copy
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 Guide-
lines 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 evidence-
based 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 num-
ber 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 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 numbers
of patients with stroke on outlying medical units are key pri-
ority 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 throm-
bolysis for acute ischaemic stroke.
Disclosures
JC was responsible for study conception and design. JC and
BM 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 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 Clini-
cal Studies (NICS) Emergency Care Nursing Grant. NICS is an
institute of the National Health and Medical Research Coun-
cil (NHMRC), Australias peak body for supporting health and
medical research.
118
References
1. Mackay J, Mensah G, editors. The Atlas of heart disease
and stroke. Geneva: World Health Organisation. Retrieved 9
April 2008 from http://www.who.int/cardiovascular diseases/
resources/atlas/en/; 2004.
2. Victorian Department of Human Services. Stroke care strategy
for Victoria. Melbourne: Metropolitan Health and Aged Care
Services Division, Department of Human Services. Retrieved 31
January 2008 from http://www.health.vic.gov.au/strokecare/
stroke care strategy.pdf; 2007.
3. National Stroke Foundation. 10 things you should know about
stroke. Retrieved on 13 January 2009 from http://www.
strokefoundation.com.au/facts-gures-and-stats; 2006.
4. National Stroke Foundation. National stroke audit clinical
report. Acute Services Melbourne: National Stroke Foundation;
2007.
5. National Stroke Foundation. National guidelines for acute
stroke management. Melbourne: National Stroke Foundation;
2007.
6. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti
D, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute
ischemic stroke. N Engl J Med 2008;359(13):131729.
7. Wahlgren N, Ahmed N, Davalos A, Hacke W, Millan M, Muir
K, et al. Thrombolysis with alteplase 34.5 h after acute
ischaemic stroke (SITS-ISTR): an observational study. Lancet
2008;372(9646):13039.
8. National Stroke Foundation. National guidelines for acute
stroke management. Melbourne: National Stroke Foundation;
2003.
9. Clarke WM, Wissman S, Albers GW, Jhamandas J, Madden KP,
Hamilton S. Recombinant tissue-type plasminogen activator
(Alteplase) for ischemic stroke 3 to 5 hours after symptom
onset. The ATLANTIS Study: a randomized controlled trial.
Alteplase thrombolysis for acute noninterventional therapy in
ischemic stroke. JAMA 1999;282:201926.
10. Clarke WM, Albers GW, Madden KP, Hamilton S. The rtPA 0
to 6 hour acute stroke trial. Part A. Results of a double-
blind placebo-controlled multicenter study. Stroke 2000;31:
8116.
11. Hacke W, Kaste M, Fieshchi C, Toni D, Lesaffre E, von Kum-
mer R, et al. Intravenous thrombolysis with recombinant tissue
plasminogen activator for acute hemispheric stroke. JAMA
1995;274:101725.
12. Kothari RU, Hanke W, Brott T, Dykstra EH, Furlan A, Koroshetz
W, et al. Stroke Ann Emerg Med 2001;37:S13744.
13. Stroke Unit Trialists Collaboration. Organised inpatient
(stroke unit) care for stroke. Cochrane database of sys-
tematic reviews. Issue 4. Art. No.: CD000197. Retrieved
on 3 March 2009 from http://mrw.interscience.wiley.com/
cochrane/clsysrev/articles/CD000197/pdf fs.html; 2007.
doi:10.1002/14651858.CD000197.pub2.2007.
14. National Stroke Foundation. Site specic report: northern hos-
pital. National stroke audit clinical report acute services.
Melbourne: National Stroke Foundation; 2007.
15. Australasian College for Emergency Medicine. Access block
and overcrowding in emergency departments. Melbourne:
Australasian College for Emergency Medicine. Retrieved 31
March 2007 from http://www.acem.org.au/media/Access
Block1.pdf; 2004.
16. Liew D, Kennedy MP. Emergency department length of stay
independently predicts inpatient length of stay. Med J Aust
2003;179(10):5167.
