1 Running head: STROKE CARE IN THE EMERGENCY DEPARTMENT
Stroke Care in the Emergency Department
University of St. Augustine
Theoretical and Scientific Underpinnings for Nursing Practice
August 8, 2019
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Stroke Care in the Emergency Department
Healthcare is continually evolving and requires constant change in order to correlate best
practices with evolving research. Practice changes in the Emergency Department (ED) setting
are frequently required due to the array of patient populations with a variety of illnesses and
injuries. ED nurses and other healthcare providers must demonstrate competence and confidence
when caring for such a diverse group. In Emergency Departments, it is common to create order
sets, algorithms, policies and protocols in order to ease the confusion when caring for the
different patient types. Despite the multitude of patient types who present to the ED for medical
treatment, stroke patients are one of the most sensitive populations.
In the Emergency Department setting, time is of the essence when managing patients who
arrive with signs and symptoms of acute stroke. Improving the duration of time spent prior to
medical intervention can reduce morbidity and mortality for this patient population. Without a
focus on time management in the care of stroke patients, patient outcomes may suffer. Stroke,
either hemorrhagic or ischemic, is a serious medical condition that is associated with long term
deficits and significant mortality rates. According to Alimohammadi et al. (2015), approximately
5.5 million people die of stroke each year worldwide, and it is known as the third cause for
mortality in the world. Early recognition, proper testing and prompt skilled intervention is
imperative to positive patient outcomes. The purpose of this paper is to outline and describe a
nursing theoretical framework to guide the evidenced based practice change surrounding a
project to expedite the treatment of ED stroke patients.
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This project utilizes best practices recommendations as well as national guidelines to
implement a standard process for patients with acute stroke symptoms in the Emergency
Department (ED). The project reviews current and emerging literature regarding care of stroke
patients and then compiles the research for a strong evidenced based process. A selection of
relevant qualitative, quantitative and systematic reviews was thoroughly examined for
applicability. The project will outline a comprehensive approach to the management of stroke
patients in the ED, however each element of the project must contain an allotted time interval. A
key component in the nursing care of stroke patients is the duration of time between patient
arrival to the facility to the completion of a Computed Tomography (CT) Scan. Practice
recommendations will encompass a brief overview of the evidence, including study findings, as
well as a clinical algorithm for ED bedside clinicians for treatment guidance.
Does implementation of a standard process (I) for patients with acute stroke symptoms
admitted in the Emergency Department (P) compared to no standard process (C) improve time
and actions for care of patients admitted with acute stroke symptoms (I) after six weeks of
revised process implementation?
Significance of the Problem
Strokes kill almost 130,000 people each year and is also the leading cause of serious,
long term disability (American Heart Association, 2018). In an eight year study by Badawi,
Alfaraj, & Pines (2018), there were greater than 3.9 million Emergency Department visits in the
United States for stroke like symptoms alone. Strokes occur when there is a lack of blood supply
to a patient’s brain. During this time, symptom recognition and rapid medical intervention is
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essential. According to Singh et al. (2015), brain cells will begin to die within just three minutes
after the interruption of blood flow. Once cell death occurs, the risk for negative patient
outcomes are increased. Many healthcare organizations lack a standard process outlining the
medical treatment plan for patients presenting to the ED with signs or symptoms of an acute
Scope of the Problem
Stroke care begins at the first recognition of symptoms and spans until the time that the
patient is discharged from the healthcare facility. However, in the ED, stroke care begins at first
notification of the patient’s arrival (or pending arrival) and concludes at the transfer of care
(either intervention area or inpatient bed). It is important that each patient’s treatment course is
established as well as based on current research as well as that there are processes in place to
provide timely, but comprehensive patient care throughout their stay in the Emergency
Patients arrive in two distinct pathways, either via Emergency Medical Services (EMS)
transport or self-presentation, and then are cared for by ED clinical staff until there time of
transport out of the Emergency Department. Timely treatment is essential no matter which mode
arrival. Patients who arrive via EMS require care coordination and open communication at the
initiation of contact to ensure that the correct treatment begins as soon as possible by the EMS
provider, whereas patients who are self-presenting do not receive care by a healthcare provider
until they arrive to the ED. Therefore, the project should include both modes of patient arrival.
Development of a thorough guide to emergent stroke care is imperative to improve
patient outcomes. When discussing overall outcomes, there are two essential elements contained
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within the guide; evidenced based nursing education as well as a process for quality assurance.
While the concentration of the project largely focuses on construction of the stroke care
algorithm, it is integral to success and sustainability of the project that these key factors be
included in the project goal.
Education efforts should not only surround the proposed project or algorithm but provide
educational material as to why protocolized and timely care is important in the management of
these patients. In their 2016 article, Hargis et al., explored nursing education and the impacts on
patient outcomes. They concluded that the “lack of nurses with education about acute stoke and
initial management breeds a lack of urgency and consequent delays” (Hargis, et al., 2015).
