Healthcare and Nursing: Stroke Guidelines

The guidelines for the management of acute ischemic stroke were developed with the guidance of the American Heart Association (AHA). Team members were prohibited from voicing their opinions or voting on matters that concerned their relations within the industry to ensure that the process was free of bias (Powers et al., 2019). As such, the stroke guideline can be considered free of bias. The clinical practice guideline was approved by relevant organizations including the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The stroke guideline discussed in this paper is an update of the 2018 stroke guidelines. It includes newly published trials involving more than 200 participants and their clinical outcomes (Powers et al., 2019). 

This paper describes the current acute ischemic stroke guidelines, detailing prehospital care, emergency evaluation and treatment with suitable therapies, and preventive measures. It also includes an analysis of the suitability of the acute ischemic stroke guideline in the healthcare set-up and how it applies to various healthcare practitioners in the provision of safe and quality care. 

Acute Ischemic Stroke Guidelines 

Prehospital Stroke Management and Systems of Care 

Prehospital System 

The guideline recommends that public health leaders should design and implement public education programs regarding stroke. The public health programs should focus on stroke systems and guiding patients on the measures they should take to seek emergency care in the case of a stroke. The developed programs should remain relevant over time and cater to inclusivity requirements. The guideline also categorically states that educational programs should target physicians, patients, and emergency service providers. The main goals of the program are to increase the utilization of 911 emergency management services (EMS), reduce the time between stroke onset and arrival times, and to increase the timely and effective use of treatment therapies. 

The educational programs are specially designed to ensure that people have adequate knowledge about stroke warning signs and risk factors. According to Powers et al. (2019), awareness of these factors is exceptionally low among Hispanics and Blacks. The lack of awareness is responsible for the disparities in stroke incidence. Therefore, physicians and hospitals should target these communities to optimize the effective use of the guidelines. Effective implementation of the education programs will ensure that patients are aware of stroke signs and seek medical attention as soon as they recognize the symptoms. 

EMS Assessment and Management 

Powers et al. (2019) provides guidelines for emergency service providers, including a stroke assessment tool for the first responders to provide first-aid in this seciton. The EMS personnel are also tasked with providing adequate prehospital notification to the receiving hospital when bringing in a patient who has suffered from a stroke. The notification should be made while on route to the hospital to ensure that suitable hospital resources are mobilized in time before the arrival of the patient. 

EMS Systems 

The guideline recommends the development of regional systems of stroke care. The regional systems should include hospitals capable of providing initial emergency care, and hospitals capable of delivering treatment therapies. EMS leaders should also develop triage paradigms and protocols to ensure rapid identification and assessment of patients who have suffered from a stroke using a standardized tool for stroke screening. When patients have a positive stroke screen, they should be transported urgently to the hospital where the first recommended cause of action if administering IV alteplase. 

Having a regional system that provides a list of all the hospitals capable of administering IV alteplase within a defined geographic region supports decision-making regarding the hospital that is most suitable to handle a stroke case. Additionally, there should be effective prehospital procedures that target identifying patients that are not eligible for some stroke therapies. For instance, if a patient is not eligible for IV thrombolysis, the patient should be immediately transported to a facility that offers mechanical thrombectomy services (Powers et al., 2019). 

Hospital Stroke Capabilities 

The guideline recommends accreditation of stroke centers by recognized and authoritative external bodies to ensure standardization of services. Suitable agencies provided in the guideline include Healthcare Facilities Accreditation Programs, The Joint Commission, of the Center for Improvement in Healthcare Quality (Powers et al., 2019). 

Hospital Stroke Teams 

Hospital stroke teams should be adequately trained on an organized protocol detailing how to evaluate a suspected stroke patient in an emergency set up. Hospitals should also ensure they designate team members responsible for offering management of acute ischemic stroke cases. The team should include physicians, nurses, laboratory, and radiology personnel. The designated team is responsible for performing a careful and thorough clinical assessment of stroke patients, such as performing neurological examinations. 

The guideline recommends implementation of multicomponent quality improvement initiatives. The quality improvement initiatives include educational programs and health professional team with neurologic expertise. Hospitals should develop stroke systems of care to ensure that patients eligible for various forms of therapy treatment have access to treatment facilities in the least possible onset-to-treatment time. Lastly, target time goals for the door to door treatment should be established and monitored, thus enhancing system performance (Powers et al., 2019). 

