VOL: 103, ISSUE: 31, PAGE NO: 32-33
Principal author: Janice L. Hinkle, PhD, CNRN, RN; Aravindakshan Manoj, MBBS, MD, MRCP; Susan Brook; Alastair Webb, BA, MB ChB; Weerasak Muangpaisan, MD; James Kennedy, MB ChB, MSc, MRCP; ; Alastair M. Buchan, BA, MA, BM BCh, MRCP, FRCP, FMedSci
Janice L. Hinkle, senior research fellow, Oxford Brookes University and acute stroke programme, John Radcliffe Hospital, Oxford; Aravindakshan Manoj is stroke research fellow; acute stroke programme, John Radcliffe Hospital, Oxford; Susan Brook and Alastair Webb are medical students, University of Oxford; Weerasak Muangpaisan is assistant professor, faculty of medicine, Siriraj Hospital, Thailand; James Kennedy is consultant, acute stroke programme, John Radcliffe Hospital, Oxford; Alastair M. Buchan is professor of clinical geratology, acute stroke programme, John Radcliffe Hospital, Oxford, and honorary consultant neurologist, Oxford Radcliffe Hospitals NHS Trust..
Abstract: Hinkle, J.L. et al (2007) Nursing triage of patients with acute stroke. www.nursingtimes.net
Prompt therapy for ischaemic stroke can reduce long-term disability. This prospective audit of 332 patients with suspected stroke investigated whether the nursing triage time and the time until first being seen by a doctor after patient arrival differed between A&E and the medical assessment unit (MAU).
There was no significant difference in the mean triage time but patients presenting to A&E were seen by a doctor sooner. Stroke is the third most common cause of death in the UK and the biggest single cause of severe disability in older people. Each year more than 130,000 people in England will have a stroke. In 2001-2002 strokes were estimated to cost the NHS 15,306 per patient over five years, increasing to 29,405 when informal care costs were included (Youman et al, 2003).
The Department of Health has recognised the importance of improving stroke services by including specific milestones, targets and actions in the National Service Framework for Older People in March 2001. In 2002 conditional EU approval was given for the treatment of ischaemic stroke with thrombolysis (Wahlgren et al, 2007). This therapy is time-dependent (Brous, 2005) and can reduce the risk of long-term disability if administered within three hours of symptom onset. Prompt nurse triage is essential to initiate early diagnosis and treatment (Domier et al, 2004). Similarly, to conserve resources, patients not likely to benefit from aggressive management need to be identified quickly. Patients with an acute illness present to hospital via the A&E department or to a MAU. In A&E, the Manchester triage system that was in use at the time of this study directs patients with stroke (most of whom are not fully conscious) to be triaged within 10 minutes (Manchester Triage Group, 2004).
The main aim of this prospective audit was to examine the descriptive characteristics of patients, characteristics of stroke and the clinical presentation of 332 patients with suspected stroke admitted during a six-month period. The main objective was to investigate if the nursing triage time and the time first seen by a doctor differed between patients arriving in A&E or MAU.
A secondary purpose was to assess other aspects of a newly implemented acute stroke thrombolysis service.
The drug alteplase (tissue plasminogen activator; t-PA) was approved by the Food and Drug Administration in the US in 1996, so there is a mass of literature and guidelines (Adams et al, 2005) from the US encouraging its use in the early treatment of ischaemic stroke. One US paper reported that the developmentof an acute stroke team and pathway decreased time to being seen by an A&E physician from 33 minutes the first year to seven minutes two years after implementation (Jahnke et al, 2003). Conditional EU approval was given for alteplase in 2002 but, despite this, in 2005 rates of thrombolysis in England were reported to be less than 1% (National Audit Office, 2005).
This review of the literature is restricted to countries with healthcare systems similar to the NHS. EU guidelines recommend patients with acute stroke receive emergency care according to a four-step chain (Hack et al, 2003). The first step is rapid recognition of and reaction to stroke warning signs and the second is immediate use of emergency medical system services. The FAST scoring system can help with the first two steps. The tool was developed from the research of Gary Ford in Newcastle, published in 2003 (Harbison et al, 2003), has been in use since 2002, and can help with these first two steps. FAST is an acronym that stands for Face, Arm, Speech and Test all three.
Facial movements: Ask the patient to smile or show teeth. Look for new lack of symmetry.
Arm movements: Ask the patient to lift their arms together and hold. Does one arm drift or fall down?
Speech: If the patient attempts a conversation, look for new disturbance of speech.
Test all three: If one or more is abnormal, suspect stroke.
