Development and Implementation of an Evidence-Based Stroke Competency Program for Emergency Department Nurses to Increase Compliance in Acute Stroke Management

Development and Implementation of an Evidence-Based Stroke Competency Program for Emergency Department Nurses to Increase Compliance in Acute Stroke Management

Development and Implementation of an Evidence-Based Stroke Competency Program for Emergency Department Nurses to Increase Compliance in Acute Stroke Management

Carmen Morales-Colón, MSN

Mass General Hospital School of Nursing

Submitted in Partial Fulfillment of the Requirements of the Doctor of Nursing Practice Degree


I would like to express my appreciation to Dr. Suellen Breakey for her patient guidance and support in this process. My appreciation to my family for always being there and being supportive during this journey.

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I would also like to thank my Stroke Team, without them, this project would not be possible, even though we still have some work to continue for the benefit of our island.

Finally, I wish to dedicate this journey to my mom, my eternal angel in heaven.


Background: More than 795,000 Americans of all ages are diagnosed with a stroke annually, and every 4 minutes, a person with a stroke dies (Centers for Disease Control and Prevention, 2017). The diagnosis of a stroke requires emergent treatment and the implementation of standardized protocols to ensure better patient outcomes and compliance with the standards of care defined by regulatory bodies such as The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS).Purpose: To implement a stroke management bundle consisting of the development of an evidence-based stroke protocol, the use of stroke nurse champions, and a stroke education program for use in the emergency department. Methods: A cohort of eighteen nurses from the ED were selected voluntarily to participate in 16-hour educational sessions that included a self-efficacy test using the Riggs Efficacy Tool, pre and post-knowledge test based on the AHA and ASA guidelines, and a full session of stroke management guidelines discussion and competencies. Results:Analysis of the 35 stroke charts evidence that the implementation of the stroke protocol decreased times for management due to the more timely intervention by the nurses that received comprehensive stroke education.

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Limitations:Due to nurses’ attrition, high volume of patients attending to the ED, and limited time for continuous education during the educational process intervention, only a total of 18 competent champion nurses received comprehensive stroke education by the end of the project.

Conclusion: Self-efficacy assessment and stroke knowledge about stroke reflect that there was a positive impact of the intervention. The results showed that the implementation of standardized protocols for stroke management in an ED improved patient outcomes due to the rapid intervention.In addition, the intervention resulted in improved scores in nurses’ knowledge and a significant change in the quality metrics. The quality improvement program needs to be implemented on a regular basis to assure compliance in all the processes.


A stroke occurs every 40 seconds, and a person diagnosed with a stroke dies every four minutes in the United States (Niemi et al., 2013). Evidence-based, standardized care is a priority in the treatment of patients experiencing a stroke.  Stroke is the fifth cause of death in Puerto Rico and the United States but the first cause of disability. Over four million individuals are living with the effects of stroke (Niemi et al., 2013). In the ED, there is a lack of standardization of protocols for stroke management, which puts patients at risk.  A priority for health care workers, particularly in the emergency department (ED), which is often the first point of care, is to have standardized protocols for stroke management that will ensure the safe therapeutic management of the patient.

The Joint Commission (TJC) implemented disease-specific care (DSC) certification in 2002. Disease-specific certification involves compliance with consensus-based national regulations. It requires effective implementation of clinical management protocols to optimize care in an organizational approach to meet quality initiatives. If a hospital is interested in seeking the DSC for stroke care certification, it is imperative to establish policies, procedures, and protocols to ensure compliance with best practices.

To have a successful stroke program, it is important that all hospital employees receive general stroke education. Stroke management demands a complex and methodical clinical order system as well as concurrent interdisciplinary communication to expedite care. Any delay in treatment can have a significant impact on the quality of life of the patient and can carry a greater financial impact related to diagnostics and possible surgical interventions (Gorelick, 2013).

Delay in early treatment may have significant consequences on patient outcomes, including a possible increase in the level of disability, poor patient satisfaction, and a much more complex post-stroke status (Fedder, 2008; Gorelick, Gorelick, & Sloan, 2008).Moreover, it is critical that nurses in the emergency department receive comprehensive stroke education. The education should include the certification and use of the National Institute of Health Stroke Scale (NIHSS), knowledge of risk factors, pathophysiology, stroke management protocols, and performed quality measures related to stroke management. All nurses from the ED should receive stroke patient and family education and a full comprehensive stroke course annually (AHA/ASA Guideline 2021; TJC, 2019). Stroke education to nursing staff was identified as an important aspect because of the lack of stroke knowledge and/or the implementation of stroke management protocols to improve consistency with stroke care.

The purpose of this quality improvement project is to determine if a bundle consisting of the development and implementation of an evidence-based stroke protocol, an educational program for nurses, and the implementation of nurse champions will decrease times (goal of within two hours of patient’s arrival to ED) of stroke management in the ED.

Background and Significance

Acute stroke is a common neurological emergency, with 17 million cases globally and 6.5 million deaths per year. In the United States, eight hundred thousand people have a stroke each year (Stroke Organization, 2015). Stroke diagnosis is the fifth leading cause of death, killing almost 130,000 Americans per year, and is the leading cause of severe long-term disability (Kochanek et al., 2011). According to a study done by Egido et al. (2009), one-third of patients with stroke can return to work within a year of the episode; half do not need help for their daily activities; 20% need help on certain occasions, and another 20% are dependent to a greater or lesser extent.

Definition, Pathophysiology, and Complications

            Stroke is a broad term describing cerebrovascular disease, a syndrome that includes a group of heterogeneous diseases with a common point: an alteration in the vasculature of the central nervous system. The change leads to an imbalance between oxygen supply and oxygen requirements, the consequence of which is a focal dysfunction of brain tissue (Alfonsoet al., 2019). Stroke refers to the nature of cerebrovascular injury and is classified into two major groups: ischemic and hemorrhagic (Arauz & Ruíz, 2012). Acute ischemic stroke is generated by occlusion of an arterial vessel and involves permanent damage due to ischemia. The overall goal of stroke treatment focuses on reducing ischemia and preventing infarction of the affected area and resulting brain cell damage (Powers et al., 2015).

However, if the occlusion is transient and self-resolving, momentary manifestations will occur, which is referred to as a Transient Ischemic Attack (TIA). A TIA is defined as an episode of focal neurological deficit due to cerebral ischemia, of less than 60 minutes duration, complete subsequent resolution, and without changes in neuroimaging (Arauz & Ruíz-Franco, 2012). On the other hand, the stroke of hemorrhagic origin is the rupture of a blood vessel that leads to a blood accumulation (Alfonzo et al., 2019). This can either be within the cerebral parenchyma or in the subarachnoid space.

Stroke Risk Factors

Risk factors for stroke include non-modifiable risk factors such as age, sex, race, genetic predisposition, and low birth weight. Modifiable risk factors can be classified as treatable medical diseases and lifestyle factors. Treatable medical diseases include arterial hypertension, dyslipidemia, diabetes mellitus, cardiovascular diseases, previous stroke, and sleep apnea.

Lifestyle factors that increase one’s risk for stroke include smoking, excessive alcohol consumption, obesity, physical inactivity, use of illicit drugs, and oral contraceptive use (American Stroke Association, 2011). The symptoms and alterations that stroke can produce vary according to the location and size of the lesion. Symptoms usually occur suddenly, with focal manifestations and resolution (Molina et al., 2010). Among the most common symptoms are hemiparesis, altered level of consciousness, visual impairment, difficulty maintaining balance and/or coordination (American Stroke Association, 2011; Texas Heart Institute, 2011).

In addition, there are other symptoms like intense vertigo, difficulty swallowing, emotional disturbance, aphasia, loss of sphincter control, memory loss, and sudden-onset headache with no known cause. The most common complications associated with stroke are cerebral edema, convulsion, clinical depression, pressure ulcers, deep vein thrombosis, urinary tract infection, and pneumonia. The severity of stroke depends fundamentally on the location of the obstruction, the degree of brain tissue affected, and the speed with which blood flow is restored (Garcia et al., 2010). Disabilities related to stroke cross the physical, psychological, and social dimensions (Parlay et al., 2010). The most common permanent sequelae in patients after stroke include hemiparesis, inability to walk, or partial or total dependence on activities of daily life.

Prevalence of Stroke in Puerto Rico

In Puerto Rico, as of 2010, 1.7% of the population aged 18 years and older self-reported having a diagnosis of stroke (Behavioral Risk Factor Surveillance System, 2011). In 2013, cerebrovascular diseases were among the top twelve causes of mortality, with 1,352 deaths (Behavioral Risk Factor Surveillance System, 2011). In Puerto Rico, strokes are one of the leading causes of death, with over 1,300 deaths per year. These diagnoses of stroke continue to increase and, in the United States, about 800 thousand cases and over 15% of people die. In addition, diseases such as hyperthyroidism, congestive heart failure, atrial fibrillation, hypertension, and even diabetes continue to be one of the main causes of strokes in Puerto Rico (Rivera, 2017).

New protocols for stroke management have been implemented in the hospital scenario to decrease stroke sequelae. There will be more stroke over the years, as stroke risk increase with age. In Mennonite Hospital, a 200-bed hospital located in the eastern-central area of Puerto Rico that provides treatment to patients with a wide variety of illnesses and injuries, a stroke education program for the implementation of stroke management protocols in the ED was developed, and training was offered to the ED nursing staff.

The ED has an average of 50,000 visits per year, of which approximately 7% are patients diagnosed with stroke. Guidelines for the management of patients with signs and symptoms of stroke based on the AHA and ASA were implemented. New protocols such as changes in triage area to perform a rapid neurological evaluation in a period of fewer than 10 minutes, using the initial triage information that contains the BEFAST scale to identify signs and symptoms of a stroke, were implemented. In cases where the patient is in the therapeutic window period for less than 4.5 hours, the nursing staff request to activate the Stroke Code. It communicates through the loudspeaker system for the purpose of notifying the multidisciplinary team that a possible stroke has arrived, and the multidisciplinary team gets activated.

