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CLINICAL ISSUES

An evidence-based practice approach to improving nursing care of


acute stroke in an Australian Emergency Department
Julie Considine and Bree McGillivray

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence
regarding prevention of early complications.
Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend con-
siderable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in
patient outcomes following stroke.
Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing
management of acute stroke.
Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time,
Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and
blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions.
Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease
in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure
(p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area
interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment
prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1%
(ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns).
Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise
patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recom-
mendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the manage-
ment of acute stroke.

Key words: Australia, emergency nursing, nurses, nursing, stroke

Accepted for publication: 12 March 2009

people die from stroke and five million people are left with
Introduction
permanent disability placing a burden on families and
Stroke is a significant and increasing health issue. World communities (Mackay & Mensah 2004). Awareness and
Health Organisation data shows that 15 million people modification of risk factors such as hypertension and smok-
worldwide suffer a stroke very year. Of these, five million ing has resulted in a reduction in the incidence of stroke

Authors: Julie Considine, RN, RM, BN, GradDipNurs, MNurs, PhD, Correspondence: Julie Considine, Senior Research Fellow, Deakin
FRCNA, Senior Research Fellow, Deakin University – Northern University, 221 Burwood Hwy, Burwood, 3125 Vic., Australia.
Health Clinical Partnership, Burwood; Bree McGillivray, RN, BN, Telephone: +61 3 9244 6175.
GCertEmergNurs, Clinical Nurse Specialist, Emergency Department, E-mail: julie.considine@deakin.edu.au
The Northern Hospital, Epping, Vic., Australia

138  2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
doi: 10.1111/j.1365-2702.2009.02970.x
Clinical issues Evidence-based practice in improving nursing care of acute stroke

however the absolute number of strokes continues to rise as a sign monitoring and that the intervals between vital sign
result of ageing populations and increased life expectancy assessment increase the longer the patient is in the ED.
(Mackay & Mensah 2004). It is important to note that the focus of this paper is on
In the Australian context, 48,000 Australians have a stroke emergency nursing management of acute stroke. Although
each year (Victorian Department of Human Services 2007). the use of thrombolysis as a treatment option for acute stroke
Of these strokes, 70% are first ever strokes and 30% of these is discussed in most stroke guidelines (Royal College of
people will have another stroke within one year (Victorian Physicians 2004, Anderson et al. 2006, Adams et al. 2007,
Department of Human Services 2007). Of those who survive National Stroke Foundation 2007, Victorian Department of
initial stroke injury, 9000 Australians die within one month Human Services 2007), most current evidence does not
of stroke, one-third of patients with stroke die within support the use of thrombolysis in acute ischaemic stroke
12 months and 78% of deaths from stroke occur in patients beyond three hours (Hacke et al. 1995, Clarke et al. 1999,
older than seventy-five years (Victorian Department of 2000, Kothari et al. 2001, National Stroke Foundation 2003)
Human Services 2007). In the next 10 years more than half to 4Æ5 hours after symptom onset (Hacke et al. 2008,
a million people in Australia will suffer a stroke (National Wahlgren et al. 2008). Further, it may be argued that for
Stroke Foundation 2006). In addition, stroke is a leading patients who are ineligible for thrombolysis, the management
cause of disability in Australia (National Stroke Foundation of fundamental aspects of stroke care is vital to optimising
2006). During 2005/2006 Victorian public hospitals man- outcomes for stroke survivors.
aged almost 12,000 episodes of stroke and just over 2800
episodes of Trans-ischaemic attack (TIA) (Victorian Depart-
Aims
ment of Human Services 2007). It is predicted that the
incidence of acute stroke will continue to increase by 2Æ7% The aim of this study was to improve the emergency nursing
annually (Victorian Department of Human Services 2007). care of acute stroke by enhancing the use of evidence
An important part of acute stroke management and regarding prevention of early complications.
decreasing stroke-related mortality is preventing complica-
tions within the first 24–48 hours (Bhalla et al. 2001,
Methods
Pendlebury & Rothwell 2004, Lees 2005, Anderson et al.
2006). The current climate of prolonged time spent in the
Study design
Emergency Department (ED) means that many aspects of
stroke management are now the responsibility of emergency A prospective pre/post-test design was used. The outcome
nurses. The ED at The Northern Hospital (TNH), Mel- measures were elements of emergency nursing care known to
bourne, Australia manages over 65,000 patients per year impact on outcomes of stroke survivors. Data were collected
(Northern Health 2007). Observations of current emergency using by medical record audit. The intervention for the study
nursing practice at TNH suggested variability in management was a guideline for the emergency nursing management of
of patients with stroke in our ED. Further assessment of 2006 stroke, the implementation of which was supported with
ED data for 113 patients with ED discharge diagnosis of tutorials. Pre-test data were collected from January–March
stroke confirmed variation in care. For example, triage 2007 and post-test data were collected between August–
category allocation was spread across all five Australasian October 2007.
Triage Scale categories (Cat 1 = 4Æ4%, Cat 2 = 19Æ5%, Cat
3 = 51Æ3%, Cat 4 = 21Æ2% and Cat 5 = 3Æ5%) suggesting Setting
variability in perceived urgency of treatment and potentially The study was conducted at The Northern Hospital: a
significant knowledge deficits among triage nurses. There was peripheral hospital 30 km north of Melbourne, Australia.
also variability in terms of waiting times to see medical staff: TNH is a 300 bed acute care campus of Northern Health.
80% of patients (n = 90) were seen within one hour and 70% The ED at TNH manages over 65 000 patients per year
of patients (n = 80) were seen within 30 minutes. The (Northern Health 2007). During 2005/06, Northern Health
average length of ED stay was 11 hours however 20% of managed 404 admissions for acute stroke (Victorian
patients were in the ED for over 20 hours before transfer to Department of Human Services 2007). The ED at TNH does
an inpatient unit highlighting the need for prevention of not routinely offer thrombolysis as an emergency treatment
complications to commence in the ED and for ED manage- option for acute ischaemic stroke due to lack of specialist
ment of acute stroke to be evidenced-based. Observations of neurology and neurosurgical services, specialist neuro-
current practice also showed variability in frequency of vital imaging capability and high dependency unit facilities.