17. Bhalla A, Wolfe CDA, Rudd AG. Management of acute physio-
logical parameters after stroke. QJM: Int J Med 2001;94(3):
16772.
18. Anderson D, Neacy K, Stead L, Koshnick R, Lee J, McRaith J,
et al. Health care guideline: diagnosis and initial treatment
Copyright Agency Limited (CAL) licenced copy
B. McGillivray, J. Considine
of ischemic stroke. 5th ed. Minnesota Institute for Clinical Sys-
tems Improvement; 2006.
19. Pendlebury S, Rothwell P. Stroke management and prevention.
Medicine 2004;32(10):628.
20. Lees KW. M. Acute stroke and diabetes. Cerebrovasc Dis
2005;20(Suppl. 1):914.
21. National Stroke Foundation. National stroke audit clinical
report: acute services. Site specic report the northern
hospital. Melbourne: National Stroke Foundation; 2007.
22. Adams Jr HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan
A, et al. Guidelines for the early management of adults with
ischemic stroke: a guideline from the American Heart Asso-
ciation/American Stroke Association Stroke Council, Clinical
Cardiology Council, Cardiovascular Radiology and Intervention
Council, and the atherosclerotic peripheral vascular disease
and quality of care outcomes in research interdisciplinary
working groups. Stroke 2007;38(5):1655711.
23. Anderson D, Larson D, Lee J, McRaith J, Haake B, Lakshmi-
narayan K, et al. Health care guideline: diagnosis and initial
treatment of ischemic stroke. 5th ed. Minnesota Institute
for Clinical Systems Improvement. Retrieved 13 January 2009
from http://www.icsi.org/guidelines and more/gl os prot/
cardiovascular/stroke/stroke ischemic diagnosis and initial
treatment of .html; 2008.
24. The European Stroke Organisation (ESO) Executive Committee
and the ESO Writing Committee. Guidelines for management
of ischaemic stroke and transient ischaemic attack 2008. 2008;
25(5):457507.
25. Royal College of Physicians. National clinical guidelines for
stroke. 2nd ed. Prepared by the Intercollegiate Stroke Working
Party. London: Royal College of Physicians; 2004.
26. Katzan IL, Sila CA, Furlan AJ. Community use of intravenous
Tissue Plasminogen Activator for acute stroke: results of the
Brain Matters Stroke Management Survey. Stroke 2001;32(4):
8614.
27. Setting new directions for stroke care.Marler JR, Jones PW,
Emr M, editors. Proceedings of a National Symposium on
Rapid Identication and Treatment of Acute Stroke. Bethesda,
MD: National Institute of Neurological Disorders and Stroke,
National Institutes of Health; 1997.
28. Gerdtz M, Considine J, Sands N, Stewart C, Crellin D, Pollock W,
et al. Emergency triage education kit. Canberra: Department
of Health and Ageing; 2007.
29. Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN,
Warlow CP, et al. A simple score (ABCD) to identify individuals
at high early risk of stroke after transient ischaemia attack.
Lancet 2005;366:2836.
30. Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins
JS, Bernstein AL, et al. Validation and renement of scores to
predict very early stroke risk after transient ischaemic attack.
Lancet 2007;369(9558):28392.
31. Aplin P. Stroke and transient ischaemic attacks. In: Cameron
P, Jelinek G, Kelly A, Murray L, Heyworth J, editors. Adult
textbook of emergency medicine. 2nd ed. Sydney: Churchill
Livingstone; 2004. p. 35264.
32. Lewandowski C, Barsan WG. Treatment of acute ischemic
stroke. Ann Emerg Med 2001;37(2):20216.
33. Elizabeth J, Singarayar J, Ellul J, Barer D, Lye M. Arterial
oxygen saturation and posture in acute stroke. Age Ageing
1993;22(4):26972.
34. The Northern Hospital. Stroke Patient. Clinical services manual
December 2006.
