International Stroke Conference 2015 - PowerPoint Presentation

Slide1

International Stroke Conference 2015Hot Topics

Jennifer Cohn, MSN, FAHA

April 17

th

, 2015Slide2

DisclosureEducational consultant for Codman Slide3

ObjectiveApply new research topics presented at the International Stroke Conference and discus the relevance of at least two new practices that many influence your own program/practice.

Slide4

ISC – What is it? And Why is it important?

Forum for disseminating clinical stroke trial results and sharing of best practices within the field

Occurs annually in

February

Next year is in Los Angeles, CA

February 16

th

is State of Science Nursing symposium

February 17

th

-19

th

ISC sessions

Options

for submitting abstracts, projects, research is open to everyone at

Strokeconference.org

Can submit to the SOS nursing symposium and the nursing section in ISC proper

2016

Call for abstracts - May

20-

Aug

11, 2015

Great opportunity to get involvedSlide5

State of the Science Nursing SymposiumNursing attendance this year was close to 800

The first year of the nursing symposium there were less than 50 participants.

The

afternoon

offers many breakouts with mix of research and clinical information

There are 4 categories:

Advances

in clinical

research, Applications of EBP and Quality enhancement, Essentials

of standard

and advanced clinical practice,

Rehab and recovery: an ongoing

process- Community Reintegration

83% of attendees also attended the ISC sessions this year

Great offerings from bench to bedside Slide6

Hot Topics from ISC:

IV

Alteplase

Slide7

Delay In Consent Is A Common Reason For Delay In

tPA

Administration

Sheree

Murphy, AHA/ASA, New York,

NY; Anna

Colello

, New York State Dept. of Health, Albany, NY

; Steven

R. Levine, SUNY Downstate Medical Center, Brooklyn,

NY

Background:

Benefit of IV

tPAtime

dependent.

Treatment

should be initiated ASAP with a guideline recommended door-to-needle < 60

minutes

This

target is missed in >50% of cases, reported as high as 70

%.

Hospital

delays in evaluation, diagnostic tests

& delay

from order to IV

tPA

initiation

are most often targeted with improvement strategies.

Jauch

, EC et al.

Stroke

. 2013;44:870–947.

Fonarow

, GC et al.

Circulation

. 2011;123:750-758.Slide8

Background -Consent2013 ASA guidelines for early management of ischemic stroke state informed patient consent for IV

tPAis

indicated

Regulatory

precedents in the U.S. & internationally support the use of IV

tPA

in

patients lacking capacity if alternative form of consent can’t be obtained within the treatment

window

Difference

of opinion &practice regarding signed, written informed consent & implied consent for IV

tPA

Previous

studies have addressed adequacy or quality of consent & capacity of acute stroke patients to give

consent

Jauch

, EC et al.

Stroke

. 2013;44:870–947.

White-Bateman

, SR et al.

Arch Neurol

. 2007 Jun;64(6):785-92.

Thomas

, L et al.

Front.Neur

.2012 Aug;3:128.Slide9

ObjectivesDetermine the frequency of the reasons for delay in IV

tPAtreatment

within New York State (NYS)

Identify

factors specifically associated with delay in patient/family consent Slide10

MethodsHospitals participating in the NYS Department of Health (DOH) Stroke Center Designation program (N= 120)

Data

were a reporting requirement for all 2012 discharges

Reasons

for delay in IV

tPA

beyond

60 minutes of hospital arrival collected in Get With The Guidelines-Stroke Patient Management Tool

Abstractors

selected all reasons either explicitly documented or clearly apparent

Only

aggregate data for all NYS hospitals were obtained

Chi

squared was used to test differences (2-tailed) Slide11

Patient/Family Consent DefinitionNo unifying definition of consent given the variability in practice patterns

Hospital

may require only oral consent

Hospital

may require signed written consent form

Case

Scenarios

Patient

able to provide consent but requested phone call to family to discuss decision

Patient

unable to provide consent

& no

family/proxy present

Did

not include initial patient/family refusal

Patient

initially declined treatment &later changed their mind to receive IV

tPA

Captured

under reason “Change in Patient Clinical Status/Condition”Slide12
Slide13
Slide14
Slide15
Slide16
Slide17
Slide18

StrengthsFirst state-based study quantifying the contribution of patient/family consent on delay IV

tPA

administration

Sample

size includes over 1,000 IV

tPA

treated

patients

I

ncludes

variety of hospital type

academic

& non-academic

r

ural

& urban

bed

size

stroke

volume

Able

to analyze some covariates that influence delay in patient/family consent Slide19

LimitationsOnly

aggregate level data available for this analysis

Could

not isolate group of patients with delay in patient/family consent as the single reason for delay in treatment

Only

select patient characteristics could be analyzed

Onset

to treatment time not available

Could

have underestimated consent related delays

Only

1 year of data

NYS

data only. May not be generalizable

“

Other” reasons not individually analyzed

Data

collection was designed for quality improvement &not for a research studySlide20

ConclusionsOur state-level data suggest that issues with consent are one of the most common reasons for delay in IV

tPA

Previous

studies have shown that delay in IV

tPA

occurs

more frequently on off-hours

& female

gender

A

potential gender issue is raised requiring further study

Delay

on weekend vs. weekday suggests Stroke Centers review variations in stroke center processes that may be present on weekends

Training

& tools to improve & shorten the consent process may reduce delays

Further

study is needed to assess other patient and hospital characteristics that may be associated with delay in patient/family consent & determine if any of the variables are independent predictor Slide21

Non-Standard Inclusion & Exclusion Criteria for Intravenous Alteplase

Administration in Acute Ischemic Stroke

Anne W.