If education is appropriately provided, then patients should receive stroke care based on
best practices and hospital policies, therefore, quality assurance would focus on chart reviews,
patient outcomes, and desired improvements based on data collection and analysis. Liu et al.
(2018) reports that the implementation of a nursing quality program which contains specific
measures surrounding stroke care is important in decreasing patient delays and contributing to
successful stroke care.
Sister Calista Roy’s Adaptation Model (RAM) is commonly used in healthcare practice
as it applies in an assortment of settings such as bedside nursing, education, and research
(Jennings, 2017). According to Shah, Abdullah, & Khan (2015), the theory views the person as
holistic adaptive system to cope the environmental changes to sustain life, wellness, and illness.
Therefore, Roy’s grand theory can highly effective in the guidance of nursing practice
throughout the care continuum of patients suffering from an acute stroke. “Roy’s Model provides
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framework for nursing care for individuals in health and in acute, chronic, or terminal illness”
(Shah, Abdullah, & Khan, 2015, p.40).
Research surrounding stroke best practices and national standards are paramount to the
project creation. Roy’s model has been shown useful in the research setting and would vast
applicability to the literature review for a nursing process to improve stroke care in the
emergency department setting. Roy’s model has been used for decades as an outline for a
multitude of healthcare research studies due to its adaptive approach. According to Coelho
(2011), it facilitates the ability for nurses to collect data, establish goals and nursing diagnoses,
the determination of nursing interventions and the subsequent evaluation process.
Once the research is compiled and the new process is developed, education becomes the
next key step towards project implementation. Roy’s model is relevant in the clinical education
of all ED staff members. RAM not only guides the practice change itself but allows the entire
interdisciplinary healthcare team to fully understand the evolution and importance of emerging
stroke care. Following the acute phase of stroke care, members of the healthcare team can
engage Roy’s model to assist with patient as well as family education, care expectations, and the
discharge planning process. According to West et al. (2017), the model allows for nurses to care
for patients while forming strong relationships with not only the patient, but as well as their
Nursing practice is instrumental to positive patient outcomes as they are involved in each
step and care transition of stroke patients. In the ED, nurses can apply Roy’s theory not only
through the implementation or research and education, but through adapting their bedside
practice to better meet the complex needs of stroke patients. “Roy model-based self-care plan is a
non-invasive, non-medication, and cost-effective method in control of physical and
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psychological problems and is conveniently applicable by the nursing staff, it can be used for
chronic patients and their problems, especially for stroke patients, to increase their adaptation”
(Alimohammadi et al., 2015, p. 225). ED bedside providers can tailor their care based on patient
presentation and individual patient needs, while still following the general project algorithm.
Analysis of Fit
Roy’s Adaptation Model applies to this healthcare project in three distinct ways,. Further,
the model complies those specific pathways for a complete clinical project. First, through
utilizing research and evidenced based literature to gather supporting data. This information and
data are then used as base for the fundamentals of the process change. This use of data fully
supports the project as a data driven change.
Second, by channeling RAM for a multifaceted approach to the delivery of project
education. Education is not solely related to the concepts and processes within the project, but
also serves as a tool to share knowledge to patients as well as their families. The sharing of
knowledge is critical as a foundation for practice driven care, and as a means of education and
sharing knowledge with families of patients.
Lastly, as a holistic and adaptive model for bedside clinicians to employ when managing
the unique needs of patients suffering from an acute stroke, the RAM model allows for
individualized approaches to patient care. The model provides adaptation of the basic elements
of a revised process in order to deliver the most comprehensive care.
Thus, the analysis of the fit of Roy’s Adaptation Model reveals that this theoretical
framework is an effective choice in this EBP Project. The synthesis of an evidence based
question and model is a smooth fit, with each component supporting other parts of the project.
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Stroke care is continually evolving as new evidence emerges on improving patient
outcomes. Roy’s model influences each phase of the strategic development of the project as well
as through research, education, and most importantly, bedside practice. Each step is instrumental
in the forward progression of healthcare and should be embraced by healthcare facilities as well
as academic organizations. Application and engagement of the concepts composed nurse
theorist, such as Roy, facilitate a robust framework for healthcare innovation and increased
patient safety as well as contribute to high quality healthcare. Nurse leaders across the world
should champion projects surrounding evidenced based practice as they are integral to improving
the global health of patients.
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Alimohammadi, N., Maleki, B., Shahriari, M., & Chitsaz, A. (2015). Effect of a care plan based
on Roy adaptation model biological dimension on stroke patients’ physiological
adaptation level. Iranian journal of nursing and midwifery research, 20(2), 275.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387655/
American Heart Association. (2018). Stroke Fact Sheet. Retrieved from
Bedaiwi, I., Alfaraj, S., & Pines, J. (2018). National trends in stroke and TIA care in U.S.
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