(Stroke. 2006;37:748.)
© 2006 American Heart Association, Inc.
Abstracts From the State-of-the-Art Stroke Nursing Symposium |
Poster Presentations
State-of-the-Art Stroke Nursing Symposium Poster Abstracts
NS P1 The Development of a Comprehensive Paediatric Stroke Program
Maria Zak, Anita Allen, Daune MacGregor, Karen Kinnear, Teesta Soman, Robyn Westmacott, Gabrielle deVeber; The Hosp for Sick Children, Toronto, Canada
Paediatric stroke remains a diagnosis not often considered among the list of differentials generated by most family physicians, paediatricians, and emergency physicians who encounter a child with acute focal neurological deficits. Despite increased awareness of paediatric stroke, acute paediatric stroke care lags behind adult stroke care. To date, no clinical trials have been conducted in paediatric stroke care. The need for specialized stroke care in children as well as the lack of information about childhood stroke prompted the development of a comprehensive Children’s Stroke Program at Toronto’s Hospital for Sick Children - the first in North America. In 1994, during its infancy, the Children’s Stroke Program consisted of a monthly clinic that evolved into a weekly clinic. The stroke team consisted of a neurology nurse and neurologists who were soon joined by a social worker, physiotherapist and occupational therapist. Today, the program has evolved and consists of an acute inpatient program, weekly stroke prevention clinic, and an outcomes research program. With a team of three neurologists, two research fellows, a neuropsychologist, a staff nurse, an advanced practice nurse, and a research team, the program continues to grow. The formation of additional partnerships with paediatric sub-specialists including a neurosurgeon, neurointerventional radiologist, neuroradiologists, haematologists, paediatric intensivists, rheumatologists and an adult regional stroke centre has further strengthened the ability of the Stroke Program to enable earlier identification of paediatric stroke through the establishment of urgent neuroimaging protocols, hyper-acute and acute medical therapies. This presentation will discuss the evolution of the Paediatric Stroke Program at the Hospital for Sick Children including the successes, challenges, barriers and strategies experienced in the developmental process. We will also examine future directions. It is our hope that other paediatric health care centres who wish to develop an acute stroke program may learn from our experiences.
NS P2 Nursing Education in a Primary Stroke Center
Kari Moore, Elizabeth Wise, Martha Dawson, Mary Beth Coty, Kerri Remmel; Univ of Louisville, Louisville, KY
Background: Ongoing education is the key to excellence in primary stroke centers (PSC) and contributes to positive patient outcomes. Nurses caring for patients in a JCAHO certified PSC are required to obtain a minimum of 8 continuing education units annually on stroke. According to the NINDS, a nursing stroke education program (NSEP) should apply the principles of effective adult education. Five major principles of adult education that lead to behavioral change include: 1) motivation to learn new practices 2) relevance to daily work 3) new concepts linked to existing knowledge and experience 4) facilitation of active learning 5) feedback to the learner. Methods: Our approach to motivate staff included: 1) making them feel a part of something new and exciting; 2) offering in-services at times and locations convenient for them; 3) paying for NIHSS certification; and 4) providing real time feedback and frequent access to experts in the field. It is important for staff to use newly acquired skills and knowledge in their daily work. Therefore, we targeted three nursing areas: ER, stroke unit, and neuroscience intensive care unit. Use of recent case scenarios linked new information to existing knowledge and experience covering issues relevant to daily care of stroke patients. To further enhance learning stroke care pocket guides were given to nurses and binders covering the benchmark guidelines for stroke with reference articles were placed on each unit. To facilitate active learning nurses were encouraged to develop their own continuing education approaches and were supported by stroke leadership and hospital administration. The NSEP was evaluated by analyzing the behavioral changes of nurses caring for stroke patients. Results: Results show 128 nurses participated in the program, 55 nurses voluntarily became NIHSS certified, and 70 nurses volunteered for community awareness programs. Hospital-wide in-services were developed. Staff independently developed mechanisms for ongoing dissemination of stroke education, and nursing was empowered to activate the stroke team. Conclusion: A stroke education program for nurses that applies the five major principles of effective adult education will enhance learning and ensure active participation of nursing staff.
