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Care of the Patient with Acute Ischemic Stroke Stroke AHA SCIENTIFIC STATEMENT Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement A Scientific Statement From the American Heart Association Endorsed by the American Association of Neuroscience Nurses Susan Ashcraft, DNP, APRN, FAHA, Chair; Susan E. Wilson, DNP, APRN; Karin V. Nystrӧm, MSN, APRN, FAHA; Wendy Dusenbury, DNP, APRN, FAHA; Charles R. Wira, MD, FAHA; Tamika M. Burrus, MD; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council ABSTRACT: The year 2020 was the year of the nurse, celebrating nurse scholarship, innovation, and leadership by promoting scientific nursing research, improving nursing practice, advancing nursing education, and providing leadership to influence health policy. As architects of stroke care, neuroscience nurses play a vital role in collaborating and coordinating care between multiple health professionals. Nurses improve accessibility and equity through telestroke, emergency medical services, and mobile stroke units and are integral to implementing education strategies by advocating and ensuring that Downloaded from http://ahajournals.org by on March 12, 2021 patients and caregivers receive stroke education while safely transitioning through the health care system and to home. Stroke care is increasingly complex in the new reperfusion era, requiring nurses to participate in continuing education while attaining levels of competency in both the acute and recovery care process. Advanced practice nurses are taking the lead in many organizations, serving as prehospital providers on mobile stroke units, participating as members of the stroke response team, and directing stroke care protocols in the emergency department. This scientific statement is an update to the 2009 “Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient.” The aim is to provide a comprehensive review of the scientific evidence on nursing care in the prehospital and hyperacute emergency hospital setting, arming nurses with the necessary tools to provide evidenced-based high-quality care. Key Words: AHA Scientific Statements ■ brain ischemia ■ health policy ■ nursing care assessment ■ nursing education research ■ reperfusion ■ stroke he year 2020 was the year of the nurse, celebrating nursing research, improving nursing practice, advancing nurse scholarship, innovation, and leadership while nursing education, and providing leadership to influence Tcommemorating the founder of modern nursing, health policy. Scientific nursing guidelines provide a body Florence Nightingale. This recognition is timely as nurses of knowledge assisting nurses in addressing complex demonstrate their immeasurable contributions and cour- health needs and promoting quality care. age on the front lines caring for patients diagnosed As the largest group of health care professionals, with coronavirus disease 2019 (COVID-19). Although nurses span multiple areas of the health care infra- these are uncertain times, the spirit of nursing has not structure and play vital roles in advancing the health wavered, thrusting a spotlight on the heroic stories of of families in their communities. Furthermore, as we healing, commitment, innovation, and leadership. Nurses learn more about health disparities, nurses are uniquely conserve Nightingale’s legacy by promoting scientific equipped to be advocates for patients of different Supplemental materials are available with this article at https://www.ahajournals. org/doi/suppl/10.1161/STR.0000000000000356. © 2021 American Heart Association, Inc. Stroke is available at www.ahajournals.org/journal/str Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000356 TBD 2021 e1 Ashcraft et al Prehospital Acute Care of Ischemic Stroke socioeconomic, racial, gender, and sexual orientations. Table 1. D’s of Stroke Care Because of the potential impact of nursing, in 2010, Detection Rapid recognition of stroke symptoms the Institute of Medicine published The Future of Nurs- Dispatch Early activation and dispatch of EMS by calling 9-1-1 ing: Leading Change, Advancing Health report, address- Delivery Rapid EMS identification, management, and transport ing the critical role that nurses play in transforming Door Appropriate triage to stroke center health care.1 Data Rapid triage, evaluation, and management within the ED AND GUIDELINES AND The neuroscience nurse has risen to the Institute of Decision Stroke expertise and therapy selection CLINICAL STATEMENTS STATEMENTS CLINICAL Medicine’s challenge by using evidence-based improve- ment to guide care, participating in research, promoting Drug Fibrinolytic therapy, intra-arterial strategies interprofessional collaboration, and expanding education Disposition