Minutes matter when a patient may have had a stroke, but being far from a physician with advanced training in neurology no longer needs to be a barrier to rapid diagnosis and intervention thanks to telestroke programs designed to improve access to the limited number of specialists, regardless of the geographic isolation of patients who may have experienced a stroke.
Telestroke, or stroke telemedicine, is a form of telehealth in which physicians with advanced training in stroke care use technology to provide immediate consultation to a local healthcare professional to recommend diagnostic imaging and treatment for patients with stroke at an originating site. Patients who present within 4.5 hours of when they were last known to be well may be eligible for thrombolytic drug therapy or endovascular intervention, often measured as door-to-needle time.
After launching a telestroke consultation program, Essentia Health, an integrated health system serving patients in Minnesota, Wisconsin, and North Dakota, increased the percentage of patients receiving thrombolytics in less than 60 minutes and decreased the average door-to-needle time.
Essentia Health initiated the telestroke program in the fall of 2019, with coverage provided by four interventional neurologists, three of whom work in the system’s Comprehensive Stroke Center in Fargo, North Dakota. In addition to this center, telestroke services are provided to five other acute stroke-ready hospitals throughout rural areas in the upper Midwest.
Through the telestroke program, neurology consultations are available to all sites 24 hours a day, every day of the year. They can be used for inpatient and emergency department stroke activations at each facility.
The team developed a tiered stroke alert algorithm and telestroke workflow chart to help healthcare professionals at rural sites determine eligibility for telestroke consultation to decide the treatment plan.
The algorithm categorized strokes as levels I to III according to the symptoms and time when the patient was last known to be well. Telestroke consults were most often used for patients with level I stroke alerts since they were within the timeframe when they might be eligible for thrombolytic drug therapy or endovascular intervention.
Once staff members determine whether a telestroke consultation will be initiated, they refer to the step-by-step workflow chart, which specifies actions needed for each multidisciplinary team member.
“Regardless of the type of stroke, rapid diagnosis and intervention are critical for improving survival rates and reducing the long-term effects of stroke,” says Chelsey Kuznia, BSN, RN, SCRN, the stroke program manager for Essentia Health’s Comprehensive Stroke Center in Fargo, one of only two such facilities in North Dakota. “People living in rural areas not only have increased stroke risk factors, but they also face challenges to getting the advanced care they need in a timely way, which leads to higher rates of disability and death.”
In 2022, telestroke connections for 42 patients were completed, with a stroke diagnosis confirmed in 25 (61%). Fourteen patients with confirmed stroke received thrombolytic therapy. In contrast, others were not eligible, either because of patient-related contraindications or because more than 4.5 hours had elapsed since their last-known well time.
Of the 25 patients with confirmed stroke, 18 (72%) were discharged home, three were discharged to skilled nursing facilities, one to an inpatient rehabilitation unit, one to hospice, and two died.
The year before the implementation of the telestroke program, 11 of 15 eligible patients (73%) received thrombolytic therapy in less than 60 minutes, with a mean door-to-needle time of 61 minutes. During the year after implementation, the results improved: 11 of 12 eligible patients (92%) received thrombolytic therapy in less than 60 minutes, and the mean door-to-needle time decreased to 38 minutes.
The position is just a few years old at this point, but nurse navigators are proving their worth as they shepherd patients and families in their journeys through the healthcare system.
What does a nurse navigator do? In an interview with the Mooresville Tribune, Arin McClune, MSN, RNC-OB, Women’s Services Navigator at Lake Norman Regional Medical Center, defines the nurse navigator as “a nurse who will help the patient facilitate and coordinate their care, depending on what their specific needs are. So whether it’s to coordinate care with the physician, with seminars, education, and then follow up on pre-hospitalization, during their hospitalization, as well as their discharge time to ensure that all their needs are being met and that their outcomes are what their goals were, their expectations.”
According to
RegisteredNursing.org,
nurse navigators have quickly established their value: “Organizations
that choose to create roles for nurse navigators are putting the
patient at the center of the care, and increased patient satisfaction
scores reinforce this fact. Numerous articles are published each year
touting not only the intangibles such as the patient’s perceived
improvement of care, but also decreased hospital readmission rates
and ED visits in the departments where nurse navigators are
utilized.”