Evidence-Based Strategies to Improve Stroke Care

In 2003 The Joint Commission (TJC) and the American Heart Association (AHA) established a relationship to improve care and outcomes for stroke patients by increasing nursing education about stroke and implementing evidence-based stroke protocols. Clinical research and education provide the means to compare new treatments and ways of delivering care with existing practices to improve the quality of care offered to patients (McCormack & Reay, 2013). Continuous monitoring of quality indicators, stroke signs and symptoms, and activation of the protocol by nurses are necessary (Lindsay et al., 2005). This will ensure patient safety and optimize patient recovery from a devastating sequel and long-term impact of stroke.

The implementation of evidence-based best practice guidelines for stroke, for example, Get With The Guidelines (GWTG)Stroke, improve patient outcomes. GWTG Stroke is an in-hospital database link to the AHA-ASA guidelines that provide a guide for stroke treatment. GWTG‘s was nationally implemented in 2003, and more than 1,600 hospitals across the US participated in the data collection for stroke management. The database includes the patient’s medical history, demographics, and current patient quality measures. Hospital participation in this program led to improvement in times of Alteplase administration within 60 minutes since the patient arrived at the hospital (Fonarow, 2014). Implementation of the quality measures from the

GWTW’s and evidence-based protocols in the patient hospitalization process are making a positive improvement in patient outcomes.

The purpose of this quality improvement project was to determine whether implementing an evidence-based protocol for acute management of patients presenting to the ED with signs

and symptoms of acute stroke, an educational intervention for ED nurses, and the use of stroke nurse champions will decrease times in several critical areas of acute stroke management that include:

  • Initial recognition and documentation stroke screening (BEFAST).
  • Completion of brain CT.
  • Consistent use of the NIHSS in documenting the neurologic assessment.
  • Completion of EKG, blood samples, and Chest X-ray.
  • Alteplase administration in patients within the therapeutic window.

Nurses Knowledge

A priority in health care is the need for education and implementing protocols regarding stroke. It is imperative for nursing staff to know and recognize stroke signs and symptoms. Cameron (2013) noted that nurses providing stroke must be highly trained in stroke management and pathophysiology, effects of stroke and addressing patient’s needs. The study found that a nurse-led stroke triage team led to significant improvements in metrics between arrival time to CT, ED physician evaluation to CT start, and neurology contact to CT start. As a result, having a patient-flow nurse (PFN) coordinator could help hasten the emergency processes and improve the quality of care to stroke patients.

Considine and McGillvray (2010) noted that there was asignificant improvement in triage decisions by 4% with the implementation of evidence-based practice regarding the prevention of early complications of stroke. Nursing outcomes may be interpreted with more meaning when they are linked to evidence-based practice guidelines that provide a structure for ensuring the provided is consistent among all health care workers and across all health care settings (Green et al., 2011). Clinical research and education provide the means to compare new treatments and ways of delivering care with existing practices to improve the quality of care offered to patients (McCormack & Reay, 2013).

To have a successful stroke program, it is important that all hospital employees receive general stroke education, and specifically, ED nurses receive a comprehensive stroke education program that includes National Institute of Health Stroke Scale Certification (NIHSS), risk factors and pathophysiology, stroke management protocols quality measures (AHA/ASA Guideline 2021) (TJC, 2019), stroke patient education and a full comprehensive stroke course of 8 hours annually. Patients treated by a stroke specialist and others with relevant stroke-specific knowledge and skills are more likely to survive a stroke, return home and become independent (Watkins et al., 2012)

Through the implementation of an educational program combined with quality improvements initiatives, nurses will increase their knowledge levels and provide evidence-based care to stroke patients. To maintain an educational program and continue reinforcement, all nurses from the ED should receive annual stroke education in current best practices. The coordinated, specialized care given in specific stroke areas has been shown to improve patients’ outcomes (Catangui & Slark, 2012).

Literature Review

For this review, a search was carried out in different databases such as APA PsycInfo, CINAHL, ERIC, and PubMed. The following search terms were used: emergency department, emergency service, emergency room, nurse education, workshop, learning, self-efficacy, metrics, competency, stroke protocols, standards, primary stroke center, GWTG’s stroke, evidence-based protocols. The criteria included adult patients presenting to ED with symptoms of stroke, peer-reviewed articles; English and Spanish; and articles published in or after 2008. Papers addressing stroke mimics; children; treatment outside the ED were excluded. Over 400 articles from the last 15 years were linked to the search terms, and the list was narrowed down to 26 articles. From the reviewed articles, it was noted that various themes were coming through. Therefore, this section addresses those themes

Guidelines for the Management of Stroke Patients in the ED

Considine& McGillivray (2010) conducted a study with the aim of improving emergency nursing care of stroke through the use of early complication prevention. This research followed a pre-test/post-test design while following a standard formulated for nurse management of acute stroke in the emergency department. These researchers explored various aspects to determine the efficacy of this program. The aspects explored include pressure injury risk, venous-thromboembolism, blood glucose and temperature, time to specialist assessment, length of stay in the emergency department, waiting time, and triage category. Upon the implementation of the program, the researchers noted that there was a substantial improvement in various patient aspects such as oxygen saturation, blood pressure, heart rate, respiratory rate assessments, and triage category and triage decision. There was also improved management of risks such as increased pressure area interventions and increased assessment of speech pathology in the emergency department.

Another study exploring the use of stroke management guidelines is a study by Middleton et al. (2018). These researchers conducted a randomized trial aiming at improving the transfer, treatment, and triad (T3) of patients experiencing a stroke in the emergency department. This study used an approach of multicenter, parallel-group trial with the participants randomized equally into the intervention and the control group. As part of the intervention, the guidelines used comprised of reminders, clinical opinion leaders, education, and workshops, which were applied in determining barriers and potential solutions. While one group received the T3 intervention support, the control group did not receive any intervention.

Upon the implementation of the intervention, various primary outcomes were evident. Primary outcomes explored included a 90-day dependency or death. On the other hand, the secondary outcomes included hospital quality of care outcomes, functional dependency, and health status. As opposed to the first study, which indicated significant improvement in various aspects upon the use of the protocol, this study showed no significant differences between the control and the experimental group in both the primary and secondary outcomes (Middleton et al., 2018). In addition, the researchers did not observe any substantial difference between the control and the intervention for all the studied care quality outcomes. The researchers observed that even though they applied an evidence-based implementation strategy which had been shown to be active in previous research, the strategy did not bring any changes in the clinical behavior of the clinicians involved in the emergency department patient stroke management. The authors implicate this observation to the fact that the emergency department is a chaotic and complex setting that has several competing priorities (Middleton et al., 2018).

Another research by Middleton et al. (2019) was conducted to explore the impact of an intervention in improving transfer, treatment, and triage for patients living the acute stroke and have been admitted to the emergency department. This study employed a cluster randomized controlled trial where they stratified hospitals by tPA volume and state in equal rations to either usual care or the use of an intervention. The intervention entailed using protocols or guidelines used in managing swallowing, hyperglycemia, and fever among patients with stroke. These guidelines were implemented using site visits, telephone, email follow-ups, written, online and face-to-face education, and workshops. The study was conducted in a total of twenty-six emergency departments, with thirteen each in the control and intervention groups.

Upon the implementation of the intervention, the researchers observed various results. The researchers did not observe any statistical difference between the control and the intervention groups in terms of the follow-up for a ninety-day modified Rankin Scale (Middleton et al., 2019). In addition, the researchers also noted that there was no significant statistical difference between the control and the intervention groups in terms of secondary outcomes. While the guideline had been shown to be efficacious when used in Stroke units, the same was not observed in the emergency departments as neither the clinician’s behavior nor the patient outcomes changed (Middleton et al., 2019).

In yet another study carried out by Heiberger et al., 2019, the researchers highlighted the importance of following established protocols and guidelines. This study focused on evaluating the impact of a nurse-led stroke team on patient outcomes and particular stroke metrics. The researchers analyzed metrics related to stroke twelve months before commencing the triage program for the purpose of finding control data. They also analyzed the same metrics twelve months later after starting the program. The metrics used include puncture for mechanical thrombectomy, tissue plasminogen delivery, head computed tomography, neurology contact, emergency department assessment, and patient arrival.

Upon the implementation of the nurse-led intervention, various outcomes, both primary and secondary outcomes, were measured and compared with the pre-intervention data. The primary outcomes considered in this study included metrics connected to the arrival of the patient. In addition, the secondary outcomes considered include thelength of hospital stay, the mRS scores at ninety-day follow-up, the mRS scores during discharge, and the time taken from the CT scan to the tPA delivery (Heiberger et al.2019). The analysis of the data revealed various results. For example, there was a substantial improvement in the metrics such as tPA commencement for the post-triage team incidences from neurology contact, the CT start from neurology contact, CT start from the emergency room physician evaluation, and between CT start from the arrival time. However, the researchers did not observe any significant differences in other metrics (Heiberger et al., 2019). This source report that integrating specially trained stroke nurses in the acute stroke triage is key for improving the quality of care and services offered to patients in the emergency department.

Recently, Purvis et al. (2019) conducted a study that focused on determining adherence to particular FeSS processes of care in care settings offering acute stroke care. The study also aimed at finding out whether changes in adherence were impacted by the Quality in Acute Stroke Care (QASC) and Quality in Acute Stroke Care Implementation Project (QASCIP). This study employed a cross-sectional observational study method where they used National Acute Service Stroke Audit retrospective clinical audit data and self-reported organizational survey.

Upon the analysis of the obtained data, the researchers noticed that there was a significant difference between the hospitals that took part in the QASCIP/QASC program and those that did not participate. The FeSS adherence within a four-year study was found to be more enhanced in those hospitals that took part in QASCIP/QASC as compared to those facilities that did not take part (Purvis et al., 2019). Therefore, from the study, it was noted that the use of FeSS protocol within the region was observed to increase during the four-year study underlying the importance of the implementation protocol used by this group of researchers.

