International Stroke Conference
2015
Hot Topics
Jennifer Cohn, MSN, FAHA
April 17th, 2015
Disclosure
• Educational consultant for Codman
Objective
• Apply new research topics presented at the International Stroke
Conference and discus the relevance of at least two new practices
that many influence your own program/practice.
ISC – What is it? And Why is it important?
• Forum for disseminating clinical stroke trial results and sharing of best practices
within the field
• Occurs annually in February
• Next year is in Los Angeles, CA
• February 16th is State of Science Nursing symposium
• February 17th-19th ISC sessions
• Options for submitting abstracts, projects, research is open to everyone at
Strokeconference.org
• Can submit to the SOS nursing symposium and the nursing section in ISC proper
• 2016 Call for abstracts - May 20- Aug 11, 2015
• Great opportunity to get involved
State of the Science Nursing Symposium
• Nursing attendance this year was close to 800
• The first year of the nursing symposium there were less than 50 participants.
• The afternoon offers many breakouts with mix of research and clinical
information
• There are 4 categories:
• Advances in clinical research, Applications of EBP and Quality enhancement, Essentials of
standard and advanced clinical practice, Rehab and recovery: an ongoing processCommunity Reintegration
• 83% of attendees also attended the ISC sessions this year
• Great offerings from bench to bedside
Hot Topics from ISC:
IV Alteplase
Delay In Consent Is A Common Reason For Delay In tPA Administration
Sheree Murphy, AHA/ASA, New York, NY; Anna Colello, New York State Dept.
of Health, Albany, NY ; Steven R. Levine, SUNY Downstate Medical Center,
Brooklyn, NY
Background:
• Benefit of IV tPAtime dependent.
• Treatment should be initiated ASAP with a guideline recommended door-toneedle < 60 minutes
• This target is missed in >50% of cases, reported as high as 70%.
• Hospital delays in evaluation, diagnostic tests & delay from order to IV tPA
initiation are most often targeted with improvement strategies.
• Jauch, EC et al. Stroke. 2013;44:870–947.
• Fonarow, GC et al. Circulation. 2011;123:750-758.
Background -Consent
• 2013 ASA guidelines for early management of ischemic stroke state informed patient
consent for IV tPAis indicated
• Regulatory precedents in the U.S. & internationally support the use of IV tPA in patients
lacking capacity if alternative form of consent can’t be obtained within the treatment
window
• Difference of opinion &practice regarding signed, written informed consent & implied
consent for IV tPA
• Previous studies have addressed adequacy or quality of consent & capacity of acute
stroke patients to give consent
• Jauch, EC et al. Stroke. 2013;44:870–947.
• White-Bateman, SR et al. Arch Neurol. 2007 Jun;64(6):785-92.
• Thomas, L et al. Front.Neur.2012 Aug;3:128.
Objectives
• Determine the frequency of the reasons for delay in IV tPAtreatment
within New York State (NYS)
• Identify factors specifically associated with delay in patient/family
consent
Methods
• Hospitals participating in the NYS Department of Health (DOH) Stroke
Center Designation program (N= 120)
• Data were a reporting requirement for all 2012 discharges
• Reasons for delay in IV tPA beyond 60 minutes of hospital arrival
collected in Get With The Guidelines-Stroke Patient Management Tool
• Abstractors selected all reasons either explicitly documented or
clearly apparent
• Only aggregate data for all NYS hospitals were obtained
• Chi squared was used to test differences (2-tailed)
• Patient/Family Consent Definition
• No unifying definition of consent given the variability in practice patterns
• Hospital may require only oral consent
• Hospital may require signed written consent form
• Case Scenarios
• Patient able to provide consent but requested phone call to family to discuss
decision
• Patient unable to provide consent & no family/proxy present
• Did not include initial patient/family refusal
• Patient initially declined treatment &later changed their mind to receive IV tPA
• Captured under reason “Change in Patient Clinical Status/Condition”
Strengths
• First state-based study quantifying the contribution of patient/family
consent on delay IV tPA administration
• Sample size includes over 1,000 IV tPA treated patients
• Includes variety of hospital type
• academic & non-academic
• rural & urban
• bed size
• stroke volume
• Able to analyze some covariates that influence delay in patient/family
consent
Limitations
• Only aggregate level data available for this analysis
• Could not isolate group of patients with delay in patient/family consent as the
single reason for delay in treatment
• Only select patient characteristics could be analyzed
• Onset to treatment time not available
• Could have underestimated consent related delays
• Only 1 year of data
• NYS data only. May not be generalizable
• “Other” reasons not individually analyzed