The third step is to transport the patient to hospital by ambulance and notify the receiving hospital. If the patient is believed to be suitable for thrombolysis, the nearest specialist centre should be pre-alerted (Pre-Hospital Stroke Guidelines Group and the Intercollegiate Stroke Working Party, 2004).
The fourth and final step in the chain is rapid and accurate diagnosis and treatment at the hospital (Hack et al, 2003). Swift nursing triage is essential for this. Many system changes have been studied in attempts to decrease various time factors in acute ischaemic stroke. One group in Finland reported the use of nurse triage (Lindsberg et al, 2006) and a Canadian group reported on the development of a regional acute stroke protocol that included rapid triage and assessment (Riopelle et al, 2001). Neither of these groups reported any actual triage times.
Acute stroke thrombolysis was introduced to Christchurch Hospital in New Zealand in 2002. Time from onset to hospital presentation, door to computed tomography scan and door to drug administration times were reported but no triage times (Fink, 2005). The door to drug administration time in Cologne, Germany, has been reported as an average of 48 minutes (Grond et al, 1998). Neither study reported nurse triage or length of time until seen by a physician.
Nursing triage times have been addressed in very few studies. A Canadian group reported using a stroke best practice pocket card that advertised their goal of triaging patients within one minute. This reduced triage times from 37 minutes before implementation of the project to eight minutes the first year, and subsequently 4.1 minutes (Bisaillion et al, 2005). An Australian group reported on optimising stroke outcomes through the use of evidence-based practices (Jones and Stewart, 2002). It highlighted that the triage nurse plays a vital role in early identification and onset of treatment for acute stroke but no triage times were reported.
Times seen by physicians have been addressed in very few non-US studies. A group in Turkey reported a 21-minute delay in the wait for neurological consultation for acute ischaemic stroke patients (Keskin et al, 2005).
A systematic review of barriers to thrombolysis for acute stroke identified that A&Es did not triage stroke as an emergency (Kwan et al, 2004) and that the median delay from arrival at hospital to first medical assessment varied from 20 minutesto four hours. Similar to the FAST score, devised to be used in the pre-hospital phase of care, a tool has been developed and validated to assist in the A&E phase of care of the stroke patients. The recognition of stroke in the emergency room (ROSIER) is a seven-item scale that has been tested on 343 patients with suspected stroke (Nor et al, 2005). Researchers have reported that ROSIER has a sensitivity of 92%, specificity of 86% and a positive predictive value of 88%. In summary, neither the average nursing triage times nor times seen by a physician for acute stroke in the UK are known. Therefore this study was undertaken.
This study used a prospective audit methodology to investigate a number of variables in 332 patients with suspected stroke admitted to John Radcliffe Hospital at Oxford Radcliffe Hospitals NHS Trust. Nursing triage times and the times until seen by a physician were compared for patients who presented to A&E and those who presented to the MAU. Demographic characteristics collected included well-accepted parameters such as age, gender and whether there had been a previous stroke or not (Demchuk and Buchan, 2000; Jongbloed, 1986). Other characteristics collected included place of residence, living arrangements (presence of carers) and mortality, as these have long been recommended to increase the comparability of stroke studies (Task Force on Stroke Impairment Disability and Handicap, 1990).
Variables characterising the stroke included the Bamford classification and stroke risk factors. The Bamford classification is in widespread use. It classifies stroke into the subtypes of lacunar infarcts (LAC), total anterior circulation infarcts (TAC), partial anterior circulation infarcts (PAC) and posterior circulation infarcts (POC), according to clinical signs and symptoms (Bamford et al, 1991). Hypertension, diabetes, cardiac disease, hyperlipidaemia and atrial fibrillation are well-known risk factors for stroke (Demchuk and Buchan, 2000; Jongbloed, 1986). Data was coded and entered into the statistical package for the social sciences (SPSS), version 14 for analysis (SPSS, 2005). Descriptive summary statistics were used to provide a description of the demographic and stroke characteristics of patients. Times were compared between patients entering the system via A&E and MAU using t-tests.
Table 1 shows the main demographic characteristics of the patients. The mean age was 76 years (range 32-97) and the majority of patients were female (54%). Prior to acute care admission, 90% were living in their own home, 2% were living in a residential home, 5% were admitted directly from a nursing home and 3% had other types of living arrangements. Irrespective of admission location, 89% arrived to the hospital via ambulance and 11% presented on their own. Most patients (53%) found their way into the health system by calling an ambulance, 40% called their GP and the other 7% contacted family members or others.