In another study, McInnes et al. (2020) conducted a qualitative study to evaluate the implementation of an evidence-based protocol for managing stroke in the emergency department. The researchers evaluated timeous transfer to a stroke unit, swallowing, hyperglycemia, fever management tissue plasminogen activator administration, and appropriate triage among stroke patients in the emergency department. This study employed face-to-face interviews among the purposively selected stroke clinicians and emergency departments selected from low and high-performing intervention sites. The clinicians were queried about their views concerning the factors that influence the uptake of designed protocols for the management of stroke in the emergency department.

This study was conducted in twenty-six emergency departments. A thematic analysis of the data was carried out and revealed various findings.  Some of the themes that came up include boundaries of care, fidelity to protocols, and readiness to change. Regarding the boundaries of care, the researchers noted that reflective monitoring or appraisal by the stroke team and the emergency department about particular clinical practice boundaries impacted negatively on the protocols uptake (McInnes et al., 2020). In addition, concerning the Fidelity to protocols, the researchers noted that beliefs about the evidence that support the protocols hinder the development of a shared understanding regarding how applicable the protocols are in the emergency department (McInnes et al., 2020). The final theme, the readiness for change, dealt with ways of mobilizing and engaging clinical teams to enhance collective action and cognitive participation.

In another study, Hasnain et al., 2019 conducted research focused on testing the impact of a collaborative, multidisciplinary, and multicomponent intervention formulated to enhance intravenous thrombolysis rates among patients with stroke in the emergency department. The study randomized a total of twenty hospitals and focused on the changes in practices and perceptions of both the nurses and physicians who work in acute stroke care. The intervention entailed a guideline that had various behavior change components such as enablement, modeling, training, persuasion, and education. These components were delivered through a one and half year period. Upon the implementation of the intervention, various results and changes were observed. Using a survey to collect the data, four domains were evident, including ambulance and emergency procedures, hospital stroke care policies and personal stroke skills, personal perceptions regarding evidence and implementation of thrombolysis, and hospital training, feedback, and performance indicators. Upon the use of the intervention, the researchers observed a substantial increase in scores in the survey domains (Hasnain et al., 2019). Therefore, the use of protocols and guidelines are key in improved care outcomes among patients with stroke.

Zhou et al., 2017 conducted a study to assess the efficacy of a new standardized nursing cooperation workflow among patients with acute stroke to lower the delays in the stroke thrombolysis. The researchers had both the study group and the control groups. While the control groups received the conventional thrombolysis treatment during the study period, the intervention group got the new standardized nursing cooperation workflow for the thrombolysis treatment. The investigators then collected vital and necessary data on various techniques used such as door-to-needle time, computed tomography, and thrombolysis use or lack of it. Analysis of the data revealed an appreciable trend.

All the aspects considered in the study were found to be better in the intervention group as compared to the control group. For example, the door-to CT initiation time among the intervention group was found to be under half of the times experienced among the control group. While the times for CT completion-to-needle time recorded for the control group was found to be 55 minutes, only 30 minutes was experienced among the intervention group. In terms of the door-to-needle time, the control group and the intervention group posted 100 minutes and 55 minutes, respectively. While an improvement was observed in thrombolysis time, the intervention group showed a greater improvement of 32.5% as compared to the 12.8% displayed by the control group (Zhou et al., 2017). These results indicate that the new standardized nursing cooperation workflow was effective in improving stroke management outcomes in the emergency department; in particular, the new protocol helped in reducing stroke thrombolysis delays among patients with stroke, with nurses taking a central role.

Gurav et al., 2019, performed a study focusing on the influence of a stroke code rapid response team in efforts to shorten the door-to-needle time and enhance the rates of intravenous thrombolysis. This study analyzed prospective patient data for those patients treated for acute ischemic stroke before and after implementing the stroke code intervention. The researchers focused on various aspects such as symptom-to-needle time, door-to-needle time, door-to-imaging, door-to-physician, and symptom-to-door. The study also computed the stroke severity by applying the National Institute of Health Stroke Score pre and post-intervention. The analysis of data showed changes at various times. For example, the door-to-needle time was reduced by almost half. The composition of patients that received thrombolysis with one hour also increased from sixteen percent pre-intervention to fifty-five percent post-intervention. Therefore the implementation of the stroke code intervention improved outcomes.

While most studies report positive results when competency programs and guidelines are implemented in stroke management, some studies have reported observing no effects. In one of such reports, Sloane et al., 2020, conducted a study to determine if a protocol of door-to-needle time went lower for emergency medical services transported stroke patients that have been routed to CT scan directly on arriving at the emergency department. The researchers performed a retrospective analysis from a stroke system that had been established in a region. While the secondary outcome considered in this analysis is door-to-imaging time, the primary outcome considered was door-to-needle time. The treatment considerations were compared for cases where there was emergency department-bed routing and direct-to-CT routing. The researchers found out that no difference in door-to-needle time existed between the groups (Sloane et al., 2020). Therefore, the analysis of the regional stroke system indicated that the facilities that had protocols for routing the stroke patients directly to CT scan did not record reduced door-to-needle in comparison to the facilities without the same protocols.

McGillivray & Considine, 2009 conducted a study that aimed at examining the evidence connected to acute stroke nursing care, identifying the evidence-based aspects of stroke care, and applying the evidence-based stroke care recommendations that can be used in formulating guidelines regarding acute stroke management in the emergency department. From this research, it was evident that the emergency care nurses need to consider timeous referral to a specialist, risk management, fluid management, psychological surveillance, and the optimal triage decisions.

Role of Nurses and Knowledge, Perception and Attitude

Another theme that stood out during the literature evaluation is the role of nurses in the management of stroke among patients at the emergency department. Various researchers have explored the important roles played by the nursing staff and how they ensure that patients have better outcomes. In one such study, Hamilton et al., 2021, conducted a study with the focus of comparing the variations that exist between the nurse practice regarding stroke management connected to the rt-PA administration in two regions. These researchers conducted a comparison between the United Kingdom and Australia and whether they found differences impact the rt-PA treatment rates.

The study used a cross-sectional approach with self-administered questionnaires administered to the identified stroke clinicians from various stroke management hospitals which offer rt-PA to the stroke patients. The researchers noted various substantial differences between the countries (Hamilton et al., 2021). From the analysis, the investigators found out that the nurses working in the UK hospitals were more likely to undertake some training in the administration of rt-PA, help in the decision regarding rt-PA with emergency department neurologist or physician, treat and diagnose, and apply telemedicine in assessment.

The nurses working in the UK were also more likely to seek informed consent, perform a screening for patients to determine their rt-PA suitability, and request a CT scan. Therefore, the nurses in the UK were observed to involve in seven of the ten practices. On the other hand, the nurses working in Australian hospitals were more likely to be involved in five of the ten practices including, undertaking rt-PA administration training, assessment of a patient’s suitability to rt-PA, seeking for informed consent, and reading and interpreting the CT scans (Hamilton et al., 2021). Therefore, these researchers demonstrate that nurses have an active role to play in the administration of rt-PA as their involvement can improve the rates of rt-PA treatments. In addition, there is a need to explore more models that can effectively widen the stroke nurses’ scope of practice to help in maximizing the rt-PA treatment rates among patients with stroke.

Another research entailing nurses’ knowledge was conducted by Baby et al., 2019. These researchers conducted a study with the aim of assessing the emergency nurses’ knowledge concerning the use of tissue plasminogen activator therapy and to find out the factors that nurses perceive as barriers to the use of thrombolysis in the management of stroke. The study used a cross-sectional survey among thirty nurses who work in the emergency department, with the researchers using self-administered questionnaires.

From the analysis, the researchers noted that various perceived barriers to thrombolysis were identified, including behavioral barriers, organizational barriers, and patient-related barriers. The nurses also stated that among the most common barriers are patients failing to arrive at the care setting in the window period and financial constraints on the side of the patients. This research also showed that there needs to be ongoing and continuing nursing education to help in filling the nurses’ knowledge gap regarding the use of thrombolysis in stroke management (Baby et al., 2019). For better results, measures should be put in place at personal, institutional, and prehospital levels to help deal with barriers to thrombolysis.

Melon et al., 2015 carried out a study that focused on assessing the knowledge of the hospital staff regarding the hospital protocols, acute treatments of stroke, and stroke symptoms. The researchers conducted a survey among the hospital staff to assess the mentioned items. They used the stroke awareness questionnaire.  A total of 96 professionals attended the survey questionnaire, with 81% of the total participants being clinical staff. While 92% of the staff were able to name at least three-stroke symptoms, only under a half of the interviewed individuals knew about thrombolysis treatment. In addition, only forty-eight percent were in a position to identify the thrombolysis administration time window. The majority of the staff who had specialties connected to stroke were more likely to identify thrombolysis as one of the treatment options for acute stroke and also identify the correct treatment window (Melon et al., 2015). Even though the study revealed that the hospital staff possessed adequate knowledge regarding the symptoms and signs of stroke, there was relatively lower awareness of the use of thrombolysis strategy as well as the correct time window to use it. Therefore, any educational initiatives or programs should be fine-tuned in such a way that they help in optimizing acute stroke care.

Recently, Yeganeh et al., 2019 conducted a study that focused on assessing the knowledge of nurses that work in emergency departments. Their knowledge was assessed with the evidence-based care guidelines used in managing the ischemic stroke acute phase as the reference point. The researchers used a cross-sectional analytic study involving a total of 129 nurses in the emergency department. They used a questionnaire tool that had ten multiple-choice questions, which were touching caring for patients with stroke and experiencing the acute phase of the condition. From the analysis, the investigators noted that the mean average of knowledge among the nurses was 40, with the highest knowledge recorded for the symptoms associated with stroke. The researchers noted that the nursing staff’s knowledge regarding stroke care in the emergency department guideline was less than satisfactory (Yeganeh et al., 2019). Therefore, they recommend that evidence-based continuing education courses should be provided and attendance made mandatory to the nursing staff working in the emergency department.

