InterSECT: Incorporating Non-Physician Stroke Specialists into the Stroke Team

Introduction

Stroke care is team-based care, but trainees in neurology programs may have little experience in working directly with stroke specialists from other disciplines. Outside of an intensive care unit, nurses and physicians rarely round as a team, and stroke neurologists often have few interactions with prehospital care providers besides a quick handoff in the emergency room. However, non-physician stroke specialists bring a broad base of expertise which overlaps with and complements the stroke neurologist’s knowledge. Increasingly, integrated stroke care is being provided by multidisciplinary teams. Team structures may vary from hospital to hospital and country to country, but often include integration of emergency medical services (particularly where mobile stroke treatment units [MSTUs] are employed); specialized nurses and nurse practitioners; and specialized therapy teams including speech and language pathologists, occupational therapists, and physical therapists with particular expertise in post-stroke care.

Pre-hospital care

The “stroke chain of survival” begins with the 911 call, yet even high-level paramedics receive little formal stroke training outside of standard Advanced Cardiac Life Support (ACLS) protocols. Emergency medical service (EMS) providers are often the first point of contact for the stroke patient and have the opportunity to collect vital information about timing of symptoms and medication use. First responders to stroke 911 calls may be Basic Life Support (BLS) or ACLS level. EMS providers should be familiar with validated prehospital stroke scales such as the Cincinnati Prehospital Stroke Scale. ¹

EMS providers who have more experience with stroke, such as paramedics who staff MSTUs, find stroke to be an exciting field due to the time-critical nature of the treatment. Therefore, it is imperative that stroke neurologists reach out to EMS providers to offer additional training in stroke care. A basic understanding of stroke syndromes is both fascinating and extremely useful to EMS providers, who are often eager to invite stroke neurologists to be part of their continuing education programs. ² Increased recognition of stroke syndromes by EMS providers may increase pre-notifications to hospitals, shortening response and treatment times in the emergency department. In addition, MSTUs use multidisciplinary teams including paramedics and vascular neurologists (either in-person or via telemedicine) to administer early thrombolysis prior to hospital arrival; greater familiarity with stroke syndromes can lead to more appropriate use of the MSTU as paramedics are able to recognize potential strokes from the clinical descriptions of the EMS dispatch team. Recognizing the signs of a large vessel occlusion can help EMS providers appropriately triage patients and direct them to the appropriate receiving hospital.

EMS providers have much to teach to stroke neurologists. They must navigate dangerous situations at times, and their skill set includes field operations protocols and situational awareness skills that physicians can learn from, such as calming an agitated or violent patient. EMS providers are adept at performing efficient, focused histories and physical exams, and gathering information from the surroundings, such as the contents of garbage cans, or eyewitness accounts from children or neighbors who may not be present later in the patient’s course of care. In addition, EMS providers have expertise in local and regional systems of care, and are skilled at making quick triage decisions. Finally, EMS providers have a comprehensive and practical understanding of the community in which they work, having spent time with people from every walk of life. The EMS provider is a highly visible member of the community, and can be a vital ally in community outreach programs and in clinical trials of prehospital stroke care, including neuroprotective agents.

Stroke unit nurses

Working with stroke patients requires a deep level of commitment from a nurse. It can be physically demanding, mentally challenging and often frustrating for all involved. However, many nurses find working with neurology patients incredibly rewarding and develop a passion for their work which can be quite inspiring for stroke neurologists. Nurses spend far more time in direct hands-on care of patients than physicians, and experienced stroke nurses have a nuanced sense of how patients typically recover, what the next steps are, and how to get patients home or to rehabilitation while avoiding medical complications. They have a unique perspective on the emotional aftermath of a devastating stroke and can help guide difficult conversations regarding prognosis and goals of care. ³

In a neuroscience or stroke unit, the stroke nurse manager is a senior nurse with specialized stroke knowledge who takes a leadership role in educating and developing the nursing team, and collaborating with medical providers on behalf of nursing and patients. In addition, stroke unit nurse managers are responsible for ensuring regulatory compliance for Joint Commission requirements. Stroke unit nurse managers may have completed extra certification training in neurology, but may not have an advanced degree. The education and development of the skill set of the nursing staff with regard to stroke-specific protocols is a key responsibility of a nurse manager. On a stroke unit, every nurse must be acutely aware of the first signs and symptoms of a stroke. A nurse trained in performing the NIHSS and neurology assessment protocols will pick up subtle changes early on and alert the neurology team. Stroke nurses also perform dysphagia screening, supervise feeding to minimize aspiration risk, screen for post-stroke depression, and help identify social and medical barriers to discharge.