• Data collection was designed for quality improvement &not for a research study
Conclusions
• Our state-level data suggest that issues with consent are one of the most
common reasons for delay in IV tPA
• Previous studies have shown that delay in IV tPA occurs more frequently on offhours & female gender
• A potential gender issue is raised requiring further study
• Delay on weekend vs. weekday suggests Stroke Centers review variations in
stroke center processes that may be present on weekends
• Training & tools to improve & shorten the consent process may reduce delays
• Further study is needed to assess other patient and hospital characteristics that
may be associated with delay in patient/family consent & determine if any of the
variables are independent predictor
Non-Standard Inclusion & Exclusion Criteria for Intravenous Alteplase
Administration in Acute Ischemic Stroke
• Anne W. Alexandrov PhD, CCRN, NVRN-BC, ANVP-BC, FAAN Professor, University of
Tennessee Health Science Center, Memphis & Australian Catholic University, Sydney
Program Director, NET SMART
Background:
• Even though the United States was the first country to approve intravenous alteplase
for the treatment of stroke and there are currently >1000 certified stroke centers,
when we compare the U.S. to European countries, our alteplase treatment rates are
significantly lower
• Hypothesis is that Informal networking with interdisciplinary colleagues on the topic
of IV tPA treatment often reveals varied interpretations of what constitutes an
acceptable IV tPA treatment candidate
Methods
• Obtain copies of inclusion/exclusion checklists for IV tPA
• Ask Stroke Coordinators to describe additional reasons for nontreatment that they have quantified in their data
• Obtain patient volumes at each site
• Obtain IV alteplase treatment volumes at each site
• Obtain sICH rates for each site
• Obtain definitions used for sICH at each site
Findings
• 24% limited tPA treatment window to 3 hours
• Academic hospital tPA treatment rates were significantly higher than
community hospitals:
• Academic hospital IV tPA treatment rate: 10.8 +7.7 (median 8)
• Community hospital IV tPA treatment rate: 8 +5.9 (median 6)
t=2.3; mean difference 2.75; p=.026, 95% CI .33-5.2
• As the number of non-standard inclusions/exclusions increased, the tPA
treatment rate decreased (r = -.153; p=.038)
• Utilization of non-standard inclusions/exclusions was predicted by hospital
type (community), admission volume (low), and use of the 3 hour window
(p<.0001).
Classification of sICH: Reliability in Question…
• Official definitions support classification of sICH for most (86%) certified
Stroke Centers, however the most common definition (48%) reported was,
“any hemorrhage on non-contrast CT or MRI in combination with any
clinical deterioration.”
• Only 17% identified the definition for sICH adopted by TJC (ECASS-3
definition).
• Among those that adhered to the TJC definition, sICH rates were
significantly lower at 3% +2.3% (median 3%; t=4.7; mean difference = 7.7;
p<.0001, 95% CI 4.4-10.95), compared to 10.6% +17.5% (median 6%).
Safety of Intravenous Thrombolysis for Wake-Up Stroke: Results of A
Prospective Multicenter Safety Study
• Andrew D. Barreto, MD MS Christopher V. Fanale, Andrei V. Alexandrov, Kara A. Sands, Kevin C. Gaffney, FarhaanS.
Vahidy, DigvijayaD. Navalkele, Chad C. Tremont, Robert K. Hamilton, Claude B. Nguyen, AmrouSarraj, George Lopez,
Nicole R. Gonzales, VivekMisra, Tzu-ChingWu, Sheryl Martin-Schild, James C. Grotta, Sean I. Savitz
Background & Purpose
• A significant number (~25%) of ischemic strokes are noticed upon awakening and are not candidates for
thrombolysis
• 58,000 patients with wake-up ischemic stroke presented to an ED in 20051
• Retrospective studies suggest thrombolysis of
• Wake-Up Strokes (WUS) may be safe and beneficial
• We tested the safety of IV-rtPAin a multicenter, single-arm, prospective, open-label study of rtPAin patients who
woke-up with stroke.
•
Mackey et al. Neurology2011.76;1662-7
• Prospective Therapeutic Trials of Wake-Up Stroke
Eligibility, Treatment & Outcomes
• Eligibility
1.Ages 18-80
2.Disabling deficits (NIHSS ≤25) noted upon awakening
• Last seen well prior evening
3.Non-contrast CT only
• Utilizing standard known onset criteria (i.e., <1/3 MCA territory hypodensity)
4.Other than onset time, all standard criteria met for IV-tPA
• Treatment
• Standard dose (0.9mg/kg) IV-rtPA started ≤3 hours of awakening
• Primary outcome -Safety
• Symptomatic intracerebral hemorrhage (ICH) -ECASS-II
• Pre-planned stopping rules
• Data safety monitoring board
Sample Size
• Assumption: Risk of thrombolysis is
unacceptable if the true rate of
sICH>10%
• Group Sequential Interval
Estimation with 90%Confidence
Intervals (CI)
• Minimum number of sICHsrequired
to yield a risk that has the lower
limit of the 90% confidence interval
>10% as the stopping rule.