Table 1. Demographic characteristics (n=28)
|Age ranges32-79 years 54%80-97 years 46%|
|Presence of carerYes 17 %|
|Lives aloneYes 33 %|
|Previous strokeYes 28 %|
Table 2 shows the presenting clinical syndromes of stroke and the major risk factors found in the patients with suspected stroke. Peripheral vascular disease was reported in 1% of the patients and congestive heart failure in 4%.
Table 2. Characteristics of stroke
|LACS 25 (84/ 332)|
|TACS 15 (51/332)|
|PACS 19 (63/332)|
|POCS 12 (40/332)|
|TIA 8 (26/332)|
|Other 7 (23/332)|
|Bamford classification missing 14 % (45/332)|
|Stroke risk factors|
|Hypertension 50 (166/332)|
|Diabetes 15 (51/332)|
|Heart disease 22 (72/332)|
|Hyperlipidemia 15 (51/332)|
|Atrial fibrillation 21 (69/332)|
|Received thrombolysis 2 (7/332)|
|LACS = Lacunar infarcts; TACS = Total anterior circulation infarcts; PACS = Partial anterior circulation infarcts; POCS = Posterior circulation infarcts; TIA = Transient ischaemic attack|
Patients arriving at A&E constituted 64% (n=213) of the sample and those presenting directly to MAU 35% (n=115). A few patients (n=4) bypassed both A&E and MAU. Table 3 shows the mean, standard deviations and the range for the triage times and time until seen by physician for patients arriving in A&E and the MAU. The mean nursing triage time for patients presenting to A&E was 14 minutes (n=183) and for those presenting to the MAU 19 minutes (n=78). There was no significant difference between these times.
Table 3. Means and standard deviations for times
|Time||Mean (SD) A&E time||Mean (SD) MAU time|
|Nurse triage||14 (+ 16) minutesRange 0-92 minutes||19 (+ 25) minutesRange 0-122 minutes|
|Time until seen by physician||49 (+ 49) minutesRange 0-198 minutes||84 (+ 70) minutesRange 0-276 minutes|
The mean time from nursing triage to the patient being seen by a doctor in A&E was 49 minutes (n=157) compared with 84 minutes in MAU (n=58). The difference between these times was significant [t=-3.468, df=77.567, p<0.001].
This study found that the mean age of stroke patients was 76 years and that the majority of patients were female. This is similar to findings by other European studies. Other researchers have reported that approximately half of all strokes in Oxfordshire occur in the over-75s (Rothwell et al, 2005). Even though they were older, only 17% of patients reported having a formal carer prior to admission. However, only 33% lived on their own, suggesting informal care arrangements were perhaps in place for managing activities of daily living before the stroke. To our knowledge, this is the first report of nursing triage times and times first seen by physicians for acute stroke in the UK.
In comparison to the initial triage time of 37 minutes reported by another study (Bisaillion et al, 2005), our nursing triage times of 14 minutes in A&E and 19 minutes in MAU are commendable. This can be explained by early teaching about thrombolysis and the use of a pocket card to increase awareness among A&E staff of the inclusion and exclusion criteria for acute stroke.
Efforts are needed to continue to improve the time and bring it within the 10-minute recommended time in the Manchester triage system that was in use at the time of the study. The reported times patients were first seen by physicians in this study of 49 minutes in A&E and 84 minutes in MAU are in the middle range of the 20-minutes to four-hour range reported in a systematic review (Kwan et al, 2004). A possible explanation for delays may be that doctors put down the time when they take the patient history and write their notes. The results of this study have been presented to A&E staff to raise awareness in attempts to shorten nurse triage time and time until seeing a doctor.
The possibility of using the ROSIER score for earlier and easier stroke recognition has been discussed. The acute stroke programme has become more involved in training junior doctors to increase their awareness of the availability of thrombolysis for patients with acute ischaemic stroke. It is also important for nurses and doctors to be aware that the benefits of early identification of patients with stroke extend to patients who do not qualify for thrombolysis. Performing computed tomography scans on all patients with stroke immediately is cost-effective (Wardlaw et al, 2004). Furthermore, the admission of patients to a stroke unit is well-recognised evidence-based practice (Stroke Unit Trialists’ Collaboration, 1997).
This study does have some limitations. The first is a sampling bias because some patients who had their stroke while in the hospital were excluded. Secondly, the audit methodology for data collection relied on nurses and physicians recording variables of interest for the study. There was missing and unusable data for times when patients were triaged and seen, as well as other variables.
This study contributes to the understanding of several factors that affect how long it is before patients with stroke in the UK are seen by a doctor. Nurses see suspected stroke as an emergency and triage the majority of patients with stroke appropriately, but still not within the 10 minutes designated by the Manchester triage system. There is a delay in physicians seeing acute stroke patients, which is greater in the MAU than in A&E. Further work is needed in this area.
