Food for thought in acute stroke

In our third blog of the week for Action on Stroke Month,  Trish Elder-Gracie, a Stroke Nurse Specialist in NHS Lothian shares her perspectives on current priorities in the acute management of stroke in the UK.

Stroke medicine has changed exponentially since I was a wee student nurse over thirty years ago when we tucked the stroke patient up in bed usually a distance away from the nurse’s station thinking nothing could be done. Research has made us focus and the evidence based medicine (practice) (EBM) means we now endeavor to provide high quality care to improve patient outcomes. Stroke continues however to be the leading cause of disability in the UK. So what is some of the evidence and how do we ensure equity.

  • Working in acute stroke the perspective is to focus on reducing disability and we work very hard at this by educating the public to act FAST to attend hospital quickly so we can assess and deliver treatment timely. Essentially we only thrombolyse 15% stroke patients who meet our criteria; 85% of cases will not meet the criteria and will also require ongoing rehabilitation.
  • For thrombectomy it is currently not known the proportions of patients who will be appropriate for this procedure but some estimate between 5-15% may be eligible. The time window is extended for those qualifying for thrombolysis and this will mean some patients will have thrombectomy but not thrombolysis.
  • We have evidence too, that ‘wake up’ stroke patients may also meet the criteria for thrombolysis but require further brain imaging to establish the eligibility for the treatment. Again the evidence is there but the resource is challenging.

Although we know that research/evidence base improves patient care we often struggle to implement this.

  • Nurses are important when it comes to delivery of EBM; all the advances in Critical care outcomes in the years prior to Extracorporeal Membrane Oxygenation (ECMO) have largely been due to improved nursing protocols to achieve EBM. This is important to recognise – it’s the same for stroke. The evidence is developed for: Thrombolysis, Thrombectomy, Intermittent Pneumatic Compression (IPC), Atrial Fibrillation (AF) detection, but few places are able to consistently offer gold standard EBM in treatments and therapies to patients because the NHS infrastructure makes change slow. Average time to implementation of new evidence is around 17 years, partly due to time for cost / benefit analysis. We need to do better as this can deny patients the care they deserve.
  • An example of relative rapid adoption of EBM was the use of intermittent pneumatic compression (IPC). There was an element where the hospitals involved in the initial trials had confidence and experience with the product so were rapid adopters once the intervention was shown to have had benefit. This means that spread of good practice produces a variability between areas where later adopters lag behind other centres.
  • If we look at swallow screening in stroke patients and the standards set out in the Scottish Stroke Care Audit (SSCA), the impact this potentially has had on nutrition, hydration and secondary respiratory infection shows best nursing care affects patient outcome.

EBM is not without its challenges and an acknowledgement that the same things may not work in different areas as one size doesn’t necessarily fit all. However to ensure the spread of evidence based practice, sharing of resources and the burden of development resource we need to work in a partnership to ensure that patients can receive best practice supported by evidence in a much more timely fashion. Nurses are the biggest resource available within the NHS and a huge sphere of influence for change; we need to unlock the potential.

 

        Trish Elder-Gracie @TElderGracie1

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