NS P3 Stroke Center Development in a Community Hospital: Methods and Outcomes
Timothy Hehr; Mercy Med Cntr, Cedar Rapids, IA
Background: Stroke is the third leading cause of death following coronary artery disease (CAD) and cancer. Within the past year we began promoting a cultural shift at Mercy, by developing tools highlighting the expectation that all providers consider Class I recommendations for treatment of acute stroke. Every patient can expect standardized, evidence-based treatment at Mercy Medical Center. Methods: Recommendations in GWTG-Stroke, Brain Attack Coalition and the ASA are incorporated into our order sets and reminder tools unique to Mercy; they are routinely used for all stroke and TIA patients. The Stroke CNS and Neurology Medical Director work together to update the order sets as the recommendations are updated. Education of staff and community are also priorities. We developed a tool called the ABCD’S of Stroke Care as an easy reminder of Class I recommendations for stroke care.(A)Antithrombotics and A-Fib ; (B) Blood pressure control; (C) Cholesterol assessment & treatment; (D) D VT prophylaxis and Dysphagia screening; and (S) Smoking cessation and Stroke rehabilitation. Our Medical Director and CNS are involved in many outreach activities. We make the communities in the area a top priority and routinely travel to their facilities providing education to their medical, nursing and EMT staff on stroke care. Our Stroke Hotline provides 24/7 access for outlying community health providers to obtain stroke information. Results: In the year since opening our Cardiac-Stroke Center and ensuring strict adherence to Class I recommendations, we have seen dramatic improvements in our compliance rates. By the first quarter of 2005, rates in patients receiving anticoagulation for atrial fibrillation were 100%, with the national rate at 97%. Smoking cessation education went from 40% in 2004 to 100% compliant in the 1st quarter 2005, with the national rate at 70.2%. Antithrombotic given at discharge went from 82% in 2004 to 100% by the 1st quarter of 2005, with the national average at 96.5%. Patients receiving a lipid agent went from 40% in 2004, to 95% in the 1st quarter of 2005, with the nation average at 77.8%.
NS P4 Can Competing Hospitals Collaborate on Stroke Education?
Pamela E Smith, Rsch Med Cntr, Kansas City, MO; Susan Stark, Shawnee Mission Med Cntr, Shawnee Mission, KS; Debbie Summers; Saint Luke’s Hosp, Kansas City, MO
Introduction Evidence based education, emphasizing best nursing practices and improving patient outcomes, is an integral part of stroke care and a requirement for Stroke Center certification. In one metropolitan area, stroke program coordinators collaborated with the American Stroke Association to provide an annual stroke symposium, but this one offering was insufficient to meet the increasing needs for staff development and JCAHO certification. Within the context of the nursing shortage, decreasing nursing hours per patient day, and limited education reimbursement, providing multiple educational programs presents a challenge. Hypothesis Collaboration among competing hospitals to provide consistent, evidence based educational opportunities promotes and enhances nursing education and increases the number of available education hours (CEUs). Methods Members of the Heartland Affiliate of the American Stroke Association Professional Education Committee invited area stroke educators and coordinators to participate in an education consortium. Each facility agreeing to participate would provide one, free, four-hour stroke program annually to consortium member hospital employees. At the initial planning meeting, hospital representatives chose topics and published an education calendar for the year. Each facility was accountable for coordination, speakers, costs, publicity, continuing education credit and materials for its program. Results Program attendance increased at all participating facilities. Costs per facility decreased and program satisfaction was consistent across organizations. Conclusions Stroke Centers can collaborate to provide more educational opportunities than any one facility has the resources to provide.
NS P5 Constructs of a Stroke Prevention Clinic
Mary Amatangelo; Partners Neurology, Boston, MA
Currently no methodology exists for the routine and consistent assessment of patients at risk for stroke/TIA in the outpatient clinic setting. We have developed a Hospital combined Healthcare system model of care to improve the transition of in-patient to out-patient care for patients with stroke. The Stroke Prevention Clinic allows rapid access to a stroke specialist within a week of discharge to follow-up on outstanding laboratory test, monitor response to therapy, and ensure that there has not been any recurrence or progression of symptoms. Actual or potential Stroke patients from within the network as well as consults are deemed appropriate. Staffed by Stroke Neurologists, Residents, Fellow and a Nurse Practictioner. The objectives of the staff are to: *Evaluate and implement primary and secondary stroke prevention strategies *Monitor stroke recovery and prevent secondary complications *Investigate unusual cause of stroke *Patient and family education *Serve as a model for developing a guideline-based practice for the Healthcare System. Integrating advanced practice nursing care combined with clinical expertise affords quality overall stroke care. Advanced Practice Nurse supported Stroke Prevention Clinic is feasible. Further research is needed to quantify the benefits in terms of cost and shortening time to follow-up.
