key: cord-1021620-lyabdted authors: Li, Dongmei; Zhang, Hongjian; Lu, Xiaoying; Zhang, Lingjuan; Liu, Jianmin title: Practice of integrated treatment process for acute ischaemic stroke in hospital coordinated by emergency stroke nurses date: 2021-11-06 journal: Nurs Open DOI: 10.1002/nop2.1101 sha: f896f63c358ebc8265fb83c98be08edf22c0b658 doc_id: 1021620 cord_uid: lyabdted AIMS: To explore the practice effect of establishing an integrated treatment process by stroke emergency nurses in general hospitals for acute ischaemic stroke (AIS). DESIGN: Compared the time spent in each link before and after the establishment of AIS integrated treatment. METHODS: Since March 2016, we set up a team of emergency stroke nurses (ESN), trained and assessed the knowledge of emergency stroke, and set up a post of ESN. RESULTS: The median time of admission‐judgement, admission‐establishment of venous access, admission‐cranial CT examination and admission‐intravenous thrombolytic therapy was statistically significantly shortened after the implementation of the integrated treatment process of AIS coordinated by stroke emergency nurses (p < .01). The new treatment process of AIS further shortens the time of each treatment link and promotes the timeliness. Stroke is one of the major diseases leading to disability and death in humans. Acute ischaemic stroke (AIS) accounts for about 80% of all strokes. The timeliness and effectiveness of its treatment are essential to reduce the morbidity and mortality of patients and can greatly improve the quality of life of patients and improve the prognosis (Emberson et al., 2014; Wang et al., 2019) . However, the treatment of AIS involves many departments, including neurology, cerebrovascular surgery, emergency department, imaging department, interventional operating room and so on. It is urgent to strengthen the unification and management of AIS first aid and improve the treatment efficiency. The shorter the door to needle time (DNT), the earlier the vascular recanalization, the better the prognosis (Emberson et al., 2014) . Continuously optimizing the process, shortening the treatment time of each link and shortening DNT are the goals that our centre has been pursuing. In August 2016, the centre began to explore the integrated treatment process of in-hospital AIS coordinated by stroke emergency nurses and achieved good results. The introduction is as follows. Stroke is one of the main diseases that cause human disability and death. Acute ischaemic stroke (AIS) is the cause of most stroke | 587 LI et aL. attacks, and due to the short treatment window of thrombolytic therapy, many patients cannot obtain satisfactory treatment results, resulting in high disability and death worldwide rate. Therefore, how to shorten the processing time of each link and shorten the DNT to enable fast and effective AIS emergency management, when the patient is admitted to the hospital is the crucial issue to reduce the disability rate and mortality rate. Lou et al. pointed out that there was a positive correlation between the level of professional knowledge of nurses and the quality of care of patients (Lou, 2011) . Studies have shown that equipping the thrombolysis team with trained nurses and coordinating green channels can effectively improve the rate of intravenous thrombolysis and reduce intravenous thrombolysis DNT (Middleton et al., 2015) . Our hospital was enrolled in the National Base for Stroke Screening and Prevention in 2013 and became the first national high-level stroke centre in 2015. The in-hospital treatment process of AIS was continuously optimized, which shortened the DNT to 45 min (X. Wang et al., 2015) . This study is a single-centre retrospective study. The data of the treatment time of AIS patients in hospital from August 2015-July 2018 were collected from the central database for statistical analysis. August 2015-July 2016 was the first aid nurse stage without stroke, as the pre-operation group. August 2016-July 2017 was the trial run stage of the first aid nurse with daytime stroke, as the trial operation group. August 2017-July 2018 is the overall coordination stage for stroke emergency nurses, as the full-day operation group. The primary endpoint is the treatment time of each link. The treatment time of each link was collected through the information system. Radio frequency identification device (RFID) was installed in the hospital's emergency pre-examination desk, emergency CT room and rescue room. After the patient was admitted to the hospital and judged to be suspected of stroke, he was positioned by wearing an RFID bracelet at the emergency pre-examination desk. When the patient arrives at the emergency pre-examination desk, emergency CT room and emergency room, the RFID hand ring automatically grabs the arrival time point and sends it to the cloud server through wireless network. The background can directly collect data analysis. Two-dimensional codes were designed on emergency preexamination desk and thrombolytic medicine box, and personal digi- This manuscript was adherence to the SQUIRE guideline. The flow chart of AIS integrated treatment before improvement in our hospital is shown in Figure 1 . link-up. When multiple stroke patients visited the hospital at the same time, there was a lack of backup nurses for stroke treatment. The flow chart of integrated treatment of acute ischaemic stroke coordinated by emergency stroke nurses is shown in Figure 2 . The post of emergency stroke nurses is at the emergency pre- From the previous rotation from emergency pre-examination nurses to CT room nurses to emergency room nurses, to the full follow-up of stroke emergency nurses throughout the treatment process. Throughout the treatment process, stroke emergency nurses are responsible for a series of observation and treatment from indwelling venous channels, blood collection, thrombolysis to thrombolysis and infusion. Before the implementation of the procedure, patients were transferred to the emergency room and thrombolysis was started by the nurses in the emergency room. After implementation, it was improved to carry intravenous thrombolysis box and micropump for emergency stroke nurses, accompany the patients to the CT room with stroke doctors, move forward to the CT room for intravenous thrombolysis dispensing and bolus injection, continuously input thrombolysis drugs by micropump and transfer them to the rescue room to continue thrombolysis, which greatly shortened the DNT time. All emergency pre-examination nurses participated in the stroke emergency nurses training and passed the examination. As a green channel for emergency treatment of stroke, the reserve nurses ensure the homogeneity of multiple patients' visits at the same time. With the leadership of the vice president