First of all, in our trust, there is a need to repeat the study to evaluate the effectiveness of strategies implemented to reduce triage times and times until patients are first seen by a physician. Second, there is a need to extend the study to other trusts and a larger population to be able to generalise the results.
Implications for nursing practice
- Ambulance services need to identify acute stroke using the FAST score and pre-alert hospitals to the arrival of patients who potentially need thrombolysis.
- Nurses working in both an A&E and MAU settings need to see patients with a stroke as an emergency and triage patients with suspected stroke quickly for early diagnosis.
- The ROSIER is a scale that can assist with recognising patients with stroke in A&E.
- Patients need to be identified early to qualify for thrombolysis therapy as well as other cost-effective diagnostic studies and interventions.
Adams, H. et al (2005) Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke; 36: 4, 916-921.
Bamford, J. et al (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet; 337:1521-26.
Bisaillion,S.et al (2005) Best practices in stroke care. Canadian Nurse; 101: 8, 25-29.
Brous, E. (2005) A patient with an undetected evolving stroke: legal lessons learned. Journal of Emergency Nursing; 31: 6, 580-582.
Demchuk, A.M., Buchan, A.M. (2000) Predictors of stroke outcome. Neurologic Clinics; 19: 2, 455-473.
Domier, R. et al (2004) From research to the road: the development of EMS specialty triage. Air Medical Journal; 23: 4, 28-31.
Fink, J. (2005) Twelve-month experience of acute stroke thrombolysis in Christchurch, New Zealand: emergency department screening and acute stroke service treatment. New ZealandMedical Journal; 118: 1214, 1-14.
Grond, M. et al(1998) Early intravenous thrombolysis for acute ischemic stroke in a community-based approach. Stroke; 29: 8, 1544-1549.
Hack, W. et al (2003) European stroke initiative recommendations for stroke management - update 2003. Cerebrovascular Diseases; 16: 4, 311-337.
Harbison, J. et al (2003) Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke; 34: 71-76.
Jahnke, H.K. et al (2003). Stroke teams and acute stroke pathways: one emergency department’s two-year experience. Journal of Emergency Nursing; 29: 2, 133-139.
Jongbloed, L. (1986) Prediction of function after stroke: a critical review. Stroke; 17: 4, 765-776.
Jones, J., Stewart,S. (2002) Optimising stroke outcomes through evidence-based nursing practice: an Australian perspective. European Journal of Cardiovascular Nursing; 1: 227-235.
Keskin, O. et al (2005) A clinic investigation into prehospital and emergency department delays in acute stroke care. Medical Principles and Practice; 14: 6, 408-412.
Kwan, J. et al(2004) A systematic review of barriers to delivery of thrombolysis for acute stroke. Age and Ageing; 33: 2, 116-121.
Lindsberg, P.J. et al (2006) Door to thrombolysis: ER reorganization and reduced delays to acute stroke treatment. Neurology; 67: 2, 334-336.
Manchester Triage Group (2004) Emergency Triage. London: BMJ Publishing Group.
National Audit Office (2005) Reducing Brain Damage: Faster Access to Better Stroke Care (HC 452 Session 2005-2006). London: Department of Health.
Nor, A.M. et al (2005) The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurology; 4: 1, 727-734.
Pre-Hospital Stroke Guidelines Group and the Intercollegiate Stroke Working Party (2004) Recognition and Emergency Management of Suspected Stroke and TIA (Guideline). London: RoyalCollege of Physicians.
Riopelle, R.J. et al (2001) Regional access to acute ischemic stroke intervention. Stroke; 32: 6, 652-655.
Rothwell, P.M. et al (2005) Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford vascular study). Lancet; 366: 9499, 1773-1783.
SPSS (2005) Statistical Package for the Social Sciences: SPSS base version 14 for Windows (Version 11). Chicago: SPSS INC.
Stroke Unit Trialists’ Collaboration (1997) Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. British Medical Journal; 314: 7088, 1151-1159.
Task Force on Stroke Impairment, Disability and Handicap (1990) Symposium recommendations for methodology in stroke outcome research. Stroke; 21: Supp II, II-68-II-73.
Wahlgren, N. et al (2007) Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet; 369: 9558, 275-282.
Wardlaw, J.M. et al (2004) Immediate computed tomography scanning of acute stroke is cost-effective and improves quality of life. Stroke; 35: 11, 2477-2483.
Youman, P. et al (2003) The economic burden of stroke in the United Kingdom. Pharmacoeconomics; 21: Supp 1, 43-50.