Alexandrov

PhD

,

CCRN

, NVRN-BC, ANVP-BC, FAAN

Professor

, University of Tennessee Health Science Center, Memphis & Australian Catholic University, Sydney

Program

Director, NET SMART

Background:

Even though the United States was the first country to approve intravenous

alteplase

for the treatment of stroke and there are currently >1000 certified stroke centers, when we compare the U.S. to European countries, our

alteplase

treatment rates are significantly lower

Hypothesis is that Informal

networking with interdisciplinary colleagues on the topic of IV

tPA

treatment often reveals varied interpretations of what constitutes an acceptable IV

tPA

treatment candidateSlide22

MethodsObtain

copies of inclusion/exclusion checklists for IV

tPA

Ask

Stroke Coordinators to describe additional reasons for non-treatment that they have quantified in their

data

Obtain

patient volumes at each

site

Obtain

IV

alteplase

treatment volumes at each

site

Obtain

sICH

rates for each

site

Obtain

definitions used for

sICH

at each

siteSlide23

Findings24% limited

tPA

treatment window to 3 hours

Academic

hospital

tPA

treatment rates were significantly higher than community hospitals:

Academic

hospital IV

tPA

treatment rate: 10.8 +7.7 (median 8)

Community

hospital IV

tPA

treatment rate: 8 +5.9 (median 6)

t=2.3

;

mean

difference

2.75; p=.026, 95% CI .33-5.2

As

the number of non-standard inclusions/exclusions increased, the

tPA

treatment rate decreased

(

r = -.153; p=.038)

Utilization

of non-standard inclusions/exclusions was predicted by hospital type (community), admission volume (low), and use of the 3 hour window (p<.0001).Slide24

Classification of sICH

: Reliability

in Question…

Official

definitions support classification of

sICH

for most (86%) certified Stroke Centers, however the most common definition (48%) reported was, “any hemorrhage on non-contrast CT or MRI in combination with any clinical deterioration.”

Only

17% identified the definition for

sICH

adopted by TJC (ECASS-3 definition).

Among

those that adhered to the TJC definition,

sICH

rates were significantly lower at 3% +2.3% (median 3%; t=4.7; mean difference = 7.7; p<.0001, 95% CI 4.4-10.95), compared to 10.6% +17.5% (median 6%). Slide25

Safety of Intravenous Thrombolysis for Wake-Up Stroke: Results of A Prospective Multicenter Safety Study

Andrew D.

Barreto

, MD

MS

Christopher

V.

Fanale

, Andrei V.

Alexandrov

, Kara A. Sands,

Kevin

C. Gaffney,

FarhaanS

.

Vahidy

,

DigvijayaD

.

Navalkele

,

Chad

C. Tremont, Robert K. Hamilton, Claude B. Nguyen,

AmrouSarraj

, George Lopez, Nicole R. Gonzales,

VivekMisra

, Tzu-

ChingWu

, Sheryl Martin-

Schild

, James C.

Grotta

, Sean I.

Savitz

Background & Purpose

A

significant number (~25%) of ischemic strokes are noticed upon awakening and are not candidates for thrombolysis

58,000

patients

with wake-up ischemic stroke presented to an ED in

20051

Retrospective

studies suggest thrombolysis of

Wake-Up

Strokes (WUS) may be safe and beneficial

We

tested the safety of IV-

rtPAin

a multicenter, single-arm, prospective, open-label study of

rtPAin

patients who woke-up with stroke.

Mackey et al.

Neurology

2011.76;1662-7Slide26

Prospective Therapeutic Trials of Wake-Up Stroke Slide27

Eligibility, Treatment & OutcomesEligibility

1.Ages

18-80

2.Disabling

deficits (NIHSS ≤25) noted upon awakening

Last

seen well prior evening

3.Non-contrast

CT only

Utilizing

standard known onset criteria (i.e., <1/3 MCA territory

hypodensity

)

4.Other

than onset time, all standard criteria met for IV-

tPA

Treatment

Standard

dose (0.9mg/kg)

IV-

rtPA

started

≤3 hours of awakening

Primary

outcome -Safety

Symptomatic

intracerebral hemorrhage (ICH) -ECASS-II

Pre-planned

stopping rules

Data

safety monitoring boardSlide28

Sample SizeAssumption

: Risk of thrombolysis is unacceptable if the true rate of

sICH

>10%

Group

Sequential Interval Estimation with

90%

Confidence Intervals (CI)