 2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144 139
J Considine and B McGillivray

Pre-hospital triage of patients with stroke by paramedics debate about changes to practice and this level of interaction
tends to result in transport of patients who may be eligible for facilitated emergency nurses’ understanding of the rationale
thrombolysis to specialist centres. As a result of pre-hospital for the recommendations made in the guideline. It was also
triage, patients with stroke who present to TNH tend to be important for the tutorials to emphasise the important
older with a high incidence of pre-morbid risk factors, influence of nursing care of outcomes for patients with acute
particularly diabetes and smoking. stroke.
Tutorials were used previously in ED at TNH by Considine
Participants and Brennan (2006) to promote uptake of evidence and
Participants were patients with an ED discharge diagnosis of change practice related to paediatric fever management
stroke (ICD-10 code I64). Pre-test data were collected for all practice in the ED at TNH. Adaptation of the ICSI Guideline
patients with an ED discharge diagnosis of stroke from (Anderson et al. 2006) and development of the tutorial
1 January–31 March 2007 (n = 64). The guideline was occurred in conjunction with the ED Clinical Nurse Educa-
implemented in July 2007 and a period of one month tors, Emergency Physicians, allied health personnel (speech
was allowed for normalisation of practice. Post-test data was pathologists, physiotherapy and dieticians) and physicians
collected for all patients with ED discharge diagnosis stroke from the inpatient medical unit that specialises in stroke
from 1 August–31 October 2007 (n = 41). management. The tutorial was delivered on eight occasions
and captured 48 emergency nurses. The guideline was also
placed in the nursing communications folder and on the desk
Ethical considerations
top of all computers in the ED and was promoted by the
This study was approved by the Human Research and Ethics researchers and ED Clinical Nurse Educators.
Committee at TNH.