Results
• October 2010 –October 2013
• All pre-planned patients enrolled
• N = 40
• Four patients (10%) determined stroke
mimics
• Migraine-2
• Neoplasm-1
• Conversion-1
• Results
• NIHSS Distribution
• 17 (43%) ≥ 8
• 12 (30%) ≥10
• Results
• Results
• RESULTS-mRS distribution at 90-days
Limitations
• Uncontrolled study with a small sample size
• Low number of severe strokes enrolled
• Patients treated ≤3-hours of awakening
• IV-thrombolysis routinely delivered up to 4.5 hours
• Substantial mimic rate (10%), but consistent with prior studies of noncontrast CT thrombolysis 9% (95% CI: 7-10%)1
• TsivgoulisG et al. Stroke. 2011;42:1771-4
Conclusions
• Based on this first reported, prospective study, intravenous
thrombolysis appears to be safe in WUS patients selected by noncontrast CT
• A randomized, effectiveness trial appears feasible using a similar,
pragmatic design
Many mild stroke patients considered "too good to treat" may actually benefit from tPA
Khawja A. Siddiqui, M.D., Massachusetts General Hospital, Boston, Mass
• Stroke patients with mild symptoms might be eligible to receive the clot-busting drug tissue plasminogen activator (tPA), but often
don't receive the therapy because they are deemed "too good to treat." However, many of these patients don't fare well after
stroke, according to research presented at the American Stroke Association's International Stroke Conference 2015.
• Using the Get With The Guidelines database from Boston's Massachusetts General Hospital, researchers analyzed 2,745
consecutive stroke admissions (01/2009 - 07/2013). Researchers studied which "too-good-to treat"-patients should be considered
for tPA because of their risk of poor health or death.
They found:
• Of the 238 stroke patients studied who arrived in time to receive tPA but did not receive it because their symptoms were too mild
or they were rapidly improving, 89 did not do well and might have benefitted from tPA.
• Only 62 percent of those studied were discharged home. Nearly 27 percent went to inpatient rehabilitation facilities; 8.4 percent
to skilled nursing facilities; and more than 2 percent either died or went to hospice.
• Risk factors for having poor outcome post-stroke in this group of patients include: being elderly; having more severe strokes; being
Hispanic; and having a stroke that affects both hemispheres of the brain. Hispanics, for example, were 11.43 times more likely than
non-Hispanics to suffer with poor health after stroke.
• More research is needed to better identify which patients might do poorly without tPA treatment, researchers said.
• Clot buster use rises most among 80 and older stroke patients-Michelle P. Lin, M.D., M.P.H., University of Southern California, Los
Angeles, Calif.
• Use of the clot busting drug tissue plasminogen activator (tPA) for ischemic stroke has increased for every age group in recent
years. But the magnitude of change has been greatest among the very elderly, 80 years and older, researchers report at the
American Stroke Association's International Stroke Conference 2015.
• Historically, rates of tPA administration in patients ages 80 years and older have been lower than the general population.
• Researchers analyzed the health records of nearly 6 million patients admitted to U.S. hospitals between 2000 and 2010. This
included patients with an ischemic stroke diagnosis, who received tPA.
• Study participants were 35 percent 80 years and older, 37 percent 65 to 79 years of age, and 28 percent were 18 to 64.
• They found that tPA administration rate increases from 2000 to 2010 were:
•
•
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0.47 to 3.55 percent for the oldest group studied;
0.92 to 3.87 percent for 65 to 79 year olds; and
1.02 to 3.61 percent in patients ages 18 to 64.
• Among 80 year-old and older individuals:
•
•
Those treated at an urban hospital and teaching hospital were more likely to receive tPA.
Women, Blacks, Hispanics and Medicaid holders were less likely to receive tPA.
• Researchers recommend that ways to improve safe and effective tPA administration among very elderly stroke patients should be
explored
Hot Topics from ISC:
Acute Care
Ongoing Research on Head of Bed Positioning
• Background
• Data from several small studies show that blood
flow within the infarct territory in patients with
large vessel occlusions is increased when the
HOB is placed at zero degrees.
• Two large studies are exploring this phenomenon
further:
• HeadPost –Does it make a difference at 3 months? –
Craig Anderson, MD, PhD The George InstituteAffiliated with the University of Sidney
• Zero DOWn SOS –Do small vessel (lacunes) benefit; is
head positioning a rescue intervention rather than
an intervention capable of affecting 3 month
outcome? –Anne Alexandrov, PhD, CCRN, NVRN-BC,
ANVP-BC, FAAN Professor, University of Tennessee
Health Science Center, Memphis & Australian
Catholic University, Sydney Program Director, NET
SMART
Wojner-Alexandrov, et al (2005)
Neurology, 64, 1354-57
Safety Endpoints
• HeadPost & Zero DOWnSOS (Zero-Degree HOB
Outcomes With Surveillance Of Stroke Symptoms):
• Aspiration pneumonia
• Zero DOWnSOS:
• Neurologic deterioration
• Example: NIHSS at zero degrees is 12 points; within 30
minutes of sitting the patient up at 30 degrees, the
NIHSS increases to 18 points.
