Authors (including presenting author) :
Kwok WYV(1), Fong WC(1), Cheung YF(1), Lo WT(1), Chan LT(1) , Chan HF(1), M Ismail (1) , Li TC(1) , Chan CC(1), Chan CH(1), Luk CO(1), Chau SK(1), Ho YT(1), Lui CM(1), Wong MS(1), YuenMK(1), Chan ST(1), Fong CS(1), Or HF(1), Chan NM(1)
Affiliation :
(1) Department of Medicine, Queen Elizabeth Hospital
Introduction :
Timely assessment and management is important for patients presenting with acute stroke so that patients could be eligible for reperfusion therapy within the therapeutic window. In Queen Elizabeth Hospital, in order to enhance the care of in-patient strokes, stroke nursing service to provide timely assessment and management for in-patient strokes has been established since 2013.All staff can call Stroke nurse for Stroke activation. Once notified, stroke nurses will timely assess those patients and speed up the management if deemed necessary.
Objectives :
To investigate if notification of stroke nurse will lead to improvement in patients’ outcome.
Methodology :
This is a retrospective cohort study. In-patient strokes admitted in the year of 2020 were identified by the stroke nursing call logbook with calls prospectively documented, as well as by CDARS discharge diagnosis of 1) acute stroke and 2) brain computed tomography (CT) scan not performed within 24 hours from admission.
Result & Outcome :
In the year 2020, there were 606 Acute Stroke calls activated and assessed by the Stroke nursing team. Amongst these 9.58% (53 patients) were In-patient strokes, the rest were activated by the AED. Twelve patients received intravenous thrombolysis, 3 received mechanical thrombectomy and 2 received a combination of both therapies. For the remaining patients, 10 had onset-to-assessment times over 4.5 hours, 5 were intracerebral haemorrhages, 1 had established infarction on CT of the brain, 5 patients had other contraindications to thrombolysis, 3 patients with risk more than benefit. Six patients had stroke symptoms fully recovered upon assessment. Three were acute stroke mimics. Lastly, 3 patients refused thrombolysis.
From the CDARS search, there were 11 in-patient strokes without notification of stroke nurses identified. Four were intracerebral haemorrhages, 1 had established infarction on CT. Three patients’ onset-to-found-unwell-time was over 4.5 hours.
In the remaining 3 cases, though onset times were not recorded, there were possible potential for acute stroke therapy according to find unwell time and last seen well time in the medical records.
In the notified group, the median symptoms identified-to-CT time was 57.5 minutes. The mean Stroke nurse assessment-to-CT time was 20.8 minutes. In the non-notified group, the median symptoms identified-to-CT time was 607 minutes. The notified group had a statistically significant shorter symptoms identified-to-CT time than the non-notified group (p=0.001). The median symptoms identified- to-assessment time in the notified group was shorter as compared to non-notified group. (80 vs 205 minutes, p=0.563)
Seventeen out of the 53 cases (32%) received reperfusion therapy in the notified group while none received reperfusion therapy in the non-notified group. (p = 0.03). The proportion of patients having 3-month Modified Rankin Scale of 0-2 in the notified group and the non-notified group were 24.5% and 0% respectively. (p=0.066)
Patients presenting with TIAs or other medical conditions could develop severe disabling stroke even during hospitalization. The study had showed that if stroke nurses are timely involved, they can help trigger off a series of management for the patient including review of patients medical and drug history, assess the neurological status, confirm whether the stroke is within the time window, and if so, help arrange immediate CT brain, and notify relevant colleagues for possible intravenous thrombolysis and or mechanical thrombectomy. All these facilitate treatment within a short therapeutic time window. More patients can be treated with reperfusion therapy. Even if ultimately the patient had ICH instead of ischemic stroke, subsequent management can proceed earlier after the CT brain is done. After the patient’s condition is settled, stroke nurses can also give feedback and have sharing with non-stroke ward colleagues on acute stroke management, and to identify potential barriers in the stroke management pathway.