Nurse navigators primarily work with oncology patients, being instituted, as RegisteredNursing.org notes, to provide “one-on-one contact with patients to offer resources and education regarding the planned treatment,” and to act as “a liaison between the patient and all members of the care team.” With their successful implementation in oncology, nurse navigators now specialize in a wide range of areas. In the Mooresville Tribune article, for example, the navigators interviewed cover everything from bariatric surgery to breast health, and chest pain/stroke patients. For Tina Hunter, a breast health specialist who spoke with the Tribune, the position brings with it some of the classic rewards of nursing: “I enjoy teaching patients, having that one-on-one time with the patients that I take care of. We all enjoy talking to patients, spending time and we wanted to do more of that.”
What requirements are needed to work in this field? Nurse.org suggests “solid clinical experience in a specific area of nursing care (usually several years)” and certification in a specialty area of practice, or in oncology nurse navigation. They also remark that the ranks of nurse navigators often include nurse practitioners and clinical nurse specialists. In assessing the abilities needed to be successful in the field, the journal Nursing Management notes that the well-trained nurse navigator “reaches out proactively, facilitates communication between providers, prevents delays in treatment, offers psychological support, monitors and manages symptoms, and identifies and recommends resources.”
As Jaycee Dedmon, BSN, RN, ONC, orthopedic nurse navigator says, the
role involves more than just guiding patients through paperwork
(though that is part of the job, too): “It’s very overwhelming
for patients. I think a lot of what I do is trying to alleviate some
of those fears and anxieties that they have about their surgery or
their diagnosis, because it’s a lot. It’s scary to have to need
surgery or be in the hospital and so (we do) as much (as) we can to
try to provide them information that’s in a way that they
understand. We could give them all the papers in the world but if
they don’t understand what it means, then we aren’t doing our job
as navigators.”
When it comes to serious health conditions like heart attack and stroke, women are more likely to be misdiagnosed and receive delayed care.
When Andrea thought she was having a heart attack and called 911, the emergency medical technicians told the 35-year-old Nashville, Tennessean that she was likely just experiencing a bout of anxiety.
“They made me walk outside, down my driveway to the ambulance. They
never turned on the sirens or lights and stopped at every light on the
way to the hospital,” she told Today.
But Andrea was not having an anxiety attack. As it transpired, she had experienced a major cardiac event as a result of a spontaneous coronary artery dissection, an uncommon condition that can affect otherwise healthy individuals.
“The delay in my care caused me to have severe heart damage and heart failure that I am still living with” she said.
While Andrea’s condition is rare, her experience with emergency care is not.
How Are Symptoms of Heart Attack and Stroke Different for Women?
Myocardial infarction, more commonly known as a heart attack, occurs when the flow of oxygen-rich blood to the heart becomes blocked.
A heart attack can be caused by:
The full or partial blockage of an artery as a result of plaque buildup.
A coronary spasm, in which a coronary artery tightens and cuts off blood flow.
When people think of what a heart attack looks like, they might
picture a man grabbing his chest and describing severe pain that extends
to his arm. While chest pain is the most notable symptom of a heart
attack, many people— especially women—experience less common symptoms.
This can lead to misdiagnosis and delayed treatment among female
patients.
According to a study from the American Heart Association, almost 62% of women who have a heart attack experience more than three non–chest pain symptoms, compared to 54.8% of men.
The perception of which symptoms necessitate emergency care can lead
women to delay seeking treatment, which affects their chances of
surviving and making a full recovery.
“If you have nausea and vomiting and back pain or epigastric pain …
the first thing that comes to you is not, ‘I’m having a heart attack,’”
said Melissa Frisvold, PhD, CNM, APRN, faculty at the Georgetown University School of Nursing & Health Studies.
Symptoms of Heart Attack in Women
Less commonly known symptoms of heart attack that are more likely to be present in women than men include stomach pain, shortness of breath, chest palpitations, nausea, and dizziness.