• Zero DOWn SOS protocol would call this as “meeting a
safety endpoint,” and allow investigators to intervene
however they choose to stabilize the patient.
• Currently, the data showing deterioration with head up
positioning exist only in small studies and only in large
vessel occlusions in the hyperacute phase, yet the
occurrence of deterioration and clinical fluctuation is
commonly reported in the clinical arena.
• Frequent, serial assessments are needed to keep these
patients safe.
Enrollment & Positioning Tips for Pneumonia
Prevention
• Screen for and exclude patients with antecedent
events that may be associated with pneumonia
(i.e. vomiting in the field)
• Exclude patients at high risk for aspiration (i.e.
patients on BiPAP; intubated patients)
• Exclude patients that cannot tolerate zero
degree positioning due to concurrent diagnoses
(i.e. CHF, COPD, etc.)
• Patients in the zero-degree arm should be kept in
side lying position, NOT supine
• Keep suction set up at bedside
• Perhaps older patients (i.e. >75) should be
excluded?
Summary
• HeadPost and Zero DOWn SOS will provide interesting information about the
utility and safety of zero and thirty degree HOB positioning in patients with
acute ischemic stroke.
Collectively, we should learn:
• Which patients are most likely to benefit from zero degree positioning;
• The safety of positioning protocols for acute stroke; and,
• The utility of zero degree positioning as a rescue therapy vs. a therapy
capable of producing a difference in outcome at 3 months.
Early Infection Worsens Intracerebral Hemorrhage
• A. Barrios-Anderson, Brown University; E. Amin, A. Cung, J. Wiese, V. Belden,
D. Espino, John J Volpi, Houston Methodist Neurological Institute
Hypothesis:
• Infection is an independent risk of worsening in hemorrhagic stroke
Methods
• Retrospective chart analysis of 200 ICH subjects
• Analyzed for infection measures:
•
•
•
•
•
•
•
•
•
•
•
Fever
Leukocytosis
Antibiotic administration
Blood Culture
Urinalysis
Chest X-Ray
Infection within 72 hours
Glasgow Coma Score
ICH score
Discharge disposition
Mortality
Conclusion
Patients that had infection recognized in first 72hrs of admission had
•
•
•
•
Greater Stroke Severity
Worse level of Consciousness
Worse Discharge
Higher Mortality Rate
People who are well hydrated at the time of their stroke have a greater
chance of better recovery compared to people who are dehydrated
Argye Hillis, M.D., and Rebecca Gottesman, M.D., Ph.D, John Hopkins Hospital, Baltimore, MA
•
Researchers gathered baseline lab measurements and MRI scans on ischemic stroke patients admitted to the Comprehensive Stroke Center at Johns Hopkins
Hospital between July 2013 and April 2014.
•
Hydration levels were evaluated based on two well-accepted measurements —BUN/creatinine ratio, which shows how well the kidneys work; and urine
specific gravity
•
After evaluating 168 ischemic stroke patients, researchers found almost half of them were dehydrated when admitted to the hospital for stroke.
•
Researchers also found:
•
•
Stroke condition worsened or stayed the same in 42 percent of dehydrated patients, compared to only 17 percent of hydrated patients.
Dehydrated stroke patients also had about a four times higher risk of their conditions worsening than hydrated patients.
•
There was little difference in hydration levels across patients’ race, gender, ethnicity or diabetes status. Patients with kidney failure were not included in this
study. The scientists tracked patients’ daily stroke severity based on their NIHSS scores, a measure of patients’ neurological health. They also used MRI scans
to calculate the volume of brain lesions caused by stroke. Even after researchers factored out the effects of age, initial NIHSS score, lesion volume and blood
sugar levels, results still pointed to dehydration negatively impacting the patients’ conditions. However, they point out that since there was no intervention in
this study, there still may be differences in the types of people who came in dehydrated as opposed to well-hydrated.
•
It is unclear why hydrated patients at the time of strke are linked to better stroke outcomes. It is possible that dehydration causes blood to be thicker causing
it to flow less easily to the brain through stenotic or blocked blood vessels
Oral Care Program Decreases Length of Stay (LOS) and Length of Time Oral Foods and
Fluids are Withheld (NPO) in Stroke Patients
Louise Talley, PhD, RN, Principle Investigator; Heather Lorenz, RN, MSN St. John
Medical Center, Tulsa, OK
Background
• Speech Pathologists addressed Nursing Practice Council concerning the quality of oral
care being provided by nursing
• Referred to Nursing Research Council to identify best practice
• Review of current evidence by Nursing Research Roundtable
Purpose of Study: Test the efficacy of an evidence-based oral assessment & oral care
program on LOS and NPO status in hospitalized, non-ventilated stroke patients
Problem:
• Oral care is identified as an area of care omission by nurses (Kalisch, 2006).
