1 Running head: STROKE CARE IN THE EMERGENCY DEPARTMENT

Stroke Care in the Emergency Department

Student Sample

University of St. Augustine

Theoretical and Scientific Underpinnings for Nursing Practice

NUR 7160

Dr. Payne

August 8, 2019

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Stroke Care in the Emergency Department

Introduction

Healthcare is continually evolving and requires constant change in order to correlate best

practices with evolving research. Practice changes in the Emergency Department (ED) setting

are frequently required due to the array of patient populations with a variety of illnesses and

injuries. ED nurses and other healthcare providers must demonstrate competence and confidence

when caring for such a diverse group. In Emergency Departments, it is common to create order

sets, algorithms, policies and protocols in order to ease the confusion when caring for the

different patient types. Despite the multitude of patient types who present to the ED for medical

treatment, stroke patients are one of the most sensitive populations.

In the Emergency Department setting, time is of the essence when managing patients who

arrive with signs and symptoms of acute stroke. Improving the duration of time spent prior to

medical intervention can reduce morbidity and mortality for this patient population. Without a

focus on time management in the care of stroke patients, patient outcomes may suffer. Stroke,

either hemorrhagic or ischemic, is a serious medical condition that is associated with long term

deficits and significant mortality rates. According to Alimohammadi et al. (2015), approximately

5.5 million people die of stroke each year worldwide, and it is known as the third cause for

mortality in the world. Early recognition, proper testing and prompt skilled intervention is

imperative to positive patient outcomes. The purpose of this paper is to outline and describe a

nursing theoretical framework to guide the evidenced based practice change surrounding a

project to expedite the treatment of ED stroke patients.

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Project Description

This project utilizes best practices recommendations as well as national guidelines to

implement a standard process for patients with acute stroke symptoms in the Emergency

Department (ED). The project reviews current and emerging literature regarding care of stroke

patients and then compiles the research for a strong evidenced based process. A selection of

relevant qualitative, quantitative and systematic reviews was thoroughly examined for

applicability. The project will outline a comprehensive approach to the management of stroke

patients in the ED, however each element of the project must contain an allotted time interval. A

key component in the nursing care of stroke patients is the duration of time between patient

arrival to the facility to the completion of a Computed Tomography (CT) Scan. Practice

recommendations will encompass a brief overview of the evidence, including study findings, as

well as a clinical algorithm for ED bedside clinicians for treatment guidance.

PICOT Question

Does implementation of a standard process (I) for patients with acute stroke symptoms

admitted in the Emergency Department (P) compared to no standard process (C) improve time

and actions for care of patients admitted with acute stroke symptoms (I) after six weeks of

revised process implementation?

Significance of the Problem

Strokes kill almost 130,000 people each year and is also the leading cause of serious,

long term disability (American Heart Association, 2018). In an eight year study by Badawi,

Alfaraj, & Pines (2018), there were greater than 3.9 million Emergency Department visits in the

United States for stroke like symptoms alone. Strokes occur when there is a lack of blood supply

to a patient’s brain. During this time, symptom recognition and rapid medical intervention is

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essential. According to Singh et al. (2015), brain cells will begin to die within just three minutes

after the interruption of blood flow. Once cell death occurs, the risk for negative patient

outcomes are increased. Many healthcare organizations lack a standard process outlining the

medical treatment plan for patients presenting to the ED with signs or symptoms of an acute

stroke.

Scope of the Problem

Stroke care begins at the first recognition of symptoms and spans until the time that the

patient is discharged from the healthcare facility. However, in the ED, stroke care begins at first

notification of the patient’s arrival (or pending arrival) and concludes at the transfer of care

(either intervention area or inpatient bed). It is important that each patient’s treatment course is

established as well as based on current research as well as that there are processes in place to

provide timely, but comprehensive patient care throughout their stay in the Emergency

Department.

Patients arrive in two distinct pathways, either via Emergency Medical Services (EMS)

transport or self-presentation, and then are cared for by ED clinical staff until there time of

transport out of the Emergency Department. Timely treatment is essential no matter which mode

arrival. Patients who arrive via EMS require care coordination and open communication at the

initiation of contact to ensure that the correct treatment begins as soon as possible by the EMS

provider, whereas patients who are self-presenting do not receive care by a healthcare provider

until they arrive to the ED. Therefore, the project should include both modes of patient arrival.

Anticipated Outcome

Development of a thorough guide to emergent stroke care is imperative to improve

patient outcomes. When discussing overall outcomes, there are two essential elements contained

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within the guide; evidenced based nursing education as well as a process for quality assurance.

While the concentration of the project largely focuses on construction of the stroke care

algorithm, it is integral to success and sustainability of the project that these key factors be

included in the project goal.

Education efforts should not only surround the proposed project or algorithm but provide

educational material as to why protocolized and timely care is important in the management of

these patients. In their 2016 article, Hargis et al., explored nursing education and the impacts on

patient outcomes. They concluded that the “lack of nurses with education about acute stoke and

initial management breeds a lack of urgency and consequent delays” (Hargis, et al., 2015).

