Cerebrovascular Accidents: A Case Study

With an increasing number of patients presenting to the Emergency Department the time of door to TPA is becoming less and it is becoming more important for health care providers to recognize the signs of a stroke. According to the Center for Disease Control and Prevention (CDC) (2017) every 40 seconds someone in the United States has a stroke and every four minutes someone in the United States dies from a stroke. These numbers account for more than 795,000 strokes in the United States per year (Division for Heart Disease and Stroke Prevention, 2017). Cerebrovascular accidents (CVA) are the second leading cause of death in the world and the first leading cause of permanent disability in adults (Santos, J., Melo, E., Silveira Junior, J., Vasconcelos,

N., Lima, M., & Damazio, L., 2017, p. 1764). Brain necrosis begins within minutes of an obstruction and the area around the initial necrosis is viable up to three hours after the initial obstruction (Santos et al. 2017, p.1764). As health care providers we are obligated to provide early recognition and treatment of individuals presenting to the Emergency Departments with signs of a stroke because time is tissue. Therefore, does further education on the National Institute of Health Stroke Scale (NIHSS) increase recognition and treatment in patients presenting to the ER with signs and symptoms of a stroke compared with nurses who have no additional education of the NIHSS.
In a research study, the effects of educating Emergency Department nurses on the application of the NIHSS and the signs and symptoms of cerebrovascular accident were evaluated (Santos et al., 2017, p.1763) In the study it was found that after completing the training on NIHSS there was a success increase of 93.75% showing that nursing staff was not aware of the NIHSS tool prior to teaching (Santos et at., 2017, p.1766) Furthermore, the scores from the pre-test and the post-test increased from 68.5% to 85.26% indicating an increased knowledge of recognizing the signs and symptoms of a CVA (Santos et al., 2017, p.

1765). Lastly, the study showed that out of the 16 nurses surveyed 15 reported an increased knowledge of the NIHSS scale and CVA’s (Santos et al., 2017, p.

1765).
According to Grove, Gray and Burns (2015) reliability is the consistency in measurement methods within a study (Grove, Gray & Burns, 2015, p.287). The four types of reliability including test-retest, alternative forms, interrater and homogeneity or internal consistency reliability. When critiquing the reliability of Santos et al. (2017) test-retest reliability was used. In the article the researchers used a closed nine-question pre-test and an 11-question post-test that evaluated the nurses’ current knowledge of the NIHSS and CVA’s. The first nine questions of both the pretest and posttest stayed the same with questions ten and 11 not being scored (Santos et al., 2015). It was unclear from the study where the questions were obtained from and how they were administered. The article Santos et al. (2015) shows reliability in measurement methods but not in data collection.
Validity is the determination of how well the instrument in a research article replicates the abstract notion being evaluated. (Groves, Gray & Burns 2015, p. 290) There are four types of validity including content validity, evidence of validity from contrasting groups, evidence of validity from convergence and evidence of validity from divergence. In critiquing the validity of Santos et al. (2017) article, a descriptive cross-sectional design was used. The study tested the effects of training on the signs and symptoms of CVA’s and the application of the NIHSS scale (Santos et al., 2017). According to Santos et al. (2015) The results of both test were analyzed using the chi-squared test and statistical package for the social sciences (SPSS 2.0) (Santos et al., 2015, p.1765). So, the Santos et al. (2015) article shows context validity in measurement methods
The Santos et al. (2015) article showed both areas of strengths and weaknesses. A strength noted within the study was the use of the same closed pretest and posttest questions that were evaluated using a chai-squared test and statistical package for the social sciences (SPSS 2.0) which showed both reliability and validity (Santos et al., 2015). A weakness within the study was that the authors did not disclose if the test was an established test or if the questions were created by the authors. Another weakness noted in the article was the use of convenience sampling that consisted of twenty nurses from the Emergency Medical unit in central-west region in Brazil (Santos et al., 2015, p.1765). Convenience sampling provides little chance to control prejudices and is consequently considered a weak approach. (Grove, Gray & Burns, 2015, p.264)
In the Clinical policy: Use of intravenous tissue plasminogen activator for the management of acute ischemic stroke in the emergency department on the National Guideline Clearinghouse website the administration of Tissue plasminogen activator (TPA) is effective for use in patients within four and a half hours of onset of symptoms for carefully selected patients (Brown, Burton, Nazarian, Promes, & American College of Emergency Physicians, 2015). The American Stroke Associations 2018 guidelines (2018) on the American Heart Association’s website states that better patient outcomes are associated with early treatment and reperfusion with endovascular therapy (Powers et al., 2018). The use of the NIHSS is the recommended tool for evaluation and determination of severity of a stroke by the American Stroke Associations 2018 guidelines (powers et al., 2018).
As more research is being performed the recommendation for door to TPA administration is decreasing and it is becoming increasingly more important for emergency department nurses to have a good understanding of the NIHSS and the symptoms of a stroke. In a study by Strbian et al (2013) IV thrombolysis within 90 minutes of symptom onset showed excellent outcomes in patients with moderate and mild stroke severity (Strbian et al., 2013). Patients who received intervention for CVA in 90 or less from onset of symptoms had a 2.8% less chance of developing an intercranial hemorrhage (Strbian et al., 2013). Overall it was concluded from the study that shorter onset to treatment times in patients presenting to the emergency room with signs of a stroke resulted in excellent outcomes for the patients (Strbian et al., 2013).
In conclusion, does further education on the National Institute of Health Stroke Scale (NIHSS) increase recognition and treatment in patients presenting to the ER with signs and symptoms of a stroke compared with nurses who have no additional education of the NIHSS. American Stroke Association (2018) states that better patient outcomes are associated with early treatment with reperfusion with endovascular therapy (Powers et al., 2018)
A recommendation for Emergency Department staff would be to receive annual training on the NIHSS to help aid in the early recognition and treatment of acute CVA’s. This would be beneficial to both nursing staff and patients because early recognition and treatment can save lives and lessen the long-term outcomes of stroke (Powers et al., 2018).
References
Brown, M. D., Burton, J. H., Nazarian, D. J., Promes, S. B., & American College of Emergency
Physicians.

(2015, September 1). Clinical policy: Use of intravenous tissue plasminogen activator for the management of acute ischemic stroke in the emergency department. Retrieved April 29, 2018, from https://www.guideline.gov/summaries/summary/49538/clinical-policy-use-of-intravenous-tissue-plasminogen-activator-for-the-management-of-acute-ischemic-stroke-in-the-emergency-department?q=alteplase

Division for Heart Disease and Stroke Prevention. (2017, September 01). Retrieved April 29,

2018, from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_stroke.htm

Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding Nursing Research: Building an

evidence-based practice (6th ed.). St. Louis, MI: Elsevier Saunders.

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K.,.

. . Tirschwell, D. L. (2018). 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke, 49(5), 3024-3029. doi:10.1161/str.0000000000000158

Strbian, D., Ringleb, P., Michel, P., Breuer, L., Ollikainen, J., Murao, K., . . . Tatlisumak, T.

(2013). Ultra-Early Intravenous Stroke Thrombolysis: Do All Patients Benefit Similarly? Stroke, 44(10), 2913-2916.

doi:10.1161/strokeaha.111.000819