Minimum

number of

sICHsrequired

to yield a risk that has the lower limit of the 90% confidence interval >10% as the stopping rule. Slide29

ResultsOctober 2010 –October 2013

All

pre-planned patients enrolled

N

= 40

Four

patients (10%) determined stroke

mimics

Migraine-2

Neoplasm-1

Conversion-1Slide30

ResultsSlide31

NIHSS Distribution

17

(43%) ≥ 8

12

(30%) ≥10Slide32

ResultsSlide33

ResultsSlide34

RESULTS-mRS distribution

at 90-daysSlide35

LimitationsUncontrolled study with a small sample size

Low

number of severe strokes enrolled

Patients

treated ≤3-hours of awakening

IV-thrombolysis

routinely delivered up to 4.5 hours

Substantial

mimic rate (10%), but consistent with prior studies of non-contrast CT

thrombolysis

9

% (95% CI: 7-10%)1

TsivgoulisG et al. Stroke. 2011;42:1771-4Slide36

ConclusionsBased on this first reported, prospective study, intravenous thrombolysis appears to be safe in WUS patients selected by non-contrast CT

A

randomized, effectiveness trial appears feasible using a similar, pragmatic designSlide37

Many mild stroke patients considered "too good to treat" may actually benefit from tPA

Khawja

A. Siddiqui, M.D., Massachusetts General Hospital, Boston, Mass

Stroke patients with mild symptoms might be eligible to receive the clot-busting drug tissue plasminogen activator (

tPA

), but often don't receive the therapy because they are deemed "too good to treat." However, many of these patients don't fare well after stroke, according to research presented at the American Stroke Association's International Stroke Conference 2015.

Using the Get With The Guidelines database from Boston's Massachusetts General Hospital, researchers analyzed 2,745 consecutive stroke admissions (01/2009 - 07/2013). Researchers studied which "too-good-to treat"-patients should be considered for

tPA

because of their risk of poor health or death.

T

hey

found:

Of the 238 stroke patients studied who arrived in time to receive

tPA

but did not receive it because their symptoms were too mild or they were rapidly improving, 89 did not do well and might have benefitted from

tPA

.

Only 62 percent of those studied were discharged home. Nearly 27 percent went to inpatient rehabilitation facilities; 8.4 percent to skilled nursing facilities; and more than 2 percent either died or went to hospice.

Risk factors for having poor outcome post-stroke in this group of patients include: being elderly; having more severe strokes; being Hispanic; and having a stroke that affects both hemispheres of the brain. Hispanics, for example, were 11.43 times more likely than non-Hispanics to suffer with poor health after stroke.

More research is needed to better identify which patients might do poorly without

tPA

treatment, researchers said.Slide38

Clot buster use rises most among 80 and older stroke patients-Michelle P. Lin, M.D., M.P.H., University of Southern California, Los Angeles, Calif

.

Use of the clot busting drug tissue plasminogen activator (

tPA

) for ischemic stroke has increased for every age group in recent years. But the magnitude of change has been greatest among the very elderly, 80 years and older, researchers report at the American Stroke Association's International Stroke Conference 2015.

Historically, rates of

tPA

administration in patients ages 80 years and older have been lower than the general population.

Researchers analyzed the health records of nearly 6 million patients admitted to U.S. hospitals between 2000 and 2010. This included patients with an ischemic stroke diagnosis, who received

tPA

.

Study participants were 35 percent 80 years and older, 37 percent 65 to 79 years of age, and 28 percent were 18 to 64.

They found that

tPA

administration rate increases from 2000 to 2010 were:

0.47 to 3.55 percent for the oldest group studied;

0.92 to 3.87 percent for 65 to 79 year olds; and

1.02 to 3.61 percent in patients ages 18 to 64.

Among 80 year-old and older individuals:

Those treated at an urban hospital and teaching hospital were more likely to receive

tPA

.

Women, Blacks, Hispanics and Medicaid holders were less likely to receive

tPA

.

Researchers recommend that ways

to improve safe and effective

tPA

administration among very elderly stroke patients should be

exploredSlide39

Hot Topics from ISC:Acute CareSlide40

Ongoing Research on Head of Bed Positioning Background

Data

from several small studies show that blood flow within the infarct territory in patients with large vessel occlusions is increased when the HOB is placed at zero degrees.

Two

large studies are exploring this phenomenon further:

HeadPost

–Does it make a difference at 3 months?

–Craig Anderson, MD, PhD The George Institute- Affiliated with the University of Sidney

Zero

DOWn

SOS –Do small vessel (

lacunes

) benefit; is head positioning a rescue intervention rather than an intervention capable of affecting 3 month outcome?

