ISCHEMIC STROKE
A 46-year-old African American female presented to the Accident and Emergency with two-hour history of inability to speak, facial asymmetry, and upper right arm weakness. She was a known hypertensive patient on irbesartan 150mg/day PO, indapamide 2mg PO qAM, spironolactone 50mg/day PO, and rosuvastatin 20mg/day PO for hypercholesterolemia. She had a history of a valve replacement surgery three years prior. Two days after admission she succumbed.
Epidemiology, morbidity and mortality
The leading cause of disability in the United States, stroke is believed that every 4 minutes someone in the United States dies of stroke. 1 in 4 of these patients dies within 1 year while half of the survivors suffer permanent disability. Stroke kills 150,000 Americans every year. ¼ of all stroke patients have suffered previous stroke. 90% of all strokes are ischemic. Stroke results in life-changing consequences for both the patient and their family, with a huge proportion of patients needing assistance in their basic activities of daily living. There patient often suffer severe physical and cognitive impairments.
Pathophysiology
Ischemic stroke is caused by sudden loss of blood supply to a specific area of the brain with resulting acute-onset focal neurological signs. Cerebral artery thrombosis or emboli causes occlusion. Ischemia results in hypoxia of brain cells and depletion of ATP. Ion transport system and consequently ionic-gradient can therefore not be maintained. This results in influx of calcium and sodium ions as well as water leading to cytotoxic edema. 90 minutes of deprivation of blood supply to brain tissues causes them to stop functioning while a 3-hour deprivation causes irreversible cell injury. Non-modifiable risk factors include African race, advancing age, female sex, and genetics. Non-modifiable risk factors include hypertension, diabetes, cardiac diseases such as atrial fibrillation, and heart failure, mitral stenosis, and hypercholesterolemia, lifestyle causes such as cigarette smoking, excessive alcohol, obesity and sickle cell disease.
PRACTICE GUIDELINES
Guidelines are recommendations that aid clinicians in the decision-making process. They are developed using an evidence based process for the management of specific medical problems in order improve patient care. The current guidelines for ischemic stroke focus on the prehospital care, urgent evaluation, thrombolytic therapies, hospital management as well as secondary prevention of stroke. For this review, the ASA/AHA Early ,management of acute ischemic stroke guidelines of 2018 were used.
Acute management of stroke includes assessment and protection of the patient’s airway. Assessment of breathing and circulation to prevent aspiration and hypoxia while stabilization and initial evaluation including laboratory and imaging studies are essential for early diagnosis. The cause of the stroke is proven to be ischemic or hemorrhagic using a non-contrast CT scan or diffusion-weighted MRI within the recommended 20 minutes of arrival.
0.9mg/kg IV Alteplase is recommended within 4.5 hours of onset of symptoms, however best results are achieved within 90 minutes of onset of symptoms. A 24-hour post-lysis CT is recommended in order to identify bleeds. Normal homeostasis must be maintained. Glucose levels must be kept between 4-11mmols/L with blood pressure maintained within normal limits. Once hemorrhagic stroke is ruled out 300mg of Aspirin is given. This is continued for two weeks before switching to a long-term antithrombotic treatment. Primary prevention of stroke includes control of risk factors while secondary prevention includes use of antiplatelet agents such as clopidogrel monotherapy.
Do the clinical practice guidelines adequately address the health problem?
In my opinion the current guidelines address the current health problem adequately. Studies have showed that the incidence of stroke in developed countries have reduced by 10% in the developed world since 1994.
Studies have also showed that higher nursing levels result in lower mortality rates and better prognosis for stroke patients. It is important for hospital facilities to have an adequate nurse to patient ratio as recommended by IOM. Early diagnosis of atrial fibrillation, screening and management of hypertension as well as treatment of transient ischemic attacks has proved effective in the prevention of stroke.
Imaging remains the testing modality of choice since it helps distinguish hemorrhagic from ischemic stroke. Computed Tomography is the most suitable and should be done within 20 minutes of patients’ arrival. Finally, the guidelines are clear, concise and interpretable, they are also printed in a single booklet making it easier for healthcare workers to study them and to refer easily when need arises.
However, while guidelines may be adequate in addressing medical problems, lack of publicity, resources, staff willingness, positive facility culture and government initiative may limit the implementation of their implementation. There need to be ways of evaluating success or failure of guidelines in order to get the best patient outcomes.
Is this practice guideline based on current evidence (within 5 years)? What is the strength of this evidence?
As nurses, use of evidence based and well established a guideline is crucial in ensuring patients have the best prognosis. Recognizing symptoms and intervening early are the two most important tools in this management. The current guidelines are based on current evidence. They are also reviewed and incorporated into the American Heart Association whose stroke council oversee and offer medical expertise. It is systematic and gives reasons why revision of the guidelines was necessary, when the reviews were made and the bodies involved in making the reviews. Thrombectomy, for example, is a new technique where the clot is retrieved from the middle cerebral artery and has proved to be very effective in the treatment of these patients
Does this clinical practice guideline adequately direct the healthcare provider in the management of a patient with this problem?
Most of the information directs the healthcare provider adequately on how to manage a stroke patient. Reading them I was able to understand most of the information and could visualize exactly how I would use it in the care of a patient. The steps for point of care nursing are well outlined and clear.