Telemedicine 

The guideline also provides recommendations about the utilization of telemedicine in the management of acute ischemic stroke. Immediate review and interpretation of brain imaging in suspected stroke patients can be expedited by using teleradiology systems in healthcare centers lacking in-house imaging interpretation proficiency. The teleradiology systems should be accepted by the US Food and Drug Administration (FDA). Utilizing teleradiology systems interconnected in a tele stroke network supports rapid imaging interpretation, thus enhancing physicians’ decision-making capabilities. Telemedicine is a modern form of offering healthcare services and should be supported by the relevant agencies and government bodies such as healthcare institutions, payers, and healthcare services vendors. Offering support to telestroke resources increases access to healthcare services and ensures 24/7 coverage and care of acute stroke patients in various health settings. 

Telemedicine can also be used to increase access to stroke management and treatment services since some health institutions lack IV alteplase administration capabilities. Therefore, patients transport to such facilities will have access to the services through the use of telestroke to guide administration from an expert in the area. Telestroke networks are also applicable and relevant for interfacility transfer of patients with stroke. Community physicians can also receive alteplase decision-making support via a telephone consultation with an expert (Powers et al., 2019). 

Organizing and Integration Protocols 

All hospitals that are authorized to care for stroke patients should develop and comply with care protocols that mirror the guidelines provided by national and global organizations. Hospitals should also have interhospital transfer protocols to support efficient patient transfers at any time. An experienced stroke center can only provide mechanical thrombectomy services with rapid access to the necessary equipment, procedures, and healthcare providers. Primary stroke centers should also ensure that they develop the essential capabilities associated with performing noninvasive intracranial vascular imaging. Acute stroke management is demanding and requires extensive resources that are not always available. Therefore, government agencies should develop and implement reimbursement schedules suitable for the provision of stroke management and treatment services (Powers et al., 2019). 

Establishment of Data Repositories 

There is a need for continuous improvement in stroke management services. Stroke centers should participate in the creation of a stroke data repository which will contribute to continuous quality improvement and enhancement of patient outcomes (Powers et al., 2019). 

Stroke Systems Care Quality Improvement Process 

The quality improvement process should be guided by a multidisciplinary quality improvement committee appointed by respective healthcare institutions. The committee should assess and monitor stroke care quality benchmarks, indicators, and outcomes, forming a committee support quality of care assurances. Healthcare institutions should ensure that they adjust the stroke outcome measures for baseline severity (Powers et al., 2019). 

Emergency Evaluation and Treatment 

Stroke Scales 

The guideline recommends the appropriate use of a stroke severity sating scale. Recommended stroke severity rating scales should be performed rapidly. They should also demonstrate the utility and support accurate and reliable implementation by healthcare providers. One of the scales recommended in the guideline is the National Institutes of Health Stroke Scale (Powers et al., 2019). 

Head and Neck Imaging 

All patients suffering from a suspected acute ischemic stroke should undergo emergency brain imaging evaluation immediately they arrive at the hospitals or stroke center. Patients who have suffered from a stroke and require IV fibrinolysis should be given priority in brain imaging services. The guideline provides probable therapy approaches for patients depending on their brain imaging results. It also provides the criteria for IV alteplase eligibility and mechanical thrombectomy eligibility. Other diagnostic tests that should be performed upon patient arrival include blood glucose tests, baseline electrocardiographic assessment, baseline troponin assessment and chest radiographs (Powers et al., 2019). 

General Supportive Care and Emergency Treatment 

Airway, Breathing, and Oxygenation 

Patients who have suffered from acute ischemic stroke and have decreased consciousness should receive airway support and ventilator assistance. Additionally, patients who have been diagnosed with bulbar dysfunction should also receive airway support since bulbar dysfunction compromises the airway. Physicians should also ensure that patients get supplemental oxygen that maintains an oxygen saturation level higher than 94%. Nonhypoxic patients who have suffered from an acute ischemic stroke should not receive supplemental oxygen. Additionally, hyperbaric oxygen is only recommended for stroke patients when the stroke is caused by air embolization (Powers et al., 2019). 

Blood Pressure 

Blood pressure (BP) should be regulated to support organ functions. Patients with heightened BP levels should have their BP prudently lowered before treatment with IV alteplase. The guideline also provides the most suitable BP levels for the various treatment options such as mechanical thrombectomy (Powers et al., 2019). 

Temperature 

The guideline recommends the identification and resolution of hyperthermia in stroke patients. Treatment of the cause of hyperthermia is deemed more effective than induced hypothermia (Powers et al., 2019). 

Blood Glucose 

Stroke patients with hyperglycemia should be treated for it before the commencement of stroke treatment therapies. Persistent hyperglycemia during the treatment process worsens patient outcomes (Powers et al., 2019). 