• Aspiration of respiratory pathogens shed from oral biofilms into the lower airway
increase the risk of developing pneumonia (Yoneyama, et al., 2006)
• Hospital-acquired pneumonia (HAP) contributes significantly to the length and cost of
hospital stays.
• Kalisch, B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21 (4),
306-313.
• Yoneyama, T., Yoshida, M.,, Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., et al (2002). Oral
care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics
Society, 50, 430-433.
Research Questions
1. In non-ventilated stroke patients, will an oral care program reduce
the length of NPO status?
2. In non-ventilated stroke patients, what is the effect of an oral care
program on LOS?
Study Design
• Quasi-experimental, posttest only with nonequivalent comparison group
Setting
• Four (4) adult medical-surgical nursing units in an acute care, 500+ bed
medical center
• 1 Progressive Medical-Surgical unit
• 1 Stroke Unit
• 2 Medical Units
Sample
• Convenience sample
• Intervention Group
• 51 stroke patients admitted to four
med-surg nursing units in 2013 after
implementation of an oral care
program
• Comparison Group
• 33 hospitalized stroke patients
admitted to four medical-surgical
nursing units in 2010
Inclusion Criteria:
• Non-ventilated adult inpatients
with a new diagnosis of stroke.
• Admission to one of the four
nursing units chosen for the study
• >18 years of age
• LOS > 3 calendar days
Exclusion Criteria:
• Ventilated any time during the
admission
Instrument
• Hospital Acquired Pneumonia (HAP) Risk Assessment Tool
• Adapted with permission from the Methodist Health System Oral
Care (Structured) Policy
• Documentation of type and frequency of oral care intervention based
on HAP risk assessment score
• Low Risk (score 0-5)
• High Risk (score >6)
Data Collected from EHR for Preand Post-intervention Groups
• Demographic:
• Age, gender
• Number of NPO days
• Length of Stay (LOS)
• Presence of Diagnoses
• HAP
• Stroke
Additional Data Collected from
Post-intervention Group
• Initial HAP Risk Score
• Final HAP Risk Score
In non-ventilated stroke patients, will an oral care program reduce the
length of NPO status?
Length of NPO Status per 100 patient days
Group
Pre-Intervention 2010
23.07
Post-Intervention 2013
3.3
87%
In non-ventilated stroke patients, what is the effect of an oral care
program on LOS?
LOS Mean
Group
Pre-Intervention 2010
9.45 days
Post-Intervention 2013
6.92 days
26.8%%
What is the effect of a structured oral care
program on HAP Risk scores from initial to final
score for the 2013 post-intervention group?
Conclusions
• Time in NPO status and LOS decreased with a structured oral care
program.
• Oral health assessment scores improved from admission to discharge.
• Frequency and quality of oral care by nursing staff improved possibly
due to more convenient oral care supplies.
• Further testing of the assessment tool and interventions with a larger
sample is recommended.
• Presenting Symptoms and Response to Dysphagia Screen Predict
Unfavorable Outcome in Acute Ischemic Stroke Patients who do not
receive IV tPA due to Mild and Rapidly Improving Stroke Symptoms
• Debbie Camp, Katja Bryant, Susan Zimmermann, Cynthia Brasher,
Kerrin M. Connelly, Joshua Dunn, Michael Frankel, MogesIdo, James
Lugtu, Fadi Nahab
Background
• Previous studies have shown that 25-30% of patients who do not
receive IV t-PA due to mild and rapidly improving stroke symptoms
(MaRISS) are not discharged home.
• Up to 36% of acute ischemic stroke (AIS) patients arriving within the 3
hour window are not treated with IV thrombolytic therapy due to
MaRISS.
Objective
• The objective of our study was to identify whether baseline
characteristics, presenting symptoms and response to initial
dysphagia screen can predict which patients not treated with IV tPA
due to MaRISS go on to have an unfavorable outcome.
Methods
• AIS patients presenting to hospitals participating in the Georgia Coverdell Acute
Stroke Registry and not treated with IV t-PA due to MaRISS only
• Study Period: January 1, 2009 -December 31, 2013
• Patients who were unable to ambulate or needed assistance to ambulate prior
to admission were excluded.
• Baseline characteristics, presenting symptoms and response to dysphagia screen
were collected from retrospective chart review at participating hospitals.
• Multivariable regression analysis was used to identify factors associated with a
lower likelihood of favorable outcome, defined as discharge to home.