NS P6 Designing and Implementing a Stroke Center of Excellence in a Community Hospital
Tammy Johnsen; Edward Hosp, Naperville, IL
Three years ago, a team of physicians, advanced practice nurses (APNs), staff nurses, rehabilitation services and others embarked on a project to improve care for the stroke patient and achieve designation as a stroke center of excellence.The Stroke Center at Edward Hospital is dedicated to reducing disability and death of patients with stroke through an interdisciplinary collaborative approach. Program goals include: 1) increase community awareness of stroke symptoms and risk factors; 2) decrease disability through an interdisciplinary plan of care; 3) provide evidence-based clinical practice; 4) deliver expert care by a team dedicated to cardiovascular disease and stroke; 5) provide comprehensive services: inpatient, outpatient, home care and rehabilitation services; 6) ensure continuous quality measurement and improvement in care; and 7) deliver care in a healing and service oriented environment. Interdisciplinary teams were organized to: 1) examine the evidence and develop plans of care and standing orders; 2) develop a rapid response "Code Stroke" protocol; 3) implement tight glucose control; 4) standardize lipid management; 5) implement "Get with the Guidelines" (American Heart Association) to measure key outcomes; 6) educate physicians, nurses and other health care professionals; 7) certify select physicians, APNs and nurses on the NIH stroke scale; 8) develop standardized patient education binder and class; 9) provide primary prevention and early detection programs for the community; and 10) establish a stroke support group. The Code Stroke team responds to 20–25 events each month. Standing orders are implemented on 95% of patients. As documented in "Get with the Guidelines" for ischemic stroke TIA patients, 100% receive antithrombotic medication within 48 hours; 100% are discharged on antithrombotics; 100% receive smoking cessation advice or medication; 100% have a documented lipid profile; and 80% receive cholesterol reducing medications. As a result of these efforts, Edward was recognized by JCAHO as one of 130 stroke centers of excellence in the United States. The team is continuing to work to improve DVT prophylaxis, dysphagia screening and aggressive lipid treatment for patients with both hemorrhagic and ischemic strokes.
NS P7 The Clinical Nurse Specialist’s Role in Blood Pressure Management to Resusitate Ischemic Penumbra
Karen A Aloe; South Nassau Community Hosp, Oceanside, NY
Background: Optimal treatment of the patient who has sustained an acute ischemic stroke requires rapid assessment and early intervention. Due to the unique susceptibility of neurons to ischemia, minutes count, as death occurs in areas of no blood flow at the onset of stroke. Around such areas of necrosis exists regions of hypoperfused, electrically silient tissue that barely receives enough blood flow to keep neurons alive. This tissue is called the ischemic penumbra; a major goal at my institution is resuscitation of the tissue. If reperfusion of the penumbra occurs expediously, neurons recover and the patient improves; with no reperfusion, a time-related attrition converts ailing neurons to frank infarction. Objectives:Methods: Utilizing the Recommendations of Brain Attack Coalition (BAC)and American Heart Association (ASA), these guidlines provided a framework to facilitate our approach to stroke care. Due to the time-related death of neurons in the penumbra the emphasis is placed on perfusion with blood pressure management. A stroke team and written stroke pathways with a set of instructions for management of blood pressure is initiated by the triage nurse who triggers a page to the stroke team. Unless systolic pressure exceeds 220 mm Hg or a diastolic pressure exeeds 120 mm Hg (sustained or repeated measurement), elevated pressure is not treated within the first days of stroke. The ischemic penumbra looses auto-regulation and it’s perfusion is directly linked to mean arterial pressure. The two exceptions are (1) after the use of tissue plasminogen activator (t-PA) blood pressure is conservatively maintained at 185/110 mm Hg, and (2) in the presence of myocardial infarction. Results: The guidlines prevented over-zealous treatment of hypertension following an acute stroke and the conversion of the ischemic penumbra into infarct. Prospective Study of Blood Pressure compliance is currently in progress to determine the parameters of elevated pressure and when antihypertensive drugs are used at the initial presentation. Conclusion: The result of the study will determine whether use of the BAC and ASA Recommendations for Blood Pressure Management has significantly improved the quality and efficiency of stroke management at our institution.