–Anne

Alexandrov

,

PhD, CCRN, NVRN-BC, ANVP-BC, FAAN Professor, University of Tennessee Health Science Center, Memphis & Australian Catholic University, Sydney Program Director, NET SMART

Wojner-Alexandrov

, et al (2005)

Neurology, 64, 1354-57Slide41

Safety EndpointsHeadPost

& Zero

DOWnSOS

(

Zero

-

D

egree HOB

O

utcomes

W

ith

S

urveillance

O

f

S

troke Symptoms):

Aspiration

pneumonia

Zero

DOWnSOS

:

Neurologic

deterioration

Example

: NIHSS at zero degrees is 12 points; within 30 minutes of sitting the patient up at 30 degrees, the NIHSS increases to 18 points.

Zero

DOWn

SOS protocol would call this as “meeting a safety endpoint,” and allow investigators to intervene however they choose to stabilize the patient.

Currently

, the data showing deterioration with head up positioning exist only in small studies and only in large vessel occlusions in the

hyperacute

phase, yet the occurrence of deterioration and clinical fluctuation is commonly reported in the clinical arena.

Frequent

, serial assessments are needed to keep these patients safe.

Enrollment & Positioning Tips for Pneumonia Prevention

Screen

for and exclude patients with antecedent events that may be associated with pneumonia (i.e. vomiting in the field)

Exclude

patients at high risk for aspiration (i.e. patients on

BiPAP

; intubated patients

)

Exclude

patients that cannot tolerate zero degree positioning due to concurrent diagnoses (i.e. CHF, COPD, etc.)

Patients

in the zero-degree arm should be kept in side lying position, NOT supine

Keep

suction set up at bedside

Perhaps

older patients (i.e. >75) should be excluded? Slide42

SummaryHeadPost and Zero

DOWn

SOS will provide interesting information about the utility and safety of zero and thirty degree HOB positioning in patients with acute ischemic stroke.

Collectively

, we should learn:

Which

patients are most likely to benefit from zero degree positioning;

The

safety of positioning protocols for acute stroke; and,

The

utility of zero degree positioning as a rescue therapy vs. a therapy capable of producing a difference in outcome at 3 months. Slide43

Early Infection Worsens Intracerebral Hemorrhage

A. Barrios-Anderson, Brown University; E. Amin, A.

Cung

, J. Wiese, V. Belden, D. Espino, John J

Volpi

, Houston Methodist Neurological Institute

Hypothesis:

Infection is an independent risk of worsening in hemorrhagic

strokeSlide44

MethodsRetrospective chart analysis of 200 ICH subjects

Analyzed

for infection measures:

Fever

Leukocytosis

Antibiotic

administration

Blood

Culture

Urinalysis

Chest

X-Ray

Infection

within 72 hours

Glasgow

Coma Score

ICH

score

Discharge

disposition

MortalitySlide45

ConclusionPatients that had infection recognized in first 72hrs of admission had

Greater Stroke Severity

Worse level of Consciousness

Worse Discharge

Higher Mortality RateSlide46

People who are well hydrated at the time of their stroke have a greater chance of better recovery compared to people who are

dehydrated

Argye

Hillis

, M.D., and Rebecca

Gottesman

, M.D.,

Ph.D

, John Hopkins Hospital, Baltimore, MA

Researchers gathered baseline lab measurements and MRI scans on

ischemic stroke patients

admitted to the Comprehensive Stroke Center at Johns Hopkins Hospital between July 2013 and April 2014

.

Hydration levels were evaluated based on two well-accepted measurements —BUN/creatinine ratio, which shows how well the kidneys work; and urine specific

gravity

After evaluating 168 ischemic stroke patients, researchers found almost half of them were dehydrated when admitted to the hospital for stroke.

Researchers also found:

Stroke condition worsened or stayed the same in 42 percent of dehydrated patients, compared to only 17 percent of hydrated patients.

Dehydrated stroke patients also had about a four times higher risk of their conditions worsening than hydrated patients.

There

was little difference in

hydration

levels across patients’ race, gender, ethnicity or diabetes status. Patients with kidney failure were not included in this study. The scientists tracked patients’ daily stroke severity based on their NIHSS scores, a measure of patients’ neurological health. They also used MRI scans to calculate the volume of brain lesions caused by stroke. Even after researchers factored out the effects of age, initial NIHSS score, lesion volume and blood sugar levels, results still pointed to dehydration negatively impacting the patients’ conditions. However, they point out that since there was no intervention in this study, there still may be differences in the types of people who came in dehydrated as opposed to well-hydrated.