Results
• Of 841 AIS patients who did not receive IV-tPA due to MaRISS, 160 (19%) did
not have a favorable outcome (were not discharged home).
• Factors associated with lower likelihood of a unfavorable outcome (Not D/C
Home):
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•
•
•
•
Medicare insurance status (OR 0.53, 95% CI 0.34 to 0.84)
Arrival by EMS (OR 0.46, 95% CI 0.29 to 0.73)
Increasing NIHSS score (per unit OR 0.89, 95% CI 0.84 to 0.93)
Weakness as the presenting symptom (OR 0.50, 95% CI 0.30 to 0.84)
Failed dysphagia screen (OR 0.43, 95% CI 0.23 to 0.80)
• During the study period, 1%of patients presenting to participating hospitals
with MaRISS within the 3 hour time window received IV t-PA.
Conclusions
• Nearly 1 in 5 acute ischemic stroke patients presenting with
MaRISSwere not discharged to home.
• Among patients who present with MaRISS and do not receive IV tPA,
Medicare insurance status, arrival by EMS, increasing NIHSS score,
weakness as a presenting symptom, and a failed dysphagia screen
were all associated with a lower likelihood of discharge to home.
• Given the very low rate of IV t-PA treatment in AIS patients presenting
with MaRISS during the study period, a prospective randomized trial
to evaluate IV t-PA treatment focusing on this subgroup of patients is
warranted.
The Needs of Family Members at the Bedside of Stroke Patients
Anita Catlin, DNSc, FNP, FAAN Principal Investigator, Consultant, Ethics and Research Kaiser
Permanente Santa Rosa & Vallejo, CA; Michelle Camicia, MSN, CRRN, CCM, Director, Kaiser
Permanente Vallejo, CA;Nina Markoff, Masters in Social Work Intern; Hua Wang, PhD, Research
Scientist
Objectives
1. Share study design and findings from the Family Needs Study
2. Discuss recommendations on how to improve care based on findings
Setting
• Serve ~700 stroke pts/year
• CMI 1.5-1.7
• Stroke ALOS=15.1
Background
• Study conducted at Kaiser
Permanente Santa Rosa with
oncology patients
• Limited studies available on
needs of family members of
stroke patients in an inpatient
setting
Research Questions
1.What are the needs of family members of stroke patients at the
bedside in the rehabilitation unit?
2.Will art therapy lead to an improved understanding of family needs?
Study Aim
• To learn how we can improve the quality of care we offer to families
whose family member has a stroke in our hospital.
Study Process
Staff Nurses identify family members who might be interested in
participating.
Director speaks with family member, explains study, & if interested,
obtains signed consents. Potential appointment times determined.
Interviewer conducts interview, art, & survey
Triangulated Study Design
Measures: Scripted Family Caregiver Interview
• Reaffirm permission to tape & review study
• “We are trying to plan better care for family members who are at the
bedside of our patients. We know your ___had a stroke & you are
involved in ___care.
• “Our study today, however, is about you. We want to hear about the
care you need while you are at the bedside & what can be done as we
build family centered care program to best serve our families.”
Measures: Interviewing in Qualitative Research
• Questions develop as the data comes in.
• If several families talk about need for food, communication, etc.,
these can be used a prompts for future interviews.
• Ask, watch, reflect and listen
• Interview ends when family member agrees that he/she has told us
what they feel and are satisfied when we reflect back what we have
heard.
Measures: Family Needs Inventory (FIN)
• Instrument developed by Kristjnson, Atwood & Degner (1995)
• Validity established via expert panel & matched family need findings
with other like instruments
• Reliability of Cronbach alpha of .83
• 20 items with a scale of 1-10 identifying if needs are met or unmet.
Art: Draw a Bridge
• A projective technique for assessment in art therapy described by Ronald
Hays & Sherry Lyons (19981)
• Indicates how an individual who is going though a difficult change may be
experiencing that change
• Can be used to enhance communication & therapeutic change in a
therapeutic session
• Interviews for qualitative research can be therapeutic in & of themselves.
Measures: Art Process
• Introduce materials
• Other people have told us that by drawing a picture of a bridge with
you on it, it will help you to formulate your thoughts
• Draw a bridge going from where you are now, to where you might be
sometime in the future.
• Place yourself on the bridge
• Describe your bridge & what surrounds it
Data Collection & Analysis
• Collect data until saturation of findings is reached & no new
information is revealed.
• FIN analyzed
• Interviewstranscribed & coded using naturalistic inquiry method.
(Miles and Huberman, 1994)
• Art
• Drawings reviewed by research team.
• Art Therapist reviews drawings & provides additional insights.