NS P8 Computerized Order Sets Increase Compliance with Joint Commission Standards
Zeina Khouri, Joyce Maygers, Rafael Llinas; Johns Hopkins Bayview Med Cntr, Baltimore, MD
Computerized order sets increase compliance with Joint Commission standards Background: Literature shows the importance of standardized stroke care in improving patient outcomes, however little is known about the contribution of Computerized Provider Order Entry (CPOE). Conventional order sets can increase awareness, utilization and compliance with established evidence based guidelines, while CPOE is advocated as a tool to decrease medical error, improve efficiency of healthcare delivery, and standardize care. We hypothesized that the implementation of order sets in CPOE would improve compliance with three of the ten JCAHO stroke measures. Methods: In 2002, stroke order sets were paper based. By 2005, we fully implemented CPOE, and received JCAHO disease specific certification of our stroke program. Retrospective chart reviews were conducted on 100% of ischemic stroke patient records for the first two quarters of fiscal years 2003 (N=72) and 2004 (N=72), and the last two quarters of fiscal year 2005 (N=79). These time frames represented 6 months of paper based order sets, 6 months of initial implementation of CPOE with nursing staff order entry, and 6 months of full implementation of CPOE with provider order entry. Charts were reviewed for compliance with order set usage and 3 JCAHO stroke measures: lipid profile on admission, deep vein thrombosis (DVT) prophylaxis, and antithrombotic medications ordered within 48 hours of admission. Results: Percentage of compliance Conclusion: We found that utilization of order sets in the care of ischemic stroke patients is vital for compliance with standardized measures. Our data suggests that the presence of standardized order sets alone does not guarantee usage or follow through. We found that CPOE increased compliance with obtaining lipid profiles, and maintained compliance with DVT prophylaxis and antithrombotic medications. Use of CPOE improved the usage of standardized order sets in the ischemic stroke population. 
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NS P9 I Know That Question Because the Answer is...
Susan Davis, Jo-Ann Burns, Dawn Lintzenich, Tanisha Burns; Barnes-Jewish Hosp, St. Louis, MO
Our stroke management and rehabilitation team was organized in 1994 to provide comprehensive care to stroke patients. Late in 2004 a joint administrative agreement was reached between the medical school and the hospital to become a primary stroke center. This was recognized as the next step in advancing the stroke care in the community. A multidisciplinary team was formed that included key stakeholders in stroke care management to oversee the primary stroke center application. One of the issues that arose at the first planning meeting was how to prepare all staff for the survey. To equip staff with the necessary information, including reminders of the JCAHO patient safety goals, required documentation, and stroke initiatives a quiz game approach was investigated. It was decided to use the game show Jeopardy format. As the survey date approached posters were developed with tear off pages to inform staff of the countdown to the survey. On each front page were the days to survey and an answer to a question. On the flip side was the question. Posters were placed in strategic locations, such as break rooms and bathrooms. This generated lively discussion of the answer of the day and the actual question. A sample answer was atrial fibrillation. The actual question was "what cardiac arrthymia can cause a stroke?". During a mock JCAHO preparation survey the answer presented to the staff was "read back". The staff were able to state that this was a patient safety goal for improved communication and stated the question would be what are the steps for verifying a telephone or verbal order. The staff was receptive to the posters and stated they felt prepared for the JCAHO survey. As a result of this game show approach the staff were confident and successful when questions were asked by the surveyor.