It is unclear why hydrated patients at the time of

strke

are linked to better stroke outcomes. It is possible that dehydration causes blood to be thicker causing it to flow less easily to the brain through

stenotic

or blocked blood vesselsSlide47

Oral Care Program Decreases Length of Stay (LOS) and Length of Time Oral Foods and Fluids are Withheld (NPO) in Stroke

Patients

Louise

Talley, PhD,

RN, Principle Investigator; Heather

Lorenz, RN,

MSN St. John Medical Center, Tulsa, OK

Background

Speech Pathologists addressed Nursing Practice Council concerning the quality of oral care being provided by

nursing

Referred

to Nursing Research Council to identify best

practice

Review

of current evidence by Nursing Research RoundtableSlide48

Purpose of Study: Test the efficacy of an evidence-based oral assessment & oral care program on LOS and NPO status in hospitalized, non-ventilated stroke

patients

Problem:

Oral care is identified as an area of care omission by nurses (

Kalisch

, 2006

).

Aspiration

of respiratory pathogens shed from oral biofilms into the lower airway increase the risk of developing pneumonia (

Yoneyama

, et al., 2006)

Hospital-acquired

pneumonia (HAP) contributes significantly to the length and cost of hospital stays.

Kalisch

, B. (2006). Missed nursing care: A qualitative study.

Journal of Nursing Care Quality, 21 (4), 306-313.

Yoneyama

, T., Yoshida, M.,,

Ohrui

, T.,

Mukaiyama

, H., Okamoto, H.,

Hoshiba

, K., et al (2002). Oral care reduces pneumonia in older patients in nursing homes.

Journal of the American Geriatrics Society, 50

, 430-433.Slide49

Research QuestionsIn

non-ventilated stroke patients, will an oral care program reduce the length of NPO status

?

In

non-ventilated stroke patients, what is the effect of an oral care program on LOS?Slide50

Study DesignQuasi-experimental, posttest only with nonequivalent comparison group

Setting

Four (4) adult medical-surgical nursing units in an acute care, 500+ bed medical center

1

Progressive Medical-Surgical unit

1

Stroke Unit

2

Medical UnitsSlide51

SampleConvenience

sample

Intervention

Group

51

stroke patients admitted to four med-

surg

nursing units in 2013 after implementation of an oral care program

Comparison

Group

33

hospitalized stroke patients admitted to four medical-surgical nursing units in 2010

Inclusion

Criteria:

Non-ventilated

adult inpatients with a new diagnosis of stroke.

Admission

to one of the four nursing units chosen for the study

>

18 years of age

LOS

> 3 calendar

days

Exclusion

Criteria:

Ventilated

any time during the admissionSlide52

InstrumentHospital

Acquired Pneumonia (HAP) Risk Assessment Tool

Adapted

with permission from the Methodist Health System

Oral Care (Structured) Policy

Documentation

of type and frequency of oral care intervention based on HAP risk assessment score

Low

Risk (score 0-5)

High

Risk (score >6) Slide53
Slide54

Data Collected from EHR for Pre-and Post-intervention Groups

Demographic:

Age

, gender

Number

of NPO days

Length

of Stay (LOS)

Presence

of Diagnoses

HAP

Stroke

Additional Data Collected from Post-intervention Group

Initial

HAP Risk Score

Final

HAP Risk ScoreSlide55
Slide56

In non-ventilated stroke patients, will an oral care program reduce the length of NPO status?

Length of NPO

Status per 100 patient days

Group

Pre-Intervention 2010

23.07

Post-Intervention 2013

3.3

87%Slide57

In non-ventilated stroke patients, what is the effect of an oral care program on LOS?

LOS Mean

Group

Pre-Intervention 2010

9.45 days

Post-Intervention 2013

6.92

days

26.8%%Slide58

What is the effect of a structured oral care program on HAP Risk scores from initial to final score for the 2013 post-intervention group?Slide59

ConclusionsTime in NPO status and LOS decreased with a structured oral care program

.

Oral

health assessment scores improved from admission to discharge

.

Frequency and quality of oral care by nursing staff improved possibly due to more convenient oral care supplies.

Further

testing of the assessment tool and interventions with a larger sample is recommended.Slide60

Presenting Symptoms and Response to Dysphagia Screen Predict Unfavorable Outcome in Acute Ischemic Stroke Patients who do not receive IV tPA

due

to Mild and Rapidly Improving Stroke Symptoms

Debbie Camp,

Katja

Bryant, Susan Zimmermann, Cynthia Brasher,

Kerrin

M. Connelly, Joshua Dunn, Michael Frankel,

MogesIdo

, James

Lugtu

,

Fadi

NahabSlide61

BackgroundPrevious studies have shown that 25-30% of patients who do not receive IV t-PA due to mild and rapidly improving stroke symptoms (

MaRISS

) are not discharged home.

Up

to 36% of acute ischemic stroke (AIS) patients arriving within the 3 hour window are not treated with IV thrombolytic therapy due to

MaRISS

. Slide62

ObjectiveThe objective of our study was to identify whether baseline characteristics, presenting symptoms and response to initial dysphagia screen can predict which patients not treated with IV

tPA

due

to

MaRISS

go

on to have an unfavorable outcome. Slide63

MethodsAIS patients presenting to hospitals participating in the Georgia Coverdell Acute Stroke Registry and not treated with IV t-PA due to

MaRISS

only

Study

Period: January 1, 2009 -December 31, 2013

Patients

who were unable to ambulate or needed assistance to ambulate prior to admission were excluded.

