Background and Significance
In the United States, stroke is the fifth leading cause of death and the leading cause of long-term disability and costs more than $34 billion annually.1 According to the American Board of Neuroscience Nursing, Stroke Certified Registered Nurses (SCRNs), only 2250 nurses nationally, possess the skill set, knowledge, and expertise to provide care to stroke patients and promote excellence and professionalism to healthcare employers and to the public.2
It is imperative for neuro and emergency room (ER) nurses to follow stroke protocols. Time is of the essence. For every second the acute ischemic stroke patient goes untreated with thrombolytics, the patient’s brain ages 8.7 hours; for every minute, the brain ages 3.1 weeks; for every hour, it ages 3.6 years; and for every stroke they have, it ages 36 years.3 The focus of the emergency department on hyperacute stroke patients is timely, efficient, and expert care. If there is a difference in the nursing care delivery process to hyperacute stroke patients being cared by an SCRN, it is advantageous and cost effective for emergency departments to employ SCRNs to guide and implement stroke protocols and hyperacute stroke patient care.
A literature review was conducted using PubMed, CINAHL, EBSCO, Agency for Healthcare Quality and Research database, American Stroke Association database, Google Scholar, and SWOOP. Key words used for the search were “specialty nursing certification,” “code stroke,” “certified stroke nurse,” “stroke activation,” “certified nursing,” “patient outcomes from certified nurse,” “acute ischemic stroke emergency,” “cost of stroke care,” “acute ischemic stroke and nursing process,” “stroke protocol and nursing,” “Benner’s novice to expert theory,” and “Donabedian’s quality care model.”
There were no research studies conducted on SCRNs related to patient outcomes. Yet, the impact of specialty nurse certification on patient outcomes has been studied. For specialty nursing certification, researchers concluded from a retrospective, descriptive, comparative study using the National Database of Nursing Quality Indicators that lower catheter-associated urinary tract infection rates are associated with higher nursing certification rates in surgical intensive care units and perioperative units (β = 0.22, P < .001) as well as surgical units (β = 0.17, P = .03).4 In a descriptive, cross-sectional survey focusing on nursing specialty certification, inpatient mortality, and failure to rescue, the researchers concluded that, for every 10% increase in the number of certified Bachelor of Science in Nursing nurses, there is a 2% decrease in the odds of patients dying.5 A retrospective, descriptive study on patient safety in medical-surgical units and nursing certification significantly found that, in units with higher certification rates, there was a lower amount of patient falls (mean, 3.3; Wald χ2 = 3.80, P = .05).6 Furthermore, a descriptive, comparative study comparing nursing specialty certification and patient falls, as reported by the National Database of Nursing Quality Indicators in 903 hospitals, reports a small statistical inverse relationship between national nursing specialty certification and the slope of total fall rates (r = −0.08, P = .04).7
Timeliness of Stroke Care Delivered
In a prospective, observational study, 134 stroke patients arrived at the ER within 3 hours of last known well; 15 were eligible for alteplase (14% received alteplase). The researchers conclude that a comprehensive protocol and rapid assessment of stroke patients in the ER allows for early identification of and treatment for acute ischemic stroke patients who are eligible for alteplase administration.8
In a retrospective, descriptive, comparative study, the researchers studied the impact the Target: Stroke initiative had on decreasing the goal of door to alteplase in 60 minutes or less. The researchers conclude that, with the implementation of Target: Stroke 10 Care Strategies, there is a statistically significant difference in preintervention to postintervention for door-to-alteplase administration times (P ≤ .001), as well as an increase in door-to-alteplase administration rates in 60 minutes or less (P ≤ .001). The researchers conclude that the implementation of a national quality improvement initiative is also associated with improvement in in-hospital mortality (P ≤ .001) and intracranial hemorrhage (P ≤ .001), as well as an increase in the percentage of patients who are discharged home (P ≤ .001).9
There is supportive research demonstrating that specialty nursing certification makes a positive difference in the nursing care delivery process in patients.4–7 Research on alteplase administration to stroke patients and protocol-driven models has shown to be effective in improving the patients’ outcomes as well.8,9 No research studies are located pertaining to the nursing care delivery process for acute stroke patients by SCRNs and whether this certification has any implications on the timeliness of hyperacute stroke patient care.
