Enhancement of Nursing Role in Hyperacute Stroke Management at Emergency Department – Nurse-Initiate TPA Call

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Authors (including presenting author) :
Leung KL(1), Yu CT(2), Chan WY(1)
Affiliation :
(1)Accident and Emergency Department, United Christian Hospital, (2)Nursing Services Department, United Christian Hospital
Introduction :
Timely administration of Intravenous recombinant tissue-type plasminogen activator (IV-rtPA) for acute ischemic stroke saves brain and is initiated by doctors at Accident and Emergency Department(AED). However, the Door-to-needle time (DNT) of IV-rtPA is longer than the international benchmark of ≤ 60 minutes suggested by NINDS. It is hypothesized from evaluation of our results that the DNT could be shortened by nurse-initiate TPA call in AED.
Objectives :
To study the effect of workflow re-engineering of initial management in hyperacute stroke phase on the DNT for IV-rtPA in AED. To enhance the nursing role in hyperacute stroke management in AED.
Methodology :
A collaboration project was implemented between stroke team and AED. Trained-nurse adopts a simple and rapid stroke assessment tool to detect acute ischemic stroke patients. The nurse then activates stroke team and AED physician simultaneously initiates the pre-planned care cascade, including CT Brain. It then allows team approach between AED physician and stroke team. Comprehensive staff training and various tools were designed before implementation of the enhancement programme.
Result & Outcome :
The pilot phase was conducted between 25/06/2018 and 30/09/2018. There were 144 TPA calls, 32 patients received IV-rtPA; 10 patients in study (nurse-initiated) group during office-hour and 22 patients in control (doctor-initiated) group out of office-hour. For the primary outcome, the Door to stroke team activation time(DAT) and DNT were compared between the study group and the control group. The mean DAT was 7.1±8.2 minutes and 15.5±9.1 minutes respectively. The DAT was reduced 8.4 minutes in target group(p=0.014). The mean DNT of the study and the control groups were 57.8±11.9 minutes and 90.3±32.5 minutes respectively with a significant reduction in DNT(p< 0.01). For the secondary outcome, accuracy of nurse activation TPA call and physician call were compared. Successful treatment of nurse activation was 10 patients received IV-rtPA out of 34 calls, 29.4%(10/34), and rate of physician activation treatment was 20%(22/110). Conclusion: Early initiation of TPA call by AED nurses can reduce the DAT and DNT significantly, giving the patient a better recovery. Moreover, it is an easy approach for AED nurses to adopt with satisfying outcome. It is planned to extend the nurse-initiated TPA call to 24-hour basis in the next phase.

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