Participants
• N = 12
• Male 33%
• Female 67%
• Age 18 -85
• (50% 46-65)
Results: Family Needs Inventory
Results- Qualitative: Themes
• Knowing what to expect when they go home (preparation for
discharge)
• Communication with care providers
• Physical comfort & self care
• Having someone care about them/provide emotional support
Theme- Knowing what to expect when they go home
• “If I had it my way, I think I'd rather have her in here a little longer, so
that we feel a little more comfortable caring for her at home”
• “When I could tell my fears about what I was afraid -about taking him
home, because he's a big man, how do I take care of this person
without him hurting himself?”
• “We bring him home on Wednesdays, what do we do next? Do we
just live? I don't know.”
Theme- Physical Comfort & Self Care
• “Sometimes I'm just emotionally drained and I don't know what to do.
...Sometimes at night when she finally goes to sleep I get a chance to
lay down, and I just collapse in the chair.”
• “I think I've had three showers since I've been here. Otherwise...I go
into the washer room and I take a sponge bath every so often and
wash my hair in the sink. So, it's been very unpleasant."
Theme- Communication
• “One point of contact with some extremely quick turnaround time would be
best...a point person that no matter what even if they can't tell you anything, calls
you and tells you...we need acknowledgement.”
• “It might be a good idea to force family member or the couple of them to sit down
with...somebody who knows all the facts but can massage it through.”
• “The communication needs to be a little stronger with the family members that
are going to be the ones ultimately giving the patient the care once they get out
of here.”
• “Once I knew that he was physically ok, that they were taking care of him, I could
start absorbing the things that people were giving me like information. I think at
first it felt like there was a whole bunch of things coming at once and I really
didn't know what to feel throughout.”
Theme - Caring about them/Emotional Support
• “As far as dealing with my mother, nobody asked me how I was
holding up or nothing like that; I never talked to anybody about that…
That might be something, yeah, that should be focused on.”
Results: What we need to keep doing
• Family-centered environment
• Open visitation
• Feeling welcome & included in the patient’s therapies
• Trust
• The most frequent theme
• All participants felt that team members were skilled & “really cared”
Results: What we need to keep doing Family-centered Environment
• Everyone has been really nice; it’s like a family environment. …They go
above & beyond just to make me feel comfortable. They opened up the
family lounge for me one night when I came in at 4:30 am.”
• “I was surprised they would let me stay the night & that there were no
visiting hours, cause they would have had a fight on their hands.”
• “Another thing that was nice was the puzzles in the family room...and
having that room to be able to go there -we'd eat dinner with him, that
was very nice.”
• “I heard a lot of repetitive & support from other fields & the fact that
they're so willing to let you sit in & watch everything & explain things was a
real support.
Results: Art
• The Draw a Bridge method did
seem to inspire deeper
communication and emotional
expression in some participants.
Incorporating Art into Research
• Questions that interviewers can use to deepen the inquiry
• Awareness of potential issues for caregivers
• Needs that cannot be articulated can sometimes be drawn
• Opens participant to emotional expression
Implications
• Proactive solutions to providing family members with emotional support
• Instill hope through interactions with interprofessional team
• Provide for physical needs
• Promote acquisition of food
• Provide comfortable sleeping chair
• Communicate availability of shower
• Implications for future research:
• Need for studies to determine the effectiveness of interventions to support
family members at the bedside in a rehabilitation and other settings
• Study other populations (e.g. traumatic brain, spinal cord injury) to compare
results
Limitations
• Due to the small sample size, no statistical significance can be
determined from the FIN scale data
• Convenience sampling of family present
• Resisting the interest to fix problems
Palliative Care in the Stroke Patient
Theresa Hamm RN, BA Stroke Coordinator Mercy Medical Center Des Moines, Iowa
Background and Purpose
• Palliative and end of life care are gaining importance in the health care
environment
• Palliative care underutilized in this population
• AHA scientific statement recognized the importance of study in this area
Methods
• Retrospective review of patients admitted during one year with
diagnosis of acute ischemic stroke or hemorrhagic stroke
• 575 records assessed
Results
• Population included 491 ischemic stroke and 84 hemorrhages
• 81 patients received t-PA
• Discharge status: 269 patients returned to home environment
• 114 patients admitted to acute rehabilitation unit
• 123 patients transferred to skilled nursing facility
• 29 patients transferred to hospice care
• 42 patients deceased in hospital
Results
• 20 patients with similar characteristics were discharged to skilled
nursing facility with no discussion of palliative care or hospice
documented.
• A review of records revealed provider disagreement for long-term
prognosis as a significant barrier to patient/family discussions
regarding end of life choices, or for supporting choices verbalized by
patient/family opting for palliative care.
c
Conclusions
• Based on this data, a palliative care nurse was added to the stroke team and the stroke
team coordinator joined the palliative care committee to assist in these conversations.
• Palliative care training for providers in now on-going in the acute care setting.
