Ischemic stroke represents 87% of all strokes.1 As worldwide initiatives move forward with stroke care, healthcare providers and institutions will be called on to deliver the most current evidence-based care. The American Heart Association/American Stroke Association (AHA/ASA) charged a panel of healthcare professionals from several disciplines with developing a practical, comprehensive overview of care for the patient with acute ischemic stroke (AIS). This article focuses on educating nursing and allied healthcare professionals about the roles and responsibilities of those who care for patients with AIS.

Nurses play a pivotal role in all phases of care of the stroke patient. For the purposes of this article, the writing panel has defined 2 phases of stroke care: (1) The emergency or hyperacute care phase,2,3 which includes the prehospital setting and the emergency department (ED), and (2) the acute care phase, which includes critical care units, intermediate care units, stroke units, and general medical units.

Stroke is a complex disease that requires the efforts and skills of all members of the multidisciplinary team. Nurses are often responsible for the coordination of care throughout the continuum.4–9 Coordinated care of the AIS patient results in improved outcomes, decreased lengths of stay, and decreased costs.10

In developing this comprehensive overview, the writing panel applied the rules of evidence and formulation of strength of evidence (recommendations) used by other AHA writing groups11 (Table 1). We also cross-reference other AHA guidelines as appropriate. 



Table 1. Applying Classification of Recommendations and Levels of Evidence 

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. …

Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient A Scientific Statement From the American Heart Association

Summary Thrombolysis with alteplase administered within a narrow therapeutic window provides an effective therapy for acute ischaemic stroke. However, mainly because of prehospital delay, patients often arrive too late for treatment, and no more than 1–8% of patients with stroke obtain this treatment. We recommend that all links in the prehospital stroke rescue chain must be optimised so that in the future more than a small minority of patients can profit from time-sensitive acute stroke therapy. Measures for improvement include continuous public awareness campaigns, education of emergency medical service personnel, the use of standardised, validated scales for recognition of stroke symptoms and for triaging to the appropriate institution, and advance notification to the receiving hospital. In the future, use of telemedicine technologies for interaction between the emergency site and hospital, and the strategy of treatment directly at the emergency site (mobile stroke unit concept), could contribute to more efficient use of resources and reduce the time taken to instigate treatment to within 60 min—the golden hour—of the onset of the symptoms of stroke.

Streamlining of prehospital stroke management: the golden hour.

Despite the proven benefits of thrombolysis for patients presenting with acute ischemic stroke, only a limited number of patients receive thrombolytic therapy. The reason for the low treatment rate is that thrombolysis is only effective a few hours after the onset of ischemic stroke, so delays in patients being admitted to hospital and being diagnosed mean that the therapeutic window is often missed. Major factors that lead to prehospital delay include the general public's lack of knowledge of stroke symptoms and their poor understanding of the appropriate course of action following a stroke. Indeed, the patients who arrive early in hospital tend to be those who recognize the symptoms of stroke and take them seriously. Deficiencies in the identification of stroke by emergency medical services and general practitioners also contribute to prehospital delay. Aggressive, combined educational programs aimed at the general public, general practitioners, and medical and paramedical hospital staff can lead to increased stroke treatment rates. In this Review, we explore the extent of prehospital delay in stroke, identify the factors that affect the time taken for patients to reach hospital, and describe strategies designed to reduce the delay.

Reducing prehospital delay in acute stroke.

Background: Prompt assessment and investigation of
transient ischaemic attack (TIA) followed by early
initiation of secondary prevention is effective in reducing
recurrent stroke. Nevertheless, many patients are slow to
seek medical advice after TIA. A systematic review was
undertaken to examine potential factors associated with
delay in seeking medical review after TIA.

Methods: The electronic databases MEDLINE, EMBASE,
and Science Citation Index were searched for observational
studies assessing patient delay in presentation after
TIA. The search was restricted to studies published
between December 1995 and September 2008.

Results: The electronic search yielded nine studies with
data on presentation delay in patients with TIA; variations
existed in study size, population and methodology. One
study included patients with TIA only (n=241), whereas
the remaining eight studies recruited both stroke and TIA
patients. Overall, TIA patients (n=821) made up only a
small proportion of the total number of patients in this
analysis (n=3,202). Length of delay varied greatly across
all studies. In most studies, patients with TIA who
attended an emergency department arrived there within
hours. Where patients first presented to their general
practitioner, 50% attended within 24 hours whereas 25%
waited 2 days or more. Recognition of symptoms as
stroke/TIA did not reduce the delay.

Conclusions: The majority of delay in seeking assessment
after TIA is due to a lack of response by the
patient—many patients do not recognise the symptoms
of stroke/TIA, and even when they do, many fail to seek
emergency medical attention. The public needs educating
on the importance of contacting the emergency medical
services or attending an emergency department immediately
after TIA.

/pdf/a-systematic-review-of-delays-in-seeking-medical-attention-4i1opdgd3d.pdf

A systematic review of delays in seeking medical attention after transient ischaemic attack

Background and Purpose—UK ambulance services assess patients with suspected stroke using the Face Arm Speech Test (FAST) The Recognition Of Stroke In the Emergency Room (ROSIER) tool has been shown superior to the FAST in identifying strokes in emergency departments but has not previously been tested in the ambulance setting We investigated whether ROSIER use by ambulance clinicians can improve stroke recognition Methods—Ambulance clinicians used the ROSIER in place of the FAST to assess patients with suspected stroke As the ROSIER includes all FAST elements, we calculated a FAST score from the ROSIER to enable comparisons between the two tools Ambulance clinicians’ provisional stroke diagnoses using the ROSIER and calculated FAST were compared with stroke consultants’ diagnosis We used stepwise logistic regression to compare the contribution of individual ROSIER and FAST items and patient demographics to the prediction of consultants’ diagnoses Results—Sixty-four percent of strokes and 78% of nons

Does Use of the Recognition Of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians

Background and Purpose— Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset. Methods— For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed. Results— One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (P=0.015) and a history of stroke or transient ischemic attack (P<0.001). More than half of the calls for a...

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Papers

Stroke Symptoms and the Decision to Call for an Ambulance