Baseline

characteristics, presenting symptoms and response to dysphagia screen were collected from retrospective chart review at participating hospitals.

Multivariable

regression analysis was used to identify factors associated with a lower likelihood of favorable outcome, defined as discharge to home.Slide64

ResultsOf

841 AIS patients who did not receive

IV-

tPA

due

to

MaRISS

, 160 (19%) did not have a favorable outcome (were not discharged home).

Factors

associated with lower likelihood of a unfavorable outcome (Not D/C Home):

Medicare

insurance

status (OR

0.53, 95% CI 0.34 to 0.84)

Arrival

by

EMS (OR

0.46, 95% CI 0.29 to 0.73)

Increasing

NIHSS

score (per

unit OR 0.89, 95% CI 0.84 to 0.93)

Weakness

as the presenting symptom

(

OR 0.50, 95% CI 0.30 to 0.84)

Failed

dysphagia

screen (OR

0.43, 95% CI 0.23 to 0.80)

During the study period,

1%

of patients presenting to participating hospitals with

MaRISS

within the 3 hour time window received IV t-PA.Slide65

ConclusionsNearly

1 in 5 acute ischemic stroke patients presenting with

MaRISSwere

not discharged to home.

Among

patients who present with

MaRISS

and

do not receive IV

tPA

, Medicare insurance status, arrival by EMS, increasing NIHSS score, weakness as a presenting symptom, and a failed dysphagia screen were all associated with a lower likelihood of discharge to home.

Given

the very low rate of IV t-PA treatment in AIS patients presenting with

MaRISS

during

the study period, a prospective randomized trial to evaluate IV t-PA treatment focusing on this subgroup of patients is warranted. Slide66

The Needs of Family Members at the Bedside of Stroke Patients

Anita

Catlin,

DNSc

, FNP,

FAAN Principal Investigator, Consultant

, Ethics and

Research Kaiser

Permanente Santa Rosa & Vallejo,

CA;

Michelle

Camicia, MSN, CRRN,

CCM, Director,

Kaiser Permanente

Vallejo

,

CA;Nina

Markoff

, Masters in Social Work

Intern; Hua

Wang, PhD, Research

Scientist

Objectives

1

. Share

study design and findings from the Family Needs Study

2

. Discuss

recommendations on how to improve care based on findings Slide67

SettingServe ~700 stroke pts/year

CMI 1.5-1.7

Stroke

ALOS=15.1

Background

Study

conducted at Kaiser Permanente Santa Rosa with oncology patients

Limited

studies available on needs of family members of stroke patients in an inpatient settingSlide68

Research Questions 1.What are the needs of family members of stroke patients at the bedside in the rehabilitation unit?

2.Will art therapy lead to an improved understanding of family needs?

Study Aim

To learn how we can improve the quality of care we offer to families whose family member has a stroke in our hospital.Slide69

Study ProcessStaff Nurses identify family members who might be interested in participating

.

Director

speaks with family member, explains study, & if interested, obtains signed consents. Potential appointment times determined.

Interviewer

conducts interview, art, & surveySlide70

Triangulated Study DesignSlide71

Measures: Scripted Family Caregiver InterviewReaffirm

permission to tape & review study

“

We are trying to plan better care for family members who are at the bedside of our patients. We know your ___had a stroke & you are involved in ___care.

“

Our study today, however, is about you. We want to hear about the care you need while you are at the bedside & what can be done as we build family centered care program to best serve our families.”Slide72

Measures: Interviewing in Qualitative ResearchQuestions

develop as the data comes in.

If

several families talk about need for food, communication, etc., these can be used a prompts for future interviews.

Ask

, watch, reflect and listen

Interview

ends when family member agrees that he/she has told us what they feel and are satisfied when we reflect back what we have heard.Slide73

Measures: Family Needs Inventory (FIN)Instrument

developed by

Kristjnson

, Atwood &

Degner

(1995)

Validity

established via expert panel & matched family need findings with other like instruments

Reliability

of Cronbach alpha of .83

20

items with a scale of 1-10 identifying if needs are met or unmet.Slide74

Art: Draw a Bridge

A

projective technique for assessment in art therapy described by Ronald Hays & Sherry Lyons (19981)

Indicates

how an individual who is going though a difficult change may be experiencing that

change

Can be used to enhance communication & therapeutic change in a therapeutic session

Interviews

for qualitative research

can

be therapeutic in & of themselves.Slide75

Measures: Art ProcessIntroduce materials

Other

people have told us that by drawing a picture of a bridge with you on it, it will help you to formulate your thoughts

Draw

a bridge going from where you are now, to where you might be sometime in the future.

Place

yourself on the bridge

Describe

your bridge & what surrounds itSlide76

Data Collection & AnalysisCollect data until saturation of findings is reached & no new information is revealed.