In one of the reports detailing the clinical significance of nurses in the management of stroke in the emergency department, Xu et al., 2021, conducted a study to compare the status of the stroke patient before and after implementing an intervention. The comparison was made to enable researchers to analyze the impact of stroke nurses on the management of patients with stroke. By employing a retrospective study, this study analyzed various aspects such as the patients’ 90 mRS scores, timelines, clinical assessment information, and medical history. Upon the implementation of the intervention, the researchers observed a considerable reduction in the door-to-needle time in the stroke group with the nurses. In addition, there was a significant improvement in the 90-day mRS clinical outcomes. Therefore, making nurses part of the stroke management team is beneficial when it comes to better outcomes among patients with stroke. Therefore, nurses should be competent enough to undertake various stroke management care activities in the emergency department, hence the need for the implementation of evidence-based competency programs.

Programs Involving Staff Training for Competency

Management of stoke in the emergency department can be a complicated and complex activity, therefore needing proper training of the staff involved. Therefore, various researchers have also explored various modes of training with the focus of positively influencing the implementation of evidence-stroke competency and management programs. In one of such studies, Ross et al., 2015 aimed at evaluating mechanisms for behavior change in the design and delivery of stroke care in the clinical environment. These researchers applied the behavior change wheel frameworks where they mapped training through the framework, examined course material, carried out a video-recorded and direct course observation, and undertaken a pre-post course survey.

Upon the use of the formulated course material, the researchers noted that there was a significant improvement in the trainee confidence and patient management skills, underlying the importance of training regarding stroke care. From the theme analysis, the researchers noted that a facilitated debrief is central in supporting the non-clinical and clinical skills. In addition, when the investigators performed follow interviews, they noted that there were sustained impacts like verbalizing thoughts, prioritization, more focus on situational awareness, and enthusiasm for particular roles (Ross et al., 2015). The researchers also noted that the simulation training program positively impacted motivation and self-reported skills, with the impacts persisting into practice. The evaluation conducted a multiple center simulation program that is in line with clinical practice can be an invaluable source of standard training to support stroke management.

Boden-Albala et al., 2015 conducted another study that involved staff training on the impact of management of stroke in the emergency department. The study used Stroke Warning Information and Faster Treatment to compare enhanced educational material and interactive intervention on the recurrent stroke arrival times among stroke attack survivors. The researchers used a randomized controlled trial with the participants randomized to either the group which used stroke preparedness or those who integrated stroke preparedness and in-hospital session. They then investigated the impact of the programs on the emergency department arrival, preparedness capacity, and stroke knowledge. The researchers noted that there was no significant difference in the arrival hours between the two groups (Boden-Albala et al., 2015). However, they observed that both groups had an increase in the proportion of arriving in under three hours. The same results were observed in race-ethnic minorities. The significance of the observed results is that even in the implementation of an evidence-based stroke competency program in the emergency program, staff training or education can be key.

In an integrative review, Jones et al., 2018 performed an analysis on existing literature regarding the impact of training and education interventions for healthcare staff such as nurses that participate in stroke care delivery. This integrative review was performed using PRISMA guidelines and by using various data sources such as CINAHL, HMIC, EMBASE, AMED, PubMed, ERIC, and MEDLINE. The review included every study that particularly explored the training or education of nurses and other professionals regarding stroke care. Among the main findings of the review is that in most cases, the nurses are taught alone (Jones et al., 2018). Besides, the researchers noted that interactive training and education delivered to the individuals involved in stroke care using established guidelines or protocols were connected with a positive effect on care outcomes quality and patient outcomes. The implication is that practice educators who educate nurses on stroke management should strive to use interactive training and education and apply appropriate guidelines or protocols.

Another study involving staff training regarding stroke management in the emergency department is an article authored by Gardside et al., 2012. This work explored the impact of using a single-day training that applies simulated scenarios in demonstrating intravenous thrombolysis protocol and stroke recognition. The researchers used audio and video clips from the real patient integrated with a patient simulator to come up with interactive scenarios for the staff working in the emergency department and handling stroke patients. When the simulation was used as part of training the nurses, the researchers revealed that within the first year of the program, there was a substantial improvement in the nurses’ stroke assessment skills and improved self-confidence among the nursing in performing various stroke care activities in the emergency department (Gardside et al., 2012). As such, this study demonstrates that in caring for patients with stroke in the emergency department, simulations can effectively be integrated with patient video materials to enhance the assessment of stroke among patients.

Rautava et al., 2013 also performed a study that focused onthe assessment of nurses’ self-reported confidence regarding their professional skills upon implementation of an emergency department reform. These data were then compared with the recorded data before the program. The nurses working in the emergency department were involved in the training program. A weekly practical educational session on the new emergency department establishment then followed the training. As part of the training, the nurses enhanced their knowledge of the new instruments and technology and their transition skills. In addition, the nurses also formulated a list detailing practical measures and skills required in the emergency department.

After training and education, there was a substantial improvement in the nurses’ confidence regarding the professional skills and especially related to the emergency department. The researchers report that the success of nurse training and education programs on the care offered in the emergency department can more successfully be used when there is a cooperation between the physicians and nurses focusing on emergency services (Rautava et al., 2013).

Ortega et al., 2018 recently conducted a study to explore the efficacy of a quality improvement program composed of nurse competency training using a combination of traditional lecture and simulation. The nurses were taught about a stroke protocol applied to improve rapid stroke recognition to meet the set quality measures regarding stroke care. A total of eighty-six nurses participated in the lecture and simulation. They used simulated cases of standardized patients having stroke symptoms. As part of the strategy to determine the efficacy of the program, the nurses were given a ten-item pre-test which was used in measuring their knowledge regarding stroke care before the program. The tests were also done pre and post-simulation in a bid to assess the change in nurses’ knowledge. After the program, the overall mean stroke knowledge scores were observed to substantially increase from pre-lecture to pre-simulation as well as from pre-simulation to post-simulation (Ortega et al., 2018). Another result worth mentioning is that a combination of lecture and simulation was observed to be more impactful than the lecture alone in enhancing nurses’ knowledge regarding the stroke protocol to be used in the hospitals.

Khan et al., 2018 also conducted a study dealing with the stroke code simulation and how best they can benefit advanced practice providers such as nurses to improve their knowledge in caring for stroke patients in the emergency settings. The researchers employed a prospective quasi-experimental study which used a pretest/posttest study. A total of nine advanced practice providers and nine neurology residents were chosen to participate in simulated cases used in determining the need for intracerebral hemorrhage, management of blood pressure, thrombectomy, and intravenous thrombolysis. The participants were requested to complete a survey before and after the intervention. The analysis of the data indicated that the intervention was efficacious. For example, the participants showed improved confidence in leading stroke code. The participants also showed improved ability in assessing patients for thrombectomy, improved decision on when to offer a thrombolytic and rapid assessment of stroke patients (Khan et al., 2018). This research shows that simulation training can effectively be used in improving nurses’ competency regarding stroke management.

Another study was carried out by Farias et al., 2021 with the focus of assessing the impact of a stroke simulation course. The researchers evaluated the impact of the course on the clinician’s confidence in managing acute stroke. The research involved a before and after study with a total of seventeen individuals participating in the stroke simulation program. The research subjects were requested to attend to pre- and post-test questionnaires that covered an evaluation of confidence in stroke care. Upon the analysis of the data, the researchers noted that there was a substantial improvement in the post-test scores as post-test scores were better than the pretest scores in the group of individuals who used simulation (Farias et al., 2021). Therefore, the researchers report that the stroke simulation course was connected with enhanced nurses’ self-perception of confidence in offering stroke care in the emergency department. The implication is that simulation can effectively be used as part of the programs to improve nurses’ competency in stroke management in the emergency department.

Aslani et al. (2016) carried out a study that aimed at improving the nurses’ skills in stroke patient self-care. The researchers explored this through an empowerment program. They noted that promotion of motivation, the response against routinization, changes in the nurses’ attitude, knowledge-based practice, and the nursing practice improvement all work towards effecting change successfully (Aslani et al., 2016). The participating nurses acknowledged that there are various barriers and facilitators when educating patients on stroke care. Therefore, action research was key in improving nurses’ skills and performances

Theoretical Framework

The Transformational Leadership Theory (Bass, 1985) was used to guide this project. Bass (1985) examined transformational and transactional leadership styles, drawing on the work of James McGregor Burns and Robert House (Burns, 1978). According to Bass (1985), transformational leaders motivate their followers to become aware of the importance of task results. Likewise, by pushing followers to go beyond their interests and activate their higher needs, the transformational leader helps bring about change in educational organizations and institutions (Bass, 1985). Organizations, in his view, are made up of subsystems, in which the following must be considered: the kind of task to be performed, the organizational climate that exists, the development of each of the subordinates, and the short and long-term objectives of the leader.

Transformational leadership is a leadership style that suits nursing leaders because the success that nurses can have in achieving necessary clinical skills in their professional practice by expanding their knowledge depends, to a large extent, on managerial performance. Transformational leaders elevate their desires for the achievement and self-development of their employees. Several of the transformational leader’s distinctive professional competencies that highlight the focus of that leadership style are having strong convictions, self-confidence, and presenting a strong yearning for power.

Bass’s theory of Transformational leadership was chosen for this project since it seeksto change the visualized concept of the ED nursing staff, encouraging their motivation to feel confident and to gain trust in the process of immediate stroke management to fulfill the goal of achieving the necessary clinical skills in their professional practice. For the purpose of this project, improving nurse’s knowledge of stroke decreased times of stroke management that will lower complications and in-hospital mortality

ED nursing staff was required to adopt changes in stroke management, which will require an increasingly adaptive and flexible leadership. The champion nurses should build confidence, admiration, and respect in the process as they are role models who their staff seeks to emulate. The stroke coordinators will be responsible for encouraging others to achieve the goals in the process of managing stroke patients quickly and with empathy. On the other hand, the administrative staff will encourage staff innovation, challenging the beliefs of the staff, the leader, and the service. The overall leaders of the stroke center should care for all the staff and should have a strong sense of acting in a supportive role, especially in times of need.