IV Alteplase 

Apart from the blood glucose recommendations, the guideline also includes recommendations on the use of IV alteplase. The benefits derived from the IV alteplase are time-dependent. Therefore, it should be performed as soon as possible. During treatment, physicians should be prepared to handle any emerging complications such as bleeding complications. Time windows and IV alteplase administration guidelines are provided. Guidelines for the performance of mechanical thrombectomy and other endovascular therapies are also outlined (Powers et al., 2019). 

Antiplatelet Treatment 

Patients should receive a dosage of aspirin upon arrival to the hospital after stroke onset. Dual antiplatelet therapy for patients presenting with minor noncardioembolic ischemic stroke should be administered 24 hours after symptom onset. Recommendations on the administration of anticoagulants, volume expansion, and neuroprotective agents are also provided (Powers et al., 2019). 

In-Hospital Management of Acute Ischemic Stroke: General Supportive Care 

Stroke units should implement specialized stroke care and incorporate rehabilitation services. General management can be improved by using standard care protocols for stroke cases. Head positioning recommendations are also provided. According to research, there is no perceived benefit of flat-head positioning for stroke patients in the early hospitalization stage. Supplemental oxygen, blood pressure, temperature, and blood glucose recommendations in this section are similar to those provided in the general supportive care and emergency treatment section. 

Patients facing an increased risk for aspiration should undergo dysphagia screening before consuming anything, including oral medication. Endoscopic evaluation can be used on suspected aspiration patients. Nutrition guidelines recommend the commencement of an enteral diet within one week of hospital admission in stroke patients. Nasogastric tubes should be used for patients with dysphagia. Additionally, a structured depression inventory is required to screen for post-stroke depression. The guideline also provides recommendations for rehabilitation guidelines using interprofessional stroke care (Powers et al., 2019). 

In-Hospital Management of Acute Ischemic Stroke: Treatment of Acute Complications 

The guideline provides treatment recommendations for brain swelling in stroke patients. Healthcare professionals should implement measures to mitigate the risk of swelling and closely monitor stroke patients vulnerable to brain swelling. Clinical deterioration resulting from brain swelling should be treated with osmotic therapy. Acute severe neurological deterioration can be treated using brief moderate hyperventilation. Brain swelling can be surgically managed using a decompressive craniectomy. The guideline provides an outline of the recommended criteria for a decompressive craniectomy. For seizures, treatment should include administration of anti-seizure drugs (Powers et al., 2019). 

In-Hospital Institution of Secondary Stroke Prevention 

Recommended stroke prevention measures include brain imaging to prevent recurrent stroke, vascular imaging, and cardiac evaluation using electrocardiographic monitoring and echocardiography. Other preventive measures include glucose monitoring, antithrombotic treatment, carotid revascularization, treatment of hyperlipidemia, smoking cessation intervention, and stroke education (Powers et al., 2019). 

Accuracy, Relevance, and Effectiveness of the Acute Ischemic Stroke Guideline 

The clinical practice guideline adequately addresses the management, treatment, and prevention of acute ischemic stroke. It addresses all the stages of care from prehospital stroke management, and systems care, emergency evaluation and treatment, general supportive care and emergency treatment, in-hospital management (general supportive care and treatment of acute complications), to the in-hospital institution of secondary stroke prevention (Powers et al., 2019). The practise guideline is an updated version of the 2018 guidelines. All new recommendations are made based on current evidence within the last five years. However, there is a utilization of proof from studies beyond the previous five years. There are data sources dated as a far back as 2000. The evidence provided is obtained from numerous scientific random clinical trials. 

The clinical guideline adequately directs the healthcare provider in the management of patients with acute ischemic stroke. The guideline provides a recommendation of preferred treatment approaches for different presenting cases and at different stages. The guideline is thorough and includes all treatment options based on patient criteria as determined by the physician. Therefore, the guideline is useful in the management of stroke patients since it covers all relevant practices and procedures. 

Analysis of the Clinical Practice Guideline 

The clinical practice guideline includes current trends in healthcare service delivery, such as the use of telemedicine. Telemedicine is rapidly growing and can potentially be used to increase access to healthcare services, reduce medical costs, and improve health outcomes. The acute ischemic stroke guideline considers the use of asynchronous and synchronous telemedicine. Daniel & Sulmasy (2015) describe asynchronous telemedicine as the transmission of patient’s medical information, such as the use of teleradiology systems to support rapid imaging interpretation. Synchronous telemedicine involves the use of real-time interactive technologies such as us administration of IV alteplase guided by a telestroke consultation. 

