Feature
Role of emergency care staff in managing acute stroke Caroline Watkins and colleagues explain how some of the latest research focuses on the head position of patients in the first 24 hours Correspondence [email protected] Caroline Watkins is professor of stroke and older people’s care and director of research at the school of health, and director of the Lancashire clinical trials unit, at the University of Central Lancashire Craig Anderson is professor of stroke medicine and clinical neuroscience medicine, at the George Institute for Global Health, University of Sydney, NSW Denise Forshaw is a senior clinical trials manager at the Lancashire clinical trials unit Liz Lightbody is senior research fellow at the clinical practice research unit Both at the school of health, University of Central Lancashire Date submitted August 26 2014 Date accepted August 26 2014 Author guidelines rcnpublishing.com/r/ en-author-guidelines
Abstract In June, the University of Central Lancashire opened its clinical trials unit, where staff will run complex intervention trials in a range of care areas, including stroke, musculoskeletal health, public health and mental health. One of the first trials looks at how hospital nursing policies in the first 24 hours after patients have had stroke affect their subsequent survival and disabilities. Known as HeadPoST, the study will recruit 20,000 patients globally, with the 6,000 UK research participants managed by Lancashire. This article explores the role of emergency nurses in supporting the research. Keywords Stroke, head position, randomised control trial STROKE IS the third leading cause of death and the single most important cause of severe disability in adults worldwide. In the UK, more than 110,000 people experience acute stroke each year, and the cost of illness is estimated at £8.3 billion annually (Scarborough et al 2011). Furthermore, with ever ageing populations, the global burden of stroke is set to increase (Truelsen et al 2006). While prevention is crucial in reducing the burden of stroke, well organised and efficient acute care strategies are important in reducing its effects on individuals and families. Outcomes can be improved if people have better access to stroke-specialist consultation, and to processes of care that ensure accurate diagnoses and appropriate delivery of time‑dependent treatments. Performance standards in the delivery of acute stroke care include: ■■ Rapid responses to 999 calls when stroke is suspected.
18 September 2014 | Volume 22 | Number 5
■■ Urgent transfer of patients to hospitals that provide specialised hyper-acute stroke services. ■■ Use of brain imaging within one hour of arrival for people in whom urgent treatment is indicated and within 12 hours for everyone else. ■■ Thrombolysis or other urgent interventions for eligible patients. ■■ Immediate patient access to a high quality stroke unit care. Stroke is a clinical emergency and, to maximise patient recovery, access to treatment must not be delayed and, in recent years, stroke services have been re-organised to improve access to stroke unit care. However, if these improvements are to lead to fewer delays, front line staff, such as paramedics and emergency nurses, must be able to recognise the signs of stroke early and accurately, and to facilitate appropriate care. In the care of people with stroke, ‘time is brain’. In practice, this means that the goal of acute stroke management is to stabilise patients and complete initial assessments, including imaging and laboratory studies, within 60 minutes of a patient’s arrival at an emergency department (ED). Practitioners need knowledge and skills to assess patients’ suitability for thrombolysis and, if they are to, request immediate brain scans and refer the patients directly to stroke services. Acute stroke management can involve, but is not limited to, reperfusion therapies with clotbusting drugs and neurointerventions involving the use of devices to retrieve clots that are occluding large intracerebral vessels. While it is accepted that stroke unit care can improve patients’ chances of surviving without major disabilities (Stroke Unit Trialist Collaboration 2013), the mechanisms that produce beneficial effects are not precisely EMERGENCY NURSE
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understood. Acute stroke units may be effective because their staff make standardised assessments, follow early management protocols, and carry out appropriate investigations, treatments and individualised patient care. Physiological monitoring is considered an important component of individualised acute stroke care even though evidence of the benefits of monitoring is unclear (Jones et al 2007). However, there is a need for nurse-initiated, evidence-based protocols for the management of fever, hyperglycaemia and swallowing dysfunction (Middleton et al 2011), while early control of elevated blood pressure has been shown to improve recovery from intracerebral haemorrhage (Anderson et al 2013).