The project design is a quality improvement project using a bundle consisting of the implementation of an evidence-based protocol to improve management times of patients presenting to the ED with presumed stroke; the identification of stroke nurse champions who facilitate the implementation of the protocol; and the educational program based on the AHA-ASA guidelines for stroke management that were conducted with18 nurse champions from the ED.A survey measuring knowledge of the guidelines (Appendix A) and perceived self-efficacy(Appendix B) was conducted pre and post the educational intervention. The Stroke

Center administrative director, stroke manager, in coordination with the Stroke Center Vascular Neurologists, developed a management guide, competencies, and an algorithm to educate the nurses in stroke management protocols (Appendix C, D, and E) based on the AHA guidelines.


               Eighty-eight nurses are employed in the ED at Mennonitehospital. Of these, 66 are Baccalaureate prepared, and 12 are Masters prepared. The target population for this quality improvement project was a cohort of 18 champion nurses who were identified to oversee the protocol implementation process. The champions were educated about the protocol and implementation process. After education was performed, a set of seven metrics were observed in the EHR for compliance. Each quality data point was measured in minutes starting at the patient’s arrival to the ED.


The setting for this project is the ED at Mennonite Hospital, a 200-bed secondary level hospital situated in the central-eastern part of Puerto Rico.  The hospital receives approximately 700 stroke cases per year.


Development of Evidence-Based Stroke Protocol

A comprehensive, evidence-based protocol was developed in collaboration with thestroke manager and stroke coordinators and approved by the vascular neurologists. The protocol was developed in accordance with the AHA-ASA guidelines for stroke care and addressed seven quality measures that should be implemented in less than two hours from arrival to the ED for patients who are outside the therapeutic window for thrombolytic therapy and less than 60 minutes for patients who are candidates for thrombolytic administration. Components of the protocol, which are also the quality measures identified by the AHA-ASA guidelines, include:

  1. BEFAST screening: a neurological assessment tool that measures signs and symptoms of stroke (B: balance, E: eyes, F: face, A: arms, S: speech, T: time of onset of symptoms that should be conducted in the triage area for patients who present with stroke symptoms. The tool was integrated into the EHR.
  2. Physician evaluation: physician from the ED should evaluate a patient immediately with signs and symptoms of stroke that arrived at the ED.
  3. National Institute of Health Stroke Scale (NIHSS): a neurological assessment specifically for stroke patients that should be performed in the ED to all patients suspected of a stroke.
  4. Head CT without contrast: should be performed immediately for all stroke code patients.
  5. Blood samples: PT-INR, CBC, Troponin, COVID Test, and CBC should be taken in the ED for patients with signs and symptoms of stroke.
  6. Chest X-R-ray and EKG
  7. Thrombolytic Therapy (r-Tpa): Door to needle times for patients eligible to receive r-Tpa should be administered in patients with ischemic stroke in less than 60 minutes from the time of the patient’s arrival to the ED (Appendix C).

The stroke management protocol was implemented in all adult patients who presented to the ED with symptoms of a stroke. All protocols and standardized order sets were included in the EHR.Implementation occurred after all 18 nurse champions had attended formal, comprehensive stroke education and all ED nurses received general stroke education.

Stroke Nurse Champions

A group of eighteen champion nurses from the ED were chosen to facilitate the successful implementation of the newly developed stroke protocol. A checklist was incorporated to facilitate the process and comply with the established protocol (Appendix F). The stroke nurse champions’  responsibilities include verifying and ensuring that the protocol is implemented for all patients identified as having signs and symptoms of a stroke.

Stroke Education Program

All ED nurses participated in an 8-hr Stroke Education Program. The content consisted of stroke pathophysiology, rapid stroke recognition, use of the NIHSS, acute stroke management, and the stroke care protocol. In addition to the educational program for nurses, other key personnel, including medical staff, laboratory personnel, and imaging staff, was trained on the process of the stroke protocol and their respectiveroles. This curriculum consisted of rapid recognition of stroke signs and symptoms, BEFAST, a stroke management protocol, appropriate documentation, desirable time to treatment, administration of thrombolytics, the use of NIHSS, and stroke education. Roles and responsibilities related to protocol implementation were

discussed with each team member. The education was done between the months of August and October 2021. Based on an assessment of the initial nursing education program, an additional eight hours of education was added to ensure nurses were adequately prepared to implement the protocol and recognize patients presenting with stroke.

Data Collection


Quality metrics data: Information was collected on seven quality measures included in the protocol to identify time to treatment, documentation and to verify that the protocol was initiated in all eligible patients. Medical records were used to collect data on all patients who presented to the ED with signs and symptoms of stroke for a five-week period from October 25 thru November 30, 2021.

Pre-Post Knowledge /Self-Efficacy Assessment Measures

Stroke knowledge was measured using a 14-item, a multiple-choice survey developed by the Stroke Manager and the Director of Neuroscience usingthe guidelines for stroke management from the AHA and validated by the vascular neurologists (Appendix C). In addition, the Personal Efficacy Beliefs Scale, which is one of four scales comprising the Riggs Self-Efficacy Tool, was used to measure nurses’ perceptions of self-efficacy and was revised to address self-efficacy specifically related to stroke care (Riggs et al., 1994). Ten questions were administered that address perceived confidence and ability in one’s job performance (Appendix B). Permission was obtained from the author (Appendix H). Both the knowledge test and the self-efficacy tool were administered prior to and at the end of the nurse champion educational program by the stroke coordinators and the stroke educator.

Data Analysis

Nurses’ knowledge, self-efficacy pre-, and post-survey data were analyzed using IBM SPSS version 24. The times to complete BEFAST, CT, NIHSS, LABS, C-X-ray, and r-TPA were recorded for four weeks prior to the protocol implementation. In addition, post-implementation times were recorded weekly for five weeks. Because these values were normally distributed, to compare the data before and after protocol implementation, independent samples t-tests were used. Wilcoxon signed-ranks tests were used to compare pre- and post-educational knowledge and self-efficacy since these data were not normally distributed. There was statistical significance if the p-value of a two-tailed test was < 0.05.

Ethical Considerations

The MGH QI Checklist was completed. This project met the criteria for quality improvement. The project is of minimal risk, and participation in completing the surveys was voluntary. Because the project lead is the Director of the Neuroscience Center, educational sessions were conducted by the Stroke Coordinator and Stroke Educator. In addition, they also distributed the surveys to participants. Surveys were de-identified and anonymous.


Demographic information from the participants was obtained (Appendix G).To help fulfill the project objectives, participants were chosen. The impact of the project will be evaluated on patients; therefore, both nurses and patients will participate in the research. All 18 nurses were Hispanic. The majority (89%) had less than five years of nursing experience. The target population for this quality improvement project was a cohort of 18 champion nurses who were identified to oversee the protocol implementation process. The champions were educated about the protocol and implementation process

Seventy-four stroke cases were identified in the 5-week period of observation. However, 47% of the cases were not included in the data analysis because these patients were transferred from other institutions. Therefore, a total of 35 patients were included in the quality metric data analysis. No patients received r-tPA during the protocol implementation process.

Quality Metrics

The times recorded to complete the tests are shown in Table 1 (Appendix I).  There were not enough data for r-tPA to draw any conclusions. In general statistics, there was a downward trend in times for CT, NIHSS, LABS, and C-X-ray, but not for BEFAST and EKG.  Comparison to pre/post protocol implementation times are displayed in Table 2 (Appendix J). A significant decrease in the time to complete NIHSS (2531.21 ± 2445.04 to 616.26 ± 558.93, p < 0.001) and the time to complete LABS (385.63 ± 375.87 to 180.86 ± 264.94,(p = 0.016) were noted.).Comparison of pre-implementation times and weekly post-implementation times show a difference in the time taken to run NIHSS (p = 0.006), specifically between time points 1 (before protocol implementation) (2531.21 ± 2445.04) and 6 (week 5 of protocol implementation) (490.40 ± 583.20): p = 0.037.

Nurses’ knowledge and Self- efficacy

The results of the Wilcoxon signed ranks tests in Table 3 (Appendix K) showed a significant increase in stroke knowledge from 11.00 ± 0.69 to 13.50 ± 1.20 (p < 0.001). In addition, there was a significant increase in the responses to eight of the ten questions on the self-efficacy survey (p < 0.05) but not in the responses to Questions 1 and 9 (p = 0.317 and 0.083, which addresses nurse knowledge on types of stroke and what kind of documentation is key in case the established time for administering Alteplase are not metrespectively.



This quality improvement project was undertaken to improve management times of patients presenting to the ED with presumed stroke; the identification of stroke nurse champions who facilitate the implementation of the protocol; and the educational program based on the AHA-ASA guidelines for stroke management. Several factors impacted the implementation of the protocol, including the high level of attrition among ED nurses and the high volume of admissions. While improvements were seen and trends in the time of completion in the seven quality metrics decreased, despite stroke education of the identified stroke nurse champions and due to a high volume of admissions and with the nursing shortage, not all metrics were statistically significant impacted even though a trend of decreasing times of management in almost all metrics was observed.

  1. Regarding knowledge and self-efficacy, there was an increase in the nurses’ job confidence.
  2. Compliance with two specific variables: NIHSS and laboratory testing times, decreased as statistically shown.
  3. There is a significant difference between the results the participants’ knowledge at the beginning of the program and after the implementation of the educational protocol.
  4. The educational intervention developed and conducted in this project had a significant effect as an increase in knowledge of the participants at the ED was observed

Implications for Clinical Practice

            Continuous nursing professional development in stroke improves patient immediate management and therefore has a more rapid rehabilitation on stroke survivors. GWTG stroke clinical practice should be part of the process of education because is linked to evidence-based practice in stroke. Education and clinical application are necessary for a successful process and assessment expertise. Stroke Center will revise all policies and procedures on an ongoing basis to ensure compliance.