35. Considine J, Botti M, Thomas S. Effect of a self-directed learn-
ing package on emergency nurses knowledge of assessment of
oxygenation and use of supplemental oxygen. Nurs Health Sci
2005;7(3):199208.
36. Considine J, Botti M, Thomas S. The effects of specic edu-
cational preparation on emergency nurses clinical decisions
Implementation of evidence into practice: Development of a tool to improve emergency nursing care of acute stroke
regarding supplemental oxygen administration. Nurs Health Sci
2006;8(2):7380.
37. Shah KH, Edlow JA. Transient ischemic attack: review for the
emergency physician. Ann Emerg Med 2004;43(5):592604.
38. Considine J. Neurologic emergencies. In: Curtis K, Ramsden C,
Friendship J, editors. Emergency and trauma nursing. Sydney:
Elsevier; 2007. p. 32751.
39. The Northern Hospital. Emergency Department, Clinical Insta-
bility Criteria.
40. Hankey G. Management of the rst-time transient ischaemic
attack. Emerg Med 2001;13:7081.
41. Christensen H, Christensen AF, Boysen G. Abnormalities on ECG
and telemetry predict stroke outcome at 3 months. J Neurol
Sci 2005;234(12):99103.
42. Hajat C, Hajat S, Sharma P. Effects of poststroke pyrexia on
stroke outcome: a meta-analysis of studies in patients. Stroke
2000;31:4104.
43. Colagiuri S, Walker AE. Using an economic model of diabetes
to evaluate prevention and care strategies in Australia. Health
Aff 2008;27(1):25668.
44. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia
an independent predictor of poor outcome after acute stroke?
Results of a long term follow up study. BMJ 1997;314:13036.
45. Cadilhac DA, Moodie ML, Lalor E, Bilney lE E, Donnan GA, on
behalf of the National Stroke Foundation. Improving access to
evidence-based acute stroke services: development and eval-
uation of a health systems model to address equity of access
issues. Aust Health Rev 2006;30(1):10918.
46. Bernhardt JD, Dewey H, Collier J, Thrift A, Lindley R, Moodie
M, et al. A very early rehabilitation trial (AVERT). Int J Stroke
2006;1(3):16971.
Copyright Agency Limited (CAL) licenced copy
119
47. Cumming TB, Collier J, Thrift AG, Bernhardt J. The effect of
very early mobilisation after stroke on psychological wellbeing.
J Rehabil Med 2008;40(8):60914.
48. National Stroke Research Institute. A phase 3, multicentre,
randomised controlled trial of very early rehabilitation
after stroke (AVERT). Heidelberg, Australia: National Stroke
Research Institute. Retrieved 13 January 2009 from http://
www.nsri.org.au/pics/clinical-trials/pdf/Protocol2006.pdf;
2006.
49. Gokula RRM, Hickner JA, Smith MA. Inappropriate use of uri-
nary catheters in elderly patients at a midwestern community
teaching hospital. Am J Infect Control 2004;32(4):1969.
50. Gokula RM, Smith MA, Hickner J. Emergency room staff educa-
tion and use of a urinary catheter indication sheet improves
appropriate use of foley catheters. Am J Infect Control
2007;35(9):58993.
51. Evans D, Hodgkinson B, Lambert L, Wood J, Kowanko I. Falls in
acute hospitals: a systematic review. Adelaide: The Joanna
Briggs Institute for Evidence Based Nursing and Midwifery;
1998, 159.
52. Myers H, Nikoletti S. Fall risk assessment: a prospective inves-
tigation of nurses clinical judgement and risk assessment tools
in predicting patient falls. Int J Nurs Pract 2003;9(3):158.
53. Jackson D, Turner-Stokes L, Khatoon A, Stern H, Knight L,
OConnell A. Development of an integrated care pathway for
the management of hemiplegic shoulder pain. Rehabil Pract
2002;24(7):298390.
54. Considine J, McGillivray B. An evidence-based practice
approach to improving nursing care of acute stroke in an Aus-
tralian emergency department. J Clin Nurs; in press. Accepted
12 March 2009.