NS P10 Best Practice Guidelines for Stroke Care: A Rehabilitation Journey
Nancy Boaro, Ramona Mileris; Toronto Rehab, Toronto, Canada
The Heart and Stroke Foundation of Ontario, supported by the Ontario Ministry of Health and Long Term Care, developed Best Practice Guidelines for Stroke Care: a Resource for Implementing Optimal Stroke Care as one of the initiatives undertaken through the Coordinated Stroke Strategy. Published in June, 2003, this resource was created in order to assist facilities and healthcare providers achieve the goal of integrated and organized stroke care across the continuum, so that all individuals in Ontario who suffer a stroke receive the best possible stroke care. Toronto Rehabilitation Institute (TRI) provides interdisciplinary inpatient and outpatient rehabilitation services to stroke survivors through its specialized Stroke Services. As a regional academic rehabilitation centre, TRI is committed to high quality evidence-based care. Consequently, there was a commitment to ensuring that any stroke patient admitted to TRI received the same level of care, no matter where he/she was admitted across the continuum. A Working Group was developed, with representation from all three services, comprised of front line clinicians, professional practice leaders and management. The objectives of the project group were: (1) Use the guide to self-evaluate our own current practices in 3 segments of the continuum - Transition Management; Rehab Management; Community Re-engagement. (2) Identify areas requiring change in order to meet best practice, as well as opportunities for enhancement of existing practices; (3) Outline recommendations, identifying an Action Plan and resource needs for each; (4) Establish priorities for improved outcomes within each Service; (5) Develop implementation plan for improving quality of patient care services; (6) Implement; (7) Evaluate effectiveness of strategies used in order to change practice and improve patient care outcomes This presentation will share with you the "lessons learned" in undertaking such a project. Specifically, the usefulness of guiding principles used in establishing priorities for implementation, the challenges of knowledge transfer and integration of changes in practice, the challenges of developing evidence based outcome measurement and program evaluation tools and strategies.
NS P12 Creating an Information Day for Childhood Stroke Survivors and their Families
Maria Zak, Anita Allen, Robyn Westmacott, Daune MacGregor, Karen Kinnear, Teesta Soman, Gabrielle deVeber; The Hosp for Sick Children, Toronto, Canada
As health care practitioners who care for patients who have had a stroke, we tend to focus on the acute treatment and rehabilitative aspects of care. Does care really end beyond the hospital doors, only to be resumed at infrequent clinic visits for check ups? What more could families want or need? "Different Strokes in Little Folks Day" has answered these questions for the health care practitioners of the Stroke Team at Toronto’s Hospital for Sick Children. Different Strokes in Little Folks Day was created for childhood stroke survivors and their families. Sponsored by the Children’s Stroke Program, it began five years ago with the goal of allowing childhood stroke survivors and their families to meet and network with other childhood stroke survivors and their families. This day has evolved to meet the needs identified by the children and their families through annual surveys and evaluations. Today, the agenda for Different Strokes in Little Folks Day has been determined exclusively by the childhood stroke survivors and their families. Topics such as ongoing cognitive development after stroke, constraint induced therapy, alternative therapies, understanding the impact of childhood stroke on siblings of survivors, updates on paediatric research, access to regional and provincial resources, and opportunities to network with other childhood stroke survivors and their families be discussed. Most importantly, five families will share their stories so that they may help other childhood stroke survivors and their families in their daily journey to adapt to life after stroke. The benefits of Different Strokes in Little Folks Day have extended to the health care providers on the Stroke Team. Over the years, they have learned more about the daily impact of stroke on the lives of childhood stroke survivors and their families and about the outcomes of paediatric stroke - and area in which outcomes are often unknown. We hope inspire and encourage the audience to consider investing into the care beyond the acute setting by holding such an event for all stroke survivors.