Implications for Education

            The Joint Commission Primary Stroke Certification recommendations stress the need for all nurses who care for stroke patients with stroke symptoms to attend annual stroke education. These recommendations are supported by this current research as nurses displayed increased knowledge scores. Such increased knowledge scores are subsequently reflected in the quality metrics. For example, a significant decrease in the time to complete NIHSS (2531.21 ± 2445.04 to 616.26 ± 558.93, p < 0.001) and the time to complete LABS (385.63 ± 375.87 to 180.86 ± 264.94,(p = 0.016) were noted. As part of the continuous education, all new nurses will receive a 1-hour education about stroke protocols regardless of the area that they will be working. An e-learning session about stroke management will be part of the annual nurse’s education. ED nurses will maintain 8 hours minimum in-person education annually. The knowledge of nursing professionals about stroke reduces its management and, in turn, will reduce complications and hospital mortality.

Implications for Policy

Aggressive and early intervention is the key to overall neurological improvement in stroke patients. All clinical staff plays an important role in the process. Community awareness and education about signs and symptoms of stroke play an important role in the process for patient immediate management and rehabilitation. Policies should be created across the board to focus on prompt intervention for the reperfusion of the damaged tissue. As it is important to manage the emergency, it is very important to create conscience about stroke risk factors by reducing hypertension, hyperlipidemia, and hyperglycemia. Nursing implications include close monitoring for complications after the diagnosis of the stroke (acute phase) or before the diagnosis by educating patients to minimize modifiable risk factors.


During the educational process, 20 champion nurses were identified. During the implementation process, two nurses resigned, leaving 18 stroke nurse champions. Moreover, 31% of the ED nurses have less than one year of experience as a result of overall nurse attrition.


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Xu, Z. H., Deng, Q. W., Zhai, Q., Zhang, Q., Wang, Z. J., Chen, W. X., … & Zhang, Y. D. (2021). Clinical significance of stroke nurse in patients with acute ischemic stroke receiving intravenous thrombolysis. BMC neurology21(1), 1-8.

Yeganeh, M. R., Bagheri, Z. F., Mohammadi, T. K., Roshan, Z. A., & Pouralizadeh, M. (2019). The Knowledge of Nurses about Evidence-based Guideline in Patients with Acute Ischemic Stroke. Journal of Pharmaceutical Research International, 1-10.

Zhou, Y., Xu, Z., Liao, J., Feng, F., Men, L., Xu, L., … & Li, G. (2017). New standardized nursing cooperation workflow to reduce stroke thrombolysis delays in patients with acute ischemic stroke. Neuropsychiatric disease and treatment13, 1215.

BUY A CUSTOM-PAPER HERE ON;Development and Implementation of an Evidence-Based Stroke Competency Program for Emergency Department Nurses to Increase Compliance in Acute Stroke Management

Appendix A

Stroke Knowledge Assessment

  1. What are the two different types of strokes?
    1. Ischemic and TIA
    2. Ischemic and Hemorrhagic
    3. TIA and hemorrhagic
    4. Myocardial infarction and TIA
  2. Which of the following acronyms contains the signs and symptoms of a Stroke and is used to guide the community?
    1. FAST
    2. ICH
    3. SDH
    4. 911
  3. Is Stroke the __________ cause of death in Puerto Rico and the United States?
    1. Second
    2. Third
    3. Fifth
    4. Sixth


  1. Which of the following statements is the most important when a patient with a possible Stroke presents to the Emergency Room:
    1. Medication reconciliation
    2. Vital signs and DXT
    3. Time and date of onset of symptoms
    4. Previous medical history
  2. Which of the following studies is the most important for diagnosing a Stroke?
    1. CBC
    2. X-Ray
    3. Head CT
    4. CMP
  3. Which of the following signs and symptoms might be indicative of a Stroke?
    1. Weakness of one or more limbs
    2. Slurred speech
    3. Deviation of the lip commissure
    4. All the above
  4. Which thrombolyticis used for the management of Ischemic Stroke?
    1. Streptokinasa
    2. Alteplase
    3. Mannitol
    4. Labetalol
  5. Which of the following is a candidate for the administration of Alteplase?
    1. Patient presents with weakness in a limb, CT positive for ischemic stroke and symptoms began 5 hours ago.
    2. Patient presents to the ED at the time of onset of symptoms, CT positive for Ischemic Stroke and with a history of GI bleeding.
    3. Patient presents with weakness and deviation of the labial commissure, dxt 550, CT negative for blood, family reports that he got up with that symptomatology.
    4. Patient arrives within 3 hours of the onset of symptoms, weakness in limb, CT positive for Ischemic Stroke.
  6. What is important to document if the established times for the administration of the Alteplase are not met?
    1. Justification for the last time he looked good
    2. Justification of the exact time of administration of the Alteplase
    3. Justify the reasons why Alteplase could not be administered in the appropriate time (e.g. HBP, poor history of the time of onset of symptoms)
    4. Justification of EMS delay upon arrival at the hospital
  7. Which of the following is a validated tool for neurological assessment used for patients diagnosed with Ischemic Stroke?
    1. GCS
    2. NIHSS
    3. ICH Score
    4. HUNT and HESS
  8. Are all Stroke risk factors modifiable?
    1. True
    2. False
  9. Which of the following assessments or evaluations should be performed on a patient diagnosed with Stroke?
    1. Swallowing evaluation
    2. Neurological evaluation
    3. Functional assessment of needs
    4. All the above
  10. What is the maximum dose of Alteplase for a Stroke patient?
    1. 89 mg
    2. 71mg
    3. 90 mg
    4. 81 mg
  11. What are the laboratory samples that must be performed on a patient that are in a Stroke code?
    1. CBC, PT, Lactic acid, type and group, CPK-MB, Covid test
    2. CBC, PT, CMP, type and group, CPK-MB, Covid test
    3. CBC, PT, troponin, CPK-MB, CMP, type and group, toxicology in urine, Covidtest
    4. None of the above.

Appendix B

 Self Efficacy Assessment

Think about your ability to do the tasks required by your job.  When answering the following questions, answer in reference to your own personal work skills and ability to perform your job. Respond with “SA” for “strongly agree,” “A” for “agree,” “AS” for “agree somewhat,” “DS” for “disagree somewhat,” “SD” for “strongly disagree.”

  1. I have confidence in my ability to do my job.
    1. _____
  2. There are some tasks required to do my job that I cannot do well.
    1. _____
  3. When my performance is poor, it is due to my lack of ability.
    1. _____
  4. I doubt my ability to do my job.
    1. _____
  5. I have all the skills needed to do my job very well.
    1. _____
  6. Most people in my line of work can do my job better than I can.
    1. _____
  7. I am an expert at my job.
    1. _____
  8. My future in this job is limited because of my lack of skills.
    1. _____
  9. I am very proud of my job skills and abilities.
    1. _____
  10. I feel threatened when others watch me do my job.
    1. ____

Appendix C: Mennonite Hospital Stroke Guide for Stroke Management at the ED

  1. Patients who arrive at the emergency room within 4.5 hours of the onset of symptoms.
  2. The nursing professionals receive the patient in the triage area and perform a rapid neurological evaluation in a period of less than 10 minutes, using initial screening that contains the BEFAST scale to identify signs and symptoms of a stroke. In cases where it is identified that patient is on therapeutic window, less than 4.5 hours, the extension 1197 is contacted to request the activation of the Stroke code. It communicates through the loudspeaker system, for the purpose of notifying the multidisciplinary team.
  3. Patient is transported to the CT area to perform a head CT scan without contrast and arrival of the Stroke team. The ER doctor evaluates the patient. The images will be reviewed by the neuro-radiologist on duty who will report the findings to the Emergency Room doctor and the vascular neurologist to rule out hemorrhage.
  4. The multidisciplinary staff that is activated (Stroke team) is composed of Emergency Room Head Nurse, Registered Nurse, Physician, Vascular Neurologist, Neuroscience Liaison Coordinator, Laboratory Technologist, Neuroscience Clinical Specialist, and Imaging Center Technologist.
  1. If the head CT is negative for bleeding, the NIHSS neurological scale (National Institute of Health Stroke Scale) is performed. By evaluating the results of the study, it is determined if the patient is a candidate for the administration of Alteplase (r-tPA – tissue plasminogen activator, known by its acronym), according to the clinical guidelines of the American Heart Association and the American Stroke Association (AHA-ASA).