• Primary care providers are being engaged in utilizing the Iowa Physician Order for Scope
of Treatment (IPOST). This document was designed to promote community care
coordination and advanced care planning in order to provide seamless communication
and execution of individual care choices across the health care continuum.
• As these strategies are implemented, an increase in end of life planning is anticipated.
Is Online NIHSS Certification Enough Training?
Christa Thompson, MSN, RN St. Claire Regional Medical Center,
Morehead, Kentucky; Chris McDavid, RN, CFRN St. Claire Regional
Medical Center, Morehead, Kentucky; Lisa Bellamy, RN,
CPHQUK/Norton Stroke Care Network
Background
• NIH Stroke Scale (NIHSS) is used for the initial assessment of patients
with acute stroke.
• Online education vs. Performance at the bedside
• Bridging the gap
Phase 1 of Training
• 114 nurses completed online NIHSS certification
• Coaching sessions offered
•
•
•
•
Voluntarily participated in the Face-to-Face Instruction
Reviewed background information of NIHSS
Reviewed the 11-item assessment
Not well attended
Nurses
• ED 25%
• ICU 28%
• Medical-Surgical 37%
• Float Pool 10%
Phase 2 of Training
• Competency evaluation
• Nursing Competency Fair
• Nurses performed the NIHSS
• Simulated stroke scenario
• Evaluator was observational only
• Feedback provided after
completion
• If failed, informed of remediation
plan
• Attend coaching session
• Repeat evaluation competency
• Submit to nurse manager
Phase 2 Results
• RNs that failed per Specialty:
(n=36)
•
•
•
•
n=19 Medical-Surgical
n=10 ICU
n=5 Emergency Department
n=2 Float Pool
Phase 3 of Training
If failed:
• Coaching session
• Repeat competency evaluation
• Initiate Remediation Plan
• Required to attend a coaching session
• Repeat competency evaluation
•
•
•
•
Nurses performed the NIHSS
Simulated stroke scenario
Evaluator was observational only
Feedback provided after completion
Phase 3 outcome
Bridging the Gap
• 100% (n=36) that received
remedial face-to-face instruction
passed the repeat competency
evaluation
In Summation
• Online education supplemented with face-to-face instruction clearly
improved the performance of the stroke assessment.
Church-based health intervention may help parishioners reduce stroke risk
Devin Brown, M.D., University of Michigan, Ann Arbor, Mich
• A church-based health intervention reduced stroke risk behaviors among Hispanic and non-Hispanic parishioners
• The Stroke Health and Risk Education (SHARE) Project was a faith-based, culturally-sensitive behavioral intervention study to
reduce stroke risk factor behaviors such as physical inactivity, poor eating habits and uncontrolled high blood pressure. The oneyear intervention included a physical activity guide with pedometer and educational materials on healthy eating and blood
pressure management. It also included motivational counseling calls and a support workshop with peers.
• Researchers applied the intervention to five of 10 Catholic churches in Corpus Christi, Texas. The other five served as a comparison
group. Those in the intervention group had an increase of 0.25 cups a day in fruit and vegetable intake compared to the control
group.
• Of the 760 Hispanic and non-Hispanic white Catholic parishioners who participated in the study:
•
•
Intervention group participants decreased salt intake by 123 milligrams per day, compared to the control group.
There was no difference between the groups in physical activity level improvement.
• While more research is needed, SHARE's success in improving stroke risk behaviors suggests that faith-based programs may be
useful to reduce stroke in communities including Hispanic Americans, the nation's largest minority population, researchers said.
Gender helps identify caregivers at poor health risk
Misook L. Chung, Ph.D., R.N., University of Kentucky, Lexington, Ky
• Female caregivers are more likely than male caregivers to report poor health, especially when they perceive their roles as difficult or
life changing
• Caregiving commonly results in caregivers' poor health. And women report more burden than men in similar caregiving situations.
But it's unclear whether gender impacts the association between caregiving and poor health.
• Researchers studied whether gender is associated with risk of poor health among caregivers based on caregivers' relationships
(spouse or non-spouse) with stroke patients and whether caregivers are the same or opposite gender as patients.
• 277 caregivers of stroke survivors were surveyed after the first two months, post-stroke.
• Results
•
•
•
Caregiving for longer periods of time, difficulty of caregiving tasks and negative changes in life were highly associated with poor health status.
Female spousal caregivers reported strong links between difficulty of caregiving tasks and poor health status, and between negative perception
of life changes due to caregiving and poor health status. The same was not true for male spousal caregivers.
Similar results were found for caregivers who were the opposite gender from patients.
• Conclusion
•
•
Caregiver gender and relationship with stroke patients might help identify caregivers at high risk of poor health.
More study is needed to examine the dynamics that influence caregiving relationships to individualize interventions
• Thank you for your attention!
• Questions?