Study There is evidence that, if patients with large-vessel ischaemic stroke are in the head-down, flat position, their cerebral blood flow improves (Olavarría et al 2014). However, the head-up position may be preferable in patients with a large amount of oedema following intracerebral haemorrhage or ischaemic stroke related to proximal occlusion of the middle cerebral artery. The head position in acute stroke trial (HeadPoST), an international cluster, cross-over, randomised control trial funded by the National Health and Medical Research Council of Australia, will determine the best head position for patients with acute stroke. Researchers will compare outcomes among patients who are nursed while lying flat with those among patients who are nursed while sitting up during the first 24 hours after they are admitted. HeadPoST is the largest trial of a stroke nursing intervention and will be co-ordinated in the UK by the Lancashire clinical trials unit. The trial has a pragmatic design to allow the inclusion of consecutively admitted patients with acute stroke who can be nursed in one of two head positions as part of their usual care. The head positions are lying flat and sitting up, and each is determined by random allocation. After 70 patients have been nursed in one position, hospital staff will cross over to nursing the next 70 patients in the other position. A cluster design has been chosen to reduce the potential for contamination between groups, promote consistent nursing care and facilitate conduct of the study across an estimated 140 hospitals, including 40 in the UK. Patients are put into the allocated head position as soon as possible after they present to EDs to ensure that the effects of head position can be assessed while there is the greatest potential for EMERGENCY NURSE
Computed tomography scan of a patient’s brain after stroke
benefit or harm. Nurses are responsible for the positioning and monitoring of patients, so they must ensure this intervention is carried out. Almost all stroke care pathways require patients to pass through EDs, where staff are essential to early diagnosis, assessment, treatment and patient management. As new therapeutic treatments for stroke emerge, the role of ED staff in stroke care may become increasingly important. Meanwhile, ED staff remain crucial patient advocates who can ensure the content, sequence and timing of stroke care produce the best outcomes for patients.
Find out more Details of the Lancashire clinical trials unit are available at tinyurl.com/lwdjn6o References Anderson CS, Heeley E, Huang Y et al (2013) Rapid blood pressure lowering in acute intracerebral hemorrhage. New England Journal of Medicine. 368, 25, 2355-2265. Jones SP, Leathley MJ, McAdam JJ (2007) Physiological monitoring in acute stroke: a literature review. Journal of Advanced Nursing. 60, 6, 577-594. Middleton S, McElduff P, Ward J et al (2011) Implementation of evidencebased treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet. 378, 9804, 1699-1706. Olavarría VV, Arima H, Anderson CS et al (2014) Head position and cerebral blood flow velocity in acute ischemic stroke: a systematic review and metaanalysis. Cerebrovascular Diseases. 37, 6, 401-408. Scarborough P, Morgan RD, Webster P (2011) Differences in coronary heart disease, stroke and cancer mortality rates between England, Wales, Scotland and Northern Ireland: the role of diet and nutrition. BMJ Open. 1, 1. Stroke Unit Trialists’ Collaboration (2013) Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 11, 9. Truelsen T, Piechowski-Jozwiak B, Bonita R (2006) Stroke incidence and prevalence in Europe: a review of available data. European Journal of Neurology. 13, 6, 581-598.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
September 2014 | Volume 22 | Number 5 19
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Role of emergency care staff in managing acute stroke Caroline Watkins and colleagues explain how some of the latest research focuses on the head position of patients in the first 24 hours Correspondence [email protected] Caroline Watkins is professor of stroke and older people’s care and director of research at the school of health, and director of the Lancashire clinical trials unit, at the University of Central Lancashire Craig Anderson is professor of stroke medicine and clinical neuroscience medicine, at the George Institute for Global Health, University of Sydney, NSW Denise Forshaw is a senior clinical trials manager at the Lancashire clinical trials unit Liz Lightbody is senior research fellow at the clinical practice research unit Both at the school of health, University of Central Lancashire Date submitted August 26 2014 Date accepted August 26 2014 Author guidelines rcnpublishing.com/r/ en-author-guidelines
Abstract In June, the University of Central Lancashire opened its clinical trials unit, where staff will run complex intervention trials in a range of care areas, including stroke, musculoskeletal health, public health and mental health. One of the first trials looks at how hospital nursing policies in the first 24 hours after patients have had stroke affect their subsequent survival and disabilities. Known as HeadPoST, the study will recruit 20,000 patients globally, with the 6,000 UK research participants managed by Lancashire. This article explores the role of emergency nurses in supporting the research. Keywords Stroke, head position, randomised control trial STROKE IS the third leading cause of death and the single most important cause of severe disability in adults worldwide. In the UK, more than 110,000 people experience acute stroke each year, and the cost of illness is estimated at £8.3 billion annually (Scarborough et al 2011). Furthermore, with ever ageing populations, the global burden of stroke is set to increase (Truelsen et al 2006). While prevention is crucial in reducing the burden of stroke, well organised and efficient acute care strategies are important in reducing its effects on individuals and families. Outcomes can be improved if people have better access to stroke-specialist consultation, and to processes of care that ensure accurate diagnoses and appropriate delivery of time‑dependent treatments. Performance standards in the delivery of acute stroke care include: ■■ Rapid responses to 999 calls when stroke is suspected.
