The Outcome of Stroke

The Outcome of Stroke

This research assignment will help in the development the ground work for understanding and integrating evidence-based practice in order to improve outcomes for stroke patients following the administration of tPA.  This assignment will also show the development of my PICOT question and how I researched my topic and review my search efforts for quality research evidence. The Outcome of Stroke

PICOT Model

The PICOT model for research questions help in defining your question using five very specific areas, such as population, intervention, comparison, outcome, and time frame.  I have worked emergency medicine most of my time as a nurse, and I have seen many patients that have come into the department for strokes.  The PICOT question for my research is (p) acute ischemic stroke patient that (I) receive tPA (c) verses not receiving thrombolytic agents (o) achieve the outcome of death or disability, (t) before being discharged from the hospital.

Background Questions

The Center for Disease Control and Prevention’s morbidity and mortality report has stroke as the fifth leading cause of dead in the United States, behind heart disease, cancer, accidents, and lower respiratory diseases (Garcia et al., 2016). There are two main types of strokes a ischemic and hemorrhagic strokes.  The ischemic is a clot that blocks the flow of blood to an area of the brain.  Then hemorrhagic strokes are a bleeding into the brain from the vessel.  Hypertension is one of the leading causes for hemorrhagic strokes and the treatment of this type of stroke is decreasing the blood pressure and possibly surgical intervention to repair the vessel that is bleeding.  The treatment of ischemic stroke is also to lower the blood pressure, and there is a medication that can bust up the clot, which is called Tissue Plasminogen Activator or tPA .  Several other large hospitals have neuro interventional radiologist that can do a procedure to remove or use medications locally to bust the clot up. The Outcome of Stroke

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Workflow in the Emergency Department of Stroke Patients

When a patient presents into the emergency department with stroke like symptoms there are many things that need to happen in a short amount of time.  Our first goal is to have to physician in the room to assess the patient within ten minutes.  This time is very important, so we also have a protocol that we can go straight to the radiology department to go a CT scan of the head without contrast to rule out a hemorrhagic stroke.  When we return after the scan the next steps which are not in order, obtain a finger stick glucose, an EKG, start an IV, and obtain a full set of vital signs.  We also need to obtain the last known well, because this will come into play.  Lastly, we have a telehealth stroke cart that we wheel into the room. We place a consult with a neurologist at our sister hospital, who comes into the monitor and assesses the patient.  The neurologist and the emergency room physician working in collaboration decide if the patient is eligible for tPA the clot busting medication.  The high goal of giving this medication is less than 60 minutes, and the regular goal is within 90 minutes.  It also needs to be given within three hours of the last known well, which I have seen them extend the time out to 4.5 hours.  There has been a increased push to have the CT scan completed and read as fast as possible, because you cannot give this medication if the patient is having a hemorrhagic stroke.  The mobile stroke unit is one that has a mobile CT scanner, point of care testing, ability to connect to telemedicine, and the ability to use tPA in route to the hospital (Vuong et al., 2017).  The first unit of this kind was started in 2014 by the University of Texas and then the Cleveland Clinic, in 2015 St. Vincent’s in Toledo had one up and running St. Vincent’s is part of our Mercy hospital group and is roughly an hour from the hospital I work at now. The Outcome of Stroke

Foreground Questions

The foreground questions are questions that can be answered by using scientific evidence about treatment, diagnosing, and overall prognosis (Melnyk & Fineout-Overholt, 2015). The foreground questions that would need to be asked for my PICOT question are pertaining to the use of thrombolytic agents for an acute ischemic stroke and the outcome in the acute phase in the hospital.  This agent continues to be under used in the USA, although many patient make it to the hospital within the window for using tPA, only a very small percentage 2% of ischemic stroke patients receive tPA (Eissa et al., 2012).  I have given this medication many times and I have only seen acute reactions to this medication twice, which both times was bleeding.  The physicians that I work with in the emergency department seem very reluctant to use this drug, I have seen an increased use of it when we started using the telehealth consults with the neurologist.

Database Search

I started off my search in the Kaplan Library.  I started by searching all databases with the keywords of stroke, tPA, and outcome.  There was very much information that came up from the search, so I knew I had to refine the search.  I then only searched the CINAHL Plus database with the same keywords, this search gave me the most direct information that I needed.  I also search the Cochrane library for more information.  I searched this database with the keywords of treatment of stroke with tPA.  It did not come up with anything, so I used the browse area to look for something that might help.  I opened the area of neurology and then found the topic of stroke.  When I did this, I found that there was a topic of treatment of ischemic stroke and there were 56 articles within this topic. The Outcome of Stroke

Conclusion

The Cochrane database search on Thrombolysis for acute ischemic strokes was a systemic review of 27 studies and involved 10187 patients (Wardlaw, Murray, Berge, & Del Zoppo, 2014).  The authors agree that thrombolytic therapy can be given up to six hours to reduce the proportion of death and disability.  They also agree that the most benefits are seen if the medication was given in the first three hours.  The downfall of this study is that they looked at all thrombolytic and they could be given one of two different routes, intravenous and intraarterial.  In further conclusion of this paper, the PICOT question needs to be refined slightly to encompass all thrombolytic medications or the author of this paper needs to complete more searching of databases on a study based only on tPA given in the emergency department. The Outcome of Stroke

References

Eissa, A., Krass, I., & Bajorek, B. V. (2012). Optimizing the management of acute ischaemic stroke: A review of the utilization of intravenous recombinant tissue plasminogen activator (tPA). Journal of Clinical Pharmacy and Therapeutics37, 620-629. https://doi.org/10.1111/j.1365-2710.2012.01366.x

Garcia, M. C., Bastian, B., Rossen, L. M., Anderson, R., Minifio, A., Yoon, P. W., … Iademarco, M. F. (2016, November 18, 2016). Potentially preventable deaths among the five leading causes of death — United States, 2010 and 2011. Morbidity and Mortality Weekly Report65(45), 1245-1255. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf. The Outcome of Stroke

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare A Guide to Best Practice (third edition ed.). Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Walkins.

Vuong, S. M., Carroll, C. P., Tackla, R. D., Jeong, W. J., & Ringer, A. J. (2017). Application of emerging technologies to improve access to ischemic stroke care. Neurosurg Focus42, 1-7. https://doi.org/10.3171/2017.1.FOCUS16520.

Wardlaw, J. M., Murray, V., Berge, E., & Del Zoppo, G. J. (2014, July 29, 2014). Thrombolysis for acute ischaemic stroke. Cochrane Library. https://doi.org/10.1002/14651858.CD000213.pub3 The Outcome of Stroke

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