Strokes in Women
For women, perceptions of symptoms can also affect treatment of another life-threatening condition — stroke.
Sometimes referred to as a “brain attack,” a stroke occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts.
Ischemic stroke — occurs when blood flow through the artery that supplies oxygen-rich blood to the brain becomes blocked.
Hemorrhagic stroke — caused by a leak or rupture in an artery in the brain.
Transient ischemic attack — also referred to as a “mini-stroke,” blood flow to the brain is blocked for a short time and is a warning for future stroke.
In addition to having misinformation about symptoms of heart attack
and stroke, Frisvold said women may also put more focus on other health
risks that they perceive to be bigger threats.
“Women worry about breast cancer or cervical cancer,” she said. “But
heart disease is the leading cause of death in women, not breast cancer
or cervical cancer.”
Symptoms of Stroke in Women
Less commonly known symptoms of stroke that are more likely to be present in women than men include loss of consciousness, general weakness, difficulty breathing, disorientation, sudden behavioral change, hallucination, nausea or vomiting, seizures, and hiccups.
How Does Gender Affect Health Care?
The misdiagnosis of heart attack and stroke in women is part of the
larger issue of gender bias in health care. This stems in part from how
clinical research has been performed in the past, which informs how care
is provided to patients today.
In a research study on sex bias in clinical studies from the Allen Institute for Artificial Intelligence, researchers examined medical research from 1993 to 2018 and found that women were underrepresented subjects in the research of several health conditions, including cardiovascular health.
“Women worry about breast cancer or cervical cancer, but heart disease is the leading cause of death in women.”
Another study on clinical trials for stroke treatment indicated that women were underrepresented in such trials, leading to suboptimal conclusions for women in outcomes and stroke care delivery.
Implicit Bias Affects Treatment
The exclusion of marginalized groups, including women and people of color, may lead to a misunderstanding of the many ways a health condition can present itself and how it should be treated. “Medical bias,” a term for that disparity, refers to cases in which an individual may receive different care from a provider who is unknowingly acting on partial judgement.
The consequences of implicit bias in health care can be seen in how
women receive treatment in comparison to men in life-threatening
situations.
Additionally, in the aforementioned study from the American Heart Association, 53% of young women (aged 18 to 55) said their health care provider did not think their initial symptoms were heart-related, compared to only 37% of young men who said their provider got it right. These researchers also discovered a pattern in female patients who said they hesitated to seek help because they feared being labeled a hypochondriac.
Because of women’s experiences with the health care system, these biases may affect how women view their own health.
How to Advocate for Women’s Health
Women, their family members and friends, and even bystanders can take steps to help improve care for heart attack and stroke. From advocating for oneself in the emergency room to taking action when someone is in distress, the following resources are a starting point for women’s health advocacy.
How to Communicate With Your Clinician
Women sometimes express that they do not feel heard by their provider when sharing health concerns. Frisvold provided these tips for self-advocacy:
BRING A FRIEND OR FAMILY MEMBER
Another person can provide support, ask additional questions, and help navigate the treatment process.
BE DIRECT
If an individual believes he or she may be having a heart attack or
stroke, being prepared to specifically communicate all concerns to the
clinician can help.
ASK QUESTIONS
Engaging in dialogue allows for an individual to push back in a way
that is specific and may help a provider check his or her bias.
DON’T LET SELF-BIAS GET IN THE WAY
“When you talk to somebody who had a heart attack, they [often] say, ‘I just knew something wasn’t right, but I just kept trying to downplay it.’ You’re better off going to the emergency room and finding out it was nothing than to err the other way,” Frisvold said.
How Bystanders Can Take Action in Health Emergencies
When another person appears to be experiencing a heart attack or stroke, there are steps you can take to help improve the chances of a positive health outcome:
DON’T HESITATE TO CALL 911
“Time is of the essence,” Frisvold said. “Those early moments are critical. Take steps early in the process to improve the health outcome of the person experiencing a heart attack or stroke.”
ASK QUESTIONS
If a stroke is suspected and the person is conscious, the bystander should ask what symptoms the individual is experiencing so the information can be shared with emergency responders if the situation worsens and requires an advocate.
