Volume 193 - Issue 7
The NICS care bundle: aiming to improve the initial care of patients with stroke and transient ischaemic attack
Authors: Jayantha I Weeraratne, Annette J Lenstra, Andrew W Lee, Kelvin M Hill, Susan D Huckson and Jodie L Clydesdale
Med J Aust 2010; 193 (7): 381-382. || doi: 10.5694/j.1326-5377.2010.tb03962.x
Published online: 4 October 2010
Published online: 4 October 2010
Introducing an innovative, evidence-based resource for use in the emergency department
In early 2008, the National Institute of Clinical Studies (NICS) Stroke Clinical Reference Group was formed to develop an acute stroke care resource for use in emergency departments (EDs) in Australian hospitals. The NICS reference group used a care bundle approach to develop a guideline implementation tool based on specific recommendations from the 2007 National Stroke Foundation (NSF) Clinical guidelines for acute stroke management relevant for ED care.1 Although these guidelines were already available, there are well known barriers to guideline implementation in the ED. These include increasing demand and acuity, and the broad diversity of clinical presentations. Clinical information provided for ED clinicians needs to be concise and relevant to the emergency care context. The nine-member NICS reference group represented a collaboration between stroke and ED specialists, prehospital providers and managers of state-based stroke networks, with additional guidance from the NSF.
Over the following 12 months, a consultative process took place, with a combination of face-to-face and teleconference meetings and email exchanges. The reference group used a Delphi process to reach consensus. In December 2009, the NICS released two documents — the Emergency department stroke and TIA care bundle: information and implementation package and the accompanying Summary for clinicians. These are available on the National Health and Medical Research Council (NHMRC) website (http://www.nhmrc.gov.au/nics/programs/emergency/stroke_tia.htm). This editorial presents a précis of the care bundle.
Care bundles have already been shown to improve guideline compliance and lead to improved patient outcomes in several settings, including the ED.2-6 A care bundle is made up of a small number of best-practice recommendation components, is not as comprehensive as a guideline, and aims to identify critical recommendations relating to areas in which there is a significant practice gap or to act as a trigger to other best practice.7
The NICS care bundle needed to bring together several components to help clinicians provide quality care to adult patients who present to the ED with suspected stroke or transient ischaemic attack (TIA) by reducing morbidity and mortality and optimising patient outcomes (Box 1). The criteria for a component’s inclusion in the care bundle were determined by the model developed by the Institute for Healthcare Improvement in the United States:7
each component must be based on sound evidence;
the delivery of each component must need improvement;
the delivery of each component must be achievable in terms of universally available resources;
no component should be a major source of controversy; and
the delivery of each component must be measurable.
Two components — stroke unit care and thrombolysis — are not included in the care bundle. We acknowledge the importance of stroke unit care — and thrombolysis for patients who meet the criteria for its use — when appropriate resources are available. The NSF recommendations, along with similar international guidelines, state that thrombolysis should only be given under the authority of a specialist team with expert knowledge of stroke management and with pathways and protocols in place to guide the acute phase.1,8-10 Although there is level I evidence that thrombolysis and stroke unit care are effective early interventions for stroke,2 currently thrombolysis is only offered in 28% of acute hospitals that manage stroke patients, and stroke unit care is only available in a third of hospitals across Australia.8
The reference group considered all of these factors and decided, by consensus, not to include thrombolysis and stroke unit care in the care bundle, as the necessary resources to support these are not universally available. However, the reference group believes that an emphasis on the first component of the bundle — a rapid initial stroke screen — could lead to earlier referral to stroke specialists and rapid access to computed tomography or magnetic resonance imaging to confirm the diagnosis and develop a management plan that would consider thrombolysis if clinically appropriate.11 This illustrates how the components of the care bundle may trigger additional best-practice recommendations as a natural consequence and establish joint clinical decision making with other disciplines to improve patient care (Box 2).
The NICS clinical reference group is planning to collaborate with key stakeholders in 2010 to evaluate the effectiveness of the care bundle, both as a format for providing specific guideline recommendations to a target audience and in terms of the impact on stroke care in the ED. An implementation plan and auditing tool have also been developed to assist in the uptake of the recommendations.