FIN

analyzed

Interviewstranscribed

& coded using naturalistic inquiry method. (Miles and

Huberman

, 1994)

Art

Drawings

reviewed by research team.

Art

Therapist reviews drawings & provides additional insights.Slide77

ParticipantsN = 12 Male 33%

Female 67

%

Age 18

-85

(50% 46-65)Slide78

Results: Family Needs InventorySlide79

Results- Qualitative: Themes Knowing

what to expect when they go home (preparation for discharge)

Communication

with care providers

Physical

comfort & self care

Having

someone care about them/provide emotional supportSlide80

Theme- Knowing what to expect when they go home“If I had it my way, I think I'd rather have her in here a little longer, so that we feel a little more comfortable caring for her at home”

“When I could tell my fears about what I was afraid -about taking him home, because he's a big man, how do I take care of this person without him hurting himself?”

“We bring him home on Wednesdays, what do we do next? Do we just live? I don't know.”Slide81

Theme- Physical Comfort & Self Care“Sometimes I'm just emotionally drained and I don't know what to do. ...Sometimes at night when she finally goes to sleep I get a chance to lay down, and I just collapse in the chair.”

“I think I've had three showers since I've been here. Otherwise...I go into the washer room and I take a sponge bath every so often and wash my hair in the sink. So, it's been very unpleasant."Slide82

Theme- Communication“One point of contact with some extremely quick turnaround time would be best...a point person that no matter what even if they can't tell you anything, calls you and tells you...we need acknowledgement

.”

“It might be a good idea to force family member or the couple of them to sit down with...somebody who knows all the facts but can massage it through

.”

“The communication needs to be a little stronger with the family members that are going to be the ones ultimately giving the patient the care once they get out of here

.”

“Once I knew that he was physically ok, that they were taking care of him, I could start absorbing the things that people were giving me like information. I think at first it felt like there was a whole bunch of things coming at once and I really didn't know what to feel throughout.”Slide83

Theme - Caring about them/Emotional Support“As far as dealing with my mother, nobody asked me how I was holding up or nothing like that; I never talked to anybody about that… That might be something, yeah, that should be focused on.”Slide84

Results: What we need to keep doingFamily-centered environment

Open

visitation

Feeling

welcome & included in the patient’s

therapies

Trust

The

most frequent theme

All

participants felt that team members were skilled & “really cared”Slide85

Results: What we need to keep doing Family-centered Environment

Everyone has been really nice; it’s like a family environment. …They go above & beyond just to make me feel comfortable. They opened up the family lounge for me one night when I came in at 4:30 am.”

“I was surprised they would let me stay the night & that there were no visiting hours, cause they would have had a fight on their hands.”

“Another thing that was nice was the puzzles in the family room...and having that room to be able to go there -we'd eat dinner with him, that was very nice.”

“I heard a lot of repetitive & support from other fields & the fact that they're so willing to let you sit in & watch everything & explain things was a real support.Slide86

Results: ArtThe Draw a Bridge method did seem to inspire deeper communication and emotional expression in some participants. Slide87

Incorporating Art into ResearchQuestions that interviewers can use to deepen the inquiry

Awareness

of potential issues for caregivers

Needs

that cannot be articulated can sometimes be drawn

Opens

participant to emotional expressionSlide88

Implications Proactive solutions to providing family members with emotional support

Instill

hope through interactions with

interprofessional

team

Provide

for physical needs

Promote

acquisition of food

Provide

comfortable sleeping chair

Communicate

availability of shower

Implications

for future research:

Need

for studies to determine the effectiveness of interventions to support family members at the bedside in a rehabilitation and other settings

Study

other populations (e.g. traumatic brain, spinal cord injury) to compare results Slide89

LimitationsDue to the small sample size, no statistical significance can be determined from the FIN scale dataConvenience sampling of family present

Resisting the interest to fix problems Slide90

Palliative Care in the Stroke Patient

Theresa

Hamm RN, BA Stroke Coordinator Mercy Medical Center Des

Moines

,

Iowa

Background and Purpose

Palliative

and end of life care are gaining importance in the health care environment

Palliative

care underutilized in this population

AHA

scientific statement recognized the importance of study in this areaSlide91

MethodsRetrospective review of patients admitted during one year with diagnosis of acute ischemic stroke or hemorrhagic stroke

575

records

assessedSlide92

ResultsPopulation included 491 ischemic stroke and 84 hemorrhages81 patients received

t-PA

Discharge

status: 269 patients returned to home environment

114

patients admitted to acute rehabilitation unit

123

patients transferred to skilled nursing facility

29

patients transferred to hospice care

42

patients deceased in hospitalSlide93

Results20 patients with similar characteristics were discharged to skilled nursing facility with no discussion of palliative care or hospice documented.

A

review of records revealed provider disagreement for long-term prognosis as a significant barrier to patient/family discussions regarding end of life choices, or for supporting choices verbalized by patient/family opting for palliative care.Slide94

c

Conclusions

Based

on this data, a palliative care nurse was added to the stroke team and the stroke team coordinator joined the palliative care committee to assist in these conversations.

