Disclosure: Dr. Lutz has no relevant disclosures
Pub Date: Thursday, Mar 11, 2021
Author: Barbara J. Lutz, PhD, RN, CRRN, PHNA-BC, FAHA, FAAN
Affiliation: McNeill Distinguished Professor, School of Nursing, University of North Carolina-Wilmington
Stroke is a sudden, unexpected life event that affects nearly 800,000 persons in the U.S.,1 with an estimated 10.3 million first strokes, globally each year.2 Approximately 23% of individuals experience recurrent stroke.1 Racial and economic disparities in stroke persist in the U.S. and around the world. Stroke disproportionately affects black and Hispanic Americans, especially those between the ages of 45 and 59. In the REGARDS study, black participants ages 45 to 54 were four times as likely to experience a stroke when compared to whites. Women also have a greater lifetime risk of experiencing a stroke. Stroke survivors often experience post-stroke functional limitations. Stroke is the second leading cause of disability worldwide, with an estimated 80 million stroke survivors experiencing some level of functional impairment.2
Because of the potentially devastating and lifelong impact of stroke, implementing comprehensive evidence-based nursing and interprofessional care across the continuum from hyper-acute (emergency) care through acute care, post-acute, and community reintegration is critical for optimizing outcomes for stroke patients and their family caregivers. The recently published scientific statement by Green et al. (2021),3 which updates the 2009 statement by Summers et al.,4 focuses on one part of this continuum—post-hyperacute through acute inpatient care to pre-hospital discharge. This updated scientific statement is one of a series of three articles focusing on the most recent evidence for providing acute stroke care for patients and their families. In this article, Green and colleagues focus on the necessary assessments and interventions to optimize outcomes for patients and families prior to acute care discharge to post-acute care and/or community reintegration.3 They integrate recommendations from multiple international organizations including the World Health Organization,5 American Heart/American Stroke Association,6 Australian Stroke Foundation,7 Heart and Stroke Foundation of Canada,8 U.K. Royal College of Physicians,9 and others.10, 11
The authors highlight the recent evidence related to strict monitoring of vital signs, including blood pressure and temperature, and screening for hyperglycemia and dysphagia, and provide recommended protocols for each of these. They also provide recommended assessments and interventions for monitoring neurological, cardiovascular, pulmonary, gastrointestinal, urinary, neuropsychological, mobility, and psychosocial status and potential complications throughout the acute care inpatient stay. The statement concludes with a focus on discharge planning, including recommendations for self-management, secondary stroke prevention, and caregiver education prior to discharge.3
Some highlights from the statement include the importance of having an acute care stroke unit. Having a stroke specific unit has demonstrated improved patient outcomes, including lower mortality rates in some studies.11 However, the authors note that because studies were not consistent in length of follow-up, outcomes, and type of inpatient care that more research should be conducted to compare effectiveness of different types of inpatient stroke care and acute stroke units.
The statement also emphasizes the critical role of comprehensive and systematic nursing assessment and intervention in the care of stroke survivors in the acute care setting. Initial and ongoing assessments of vital signs including blood pressure, temperature, respiratory rate and effort, oxygen saturation, and level of consciousness. Implementing best practices for fever management, hyperglycemia, and swallowing difficulties are crucial to prevent avoidable post-stroke complications.12-15 For example, in a randomized clinical trial in Australia, addressing these three areas within the first 72 hours demonstrated a reduction in mortality and improved function.12,13 These outcomes, when combined with care on an acute stroke unit, were sustained long-term. The statement also discusses the implications of impaired mobility and advocates for a “formal rehabilitation assessment” during the inpatient stay.3
Strengths of the statement include the inclusion of a global perspective and integration of evidence-based practices from a number of guidelines and randomized controlled trials from around the world. The statement also provides nurses and other members of the interprofessional team with a path to follow in providing the best care to stroke patients from admission to the acute care inpatient unit through to discharge planning. Gaps noted by the authors are the need for more research focused on defining the specific elements of specialized nursing care for stroke and studies to determine the impact of nursing care, and specifically care provided by stroke certified nurses, on patient outcomes.3
The authors highlight that the transition from acute care back to the community is “one of the most vulnerable and significant periods in the continuum of care for patients and families”.3 They include a table of recommended discharge planning topics. However, in order to better tailor discharge plans for stroke survivors and their family caregivers, the gaps in caregiver readiness to assume the caregiving role also needs to be assessed. Camicia et al’s. 2020 AHA CVSN Stroke Nursing Article of the Year provides a promising new tool to address this gap in practice.16 While the tool was developed and found to be psychometrically valid and reliable for caregivers of patients receiving acute inpatient rehabilitation,17 the readiness domains may similarly apply to caregivers of post-stroke patients being discharged directly home from acute inpatient care. These readiness domains can be used in conjunction with the discharge planning items included in the statement by Green et al.3 to better tailor care plans to prepare family members for assuming the caregiving role. This type of assessment is especially important during this time of the COVID-19 pandemic where more patients recovering from stroke, who might normally be discharged from acute care to inpatient, sub-acute, or outpatient rehabilitation settings, are being discharged directly home, to be cared for by family members, often without additional services.
The article by Green and colleagues is an excellent step forward for implementing evidence-based stroke care. It, in conjunction with the other two papers in the series, provides us with the best practices for advancing stroke care within the acute care setting. The next step is to expand our view of comprehensive stroke care to encompass the entire trajectory from onset to community reintegration with a focus on long-term patient and caregiver outcomes.