The NICS care bundle is based on the 2007 NSF clinical guidelines,1 and its recommendations are consistent with the current draft of the 2010 NSF guidelines. It is intended that the care bundle will evolve to ensure that recommendations relevant to the ED remain current.
1 Components of the NICS care bundle
Rapid initial stroke screen (grade C; level II)*
ABCD2 assessment† for suspected TIA (grade B; level II)
Urgent‡ CT or MRI (grade A; level I)
Nil by mouth until bedside swallow screen (within 24 hours) for stroke (grade C; level I)
Aspirin as soon as possible,§ if haemorrhage excluded (grade A; level I): 150–300 mg one-time loading unless contraindicated
Physiological monitoring and treatment
Neurological status (grade C; levels II and III-2): regular monitoring to establish baseline and identify change
Blood glucose (grade B; level II): cautious treatment of markedly elevated blood glucose levels; early, intensive maintenance of euglycaemia is not recommended. Avoid hypoglycaemia
Blood pressure (consensus¶): cautious lowering by no more than 10%–20% if extremely high (≥ 220/120 mmHg); monitor for neurological deterioration
Hydration status (grade B; level II): maintain euvolemia
NICS = National Institute of Clinical Studies. TIA = transient ischaemic attack. CT = computed tomography. MRI = magnetic resonance imaging. * Evidence-based grades and levels as per 2007 National Stroke Foundation clinical guidelines.1 † A seven-point score calculated from age, blood pressure, clinical features, duration of symptoms, and diabetes status. ‡ “Urgent” means as soon as possible, but certainly within 24 hours.1 § “As soon as possible” means within 48 hours.1 ¶ Recommended best practice based on clinical experience and expert opinion.
2 Application of the NICS care bundle*
Case study 1: a 68-year-old man presents to a hospital emergency department (ED), having woken with marked weakness of his left arm. Enquiry establishes that he was fine when he went to bed 7 hours earlier. The patient’s blood pressure (BP) at triage is 186/99 mmHg. The triage nurse is concerned that the patient is having a stroke.
Case study 2: a 74-year-old woman with a history of type 2 diabetes mellitus and hypertension presents to a metropolitan tertiary hospital ED. She is unable to speak and has no strength in her right arm or right leg. Her friend states that the symptoms started only 2 hours ago. The patient’s BP is 170/95 mmHg; her heart rate is 80 beats/min and the heart is in sinus rhythm; and her blood glucose level is 9 mmol/L.
The following care is provided for these patients, consistent with the use of the care bundle:
as part of the patient’s assessment, and based on clinical findings, conduct a rapid initial stroke screen using a validated stroke screening tool to determine whether the patient is likely to have had a stroke. If a stroke is suspected, promptly refer the patient for expert stroke management — this may include referral to a stroke unit, or thrombolytic treatment (which is likely for the patient in case study 2);
order an urgent computed tomography (CT) scan of the brain;
ensure no oral intake until the patient undergoes a swallow screen for dysphagia;
maintain hydration via intravenous or nasogastric fluids;
administer aspirin (150 mg) within 48 hours if the brain CT scan excludes haemorrhage (if the patient in case study 2 proceeds to thrombolysis, delay aspirin treatment until 24 hours after thrombolysis);
monitor the patient’s neurological status, blood glucose level, BP and hydration status to prevent further deterioration.
NICS = National Institute of Clinical Studies. * The NICS care bundle was written for the care of stroke patients while in the ED. If the patient is transferred out of the ED early in his or her care, it is anticipated that the remaining components of the bundle will still be provided in the new setting.
Acknowledgements
We would like to acknowledge the contribution of the NICS Stroke Clinical Reference Group in the development of the care bundle. The NICS care bundle was reviewed by national and international experts in both clinical care and bundle methodology; endorsed by the NSF, the Australasian College for Emergency Medicine, the Australian College of Emergency Nursing and the College of Emergency Nursing Australasia; and approved by the NHMRC.
References
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