Effectiveness of the clinical guidelines
The 2018 AHA/ASA guidelines for stroke management are an updated version of the 2013 version. They shed light to the effectiveness of mechanical thrombectomy with stent retriever as a new treatment modality for stroke patients with large vessels occlusion within 16-24 hours of onset of symptoms.
Assessment of the effectiveness of patient management
I would review all stroke patients who have been admitted in the facility and neighboring facilities in my state for the past one year. Evaluate the management approach for these patients and check the prognosis. I would also check if the set guidelines are being used in the management, how often they are being used, the barriers that hinder them from being implemented and the effect of not implementing them.
Need for revision
The practice guidelines need evaluation. The question about why we still have stroke as a leading cause of disability and a top leading cause of death need to be answered. It means that the prevention strategies are not working, stroke is not being managed adequately or that we still don’t have adequate intervention measures to manage stroke.
Thrombectomy require a neurosurgeon that may not be available in every setting. The cost of care is also too high for most families to afford. Further, thrombectomy is only suitable for larger arteries and is ineffective in stroke affecting small cerebral arteries.
There is also need for guidelines to be standardized, for example while many guidelines support the use of IV Alteplase, there is conflicting information on whether the period of its effective use is less than 3 hours or less than 4.5 hour.
If you were going to revise this clinical practice guideline, what would you change? What evidence would you use to base your changes on?
There should also be an increased and vigorous campaign for the public to identify stroke symptoms and risk factors. The FAST mnemonic Face asymmetry, Arm/Leg weakness, Speech difficulty and Time to call 999 should be taught to the public. The public awareness must be tailored to reach the sex, age, race and ethnically diverse population.
These prehospital systems would be designed and implemented by public health officials, medical professionals. This is in keeping with the fact that prompt recognition n and seeking for care is very essential in a stroke patient. However various populations such as the Hispanic and the blacks have low stroke awareness and prehospital delays and this may well be the reason for the disparities in the outcome.
Where thrombolytic therapy results in complications such as angioedema or hemorrhage, hospitals should have adequate protocols to ensure that coagulopathy is reversed. The contraindications of use of TPA such as recent head injury, an INR of greater than 2, history of hemorrhagic stroke and history of a major surgery would be highlighted to prevent complications of thrombolytic therapy.
I would ensure that the importance of multidisciplinary team and effective communication across all healthcare workers is stressed. Studies have proved that this positively influences patient outcomes. I would base my changes on evidence from various publications while comparing it with actual patient management outcomes in my state’s hospitals.
How might changes in US demographics and healthcare reform affect this clinical practice guideline?
Advancing age is a risk factor for stroke. This therefore means that the number of stroke patients is likely to increase if measures to evaluate risk factors are not implemented. Lack of insurance has greatly affected the prognosis of stroke patients these may partly be due to lack of access to primary care physicians. There reduced access to rehabilitation, medication and specialists among the uninsured compared to the insured population. Medicaid however aims to bridge this gap. Medicaid also aims to cater for the population with racial/ethnic disparities. The African American and Hispanic population is another risk factor for stroke and Medicaid offers to cater for this population in the stroke belt states. There is an increase in stroke incidence in younger patients probably due to increase of drug abuse and contraceptive use. Finally, patients with COVID-19 due to higher incidences of organ failure are also presenting with stroke. Guidelines may have to be reviewed to cater for these patients.
What strategies would you use to increase the likelihood that a new or modified clinical practice guideline would be adopted and used in clinical practice?
The guidelines should be studied and evaluated by renowned stroke specialists in the country, including expert peer reviews and feedback from policy makers. They need to critique the evidence and reasons for using certain methods of management over others. Liaise with stakeholder organizations such as AHA and ASA to adopt and endorse the guidelines.
Giving regular and scheduled stroke education to staff members, especially nursing staff, physicians and those who work in the emergency department using webinars and webcasts to maintain skills and remain current on the new advances made in management of stroke. I would also liaise with health societies and unions in ensuring that facilities have stroke center certification in order to enhance compliance.
I’d also advocate that the new guidelines be taught in institutions of learning that offer medical courses so that the students can then apply them in the practice. Acute Cardiac Life Support Certification of pre-hospital care providers ensures that they are well informed on the current stroke warning signs as well as triage procedures for easy identification of stroke patients.
Publicizing the guideline achievements and accomplishments of my facility is can be used to ensure the guidelines are followed. This includes tent ads, signage on walls of restrooms, internal circuit TV advertisement, an article on the hospitals magazine or newsletter, a memo to all health workers in the hospitals including directors and CEO. Coming up with a guideline champion who would help steer the campaign and provide programs for recapping and reevaluation. An advertisement on the local newspaper may also prove beneficial (Heart.org, 2018).
This publicity should outline the advantages that come with specific interventions for stroke such as reduction in disability and death. I would also ensure that the guidelines focus sufficiently on nurses’ role in the management of stroke patients. Finally the guidelines should be clear and unambiguous with easily identifiable key recommendations.
EVALUATION: How would you determine its effectiveness of this revised clinical practice guideline in directing care for patients with the identified health problem? Outline the steps you might employ.
Evaluation of effectiveness of management of stroke is very essential because it shows clinicians if the interventions they implemented are suitable or not. Steps that I would employ would include starting with checking for awareness at the local healthy facility level.