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Improving stroke care

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IT IS MAY 2003. A patient is admitted to an acute medical ward with a suspected ischaemic stroke. Ten days later he receives his first dose of aspirin - a week later than the recommended 48 hours of the National Clinical Guidelines for Stroke. Despite a swallowing assessment advising thick oral fluids only, he is prescribed oral soluble aspirin. A month later he dies.

IT IS MAY 2003. A patient is admitted to an acute medical ward with a suspected ischaemic stroke. Ten days later he receives his first dose of aspirin - a week later than the recommended 48 hours of the National Clinical Guidelines for Stroke. Despite a swallowing assessment advising thick oral fluids only, he is prescribed oral soluble aspirin. A month later he dies.

It is May 2004. A patient is admitted via A&E, where he is assessed by a nurse from the new acute stroke unit. A CT scan is ordered by a senior nurse the following morning and the results are ready by the time the patient returns to the unit. A nurse prescribes a rectal dose of aspirin after carrying out a swallowing assessment. The patient is soon transferred for rehabilitation.

This stark contrast in patient care demonstrates the success of a groundbreaking expansion of the role of nurses on the acute stroke unit at HopeHospital in Manchester, part of Salford Royal Hospitals NHS Trust.

Aspirin is the main treatment for ischaemic stroke, saving one life per 100 patients treated. As the condition is initially indistinguishable from haemorrhagic stroke, a CT scan is required. In addition, 50 per cent of stroke patients have swallowing difficulties, which means that without an assessment the administration of aspirin by an inappropriate route can do more harm than good.

When the unit opened last May, the role of nurses was extended to include ordering CT scans (senior nurses only), carrying out swallowing assessments and prescribing first doses of aspirin.

'As far as I am aware, there is not another trust where nurses actually have this role. It

is very exciting to be involved,' says ward manager Sarah Roberts (pictured right). And last year, this achievement won the unit's multidisciplinary team the BUPA Foundation Award for Clinical Excellence.

'For us, it is what I would call the 'feel good factor',' enthuses Doreen Kerfoot (pictured left), one of the staff nurses at the unit.

This success is a testimony to the power of effective multidisciplinary working.

First, Ms Roberts, together with junior sister Claire Ardron, one of the stroke specialist nurses, a doctor and a speech and language therapist devised a programme to train nurses on the unit in water swallowing assessments.

A patient group directive was then written for the supply and administration of 300mg of aspirin by nurses, and Ms Roberts and Ms Ardron undertook the radiology training necessary to order CT scans.

Initially 12 nurses between D and G grade were trained to take on the new role. 'It was very exciting,' recalls Ms Kerfoot. 'It was very good for my development and actually improved my confidence immensely. Although there is always support there, it was a bit scary at first.'

The experience has proved invaluable. 'It has given me a better understanding of stroke and the immediate treatment needed,' says Ms Kerfoot.

Ms Roberts agrees. 'You are looking for things you wouldn't usually look for, acutely aware of certain implications and problems,' she says, adding that this increased nursing expertise has been recognised by colleagues around the hospital. 'We've been accepted well, especially by A&E staff. People are now ringing for advice.'

However, it did take a while for colleagues in other professions to adjust to the change. 'In the beginning we got resistance from speech and language therapists. But now we are well received, and our reputation goes before us. A lot of trusts are coming to us to see what we have done,' enthuses Ms Roberts.

The benefits to patients have been clear and immediate. 'Now they are getting stroke care from the moment they arrive at hospital by nurses who are experienced and enthusiastic about stroke care,' says Ms Roberts.

And the data confirms her enthusiasm for the scheme. Now as many as 80 per cent of patients receive a swallowing assessment on their day of admission, a CT scan within 24 hours, and their first dose of aspirin within 48 hours. In addition, the average length of stay has fallen from 29 to 15 days.

A particularly successful aspect of the scheme has been enabling nurses to initiate treatment quickly without waiting for medical staff.

'When someone comes in at 7pm and fails a swallowing test, we can insert a nasogastric tube straightaway and initiate an emergency enteral feeding regime that we can use for up to three days,' explains Ms Roberts.

Phase two of the project is due to start in March. Nurses will then be trained to carry out diet swallowing assessments to ascertain whether patients can tolerate a normal or pureed diet or should remain nil by mouth, preventing the unnecessary insertion of nasogastric tubes.

Some of the £10,000 prize money from the BUPA award will be used to train more nurses and support workers to carry out the role. But Ms Roberts says the award has boosted more than monetary funds.

'For someone to turn around and say 'this is clinical excellence' makes you sit up and think what excellent care we do give on the unit. It is great for that to be recognised.'

She believes the unit's success shows how updating nurses' skills can raise the national standard of acute stroke care and boost the profession.

'The new roles have made people more aware of what nurses can do. It shouldn't make a difference whether you are admitted at 2am or 4pm. We should be able to provide the same service to patients 24 hours a day, and that is what we are now providing.' 

Extending the role of nurses

to improve care of patients

 Securing the support and backing of a multidisciplinary team is crucial - especially

as extending nurses' roles may mean 'encroaching' on the skills set of other professional groups.

 Audit before the role is introduced, and again using similar parameters a set period afterwards, so that you have clear evidence of its impact on patient care.

 The opening of a new unit, ward or service can be the ideal time to think about extending nurses' roles - a new environment on its own is often not enough to significantly improve patient care.

 Make sure you put your team forward for any appropriate awards. They are a valuable way to share best practice, draw attention to your effort and secure future funding.

 Always plan ahead. A well thought-out training programme, and ongoing support for staff taking on new roles, is crucial to success and to demonstrating competence and guaranteeing patient safety.

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