18 September 2014 | Volume 22 | Number 5
■■ Urgent transfer of patients to hospitals that provide specialised hyper-acute stroke services. ■■ Use of brain imaging within one hour of arrival for people in whom urgent treatment is indicated and within 12 hours for everyone else. ■■ Thrombolysis or other urgent interventions for eligible patients. ■■ Immediate patient access to a high quality stroke unit care. Stroke is a clinical emergency and, to maximise patient recovery, access to treatment must not be delayed and, in recent years, stroke services have been re-organised to improve access to stroke unit care. However, if these improvements are to lead to fewer delays, front line staff, such as paramedics and emergency nurses, must be able to recognise the signs of stroke early and accurately, and to facilitate appropriate care. In the care of people with stroke, ‘time is brain’. In practice, this means that the goal of acute stroke management is to stabilise patients and complete initial assessments, including imaging and laboratory studies, within 60 minutes of a patient’s arrival at an emergency department (ED). Practitioners need knowledge and skills to assess patients’ suitability for thrombolysis and, if they are to, request immediate brain scans and refer the patients directly to stroke services. Acute stroke management can involve, but is not limited to, reperfusion therapies with clotbusting drugs and neurointerventions involving the use of devices to retrieve clots that are occluding large intracerebral vessels. While it is accepted that stroke unit care can improve patients’ chances of surviving without major disabilities (Stroke Unit Trialist Collaboration 2013), the mechanisms that produce beneficial effects are not precisely EMERGENCY NURSE
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 10, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Science Photo Library
understood. Acute stroke units may be effective because their staff make standardised assessments, follow early management protocols, and carry out appropriate investigations, treatments and individualised patient care. Physiological monitoring is considered an important component of individualised acute stroke care even though evidence of the benefits of monitoring is unclear (Jones et al 2007). However, there is a need for nurse-initiated, evidence-based protocols for the management of fever, hyperglycaemia and swallowing dysfunction (Middleton et al 2011), while early control of elevated blood pressure has been shown to improve recovery from intracerebral haemorrhage (Anderson et al 2013).
Study There is evidence that, if patients with large-vessel ischaemic stroke are in the head-down, flat position, their cerebral blood flow improves (Olavarría et al 2014). However, the head-up position may be preferable in patients with a large amount of oedema following intracerebral haemorrhage or ischaemic stroke related to proximal occlusion of the middle cerebral artery. The head position in acute stroke trial (HeadPoST), an international cluster, cross-over, randomised control trial funded by the National Health and Medical Research Council of Australia, will determine the best head position for patients with acute stroke. Researchers will compare outcomes among patients who are nursed while lying flat with those among patients who are nursed while sitting up during the first 24 hours after they are admitted. HeadPoST is the largest trial of a stroke nursing intervention and will be co-ordinated in the UK by the Lancashire clinical trials unit. The trial has a pragmatic design to allow the inclusion of consecutively admitted patients with acute stroke who can be nursed in one of two head positions as part of their usual care. The head positions are lying flat and sitting up, and each is determined by random allocation. After 70 patients have been nursed in one position, hospital staff will cross over to nursing the next 70 patients in the other position. A cluster design has been chosen to reduce the potential for contamination between groups, promote consistent nursing care and facilitate conduct of the study across an estimated 140 hospitals, including 40 in the UK. Patients are put into the allocated head position as soon as possible after they present to EDs to ensure that the effects of head position can be assessed while there is the greatest potential for EMERGENCY NURSE
Computed tomography scan of a patient’s brain after stroke
benefit or harm. Nurses are responsible for the positioning and monitoring of patients, so they must ensure this intervention is carried out. Almost all stroke care pathways require patients to pass through EDs, where staff are essential to early diagnosis, assessment, treatment and patient management. As new therapeutic treatments for stroke emerge, the role of ED staff in stroke care may become increasingly important. Meanwhile, ED staff remain crucial patient advocates who can ensure the content, sequence and timing of stroke care produce the best outcomes for patients.
Find out more Details of the Lancashire clinical trials unit are available at tinyurl.com/lwdjn6o References Anderson CS, Heeley E, Huang Y et al (2013) Rapid blood pressure lowering in acute intracerebral hemorrhage. New England Journal of Medicine. 368, 25, 2355-2265. Jones SP, Leathley MJ, McAdam JJ (2007) Physiological monitoring in acute stroke: a literature review. Journal of Advanced Nursing. 60, 6, 577-594. Middleton S, McElduff P, Ward J et al (2011) Implementation of evidencebased treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. The Lancet. 378, 9804, 1699-1706. Olavarría VV, Arima H, Anderson CS et al (2014) Head position and cerebral blood flow velocity in acute ischemic stroke: a systematic review and metaanalysis. Cerebrovascular Diseases. 37, 6, 401-408. Scarborough P, Morgan RD, Webster P (2011) Differences in coronary heart disease, stroke and cancer mortality rates between England, Wales, Scotland and Northern Ireland: the role of diet and nutrition. BMJ Open. 1, 1. Stroke Unit Trialists’ Collaboration (2013) Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews. 11, 9. Truelsen T, Piechowski-Jozwiak B, Bonita R (2006) Stroke incidence and prevalence in Europe: a review of available data. European Journal of Neurology. 13, 6, 581-598.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
September 2014 | Volume 22 | Number 5 19
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