Rapid admission to stroke unit, critical care unit for patients, families, and health care professionals.2 As ED indicates emergency department; and EMS, emergency medical services. one of the architects of the stroke care team, the nurse Adapted from Jauch et al.6 Copyright © 2010 American Heart Association, Inc. plays a vital role in collaborating and coordinating care between multiple health professionals. Nurses are inte- safely deliver the patient to the appropriate acute care gral to implementing education strategies by advocating setting. and ensuring that patients and caregivers receive stroke Nurses have been at the forefront, providing exten- education and are safely transitioned through the health sive educational opportunities to prehospital providers, care system and to home. dispatchers, and community members to support the “D’s Stroke care is increasingly complex in the new reper- of Stroke Care.” The D’s of Stroke Care (Table 1) have fusion era, requiring nurses to participate in continuing been identified as major steps in the diagnosis and treat- education while attaining levels of competency in both ment of stroke and highlight integral points where nurses 6 the acute and recovery care process. Advanced practice facilitate time-sensitive stroke care. nurses are taking the lead in many organizations, serving as prehospital providers on mobile stroke units (MSUs), Detection participating as members of the stroke response team, Nurses have historically played a role in educating the and directing stroke care protocols in the emergency public on recognizing the warning signs and symptoms of department (ED). This scientific statement is an update stroke. Understanding the social determinants of health to the 2009 “Comprehensive Overview of Nursing and Downloaded from http://ahajournals.org by on March 12, 2021 and targeting high-risk groups to tailor interventions are Interdisciplinary Care of the Acute Ischemic Stroke essential in improving individual response to stroke symp- Patient.”3 The aim is to provide a comprehensive review tom recognition.5 In fact, certified stroke programs are of the scientific evidence on nursing care in the prehos- required to host yearly public awareness campaigns to pital and hyperacute emergency hospital setting, arming meet certification standards. Programs directed at com- nurses with important clinical tools to provide evidenced- munity awareness of stroke warning signs and symptoms based care. Recommendations for future research to and personal risk factors have been successful in venues guide nursing practice are also proposed. such as elementary and middle schools (ie, Hip Hop Stroke and Stroke Heroes Act Fast); faith-based communities; local service organizations; festivals (ie, Stomp Out Stroke); PREHOSPITAL STROKE CARE: sporting events (ie, Strides for Stroke and Strike Out EMERGENCY MEDICAL SERVICES AND Stroke); independent-living communities; barbershops; and MSUs sustained public education campaigns supported by state, health care, and national organizations such as the Ameri- Prehospital can Heart Association (AHA)/American Stroke Associa- The “time is brain” principle emphasizes the time-sensi- tion. Familiarity with signs and symptoms of stroke enables tive nature of early identification of patients with a sus- the public to recognize when someone may be exhibiting pected ischemic stroke and early intervention to prevent stroke symptoms and rapidly activate EMS.5 a delay in reperfusion that leads to irreversible tissue damage and poor patient outcomes.4 Inequities related to emergency care access and knowledge of stroke Dispatch warning signs remain poor, with the largest disparities Prehospital dispatch personnel, generally one of the occurring in women and underrepresented race and eth- first points of entry into the health care system, play an nic groups, contributing to delays in emergency medical important role in the timely care and possible treatment services (EMS) activation and ED presentation.5 There- options for the patient with a potential stroke.6 The dis- fore, it becomes critically important that, when activated, patcher should be trained to recognize when a caller may prehospital professionals recognize stroke symptomatol- be requesting help for a person with a range of neuro- ogy, work quickly to obtain the required information, and logical deficits and have the ability to talk a caller through e2 TBD 2021 Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000356 Ashcraft et al Prehospital Acute Care of Ischemic Stroke Table 2. Prehospital Triage Factors assessment, collection of the patient’s current medica- STATEMENTS CLINICAL Distance to stroke-capable facility
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