Procedure/data collection
Intervention
One of the researchers (BM) collected following data by
The intervention for the study was a guideline for the medical record audit:
emergency nursing management of stroke that was imple- • demographic data: patient age and gender;
mented in June 2007. Details of the guideline development • ED system data: time of arrival, triage category, waiting
and content are presented elsewhere (McGillivray & time, mode of arrival and ED length of stay;
Considine 2009). The guideline was based primarily on • specialist referrals: assessment by stroke unit, speech
the Institute for Clinical Systems Improvement (ICSI) pathology, physiotherapy, dietician and occupational
Diagnosis and Initial Treatment of Ischemic Stroke Guide- therapy;
line (Anderson et al. 2006). The evidence presented in the • nursing assessment data: vital sign assessment, oxygen
ICSI Guideline was augmented by evidence-based recom- saturation and blood glucose monitoring, IV fluid regimes;
mendations from other key documents related to stroke • frequency of oral intake prior to swallowing assessment;
management: Australian National Stroke Foundation • risk management: documentation of nil orally status, tim-
Guidelines (National Stroke Foundation 2003), meta- ing of swallow assessment, IV fluid regimes, venous
analyses related to stroke management (Hajat et al. thromboembolism risk assessment and interventions,
2000), outcome studies (Weir et al. 1997) and local pressure injury risk assessment and interventions.
pressure injury and venous thromboembolism assessment
and prophylaxis policies that supported the ICSI recom-
Data analysis
mendations. The guideline was designed to be a summary
document that accompanied usual ED nursing documenta- Data analysis was performed using the computer software

tion: this decision was pragmatic and aimed to increase SPSS 14.0 for Windows (SPSS Inc., Chicago, IL, USA) Pre-

clinical utility of the guideline. test and post-test data were compared to determine if
Guideline implementation which was supported by a prevention of early complications improves ED manage-
tutorial on stroke care delivered during nursing education ment of stroke. In addition to descriptive statistics (per-
time. An overview of the evidence contained in the guideline centages, means, standard deviations), non-parametric data
was presented during the 30 minute tutorial and the rationale were compared using chi-square and Mann–Whitney
for changes in emergency nursing care of stroke discussed. U-tests and parametric data were compared using indepen-
Importantly, the tutorials provoked robust discussion and dent samples t-test (Polgar & Thomas 1991).

140  2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
Clinical issues Evidence-based practice in improving nursing care of acute stroke

Results Table 2 Median number of repeated nursing assessments by group

A total of 104 patients were recruited to the study: 63 Pre-test Post-test

patients in the pre-test group and 41 patients in the post- Mdn (IQR) Mdn (IQR) p*
test group. As the study data were not normally distrib-
Respiratory rate 8 (5–13) 12 (6–19) 0Æ009
uted, medians and inter-quartile ranges are presented and Heart rate 8 (5–12) 11 (5Æ75–19) 0Æ022
non-parametric analyses were used to compare groups. Blood pressure 8 (5–11) 12 (5Æ75–19) 0Æ032
There were no significant differences in the gender or age Temperature 4 (2–5) 4 (2–6Æ5) 0Æ310
distribution of both groups: males comprised 49Æ2% of the Glasgow Coma Score (GCS) 4 (3–8) 7 (3Æ5–9Æ5) 0Æ163
pre-test group (n = 31) and 56Æ1% of the post-test group SpO2 5 (3–10) 10 (5Æ5–19) 0Æ001
Blood sugar level (BSL) 4 (2–5) 4 (2–6Æ5) 0Æ310
(n = 23) (v2 = 0Æ472, df = 1, p = 0Æ492). Patients in the
pre-test group had a median age of 75 years [Inter-Quartile *Mann–Whitney U.
Range (IQR) = 59–82] and post-test group patients had a
median age of 66 years (IQR = 58–77) (U = 1087Æ0,
Table 3 Risk assessment and interventions by group
p = 0Æ174). This between-group difference in median age
was not statistically significant. There was no significant Pre-test Post-test
between-group difference in the proportion of patients
n % n % p*
arriving by ambulance (54Æ0 vs. 53Æ7%) (v2 = 0Æ001, df = 1,
p = 0Æ975) or who required interpreting services (27Æ4 vs. Nil orally 27 52Æ9 20 66Æ7 0Æ227
status documented
14Æ6%) (v2 = 2Æ326, df = 1, p = 0Æ127).
Swallow assessment 12 46Æ2 28 87Æ5 0Æ003
This study had three major findings following implemen- prior to oral intake
tation of the ED stroke guideline. First, there was significant VTE assessment 22 40Æ7 11 34Æ4 0Æ557
21Æ4% increase in triage to Australasian Triage Scale (ATS) VTE interventions 35 64Æ8 21 65Æ6 0Æ939
category 2 following implementation of the stroke guideline Pressure area assessment 21 38Æ9 16 47Æ1 0Æ450
and significant 15Æ6% decrease in triage to ATS category 4 Pressure area interventions 13 24Æ1 18 52Æ9 0Æ006