  1. If the neurologist is not at the Institution, the emergency room doctor must notify him within a period of no more than 15 minutes after the arrival of the patient. If necessary, after the case discussion with the emergency room physician, the neurologist will go to the institution to evaluate the patient or will use telemedicine as a mechanism for immediate neurological evaluation.
  2. An inclusion and exclusion screening are performed to determine if the patient is a candidate for r-tPA. This is indicated for the treatment of acute ischemic stroke intravenously (when the signs and symptoms begin in a period of less than 4.5 hours). The Alteplase is ordered by the emergency room physician after consulting with the vascular neurologist on duty. The medication must be administered within 45 minutes of the patient’s arrival at the emergency room. If the stipulated period is not met, the doctor must justify the reason. Within the inclusion screening, the following is evaluated:

Level I (absolute contraindications for r-tPA IV)

  • Allergy to r-tPA
  • Uncontrolled blood pressure at the time of treatment (systolic pressure> 185 or diastolic pressure> 110)
  • Intracerebral hemorrhage /Subarachnoid hemorrhage or suspected subarachnoid hemorrhage
  • Brain CT imaging shows extensive regions of clear hypoattenuation
  • Ischemic stroke in the last three months
  • Severe head trauma in the past three months
  • History of intracranial hemorrhage
  • Intracranial / spinal surgery in the last three months
  • Active internal bleeding
  • Consistent symptoms of infective endocarditis
  • Known or suspected aortic arch dissection
  • Concurrent use or full dose of Lovenox in the last 24 hours
  • Taking direct thrombin inhibitors or direct factor Xa inhibitors unless laboratory tests are normal, or the patient has not received a dose of these agents for less than 48 hours (assuming normal renal metabolism function).
  • Concurrent use of IIB / IIIA (Abciximab-ReoPro)
  • Platelet count <100,000 per microliter
  • INR> 1.7
  • APTT> 40 seconds (heparin)
  • Intracranial / intra-axillary tumor (GBM / METS)
  • Allergy to r-tPA
  • Uncontrolled blood pressure at the time of treatment (systolic pressures> 185 or diastolic pressures> 110)
  • Intracerebral hemorrhage / Subarachnoid hemorrhage or suspected subarachnoid hemorrhage
  • Brain CT imaging shows extensive regions of clear hypoattenuation
  • Ischemic stroke in the last three months
  • Severe head trauma in the past three months
  • History of intracranial hemorrhage
  • Intracranial / spinal surgery in the last three months
  • Active internal bleeding
  • Consistent symptoms of infective endocarditis
  • Known or suspected aortic arch dissection
  • Concurrent use or full dose of Lovenox in the last 24 hours
  • Taking direct thrombin inhibitors or direct factor Xa inhibitors unless laboratory tests are normal, or the patient has not received a dose of these agents for less than 48 hours (assuming normal renal metabolism function).
  • Concurrent use of IIB / IIIA (Abciximab-ReoPro)
  • Platelet count <100,000 per microliter
  • INR> 1.7
  • APTT> 40 seconds (heparin)
  • Intracranial / intra-axillary tumor (GBM / METS)
  • Malignant gastrointestinal / gastrointestinal bleeding in the past 21 days

Level II (Relative contraindications for r-tPA IV)

  • Recent major trauma (not head) in the past 14 days (call neurosurgeon)
  • Recent major surgery <14 days (call surgeon)
  • Pregnancy, when the anticipated benefits of treating a severe or moderate stroke outweigh the increased risk of uterine bleeding (call OB / GYN)
  • Postpartum <14 days (call the obstetrician-gynecologist)
  • Recent or active vaginal bleeding causing clinically significant anemia (call OB / GYN)
  • Giant intracranial aneurysm not ruptured or secured
  • Untreated and unruptured intracranial vascular malformation, if the high probability of morbidity and mortality outweighs the anticipated risk of intracerebral hemorrhage
  • The previously high burden of cerebral micro bleeds (> 10) showing on MRI whether there is potential for substantial benefit
  • A history of diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions, but the possible increased risk of visual loss must be weighed against the benefits of treatment.
  • Arterial puncture in the last 7 days
  • Intracranial dissections


  1. Initial blood glucose levels <50 or> 400 mg / dl that later normalize the laboratory tests are carried out under what is known as the Stroke Panel Code and are:

✓ Capillary glucose sample (DXT)

✓ CBC (red cell count)

✓ PT, INR (blood coagulation tests)

✓ CMP (complete metabolic panel)

✓ CPK MB and troponins (cardiac enzymes)

✓ Urine toxicology

✓ Type and Group

  1. The nursing professional will measure your neurological and hemodynamic status every 15 minutes for the first 2 hours, every 30 minutes for 6 hours, and every 1 hour until the 24-hour administration of r-tPA is completed.
  2. A COVID test, chest X Ray and electrocardiogram (EKG) are performed.


  1. The nursing professional and the Emergency Room doctor will always be with the patient for a period of no less than 60 minutes, watching for any signs and symptoms of an adverse reaction to the medication.


  1. Products for the acute management of patients with Stroke (Cryoprecipitates or Fresh Frozen Plasma) are available at the Hospital Blood Bank to be used immediately in the event of any bleeding complication.


  1. When patients with Hemorrhagic Stroke are received with a history of use of anticoagulants (Xarelto, Pradaxa, Eliquis, Coumadin) – their pharmacological treatment and recommendation based on AHA-ASA clinical management guidelines for is K-Centra and Vitamin K (depending on the anticoagulant used).
  2. The patient is admitted by internal medicine to the Neuroscience Unit for specialized management.
  3. The multidisciplinary staff consultation process begins (physicians, speech pathology, nutritionist, rehabilitation, discharge planning, social worker).
  1. Patients outside the 4.5-hour window (the Stroke code will not be activated) but the entire protocol will be performed within two hours of arrival at the hospital.
    1. The patient undergoes a CT scan of the head without contrast.
    2. A 12-lead electrocardiogram and chest plate were performed.
    3.  The laboratory tests are carried out under what is known as the Stroke Panel Code and are:

✓ Capillary glucose sample (DXT)

✓ CBC (red cell count)

✓ PT, PTT, INR (blood coagulation tests)

✓ CMP (complete metabolic panel)

✓ CPK MB and troponins (cardiac enzymes)

✓ Urine toxicology

✓ Type and Group

✓ Rapid sample and COVID PCR

    1. The nursing professional will measure neurological and hemodynamic status every 2 hours for the first 48 hours.
    2.  The ER physician notifies the vascular neurologist and consults internal medicine for the patient’s admission.
    3. The patient is admitted to the Neuro Telemetry Unit (Stroke Unit)
    4. The multidisciplinary staff consultation process begins (doctors, physiatrist, speech pathology, nutritionist, social worker)

Appendix E: Stroke Competencies for Nurses



      I.            o   Performs the NIHSS (National Institute of Health Stroke Scale)

  • Level of consciousness (A LOC)
  • Answer to questions (B LOC)
  • Response to Commands (LOC)
  • Best look
  • Visual fields
  • Facial paralysis
  • Motor evaluation of the arms
  • Motor evaluation of the legs
  • Limbataxia
  • Sensory assessment
  • Language assessment
  • Pronunciation assessment (dysarthria)
  • Neglect
2 Glasgow

a.      Opening of the eyes

  b.     Better verbal response      
  c.      Better motor response      
3 Motor

Arms (Normal, Mild Weakness, Severe Weakness, Flacid, Rigid, Spastic, Abnormal extension, Abnormal flexion)

  Legs (Normal, Mild Weakness, Severe Weakness, Flaccid, Rigid, Spastic, Abnormal extension, Abnormal flexion)      
4 Pupillary reaction

Right (size, type, reaction to light)

Left (size, type, reaction to light)

5 Reflexes (Corneal, Doll’s Eyes, Blink, Cough/GAG, Babinski)

  1. Present
  2. Absent
6 Notifies the physician if the patient has significant changes during the neurological assessment.      

Total, of points %


Actions:Corrective Techniques: □ Demonstration□ Written Material □ Verbal Orientation

Referral: □ Staff Development and Education Program



  CRITERIA TO BE EVALUATED Competent Not competent N/A





Recognizes and identifies signs and symptoms of acute stroke by applying the Cincinnati Scale (BE FAST).

·       Balance sheet

·       Eyes      
·       Face      
·       Arm (arm)      
·       Speech      
·       Time      


Recognizes and initiates documentation in intervention in BE FAST for stroke code activation.      






Recognizes and describes flowcharts of stroke patient management:

·       Management of patients with ischemic stroke in the Emergency Room

·       Management of patients with hemorrhagic stroke in the Emergency Room.      
·       Management of stroke patients in clinical units.      
·       ICH induced by r-tPA.      
·       Anaphylactic reaction or angioedema.      



Recognizes and describes the types of stroke:

·       Ischemic stroke

·       Hemorrhagic stroke

–        Intracerebral

–        Subarachnoid

·       TIA      
5 It recognizes that it is the gloom and its importance for functional recovery.      


Recognizes and identifies the anatomical regions of the brain and their basic functions:

·       Frontal lobe – movements, intelligence, reasoning, behavior, memory, and personality.


·       Parietal lobe – intelligence, reasoning, distinguishing between left and right, language sensation and reading.      
·       Temporal lobe – speech, behavior, memory, hearing, vision, and emotions.      
·       Occipital lobe – vision.      
·       Cerebellum – balance, coordination, and fine control of muscles.      
·       Brain stem – breathing, blood pressure, heartbeat, and swallowing.      





Recognizes and identifies the blood supply of the cerebral cortex:

·       Carotid system

·       Vertebral and basilar      
·       Willis Polygon

–        Anterior cerebral artery

–        Middle cerebral artery

–        Anterior communicating artery

–        Posterior cerebral artery

–        Communicating posterior artery














Recognizes and describes the five main stroke syndromes based on the presentation of signs and symptoms:

·       Left hemisphere

–        Deficit of the right visual field

–        Right hemiparesis

–        Right hemisensory loss

–        Aphasia

–        Deviation from the look to the left

·       Right hemisphere

–        Left visual field deficit

–        Left hemiparesis

–        Left hemisensory loss

–        Inattention (neglect syndrome)

–        Deviation of the gaze to the right

·       Brain stem

–        Crossed signs such as a side of the face and the contralateral of the body

o   Hemiparesis

o   Hemisensory loss

–        Total paresis – sensory loss in all extremities

–        Vertigo

–        Tinnitus

–        Nausea, vomiting

–        Hiccup

–        Abnormal breathing

–        Dysarthria, dysphagia

–        Diplopia, decoupled gaze, deviation from gaze

·       Cerebellum

–        Ipsilateral ataxia of the extremities (lack of coordination)

–        Trunk or walking ataxia

·       Possible bleeding

–        Headache

–        Nausea, vomiting

–        Decreased levelsof consciousness

–        Intolerance to light

–        Neck stiffness or pain

–        Focal signs such as hemiparesis (like ischemic stroke)



Recognizes and identifies by image the ischemic and hemorrhagic stroke in the studies of the head of:

·       CT

·       MRI      
10 Mention stroke risk factors, modifiable and non-modifiable.      