The stroke clinical practice guideline should be revised to include the use of more types of telemedicine, such as remote patient monitoring and mobile healthcare services. Remote patient monitoring allows physicians to gather, transmit, and store patient’s health information for future use. This revision would recommend the use of remote patient monitoring in patients at risk of suffering from stroke. It would help in the recognition of the early warning signs. For mobile healthcare services, smartphone applications can used as an education platform to create awareness about acute ischemic stroke (Daniel & Sulmasy, 2015). 

The stroke guideline recommends the involvement of government and third-party financing agencies in offering reimbursements for acute ischemic stroke treatment and management. Therefore, healthcare reforms targeting healthcare reimbursements would increase stroke center capacities in stroke management. The guideline also recommends the involvement of government agencies in the development and implementation of educational programs (Powers et al., 2019). Implementation of healthcare reforms targeting educational programs about stroke prevention and treatment would support the clinical practice guideline and demand expansion of recommendations. 

Changes in US demographics would not affect the clinical practice guideline since it is inclusive of all races and ethnicities. Additional research studies guided by the recommendations provided in the guideline would support or dissuade the practicability of the recommendations, thus increasing the likelihood for development of a modified clinical practice guideline. Feedback from stroke care centers and other healthcare institutions should be solicited to determine whether the guidelines are practical. If not, modifications should be made. 

Evaluation 

The Appraisal of Guidelines for Research and Evaluation II (AGREE) international tool would be used to evaluate the quality and usefulness of the modified clinical practice guideline in directing the care of stroke patients. The first step would be the determination of the scope and purpose of the guideline. It would be followed by stakeholder involvement, determination of the rigor of development, evaluating the clarity of presentation, the guidelines applicability, and determination of editorial independence. Evaluation results are rated on a scale of 1 to 7, with 1 depicting strong disagreement and 7 depicting strong agreement. ("AGREE II - AGREE Enterprise website", 2020). 

Scope and Purpose 

While evaluating the scope and purpose of the stroke guideline, factors considered include the provision of specifically defined objectives, health questions, and the target population. The target population is adults with stroke. The objectives, health questions, and target population description have a score of 6, 6 and 3 respectively. Health questions are not addressed, hence the low score. 

Stakeholder Involvement 

Evaluation of stakeholder involvement includes considerations on whether the guideline development group is inclusive of all relevant specialized groups, whether public views and preferences have been sought, and presence of a clearly defined target population. All relevant professional groups were involved in the development of the guideline and the target population is defined hence the two aspects are assigned a score of 7. However, public views and preferences were sought, hence it is assigned a score of 1. 

Rigor of Development 

Rigor of development is evaluated on a scale of 1 to 7. The scores are indicated in parenthesis. The guideline describes the scientific methods used to identify relevant evidence (6). The provided recommendations include the side effects and risks in stroke cases (7). There is also a clear link between recommendations and supporting evidence (7). The stroke guideline has not been externally reviewed by experts and the criteria for selecting evidence, strengths and limitations of the evidence were not clearly described. 

Clarity of Presentation 

The stroke guideline provides specific and unambiguous recommendations. Different options for stroke management are provided, and key recommendations are identifiable. All aspects in the clarity of presentation have a 6 score. 

Applicability 

The guideline describes how the recommendations can be implemented. However, it does not describe facilitators and barriers to its application and excludes monitoring and auditing criteria. Therefore, the three aspects get a score of 6, 1, and 1, respectively. 

Editorial Independence 

The guideline is free of bias and conflicts of interest are disclosed hence a score of 7 on both items. 

Learning Points 

The acute ischemic stroke clinical practice guideline adequately addresses acute ischemic stroke management, treatment, and prevention practices. 

It incorporates future health trends by incorporating telemedicine to ensure access to care and provision of timely care, which is critical for stroke patients. 

The practice guideline can be evaluated using the AGREE II international tool. 

Conclusion 

The acute ischemic stroke guideline provides comprehensive recommendations for healthcare providers caring for adults with acute ischemic stroke. It provides recommendations for pre-hospital stroke management, provision of emergency management services, hospital stroke capacities, treatment, and in-hospital general supportive care among others. Possible revisions in the stroke clinical practice guideline include implementation of additional types of telemedicine, such as remote patient monitoring and mobile health services. The revised stroke guideline can be evaluated using the AGREE II tool. Factors considered in evaluation include description of the scope and purpose of the guideline, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. 

References 

AGREE Advancing the science of practice guidelines. (2017, December 25). AGREE Enterprise website. Retrieved July 19, 2020, from https://www.agreetrust.org/agree-ii/. 

Daniel, H., & Sulmasy, L. S. (2015). Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper.  Annals of internal medicine ,  163 (10), 787-789. https://doi.org/10.7326/M15-0498 

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... & Jauch, E. C. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.  Stroke ,  50 (12), e344-e418.