If education is appropriately provided, then patients should receive stroke care based on

best practices and hospital policies, therefore, quality assurance would focus on chart reviews,

patient outcomes, and desired improvements based on data collection and analysis. Liu et al.

(2018) reports that the implementation of a nursing quality program which contains specific

measures surrounding stroke care is important in decreasing patient delays and contributing to

successful stroke care.

Theoretical Framework

Sister Calista Roy’s Adaptation Model (RAM) is commonly used in healthcare practice

as it applies in an assortment of settings such as bedside nursing, education, and research

(Jennings, 2017). According to Shah, Abdullah, & Khan (2015), the theory views the person as

holistic adaptive system to cope the environmental changes to sustain life, wellness, and illness.

Therefore, Roy’s grand theory can highly effective in the guidance of nursing practice

throughout the care continuum of patients suffering from an acute stroke. “Roy’s Model provides

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framework for nursing care for individuals in health and in acute, chronic, or terminal illness”

(Shah, Abdullah, & Khan, 2015, p.40).

Research surrounding stroke best practices and national standards are paramount to the

project creation. Roy’s model has been shown useful in the research setting and would vast

applicability to the literature review for a nursing process to improve stroke care in the

emergency department setting. Roy’s model has been used for decades as an outline for a

multitude of healthcare research studies due to its adaptive approach. According to Coelho

(2011), it facilitates the ability for nurses to collect data, establish goals and nursing diagnoses,

the determination of nursing interventions and the subsequent evaluation process.

Once the research is compiled and the new process is developed, education becomes the

next key step towards project implementation. Roy’s model is relevant in the clinical education

of all ED staff members. RAM not only guides the practice change itself but allows the entire

interdisciplinary healthcare team to fully understand the evolution and importance of emerging

stroke care. Following the acute phase of stroke care, members of the healthcare team can

engage Roy’s model to assist with patient as well as family education, care expectations, and the

discharge planning process. According to West et al. (2017), the model allows for nurses to care

for patients while forming strong relationships with not only the patient, but as well as their

families.

Nursing practice is instrumental to positive patient outcomes as they are involved in each

step and care transition of stroke patients. In the ED, nurses can apply Roy’s theory not only

through the implementation or research and education, but through adapting their bedside

practice to better meet the complex needs of stroke patients. “Roy model-based self-care plan is a

non-invasive, non-medication, and cost-effective method in control of physical and

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psychological problems and is conveniently applicable by the nursing staff, it can be used for

chronic patients and their problems, especially for stroke patients, to increase their adaptation”

(Alimohammadi et al., 2015, p. 225). ED bedside providers can tailor their care based on patient

presentation and individual patient needs, while still following the general project algorithm.

Analysis of Fit

Roy’s Adaptation Model applies to this healthcare project in three distinct ways,. Further,

the model complies those specific pathways for a complete clinical project. First, through

utilizing research and evidenced based literature to gather supporting data. This information and

data are then used as base for the fundamentals of the process change. This use of data fully

supports the project as a data driven change.

Second, by channeling RAM for a multifaceted approach to the delivery of project

education. Education is not solely related to the concepts and processes within the project, but

also serves as a tool to share knowledge to patients as well as their families. The sharing of

knowledge is critical as a foundation for practice driven care, and as a means of education and

sharing knowledge with families of patients.

Lastly, as a holistic and adaptive model for bedside clinicians to employ when managing

the unique needs of patients suffering from an acute stroke, the RAM model allows for

individualized approaches to patient care. The model provides adaptation of the basic elements

of a revised process in order to deliver the most comprehensive care.

Thus, the analysis of the fit of Roy’s Adaptation Model reveals that this theoretical

framework is an effective choice in this EBP Project. The synthesis of an evidence based

question and model is a smooth fit, with each component supporting other parts of the project.

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Conclusion

Stroke care is continually evolving as new evidence emerges on improving patient

outcomes. Roy’s model influences each phase of the strategic development of the project as well

as through research, education, and most importantly, bedside practice. Each step is instrumental

in the forward progression of healthcare and should be embraced by healthcare facilities as well

as academic organizations. Application and engagement of the concepts composed nurse

theorist, such as Roy, facilitate a robust framework for healthcare innovation and increased

patient safety as well as contribute to high quality healthcare. Nurse leaders across the world

should champion projects surrounding evidenced based practice as they are integral to improving

the global health of patients.

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References

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on Roy adaptation model biological dimension on stroke patients’ physiological

adaptation level. Iranian journal of nursing and midwifery research, 20(2), 275.

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American Heart Association. (2018). Stroke Fact Sheet. Retrieved from

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ucm_501842.pdf

Bedaiwi, I., Alfaraj, S., & Pines, J. (2018). National trends in stroke and TIA care in U.S.

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