(Table 1). Second, there was increased frequency of repeated *Chi-square.


assessments of respiratory rate, heart rate, blood pressure and
oxygen saturation (Table 2). There was also a non-significant
vs. 26Æ1%, n = 6) (v = 2Æ390, df = 1, p = 0Æ122) and median
increase in median number of Glasgow coma score assess-
time to speech pathology assessment decreased by 93Æ5 min-
ments.
utes. The median time for speech pathology assessment for
Third, there were significant improvements in risk man-
the pre-test group was 25Æ7 hours (IQR 17–52Æ9) and
agement. There was a 41Æ3% increase in patients who
24Æ1 hours (IQR 14Æ6–66Æ7) for the post-test group
underwent a swallow assessment prior to oral intake
(U = 332Æ000, p = 0Æ816).
(p = 0Æ003) and 13Æ8% increase in documentation of nil
orally status (Table 3). There was no change in the frequency
of risk assessments for venous thromboembolism or pressure Discussion
areas however there was a significant 28Æ8% increase in the
The results of this study highlight three major areas of
frequency of documentation of pressure area interventions
practice change following implementation of the ED stroke
(p = 0Æ006) (Table 3). In addition, the frequency of speech
guideline so the discussion to follow will focus on the
pathology assessment in ED increased by 16Æ1% (n = 3, 9Æ7
importance of these changes in clinical practice for ED
patients with acute stroke. The first major finding of this
Table 1 Distribution of ATS categories by group study was a significant shift in triage decision making with
Pre-test Post-test
increased triage to Australasian Triage Scale category 2 (seen
within 10 minutes) and decreased triage to Australasian
n % n % p* Triage Scale category 4 (seen within 60 minutes). This finding
ATS 1 0 0 4 9Æ8 0Æ011 is important as it suggests increased perception of urgency of
ATS 2 8 12Æ7 14 34Æ1 0Æ009 stroke care by emergency nurses and acknowledgement that
ATS 3 39 61Æ9 19 46Æ3 0Æ118 stroke is a medical emergency (National Stroke Foundation
ATS 4 16 25Æ4 4 9Æ8 0Æ048
2007). Further, triage of patients with actual or potential
*Chi-square. stroke as high acuity is the first step in facilitating early

 2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144 141
J Considine and B McGillivray