NS P13 Optimizing Stroke Outcomes: A Model for Post-Stroke Care Management
Susan Hazelett, Jan Weinhardt, Summa Hlth System, Akron, OH; David Jarjoura, The Ohio State Univ, Columbus, OH; Kyle Allen; Summa Hlth System, Akron, OH
Background: Stroke is the leading cause of disability in the United States, making it an important chronic condition. Interdisciplinary care management has been shown to optimize outcomes in numerous chronic conditions, yet no model of care has been proven effective for optimizing the long-term physical and psychosocial well-being of stroke survivors. Purpose: To describe a model for a successful post-stroke care management intervention. Main elements of the intervention include 1) comprehensive assessment, 2) focus on self care skills and stroke knowledge, 4) evidence based care planning, 5) interdisciplinary team, 6) collaboration with PCP, 7) frequent follow up, and 8) prompt revision of the care plan as needed. Theoretical Framework: Wagner’s Model for Effective Chronic Illness Care. Operationalizing the Framework: Main elements of the framework are implemented as follows: 1) community linkages are provided by the interdisciplinary team’s social worker, 2) self management support is provided by an Advanced Practice Nurse (APN) who visits the patient in his/her home to assist the patient in developing personal goals and to help develop problem-solving skills, 3) delivery system redesign is accomplished by using an APN as a care manager to eliminate fragmentation of care, providing each patient with access to specialist care through the interdisciplinary team, and performing regular follow up, 4) decision support is enhanced by building the interdisciplinary plan of care around evidence-based protocols developed for each problem addressed by the intervention and by providing academic detailing to each PCP regarding the care plan, 5) clinical information sharing is improved by communicating in-hospital and in-home assessment findings directly to the PCP and by collaborating with the PCP regarding implementation of the interdisciplinary plan of care, and 6) organizational leadership is provided by the interdisciplinary team serving as a resource for the PCP. Results: Results from a pilot study testing this intervention showed a statistically significant positive effect of the intervention on outcomes. Conclusion: Wagner’s model for effective chronic illness care can be successfully applied to post-stroke care to improve patient outcomes.
NS P14 Implementation of Best Practice Guidelines for Neurological Assessment of Acute Stroke Patients
Sophia J Gocan, Andrea Fisher; The Ottawa Hosp General Campus, Ottawa, Canada
Introduction - The use of standardized, valid and reliable assessment tools to facilitate the neurological assessment of acute stroke patients has been well supported by best practice guidelines. Clinical nurses from the regional stroke program at the Ottawa Hospital identified limitations in the usefulness of the Glasgow Coma Scale as a standard for acute stroke assessments. An expert panel of nurses with input from the multi-disciplinary team reviewed best practice guidelines for neurological assessment. Members of the panel critically appraised research evidence and developed recommendations for use of the National Institutes of Health Stroke Scale (NIHSS) as a standard of care for neurological nursing assessment. Implementation - The implementation process included clinical nursing staff involvement in planning and implementation, collaboration with medical staff, educational workshops, follow-up in the clinical setting, and competency evaluation. Over 90 nurses attended a three hour educational workshop and have been certified as competent in performing the NIHSS. Evaluation - The NIHSS gives nurses a means for quantifying a patient’s stroke severity and has assisted in the early identification of neurological improvement or deterioration. It has resulted in improved communication of neurological findings with physicians as it provides a common language. The NIHSS has provided a foundation for patient-specific care plan development identifying risk factors for safety and conditions which would benefit from the consultation of medical or multidisciplinary team members, and the initiation of further investigations or interventions. The project evaluation phase consisted of feedback focus groups, continuous quality improvement initiatives, and a self-assessed nursing competency evaluation of neurological assessment techniques based on the work of Dr. Patricia Benner. This presentation will focus on the project development, implementation and evaluation process. Strategies for promoting successful implementation of a stroke severity scale in clinical nursing practice will be reviewed. Valuable lessons and key messages from clinical nurses to support sustainability will be highlighted.
NS P15 Geriatric Considerations in Acute Ischemic Stroke
Janice L Hinkle; John Radcliffe Hosp, Headington Oxford, United Kingdom
Cerebrovascular accident (CVA), ischemic stroke or brain attack is the third leading cause of death in the United States and world wide. Age is a known risk factor for stroke and there are disparities in death following stroke related to age. While the majority of patients who have an ischemic stroke are elderly (> 65 years of age) the principles of geriatric nursing are rarely applied to the care of this patient population. This presentation will review evidence based interventions for ischemic stroke including treatment in the acute phase of care, secondary prevention, and recovery with a geriatric focus. Research has identified strategies that can assist in healthy aging following a stroke and these will be discussed as well.
