Kiernan, Terri E

The evidence base supporting the management of patients with acute stroke is evolving at a rapid rate, as new methods that aim to reduce disability and death from stroke are explored. Intravenous tissue plasminogen activator remains the only treatment shown in numerous studies to reduce disability 3 months after stroke with no increase in the risk of death and a relatively minor rate of symptomatic intracerebral hemorrhage complications. Despite these findings, health care providers have been slow to adopt this evidence-based treatment, which results in many patients experiencing disability caused by stroke. Numerous controversies exist related to the management of patients with acute stroke, including the use of tissue plasminogen activator, positioning and early mobility, blood pressure lowering in acute intracerebral hemorrhage, and even the use of innovative advanced practice nurse–led stroke treatment teams, with varying amounts of evidence available to provide direction. This article explores controversies associated with both approved and evolving treatments for ischemic and hemorrhagic stroke and makes recommendations for practice on the basis of the body of existing evidence, with an aim to improve the delivery of acute stroke treatment.

Background: The promotion of acute stroke care is stronger now than it has ever been with hospitals being encouraged to become primary and comprehensive stroke centers (PSC & CSC). This is a hardship for some institutions due to the national shortage of American Board of Psychiatry and Neurology certified Vascular Neurologists and Emergency Medicine Physicians’ concern over independent decision making regarding thrombolysis eligibility without neurology collaboration. Hospitals and private physician practices are turning to Clinical Nurse Specialists (CNS), Nurse Practitioners (NP) and Physician Assistants (PA) to provide a continuum and maintain coordination of care in concurrence with vascular neurologists. The aim of this presentation is to identify the CNS-NP-PA roles and responsibilities. Method: An eight question, multiple choice with 3 multiple answer survey, which addressed certification, duration of stroke experience, role with CT reviewing, thrombolysis administration, and duties was sent to community and academic PSC and CSC CNS-NP-PAs from Neurovascular Education and Training in Stroke Management and Acute Reperfusion Therapy (NET SMART) program by means of a URL. Results: There were 44 respondents, NPs 65.9%, PAs 4.9% and CNS 29.2% with experience in stroke care totaling 1 to 2.9 years in 20.5%, 3 to 4.9 years in 15.9% and ≥ 5 years in 63.6%. Acute CT evaluation was completed autonomously by 10%, with radiology collaboration in 47.5%, and with neurology collaboration in 37.5%, with 5% responding “do not review”. Multiple choice with multiple answers pertaining to thrombolysis decision making; 7.3% reported working autonomously, 29.3% with physician collaboration by telephone, 63.4% with physician at bedside, and 17.1% reported no involvement with thrombolysis decisions. Delineation of responsibilities, also completed with multiple answers included acute inpatient stroke care for 95.2%, out patient stroke care for 23.8%, discharge planning 45.2%, stroke coordinator role 71.4%, core measure database extraction for 50.0% with input of database completed by 47.6%. Education conducted for patients at 81%, for nursing was 90.5%, for peers at 57.1%, for medical residents 40.5%, for neurology residents 16.7% and for community education 73.8% of responders. Conclusion: Although individual responsibilities may vary, the survey illustrates the CNS-NP-PA are valuable roles in the assessment, diagnosis, management, coordination and continuum of stroke care. More research is warranted to further evaluate these roles and quality stroke patient outcomes.

Background: Atrial fibrillation (AF) is an important modifiable and independent risk factor for stroke. AF is associated with 2-4% annual risk for first time stroke and about 8% annually for recurrent stroke. Anticoagulant therapy reduces the risk by 60%, while the relative risk reduction (RRR) obtained from antiplatelet therapy is only 20%. The effect is more robust for secondary than for primary prevention. Risk stratification schemes are utilized to assess an individual’s risk of future stroke and to determine the optimal antithrombotic or anticoagulation regimen for stroke prevention. Despite Warfarin’s superiority over antiplatelet therapy to reduce the risk of AF related systemic embolism, Warfarin is largely underutilized. The aim of this study was to determine the frequency and reasons behind withholding anticoagulation in patient with AF related cardioembolic stroke in our institution. Method: We extracted patients from our Get With The Guideline’s (GWTG) database who were admitted to Mayo Clinic AZ between January 2004 and December 2009. Two authors (TK and NL) independently identified all patients with the diagnosis of atrial fibrillation who were not prescribed Warfarin therapy upon discharge, then reviewed to identify the reason(s) why anticoagulation was not initiated. Factors such as discharge disposition (home, acute rehabilitation, long term nursing facility, hospice, other) and functional status (able to ambulate independently, with assistance, unable to ambulate, or not documented) were also assessed to help support the decision process. Results: From a total of 1295 patients, 305 with AF were identified. Patients who expired 48 (3.7%) from un-related causes were excluded. Of the 257 patients, 206 (80.2%) were anticoagulated and 51 (19.8%) were not anticoagulated. We found that in the anticoagulated group, patients discharged home were more likely to receive anticoagulation (89.2%), followed by those discharged to acute rehabilitation and skilled nursing facilities (77%). Those discharged to hospice were the least likely to receive anticoagulation (6.4%). In addition, patients with greater functional ability were also more likely to receive anticoagulation (independent 89.8%, vs. assisted 76.7%, vs. non-ambulatory 33.3%; p<0.0001). Reasons to withhold anticoagulation therapy at discharge included terminal illness/comfort measures only (40.0%); risk/discomfort due to bleeding (24%); risk of falls (13.0%); and patient refusal (9.0%). Discussion: Based on the results, we conclude that functional status and disposition at discharge are significant factors influencing the decision to anticoagulate after cardioembolic stroke attributed to AF.