Duncan et al.18, propose a “paradigm shift” in how we conceptualize “comprehensive” stroke care. In her paper, based on her 2020 Sherman Lecture at the AHA International Stroke Conference, Dr. Duncan and colleagues encourage stroke systems of care and stroke care providers to view stroke care proactively and to anticipate the patients’ and families’ needs for rehabilitation, recovery, and community reintegration beyond the acute care phase. They recommend expanding quality metrics to include post-acute care and longer-term patient and caregiver outcomes. This paradigm shift would require 1) establishing criteria for comprehensive stroke centers to be classified as “rehabilitation ready”; 2) expanding the American Heart Association GWTG-Stroke program to include metrics for rehabilitation readiness and 90-day patient outcomes; and 3) developing “hopeful and actionable messaging for secondary prevention and recovery of function and health”.18
To meet these goals, Duncan et al. suggest several criteria that could be used to classify comprehensive stroke centers as being “rehabilitation ready”. These include 1) integrating and coordinating community-based post-acute care follow-up in acute care neurology clinics, 2) establishing an advisory panel of rehabilitation experts (physicians, nurses, therapists), community-based service providers, patients, and caregivers; 3) assessing and addressing unmet social needs through coordination and integration with community-based services; and 4) establishing metrics to evaluate transition planning to facilitate transfers to the appropriate level of post-acute care and linkages to community-based services, including lifestyle management programs.18 Stroke nurses and other members of the interprofessional team can take the lead in advocating for this paradigm shift to ensure that stroke care is truly comprehensive and traverses the care continuum beyond acute care to better address the long-term needs of stroke survivors and their family caregivers.
Green TL, McNair ND, Hinkle JL, Middleton S, Miller ET, Perrin S, Power M, Southerland AM, Summers DV; on behalf of the American Heart Association Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. Care of the patient with acute ischemic stroke (posthyperacute and prehospital discharge): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association [published online ahead of print March 11, 2021]. Stroke. doi: 10.1161/STR.0000000000000357
- Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN., et al. Heart disease and stroke statistics - 2021 update: a report from the American Heart Association. Circ. J. 2021;143:e1-e490 https://www.ahajournals.org/doi/10.1161/CIR.0000000000000950
- GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18:439–458. doi: 10.1016/S1474-4422(19)30034-1
- Green TL, McNair ND, Hinkle JL, Middleton S, Miller ET, Perrin S, Power M, Southerland AM, Summers DV; on behalf of the American Heart Association Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. Care of the patient with acute ischemic stroke (posthyperacute and prehospital discharge): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association [published online ahead of print March 11, 2021]. Stroke. doi: 10.1161/STR.0000000000000357
- Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH. Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement from the American Heart Association. Stroke. 2009;40:2911-2944
- Lindsay P, Furie KL, Davis SM, Donnan GA, Norrving B. World Stroke Organization global stroke services guidelines and action plan. Int J Stroke. 2014;9:4-13
- Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344-e418
- Stroke Foundation. Clinical Guidelines for Stroke Management. 2019. https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management
- Boulanger J, Lindsay P, Gubitz G, Smith EE, Stotts G, Foley N, Bhogal S, Boyle K, Braun L, Goddard T, Heran MKS, Kanya-Forster N, Lang E, Lavoie P, McClelland M, O’Kelly C, Pageau P, Pettersen J, Purvis H, Butcher K. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke. 2018;13:174749301878661.
- Bowen A, James M, Young G. Royal College of Physicians 2016 National clinical guideline for stroke. 2016. https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines
- Middleton S, Grimley R, Alexandrov AW. Triage, treatment, and transfer: evidence-based clinical practice recommendations and models of nursing care for the first 72 hours of admission to hospital for acute stroke. Stroke. 2015;46:e18-e25
- Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst. Rev. 2013;9:1-84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6474318/
- Middleton S, Coughlan K, Mnatzaganian G, Low Choy N, Dale S, Jammali-Blasi A, Levi C, Grimshaw JM, Ward J, Cadilhac DA. Mortality reduction for fever, hyperglycemia, and swallowing nurse-initiated stroke intervention: QASC Trial (Quality in Acute Stroke Care) follow-up. Stroke. 2017;48:1331-1336
- Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D'Este C, Drury P, Griffiths R, Cheung NW, Quinn C. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet. 2011;378:1699-1706
- Alexandrov AW, Palazzo P, Biby S, Doerr A, Dusenbury W, Young R, Lindstrom A, Grove M, Tsivgoulis G, Middleton S. Back to Basics: Adherence with Guidelines for Glucose and Temperature Control in an American Comprehensive Stroke Center Sample. J Neurosci Nurs. 2018;50:131-137
- Middleton S, McElduff P, Drury P, D’Este C, Cadilhac DA, Dale S, Grimshaw JM, Ward J, Quinn C, Cheung NW. Vital sign monitoring following stroke associated with 90-day independence: A secondary analysis of the QASC cluster randomized trial. Int J Nur. Stud. 2019;89:72-79
- Camicia M., Lutz BJ, Harvath T, Kim KK, Drake C, Joseph J G. Development of an instrument to assess stroke caregivers’ readiness for the transition home. Rehabil Nurs. 2020;5:287-298. doi: 10.1097/rnj.0000000000000204
- Camicia, M.E. Lutz, B.J., Joseph, J.G., Harvath, T.A., Drake, C.M., Theodore, B.R., & Kim, K.K. (2021) Psychometric properties of the preparedness assessment for the transition Home after stroke instrument. Rehabil Nurs. 2021. doi: 10.1097/RNJ.0000000000000310. Epub 2021 Jan 22
- Duncan P, Bushnell C, Sissine M, Coleman S, Lutz B, Johnson A, Radman M, Bettger JP, Zorowitz R, Stein J. Comprehensive Stroke care and outcomes: Time for a paradigm shift. Stroke. 2021;1:385-393. doi: 10.1161/STROKEAHA.120.029678. Epub 2020 Dec 22.
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