Palliative

care training for providers in now on-going in the acute care setting.

Primary care providers are being engaged in utilizing the Iowa Physician Order for Scope of Treatment (IPOST). This document was designed to promote community care coordination and advanced care planning in order to provide seamless communication and execution of individual care choices across the health care continuum.

As

these strategies are implemented, an increase in end of life planning is anticipated.Slide95

Is Online NIHSS Certification Enough Training?

Christa

Thompson, MSN,

RN St

. Claire Regional Medical Center,

Morehead

,

Kentucky; Chris

McDavid, RN,

CFRN St

. Claire Regional Medical Center, Morehead,

Kentucky; Lisa

Bellamy, RN,

CPHQUK/Norton

Stroke Care NetworkSlide96

BackgroundNIH Stroke Scale (NIHSS) is used for the initial assessment of patients with acute stroke.

Online

education vs. Performance at the bedside

Bridging

the gap Slide97

Phase 1 of Training114 nurses completed online NIHSS certification

Coaching

sessions offered

Voluntarily

participated in the Face-to-Face Instruction

Reviewed

background information of NIHSS

Reviewed

the 11-item assessment

Not

well attended

Nurses

ED 25

%

ICU 28

%

Medical-Surgical 37

%

Float

Pool 10%Slide98

Phase 2 of TrainingCompetency evaluation

Nursing Competency Fair

Nurses performed the NIHSS

Simulated stroke scenario

Evaluator was observational only

Feedback provided after completion

If failed, informed of remediation plan

Attend coaching session

Repeat evaluation competency

Submit to nurse manager

Phase 2 Results

RNs that failed per Specialty: (n=36)

n=19 Medical-Surgical

n=10 ICU

n=5 Emergency Department

n=2 Float PoolSlide99

Phase 3 of Training

If failed:

Coaching

session

Repeat

competency evaluation

Initiate Remediation Plan

Required

to attend a coaching session

Repeat

competency evaluation

Nurses

performed the NIHSS

Simulated

stroke scenario

Evaluator

was observational only

Feedback

provided after completion

Phase 3 outcome

Bridging the Gap

100

%

(n=36) that received remedial face-to-face instruction passed the repeat competency evaluation Slide100

In SummationOnline education supplemented with face-to-face instruction clearly improved the performance of the stroke assessment.Slide101

Church-based health intervention may help parishioners reduce stroke risk

Devin Brown, M.D., University of Michigan, Ann Arbor,

Mich

A church-based health intervention reduced stroke risk behaviors among Hispanic and non-Hispanic

parishioners

The Stroke Health and Risk Education (SHARE) Project was a faith-based, culturally-sensitive behavioral intervention study to reduce stroke risk factor behaviors such as physical inactivity, poor eating habits and uncontrolled high blood pressure. The one-year intervention included a physical activity guide with pedometer and educational materials on healthy eating and blood pressure management. It also included motivational counseling calls and a support workshop with peers.

Researchers applied the intervention to five of 10 Catholic churches in Corpus Christi, Texas. The other five served as a comparison group.

Those

in the intervention group had an increase of 0.25 cups a day in fruit and vegetable intake compared to the control group.

Of the 760 Hispanic and non-Hispanic white Catholic parishioners who participated in the study

:

Intervention group participants decreased salt intake by 123 milligrams per day, compared to the control group.

There was no difference between the groups in physical activity level improvement.

While more research is needed, SHARE's success in improving stroke risk behaviors suggests that faith-based programs may be useful to reduce stroke in communities including Hispanic Americans, the nation's largest minority population, researchers said.Slide102

Gender helps identify caregivers at poor health risk

Misook

L. Chung, Ph.D., R.N., University of Kentucky, Lexington,

Ky

Female caregivers are more likely than male caregivers to report poor health, especially when they perceive their roles as difficult or life

changing

Caregiving commonly results in caregivers' poor health. And women report more burden than men in similar caregiving situations. But it's unclear whether gender impacts the association between caregiving and poor health.

Researchers studied whether gender is associated with risk of poor health among caregivers based on caregivers' relationships (spouse or non-spouse) with stroke patients and whether caregivers are the same or opposite gender as patients

.

277

caregivers of stroke

survivors were surveyed

after the first two months, post-stroke.

Results

Caregiving for longer periods of time, difficulty of caregiving tasks and negative changes in life were highly associated with poor health status.

Female spousal caregivers reported strong links between difficulty of caregiving tasks and poor health status, and between negative perception of life changes due to caregiving and poor health status. The same was not true for male spousal caregivers.

Similar results were found for caregivers who were the opposite gender from patients.

Conclusion

Caregiver

gender and relationship with stroke patients might help identify caregivers at high risk of poor health.

More

study is needed to examine the dynamics that influence caregiving relationships to individualize

interventionsSlide103

Thank you for your attention!Questions?