Like stroke physicians, stroke nurses are focused and committed to their craft, and take great pride in their work. Unfortunately, the academic medicine environment often does not provide formal integrated learning opportunities for doctors and nurses, instead creating silos which unnecessarily separate disciplines. ⁴ Including nursing staff in bedside patient rounds or teaching conferences on the unit are good ways to drive better teamwork, pushing everyone to be skilled practitioners learning together and from each other. The recognition of stroke syndromes is both a highly practical and fascinating subject which stroke neurologists can offer to stroke nurses. For example, an understanding of the behavioral effects of non-dominant hemispheric strokes can help nurses tailor their care for agitated patients, increase nurses’ confidence in the care they provide, and enhance their ability to interact with patients and counsel their families about what to expect. Stroke unit nurse managers can be a key ally in facilitating better communication and teamwork between stroke neurologists and the entire multidisciplinary stroke team, including stroke nurses, physiotherapists, speech pathologists and social workers.

Stroke nurse practitioners

Stroke nurse practitioners (NPs) are nurses who undergo advanced practice training enabling them to function as independent stroke providers. In practice, this can mean taking on a broad variety of clinical tasks, including direct patient care during stroke codes and complex medical decision-making such as management of refractory hypertension and decisions about thrombolysis; inpatient stroke care or observation units; and staffing of hospital follow-up and/or rapid access TIA clinics. A stroke NP can also take on significant administrative responsibilities such as data gathering for research purposes or quality assurance and quality improvement, including chart audits to ensure compliance with Joint Commission and other mandated stroke quality measures. Stroke NPs can perform follow up calls with stroke patients after discharge, ensuring that patients understood what happened, what was done in the hospital, which medications they should be taking, and where they should follow up, and take a leadership role in community stroke education and stroke survivors support groups. In addition, stroke NPs have much to offer in terms of educating nurses on neurology units about stroke, expected treatments for stroke patients, how to perform an appropriate neurological exam, and what to look out for post stroke. ⁵

Formal stroke-specific training for stroke NPs should include passing a stroke certification examination offered by the American Board of Neuroscience Nurses, which confers a Stroke Certified Registered Nurse (SCRN) certification. Informally, stroke NPs often come with a significant background in specialized nursing care, such as neurocritical care or cardiac care units.

While a stroke NP can help alleviate some of the pressure that comes from a high-volume practice, their potential extends far beyond that. Stroke NPs are highly motivated individuals who are hungry for specialized knowledge. A stroke neurologist can offer a different perspective to a stroke NP who may have extensive training in practical skills but less background in evidence-based medicine. Stroke NPs should be included in journal clubs, continuing education meetings, neuroradiology conferences, and teaching rounds to hone their skills and keep them up-to-date on new developments in the field.

The field of stroke care is ripe for help from NPs, who represent an untapped and underutilized entity that can enhance the care of stroke patients across the healthcare spectrum. Most physicians do not realize the capabilities, training and knowledge an NP can possess. In fact, in some institutions, NPs comprise the entire stroke team. An NP is a widely useful resource that can enhance the patient experience and improve the quality of stroke care, from primary prevention to acute stroke care and long-term follow-up.

Conclusion

Stroke care is always evolving and changing, with hospitals working constantly to push the envelope to provide the highest level of care. Academic stroke centers care for critically ill stroke patients that no other hospital will take; specialized stroke stepdown units care for patients who would be in intensive care units at non-specialized centers. Stroke experts from diverse disciplines and backgrounds are all fighting to maximize stroke education and prevention, and when that fails, to minimize the damage done. A stroke neurologist must lead this fight by example, share her knowledge and expertise, and listen to her team members before reaching her final decision.

Stroke neurologists have an opportunity and a responsibility to guide, grow and develop stroke expertise in other health care professionals. In turn, these non-physician stroke experts can push the whole team to have a deeper knowledge and understanding of the entire picture of stroke care. Everyone needs to understand the science and medicine, but also be grounded in an understanding of the community from which the patient comes and will ultimately return to. Non-physician stroke specialists, including EMS providers, nurses and nurse practitioners, physical and occupational therapists, and speech pathologists should be included and welcomed in regional, national and international stroke meetings. Multidisciplinary symposia and workshops, either within an institution or at larger meetings, can help to build connections between specialties and improve team-based care. With stroke experts from multiple disciplines speaking the same language and guiding patients together, we can only continue to succeed.