diagnosis, treatment and referral to specialist services: these pathology assessment in ED increased by 16Æ1% and median
factors are known to improve outcomes and prevent compli- time to speech pathology assessment decreased by 93Æ5 min-
cations following stroke (Davernport & Dennis 2000, utes. Although these differences in speech pathology assess-
National Stroke Foundation 2003). ment did not reach statistical significance, it may be argued
The second major finding of this study was increased that they are clinically significant. A key focus of the
frequency of repeated physiological assessments. Increased guideline used in this study was early referral to speech
physiological surveillance is a positive finding because control pathology and prior to guideline development, speech
of abnormal physiological parameters may be a neuropro- pathology referral was ad hoc and dependent on individual
tective strategy following stroke (Bhalla et al. 2001). The clinician knowledge and motivation. Speech pathology refer-
median number of oxygen saturation assessments doubled in ral occurred mostly using telephone paging system which had
the post-test group despite no real differences ED length of major limitations out of hours when speech pathologists were
stay suggesting increased frequency of assessment. Oxygen not in the hospital. To coincide with implementation of the
saturation monitoring is important following stroke as guideline, an electronic allied health referral system was
patients with acute stroke have lower oxygen saturation than activated on all ED computers. The increased incidence of
matched controls (Elizabeth et al. 1993) and hypoxia speech pathology assessment in ED and decreased time to
increases cerebral injury following stroke (Bhalla et al. speech pathology assessment suggest that these changes were
2001, National Stroke Foundation 2003). Unfortunately, effective although there is scope for further improvement in
there were no major changes to temperature and blood facilitating speech pathology assessment.
glucose monitoring and this is an area of ongoing work for A further finding related to risk management was increased
the ED. Temperature monitoring following stroke is impor- the frequency of documentation of pressure area interven-
tant as hyperthermia is common in stroke patients due to tions. Pressure ulcer risk assessment and prophylaxis are an
infection preceding stroke, stroke related damage to the important aspect of stroke care and patients with stroke are
hypothalamus or as a result of thromboembolism (National particularly prone to pressure ulcers as a result of increased
Stroke Foundation 2003). Early hyperthermia in acute stroke age, immobility, incontinence, poor nutritional status, cog-
increases risk of poor outcome, mortality and increased nitive impairment and diabetes (National Stroke Foundation
infarct size (Bhalla et al. 2001, Lewandowski & Barsan 2001, 2007). The ED stroke guideline used in this study highlighted
Anderson et al. 2006). One meta-analysis of hyperthermia existing organisational policies related to pressure ulcer
and stroke outcomes showed a 19% increase in mortality for prevention.
febrile patients (OR 1Æ19, 95% CI, 0Æ99–1Æ43) (Hajat et al.
2000) highlighting the importance of temperature control in
Limitations
patients with acute stroke. Hyperglycaemia following stroke
is also associated with increased mortality and/or decreased There are several limitations that should be considered when
functional outcome (Weir et al. 1997, Bhalla et al. 2001, interpreting the study findings. First, this was a relatively
Lewandowski & Barsan 2001, National Stroke Foundation small study conducted in one ED so the generalisability of
2003, Anderson et al. 2006) and blood glucose level over findings may be limited. Second, the study method was reliant
8 mmol/l is a known predictor of mortality following stroke on nursing documentation as a proxy for care delivery and it
(adjusted for age, stroke severity and stroke type) (Weir et al. may be argued that documentation does not accurately reflect
1997). actual practice. Observations of clinical practice would
Finally, there were significant improvements in risk man- suggest that documentation is under-representative of nursing
agement, particularly related to safe swallowing. Documen- care; that is care is delivered but not documented. The
tation of nil orally status increased by 13Æ8% indicating findings of this study may therefore under-represent actual
increased awareness of nil orally status until swallowing is improvements in stroke management. Finally, the use of a
assessed. There was also a 41Æ3% increase in patients who pre-test post-test design has limitations given that data
underwent a swallow assessment prior to oral intake again collection occurred over two different periods in time.
highlighting the importance of safe swallowing following Although there were no major changes in staff or ED policies
stroke. Impaired swallowing following stroke is associated during this time, the use of a control group would have been
with increased mortality (Lewandowski & Barsan 2001) and an ideal study design. The model of emergency nursing care
gag assessment is now known to be an unreliable indicator of delivery at TNH is team nursing: if staff were assigned to
swallowing (Lewandowski & Barsan 2001, National Stroke control and intervention groups the need to work together
Foundation 2003). In addition, the frequency of speech would make contamination of a control group unavoidable.

142  2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
Clinical issues Evidence-based practice in improving nursing care of acute stroke

Conclusion Disease and Quality of Care Outcomes in Research Interdisci-


plinary Working Groups. Stroke 38, 1655–1711.
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in ED following acute stroke making emergency nursing ber 2006, Minnesota.
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optimising patient outcomes following stroke. The results physiological parameters after stroke. QJM: An International
Journal of Medicine 94, 167–172.
of this study have shown that an evidence-based guideline
Clarke WM, Wissman S, Albers GW, Jhamandas J, Madden KP &
can improve stroke care in the ED and decrease clinical risk Hamilton S (1999) Recombinant tissue-type plasminogen activa-
associated with acute stroke. Unfortunately, emergency tor (Alteplase) for ischemic stroke 3 to 5 hours after symptom
nursing care is under-represented in many guidelines for the onset. The ATLANTIS Study: a randomized controlled trial.
management of acute stroke and most guidelines focus on use Alteplase Thrombolysis for Acute Noninterventional Therapy in
of thrombolysis as the key to ED management of acute Ischemic Stroke. Journal of the American Medical Association
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