of the hospital stroke emergency nurses supervise and manage the quality of the integrated process. In the process of controllable and improved treatment of stroke patients in the whole DNT, it involves the cooperation of multiple disciplines and departments. Through the practice of the whole process of stroke emergency nurses, process details are found and submitted to the team to discuss its feasibility. Then the PDCA cycle can be implemented, so that the treatment process can be institutionalized and standardized, and the quality of operation can be improved. SPSS18.0 was selected to complete the data information sorting and statistics. Because the measurement data did not conform to the characteristics of normal distribution, the median (P10, P90) was used to express, and the non-reference test was chosen. The chisquared test was chosen in this study, and the difference was statistically significant when p < .01. After the trial operation of the overall coordination system for emergency nurses during the day, the time spent in each link has been greatly reduced. In the full-day operation group, the time spent was further shortened, especially the median time from admission to diagnosis was shortened from 6.67 min-0.15 min (p < .0001), that is, rapid diagnosis was achieved and time was saved for patient rescue. For the most important DNT, it is shortened from 43 min-20 min (p < .0001), which is more than double (Figure 3) . According to the current medical research results, the gold treatment time of acute ischaemic stroke is 4.5 hr, which is commonly known as the "time window" of thrombolytic therapy. The pathological changes of brain tissue in this period after cerebral infarction are slight, without obvious ischaemic changes and necrosis. The ischaemic penumbra still exists and occupies the majority of the lesions. It is in the ischaemiareperfusion time window, which is the key period of treatment. Early reperfusion of cerebral blood flow can reduce the degree of ischaemia and limit the damage of nerve cells and their functions. The reduction of DNT time greatly improves the treatment effect and prognosis of patients. AIS has the characteristics of high incidence, high disability rate, high mortality rate and high recurrence rate. Intravenous thrombolysis and mechanical thrombectomy after the onset of AIS are effective treatment methods, but the treatment effect has a clear correlation with time (Liu & Pu, 2015; X. Wang et al., 2015) . The centre set up a team of emergency stroke nurses, whose members worked after unified training. Stroke nurses coordinate the green channel and reduce the rotation of nurses in multiple positions in emergency pre-examination to CT room to emergency room. The venous thrombolysis site was moved forward to the CT room, which reduced the invalid transit time from the CT room to the rescue room. Stroke nurses also conduct quality supervision and management of the integrated process. The results showed that after the implementation of the integrated treatment process of AIS coordinated by stroke emergency nurses, the treatment time of each link in the hospital was shortened, DNT was statistically significantly shortened, and the treatment efficiency of stroke was statistically significantly improved. In range from <35, 000->27 million neurons will die every minute after AIS, and irreversible damage to the brain may occur if blood flow does not recover in time (Desai et al., 2019) . Poisson (Poisson & Josephson, 2011) and other studies suggested that patients receiving intravenous rt-PA in 90 min had better prognosis than patients receiving rt-PA in 90-180 min. Therefore, shortening the treatment time as much as possible is the key to improve the treatment effect of AIS and improve the prognosis of patients (X. Wang et al., 2015) . However, stroke treatment involves multi-disciplinary cooperation of neurology, surgery, radiology and emergency. These departments have clear boundaries and interdisciplinary cooperation is extremely challenging. At the beginning of the establishment of the Cerebrovascular Disease Diagnosis and Treatment Center of our hospital, doctors of Neurology and surgery were organized together in the hospital, but each person's administrative relationship belongs to their own departments, so it is difficult to change the treatment habits starting from their own specialty. Since September 2013, the construction of stroke centre in our hospital has been regarded as a top leadership project. The deputy president of the hospital serves as the director of the stroke centre, integrates stroke-related departments, and establishes a new in-hospital stroke treatment model, which statistically significantly improves the early treatment efficiency of AIS patients (Chen et al., 2018) . Under the leadership of the vice president, the central management team regularly supervises and organizes expert meetings to summarize and analyse the in-hospital treatment process and continuously improve it. We innovatively allocated stroke emergency nurses to coordinate the integrated treatment process, and maintained the median DNT for 20 min, reaching the first domestic and international leading level. year. At the 2018 China Stroke Congress, the integrated treatment process of AIS coordinated by stroke emergency nurses was promoted to the whole country as one of the highlights of the "Changhai Model." As the stroke training base of the National Brain Defense Commission of China, more than 300 emergency stroke nurses have been trained. After the implementation of AIS integrated treatment process, the time of each link of AIS first aid has been statistically significantly shortened, which has won valuable time for rescuing patients. However, the current emergency stroke nurses are far from meeting the needs of stroke patients, so it is urgent to strengthen training efforts and make a good staff reserve. Due to the characteristic of the research design, it was not possible to establish control procedures for potential confounding variables to avoid potential bias in results. However, the study does make it possible to establish the possible relationship between the variables involved to conduct analytical studies. In the follow-up training, it is necessary to increase the emergency treatment ability and prevention and control skills of infectious diseases, so as to achieve good protection while completing the treatment of stroke patients. None. The authors declared that they have no conflict of interest. Dongmei Li performed the research; Hongjian Zhang analysed the data; Xiaoying Lu and Lingjuan Zhang designed the study; Jianmin Liu conceived of the study; all authors discussed the results and revised the manuscript. 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