Recognizes conditions that mimic a stroke (mimic)

·       Hypoglycemia

·       Seizures

·       Migraine

·       Tumor

·       Subdural hematoma

·       Facial paralysis







Recognizes and identifies severe potential complications of stroke patients:

·       Hemorrhagic transformation

·       Cerebral edema      
·       Increased intracranial pressure      
·       Cardiac arrhythmias, cardiac ischemia      
·       Venous thromboembolism      
·       Seizures      
·       Recurrent strokes      







Recognizes, analyzes, and executes standardized medical orders according to stroke diagnosis:

·       ER TIA/Stroke/ICH

·       Prothrombin Complex Concentrate PCC for Life-threatening Bleed Protocol      
·       Alteplase (r-tPA) Standing Orders for Acute Ischemic Stroke in Adults Patients      
·       Acute Stroke Post IV rt-PA Admission      
·       Admission Standing Order for Hemorrhagic Stroke      
·       Admission Standing Order for Ischemic Stroke and TIA      





Recognizes and relates the most common studies performed on patients with a stroke diagnosis:

·       CT and CTA head and neck

·       MRI and MRA of head and neck      
·       X-Ray Chest      
·       Echocardiogram      
·       Carotid Doppler      
·       Transesophageal      


Recognizes and relates laboratory tests for stroke diagnosis:

·       Stroke Code Panel

·       Stroke Admission Panel      


Recognizes function and initiates antithrombotic therapy:

·       Antiplatelets

·       Anticoagulants      


Recognizes the function and initiates DVT prophylaxis therapy in patients according to their stroke diagnosis:

·       Anticoagulants

·       Pneumatic Stockings      





Recognizes and notifies consultations to a multidisciplinary team:

·       Neurologist

·       Speech pathologist      
·       Physiatrist      
·       Nutritionist      
·       Social work      
·       Stroke Coordinator      
·       Physical/occupational therapy      





Recognizes and offers patient and family education on:

·       Medical Diagnosis

·       Signs and symptoms      
·       Risk Factors      
·       Activation of medical emergencies 9-1-1      
·       Medications ordered      
·       Follow-up after discharge      
20 Recognizes the importance of keeping the patient with a stroke diagnosis in NPO, until there is a swallowing evaluation.      



Recognizes the types of consistencies in feeding and assists in feeding in patients diagnosed with stroke.

·       Correctly apply the use of thickeners (in cases where applicable)




Describes and demonstrates the management of several alternative feeding methods used with patients with stroke diagnoses, for example:

·       Tube feeding

·       Total parenteral nutrition      
23 Recognizes the importance of physical therapy and collaborates with therapy staff on the recommended work plan.      



It demonstrates adequate management, positioning and transfer considering complications such as decreased balance, hemiplegia and muscle weakness in patients diagnosed with stroke.      



Recognizes that changes in care environments are difficult and stressful for patients diagnosed with stroke and therefore provide support and education to prepare them for transition.      
26 Recognizes and participates in the planning of discharge of the patient with stroke diagnosis and care.      





Recognizes terminology most used in patients with stroke diagnosis:

·       Dysphagia

·       Dysarthria      
·       Aphasia      
·       Apraxia      
·       Ataxia      
·       Limb ataxia      
·       Diplopia      
·       Nystagmus      
·       Hemianopsia      
·       Hemiplegia      
·       Hemiparesis      

Total, of points %



Actions: Corrective Techniques: □ Demonstration□ Written material  □ Verbal Orientation

Appendix F: Checklist



  • BEFAST documentation
  • Performed NIHSS and document important findings
  • Keep patient NPO – Including Medications
  • Code Stroke Panel:
    • CBC
    • PT-INR
    • CMP
    • Blood Type
    • Troponin Levels
    • COVID test
    • Urine toxicology
    • CPK-MB
  • Studies
    • Chest X Ray
    • EKG
    • Head CT
    • CT Angio
  • r-tPA administration 60 minutes or less

Appendix G: Demographics

Demographic Information

Category                                 n=18                            %


Male                                        4                                  22%

Female                                    14                                88%


White                                      0

African American                   0

Hispanic                                  18                                100%

Other                                       0

Age group

21-30 years                             15                                83%

31-40 years                             3                                  17%

41-50 years                             0

51 + years                               0


Years of Nursing Experience

0-5 years                                 16                                89%

6-10 years                               2                                  11%

11-15 years                             0

15 + years                               0



Educational Degree

Associate Degree                    0

Bachelor’s Degree                  16                                89%

Master Degree                        2                                  11%

Doctorate degree                    0

Appendix H: Riggs Efficacy Tool Permission

        External Email – Use Caution        

Hello Carmen!

I would be happy to have you use the scales.  They have been used in the nursing education context before and seemed to work well there.  Good luck with your research!

Good afternoon:

My name is Carmen Morales and I’m a doctorate level student at Mass General Hospital Institute of Health Professions. I’m writing you to ask for permission to use the Briggs Efficacy Tool in my final project. Currently I’m educating ED nurses on stroke and will like to know their self-efficacy before starting to measure their knowledge in acute stroke management.

Please advise,


Carmen Morales, MSN, CCN

The information in this e-mail is intended only for the person to whom it is addressed. If you believe this e-mail was sent to you in error and the e-mail contains patient information, please contact the Mass General Brigham Compliance HelpLine at . If the e-mail was sent to you in error but does not contain patient information, please contact the sender and properly dispose of the e-mail.

Please note that this e-mail is not secure (encrypted).  If you do not wish to continue communication over unencrypted e-mail, please notify the sender of this message immediately.  Continuing to send or respond to e-mail after receiving this message means you understand and accept this risk and wish to continue to communicate over unencrypted e-mail.

The information in this e-mail is intended only for the person to whom it is addressed. If you believe this e-mail was sent to you in error and the e-mail contains patient information, please contact the Mass General Brigham Compliance HelpLine at . If the e-mail was sent to you in error but does not contain patient information, please contact the sender and properly dispose of the e-mail.


Appendix I: Table 1 –Results of Quality Indicators for Stroke Management


Time N=number of patients Mean Time (minutes) S.D.
CT Pre implementation (January 2021) 30 307.60 412.44
  1-week post implementation 4 235.25 184.05
  2-week post implementation 8 184.63 167.04
  3-week post implementation 9 200.33 85.16
  4-week post implementation 4 103.50 102.39
  5-week post implementation 10 134.70 191.27
  Total 65 234.00 306.38
NIHSS Pre implementation 28 2531.21 2445.04
  1-week post implementation 4 744.25 362.22
  2-week post implementation 7 824.43 677.58
  3-week post implementation 9 504.00 497.62
  4-week post implementation 4 691.25 696.60
  5-week post implementation 10 490.40 583.20
  Total 62 1481.08 1933.43
LABS Pre implementation (January 2021) 30 385.63 375.87
  1-week post implementation 4 193.25 182.11
  2-week post implementation 8 358.50 495.95
  3-week post implementation 9 125.22 103.23
  4-week post implementation 4 136.50 98.93
  5-week post implementation 10 101.60 104.90
  Total 65 275.37 334.50
CXRAY Pre implementation (January 2021) 29 709.86 1080.91
  1 week post implementation 4 997.75 999.40
  2-week post implementation 8 524.88 667.73
  3-week post implementation 9 346.00 477.06
  4-week post implementation 4 449.25 584.63
  5-week post implementation 10 329.60 776.56
  Total 64 577.86 886.44
EKG Pre implementation (January 2021) 26 471.42 675.66
   1 week post implementation 4 456.00 638.83
  2-week post implementation 8 259.13 247.84
  3-week post implementation 9 368.67 572.45
  4-week post implementation 4 479.00 720.19
  5-week post implementation 10 405.90 485.32
  Total 61 417.16 572.78

Appendix J: Table 2 –Time to Treat Pre/Post Protocol Implementation

Pre-Implementation Post-Implementation  
N (patients included) Mean Time (minutes) S.D. N (Patients included) Mean S.D. p-value
BEFAST 12 36.08 39.76 19 57.79 134.8 0.593
CT 30 307.6 412.44 35 170.91 150.76 0.094
NIHSS 28 2531.21 2445.04 34 616.26 558.93 0.000
LABS 30 385.63 375.87 35 180.86 264.94 0.016
CXRAY 29 709.86 1080.91 35 468.49 683.12 0.282
EKG 26 471.42 675.66 35 376.86 489.25 0.528
r-TPA 0     4 90 42.62  

Appendix K Table 3 – Riggs Self-Efficacy Reports Pre/Post Education

  Pre Post  
N Mean S.D. Mean S.D. p-value

Question 1:I have confidence in my ability to do my job.

18 4.78 0.43 4.89 0.32 0.317
Question 2:There are some tasks required to do my job that I cannot do well. 18 3.39 0.85 1.06 0.42 0.000
Question 3: When my performance is poor, it is due to my lack of ability 18 2.06 1.30 1.06 0.24 0.010
Question 4:I doubt my ability to do my job. 18 1.56 1.10 1.00 0.00 0.034
Question 5:I have all the skills needed to do my job very well. 18 4.00 1.28 4.94 0.24 0.005
Question 6:Most people in my line of work can do my job better than I can. 18 1.83 0.99 1.22 0.55 0.013
Question 7:I am an expert at my job. 18 3.67 0.77 4.94 0.24 0.000
Question 8:My future in this job is limited because of my lack of skills. 18 1.83 1.15 1.00 0.00 0.016
Question 9:I am very proud of my job skills and abilities. 18 4.83 0.38 5.00 0.00 0.083
Question 10:I feel threatened when others watch me do my job. 18 1.61 0.70 1.00 0.00 0.005


“SA” for “strongly agree,” “A” for “agree,” “AS” for “agree somewhat,” “DS” for “disagree somewhat,” “SD” for “strongly disagree.”


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