Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association.

The year 2020 was the year of the nurse, celebrating nurse scholarship, innovation, and leadership by promoting scientific nursing research, improving nursing practice, advancing nursing education, and providing leadership to influence health policy. As architects of stroke care, neuroscience nurses play a vital role in collaborating and coordinating care between multiple health professionals. Nurses improve accessibility and equity through telestroke, emergency medical services, and mobile stroke units and are integral to implementing education strategies by advocating and ensuring that patients and caregivers receive stroke education while safely transitioning through the health care system and to home. Stroke care is increasingly complex in the new reperfusion era, requiring nurses to participate in continuing education while attaining levels of competency in both the acute and recovery care process. Advanced practice nurses are taking the lead in many organizations, serving as prehospital providers on mobile stroke units, participating as members of the stroke response team, and directing stroke care protocols in the emergency department. This scientific statement is an update to the 2009 "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient." The aim is to provide a comprehensive review of the scientific evidence on nursing care in the prehospital and hyperacute emergency hospital setting, arming nurses with the necessary tools to provide evidenced-based high-quality care.

Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update.

In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

PURPOSE: Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care. METHODS: A literature search was undertaken to examine the current status of telestroke and relevant quality indicators. The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus. RESULTS: Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation.

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services.

BACKGROUND AND PURPOSE: The failure to recognize an ischemic stroke in the emergency department is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital. METHODS: A retrospective chart review was performed from February 2013 to February 2014. RESULTS: A total of 465 patients with ischemic stroke were included in the analysis; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed that is 22% of the included strokes at the combined centers. Fifty-five of these were missed at the academic hospital (22%) [corrected] and 48 were at the community hospital (26%, P=0.11). Thirty-three percent of missed cases presented within a 3-hour time window for recombinant tissue-type plasminogen activator eligibility. An additional 11% presented between 3 and 6 hours of symptom onset for endovascular consideration. Symptoms independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (odds ratio, 4.02; 95% confidence interval, 1.60-10.1), dizziness (odds ratio, 1.99; 95% confidence interval, 1.03-3.84), and a positive stroke history (odds ratio, 2.40; 95% confidence interval, 1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (P<0.001). CONCLUSIONS: Atypical symptoms associated with posterior circulation strokes lead to misdiagnoses. This was true at both an academic center and a large community hospital. Future studies need to focus on the evaluation of identification systems and tools in the emergency department to improve the accuracy of stroke diagnosis.

Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech-language pathologists.

AIMS AND OBJECTIVES: (1) To describe the results of a web-based teaching module used by registered nurses to identify patients at risk of aspiration and (2) to determine accuracy of the registered nurse-administered 3-ounce water swallow challenge protocol, that is, drinking three ounces of water, a basic cognitive screen and oral mechanism evaluation, when compared with blinded ratings from speech-language pathology. BACKGROUND: Early identification of potential swallowing problems is important prior to ingestion of food, fluid and medications. Unfortunately, current nurse-administered screens use a variety of non-evidence-based assessments. It would be beneficial to use a valid, reliable and evidence-based screen, that is, the Yale swallow protocol. DESIGN: Prospective, blinded, referral-based. METHODS: Fifty-two registered nurses and 101 inpatients participated. First, each participant was administered the 3-ounce water swallow challenge protocol by a speech-language pathologist. Second, a nurse administered the protocol to the same patient within one hour and independently recorded results and diet recommendations. The nurse was blinded to the study's purpose and results of the speech-language pathologist's initial screening. Out of view, but simultaneous with the nurse-administered protocol, a speech-language pathologist rerated the patient's challenge for comparison with initial results and determined the accuracy of the nurse-administered protocol. RESULTS: Intra- and inter-rater protocol agreements for the two speech-language pathologists were 100%. Inter-rater protocol agreement between registered nurses and speech-language pathologists was 98·01%. CONCLUSIONS: Results confirm the reliability and accuracy of a registered nurse-administered Yale swallow protocol. The consequence of 98% accuracy combined with previously reported 96·5% sensitivity, 97·9% negative predictive value and <2% false negative rate allowed for adoption of the protocol for the entire general hospital population. RELEVANCE TO CLINICAL PRACTICE: Avoidance of preventable prandial pulmonary aspiration as a cause of nosocomial infection is an important goal for all acute care hospitalised patients deemed at risk of aspiration.