NS P16 Redefining Hyper Acute: Delivering Neuroprotectants within Two Hours of Stroke Symptom Onset
Gigi Schlueter, Pamela J Nye, Dolores Morales-Tatgenhorst, Theresa Haley, Maria J Fitzgerald, Jeffrey Saver, Sidney Starkman; UCLA Med Cntr, for the FAST-MAG Investigators, Los Angeles, CA
Field Administration of Stroke Therapy Magnesium (FAST-MAG) is a Phase III, NIH funded, randomized, placebo controlled, double blind study designed to deliver IV magnesium sulfate or placebo as a stroke therapy, within the first two hours of stroke symptom onset. Unique in its design, preliminary data demonstrates record-breaking ability to deliver stroke therapy utilizing a possible neuroprotectant for stroke survivors in the hyper-acute phase of the illness. Neuroprotectants have been studied for years, most with little promise, due to the inability to deliver the study drug quickly enough (IMAGES, ANCROD). The FAST-MAG Clinical Trial has demonstrated a mean time of 52 minutes from symptom onset to treatment. Most other neuroprotectant trials achieve delivery of study drug to the patient 4 
hours after symptom onset. By using the Emergency Medical Services of Los Angeles County, study drug is being delivered in record breaking time. This has been done by training the paramedics in the early identification of stroke symptoms via the Los Angeles Pre-Hospital Screen (LAPSS), facilitation of the informed consent process via cell phone, and initiation of the study agent while still in the field. In addition to shortening the time for study agent delivery, the design of this study is unique in the consenting process. Paramedics initiate a phone call to one of five physician investigators at the University of California, Loa Angeles, from distant locations. The consent is obtained through a patient/investigator phone conversation and paramedic facilitation of obtaining consenting signatures.
NS P17 The MERCI Clot Retrieval Device: What Nurses Need to Know
Norma D McNair; UCLA Med Cntr, Los Angeles, CA
Until early 2005, interventions for the patient with an acute stroke has been limited to the administration of tPA. While tPA has been effective in some patients in reversing stroke symptoms, limitations related to the time frame for administration and very specific clinical critera has prevented the use of tPA in most acute stroke patients presenting to an Emergency Room. A promising new intervention, recently approved by the FDA, the MERCI clot retrieval device provides an addition to the armamenatrium of the acute stroke team. The device can be used in patients for whom tPA is not an option. Review of the device, its indications and nursing management post-procedure will be discussed. Case studies and video will supplement the presentation.
NS P18 A Literature Review of Prehospital Delays in Stroke Patients
Janet E Bray, Eastern Melbourne Neuroscience, Box Hill Hosp, Deakin Univ, Melbourne, Australia; Bev O’Connell, Anne Gardner, Deakin Univ, Melbourne, Australia; Amanda Gilligan, Eastern Melbourne Neuroscience, Box Hill Hosp, Melbourne, Australia; Christopher Bladin; Eastern Melbourne Neuroscience, Box Hill Hosp, Monash Univ, Melbourne, Australia
Introduction: Many patients remain excluded from acute stroke therapies, particularly thrombolytic therapy, due to extensive delays from symptom onset to presentation at hospital. Educational campaigns, focusing on awareness of symptoms and messages of urgency, have proved ineffective in reducing delays. New approaches, developed from an in-depth understanding of behavioural influences within this time, are required. This poster will present the findings from a review of literature regarding prehospital delays among stroke patients. Methods: A database search and review of citation lists found 25 quantitative studies using multivariate analysis. These studies were critiqued against current illness behaviour theory, which describe and conceptualize the process that occurs following the onset of symptoms. Results: Studies used a wide range of methods and there were many inconsistencies in findings between studies. Only sudden onset, severe strokes, and use of ambulance were consistently associated with prompt hospital presentation. Examination of methodologies demonstrated poor consideration of illness behaviour theory in study designs, in particular, a lack of exploration of cognitive, emotional, and social factors; a potential confounding of factors by not considering the phases of delay that occur within this timeframe; and insufficient consideration of the role and influence of others. Conclusion: Future research aiming to identify modifiable factors related to patient delay in stroke could benefit from frameworks provided by illness behaviour theory. The identification of modifiable factors is vital to directing interventions to reduce prehospital delay.
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