Patricia Benner’s novice to expert theory and Donabedian’s quality framework provide a blueprint for this study. Benner’s theory discusses how nurses develop skills and expertise over time.10–13 Benner’s theory supports certification, and has 5 stages: novice, advanced beginner, competent, proficient, and expert. The competent stage correlates with nurses who have 2 to 3 years of experience. These nurses recognize clinical situations more quickly than advanced beginners. In the proficient stage, the nurses perceive and understand clinical situations as a whole, rather than as parts. These nurses know from experience what to expect in clinical situations. As the expert, certified nurses no longer rely on rules to guide their actions; their experience and knowledge lead them in delivering evidence-based nursing care and improving patient care outcomes.10
Donabedian’s quality framework14 provides understanding of the nursing care delivery process. Emergency room stroke protocols (structures of care concept) are a key factor in providing efficient care. The processes of care refer to the nurse as coordinating the stroke patient’s care and implementing the acute stroke protocol. The timeliness of the nursing care delivered by SCRNs has the potential to impact the patient’s outcome. The goal of the ER team is to reduce, if not eliminate, the patient’s stroke symptoms without causing further harm while meeting quality goals. Research has shown that faster alteplase administration times are associated with better outcomes for the stroke patient.9,15,16
As shown in Figure 1 (Supplemental Digital Content 1, available at http://links.lww.com/JNN/A148), Benner’s novice to expert theory correlates with the process concept of Donabedian’s theoretical framework.17 According to the American Board of Neuroscience Nursing, SCRNs are considered to have a higher level of knowledge, competence, and expertise in the delivery of evidence-based stroke care.2
This study examines whether the nursing care delivery process for hyperacute stroke patients cared for by SCRNs has a significant difference in the timeliness of care delivered as compared with non-SCRNs. Research findings support specialty certification in nursing and the implications it has on the delivery of patient care and patient outcomes for many areas in nursing.4–7 Yet, there are no studies conducted on the SCRNs’ delivery of care making a difference in the hyperacute phase of stroke care.
The research questions are: Is there a difference in (1) door-to-stroke team activation time, (2) door-to-computed tomography (CT) time, (3) door to initiation of teleneurology consult, (4) door to alteplase administration, and (5) door to appropriate disposition of the hyperacute stroke patient cared for by an SCRN versus a non-SCRN. Finally, 1 hypothesis is tested: Is there a difference in the total nursing care process time by SCRNs of the hyperacute stroke patient versus the non-SCRNs?
The target population includes a convenience sample of all acute stroke activations that arrive at the ER of a level III stroke facility in the southwestern region of the United States. This ER cares for 900 to 1000 patients per month. The ER is staffed with thre3 RNs, 1 ER physician, and an admissions clerk. All RNs receive the same new hire orientation and annual stroke education. Twenty-four RNs rotate between the ER and the medical unit. Eleven of the 24 RNs are SCRN certified (46%). Beginning in May 2015, only 1 of the 11 SCRNs was already SCRN certified. The remaining 10 SCRNs worked as non-SCRNs initially and obtained SCRN certification by September 2016. For 2016, this ER was 100% compliant on meeting Target: Stroke goal of patients receiving alteplase within 60 minutes of arrival.14 Stroke activations are nursing driven; nurses activate the stroke team based on stroke symptoms and last known well to 4.5 hours (within the alteplase window) and follow the stroke protocol without requiring a physician order.
A retrospective, nonexperimental, comparative descriptive design was conducted to determine whether there is a difference in the timing of the nursing care delivery process by an SCRN versus a non-SCRN in the care of the hyperacute stroke patient. University and healthcare facility institutional review board approval has been granted.
Data Collection and Analysis
The Stroke Program Manager for the facility provides a list of patient account numbers for eligible patients. Nursing demographics are obtained from the Director of Nurses; and user access to the electronic medical record and radiology system, from the Regional Informatics Director. Nursing documentation of patient care delivered is collected to determine timeliness of care, along with CT initiation times as recorded in the radiology system. The goal times for all timed measures are based on American Heart Association/American Stroke Association and Target Stroke Phase II guidelines.14,18
The facility has an average of 5 stroke activations per month. All acute stroke activations from May 2015 to December 2016 (n = 95) compose the convenience sample (Table 1). The inclusion criteria for the retrospective chart audit are: acute stroke activation with a last known well of 4.5 hours or less and age of at least 18 years. Fifty-one of the stroke activation patients were cared for by an SCRN (54%), and 19 patients received alteplase (20%). Eleven of the 19 patients who received alteplase are cared for by an SCRN (58%).