Missed opportunities for recognition of ischemic stroke in the emergency department.

INTRODUCTION: Evidence suggests that a significant number of patients discharged from the hospital with a diagnosis of ischemic stroke are not identified as having a stroke on admission. Those presenting with "nontraditional" stroke symptoms may be less likely to be diagnosed correctly. We aimed to establish whether there was an association between symptom presentation and diagnostic accuracy and to identify the type and frequency of nontraditional symptoms that resulted in a missed diagnosis in the emergency department. METHODS: We reviewed the medical records of 189 patients discharged with a diagnosis of ischemic stroke from Yale-New Haven Hospital. We performed χ(2) analysis to determine whether an association existed between symptom presentation and diagnostic accuracy. Descriptive statistics allowed us to identify symptom type and frequency in patients with a missed diagnosis. RESULTS: A diagnosis of suspected stroke was missed in 15.3% of patients who presented to the emergency department. We found a strong association (P < 0.0001) between symptom presentation and diagnostic accuracy. Of the patients presenting with any "traditional" symptom, 4% were missed. Of those presenting with only nontraditional symptoms, 64% were missed (odds ratio, 43.4; 95% confidence interval, 15.0-125.4). Nontraditional symptoms included generalized weakness, altered mental status, altered gait, and dizziness. DISCUSSION: In order to facilitate appropriate management of patients with ischemic stroke, emergency nurses must be aware that symptom presentation is highly variable. Patients presenting with nontraditional symptoms may benefit from an immediate and comprehensive neurological evaluation.

Poststroke depression incidence and risk factors: an integrative literature review.

Depression is a frequent complication of stroke, but few nurse researchers have studied poststroke depression (PSD). We reviewed all published research (January 1980-March 2005) that examined the incidence of and risk factors for depression among stroke survivors during the first 3 months after stroke. Many of the 49 studies reviewed were complicated by methodological limitations, including differing definitions of stroke and depression, the use of screening instruments to diagnose depression, selection bias, assessment at different time intervals poststroke, exclusion of patients with physical or cognitive impairments, and failure to control for associated variables. The incidence of PSD ranged from 5% to 63%. A history of depression, increased stroke severity, and poststroke cognitive or physical impairment were found to be risk factors for PSD.

Intra-arterial treatment of acute ischemic stroke: the continued evolution.

OPINION STATEMENT: The devastation caused by acute ischemic strokes is evident in every intensive care unit across the world. Although there is no doubt that progress has been made in treatment, it has been slow to come. With the emergence of new technologies in imaging, thrombolysis and endovascular intervention, the treatment modalities of acute ischemic stroke will enter a new era. In this review, we present the concept of the seven evolutionary phases in the treatment of acute ischemic stroke to date.

Controversies in acute stroke treatment.

The evidence base supporting the management of patients with acute stroke is evolving at a rapid rate, as new methods that aim to reduce disability and death from stroke are explored. Intravenous tissue plasminogen activator remains the only treatment shown in numerous studies to reduce disability 3 months after stroke with no increase in the risk of death and a relatively minor rate of symptomatic intracerebral hemorrhage complications. Despite these findings, health care providers have been slow to adopt this evidence-based treatment, which results in many patients experiencing disability caused by stroke. Numerous controversies exist related to the management of patients with acute stroke, including the use of tissue plasminogen activator, positioning and early mobility, blood pressure lowering in acute intracerebral hemorrhage, and even the use of innovative advanced practice nurse-led stroke treatment teams, with varying amounts of evidence available to provide direction. This article explores controversies associated with both approved and evolving treatments for ischemic and hemorrhagic stroke and makes recommendations for practice on the basis of the body of existing evidence, with an aim to improve the delivery of acute stroke treatment.

Obesity and heart failure.

Current statistics on global obesity are staggering. In 2002, the International Obesity Task Force estimated that worldwide, nearly 1 billion (6%) people were overweight or obese. The American Heart Association's 2002: "Top 10" Research Advances for the Treatment of Heart Disease include obesity as a strong and independent risk factor for developing heart failure. This article outlines national and world statistics, cardiac risk factors, and pathophysiologic theories outlining the cellular mechanisms that associate obesity and heart failure. Access to guidelines for effective screening, evaluation, and treatment of obesity are also provided.