Data was entered into IBM SPSS Statistics.19 For the research questions and the hypothesis, descriptive statistics are calculated to determine the times of care delivered, and the t test statistic is calculated to test for significance at the .05 level. To test the hypothesis, totals of times completed by the SCRN and non-SCRN for research questions 1 through 5 were added together and a t test was run and tested for significance.
Of the 24 RNs, 11 are SCRN certified (46%) and 13 are non-SCRN (54%). Beginning in May 2015, only 1 of the 11 SCRNs was already SCRN certified. The remaining 10 SCRNs worked as non-SCRNs initially and obtained SCRN certification throughout September 2015 to September 2016. Therefore, those 10 RNs were coded using 2 codes, one for while they were non-SCRN and another for when they became SCRN certified.
The first 4 research questions are significant for timeliness of patient care delivered by the SCRN: research question 1, timing for door to stroke team activations (t = −3.291, P = .001); research question 2, door-to-CT times for stroke activation patients (t = −4.020, P < .001); research question 3, door to initiation of teleneurology consult for stroke activation patients (t = −4.020, P < .001); and research question 4, door to alteplase administration for patients (t = −3.367, P = .004). The fifth research question, the data for door to appropriate disposition, shows no significant difference in hyperacute stroke patients who are cared for by the SCRN versus the non-SCRN (t = −1.278, P = .218).
Nineteen patients who received alteplase are included in the analysis. One patient is excluded for missing data. There is a statistical significance in the total care times for hyperacute stroke patients who received alteplase and are cared for by an SCRN versus a non-SCRN (t = −4.109, P = .001). Table 2 summarizes all stroke protocol goals, research questions, and hypothesis.
The SCRNs meet the goal times for all stroke activation process times. By placing the SCRN as the coordinator of care (Donabedian’s process of care) for the hyperacute stroke patient in the expert stage of Benner’s theory and precisely following the hyperacute stroke activation protocol (Donabedian’s structures of care), the SCRN delivers a significant difference in door-to-alteplase administration times (t = −3.367, P = .004). Furthermore, the SCRN administers alteplase in less than 60 minutes from arrival time to 10 of the 11 hyperacute stroke activation patients who received alteplase (91%) and to 6 of the 11 alteplase patients in 45 minutes or less (60%).
The non-SCRNs meet most protocol times but are outside the stroke activation protocol goal time of 15 minutes or less for door to teleneurology initiation (mean, 17.87 minutes; median, 14 minutes) and goal time of 60 minutes or less for door to alteplase administration (mean, 69.13 minutes; median, 61.5 minutes). The non-SCRNs are considered in the confident to proficient stage of Benner’s theory as the coordinator of care for the process concept of Donabedian’s quality framework. The non-SCRNs still need to rely on some rules and guidelines when delivering stroke care.
The findings are limited because of the sample size of hyperacute stroke activations (95) and patients who received alteplase (19). In addition, because the facility has an average of only 5 hyperacute stroke activations per month, for some nurses, this may have been their first experience delivering primary care to a hyperacute stroke activation patient. Of 24 RNs, 19 have been the primary nurse for 3 or less hyperacute stroke activation patients. Only 1 was SCRN certified when retrospective data collection began. The other 10 SCRNs obtained SCRN certification by September 2016, and improvement in protocol times and documentation was noted resulting in a potential skew of data for the non-SCRN care process times. Finally, all times used for data collection are based on nursing documentation. There are data points from May 2015 to December 2016 that were not collected because of missing documentation.
The statistical significance and compliance with hyperacute stroke protocol times demonstrate that SCRNs are more knowledgeable, confident, and timely in activating and implementing the hyperacute stroke protocol. As experts, SCRNs consistently recognize stroke symptoms, activate the stroke process, follow protocols, and deliver quality care to stroke patients. The SCRNs align with Benner’s theory in the expert stage and on Donabedian’s processes of care as the patients’ care coordinator. The demonstration of faster hyperacute stroke activation protocol times and obtaining SCRN certification by September 2016 align with the non-SCRNs’ nursing knowledge moving from the confident/proficient stage of Benner’s theory to the expert stage and the impact certification has on the implementation of the hyperacute stroke protocol.10 For validation of these statistical findings, replication should be conducted at a larger stroke facility.
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