Many are cognizant of the controversy circulating the topic of nursing certifications. Nurses wonder: Is getting certified worth it? Will I get a raise? How will this benefit me? Does it make a difference? Why are so many hospitals recommending it? In fact, some even degrade the importance of obtaining certifications. However, several hospitals, especially those with magnet status, those that desire magnet status, or even those that have a clinical advancement ladder, encourage their employees to obtain a certification relevant to their specialty. Additionally, many of said hospitals have reimbursement opportunities to assist individuals with the financial burden associated with exam fees and study tools.
Nursing is an evolving profession that requires us to remain up to date with current evidence-based practices. I like to think of certifications as continuing my education—although, evidently on a significantly smaller degree. I’m here to share my story of how obtaining my certifications played a vital role in my career advancement. I personally used it as a tool to expand my knowledge base and advance in my career—and, you can too!
As an Associates Degree in Nursing (ADN) student, I knew I wanted to work in a large medical center after I obtained my Bachelors of Science in Nursing (BSN). After graduation, I was under the impression that the only obstacle between said hospital, and me, was my BSN. Therefore, I worked on an acute care unit, at a small community hospital, while I completed my RN-BSN program. Soon after, I applied, and after months of not receiving a call, I got the notion that they were not interested in me. It was evident that I was required to strengthen my application to become a competitive candidate; so I got back to the drawing board.
I decided the next step I had to take was to get experience working in the specialty that I desired the most. Subsequently, I transferred to critical care and worked there for approximately two years before trying my hand again at my dream job. Again, no call for an interview. I was confounded; I was sure I took all the steps I needed to take to land the job, but my mentor begged to differ.
She encouraged me to familiarize myself with certifications and consider obtaining one. After dedicating the next few months of my life to endless studying, I received my Critical Care Registered Nurse (CCRN) and Stroke Certified Registered Nurse (SCRN) certifications, all at the expense of my employer. Getting certified not only enabled me to advance up the clinical ladder at my place of employment, but I finally got the job! Let us not forget about the thoughtful recognition that came with it!
Furthermore, if you ask me, “is it worth it,” I would say “yes.” Will you get a raise? All hospitals are different, and although some hospitals may give you a pay increase, many hospitals apply it as points that will allow you to advance up the clinical ladder; and others give you additional educational funds. However, it is worth looking into with your employer. How will it benefit you? It could help you achieve career advancement, just as it did for me—and much more! Why are so many hospitals recommending it? I have my speculations, but there is a lot of literature surrounding this topic; I highly recommend you dive into them to get the best answer. Does getting certified make a difference? In my opinion and by the example of my experience, without a doubt!
In all, I hope my story gives you some insight on how nursing certifications can have a critical impact on your career. If obtaining a nursing certification has never invigorated your mind before, I foresee that after reading this article you have become inspired to do your research on certifications relevant to your specialty and the associated requirements. Now, go out there and get certified—good luck!
Anne M. Cabello, RN, BSN, CRRN, was only 12 years old when she experienced a mild stroke. Luckily for her, with good, acute rehabilitative care—as well as, she says, much love, prayers, and support—she made a full recovery. This experience, though, led her to become a rehabilitation nurse when she grew up.
“Rehabilitation nursing allows me to give back what I have been given and to provide nursing care to a patient for a significant period of time, often watching them progress to a lesser dependent state than what they were at when the stroke first occurred,” Cabello says.
Since 1995, Cabello has worked for Burke Rehabilitation Hospital in White Plains, New York, and she is a staff RN on an acute rehabilitation stroke unit. “The majority of my patients have suffered some form of a stroke resulting in impaired mobility usually on one side of their body—affecting their arm, hand, and/or leg, impaired speech and swallowing ability, impaired cognition, impaired vision, and impaired bladder and bowel function,” explains Cabello.
Working the 7 p.m. to 7 a.m. shift, Cabello says that being the primary nurse for neurology patients means that she cares for people who have worked hard during the day doing intense physical, occupational, and speech therapy. Her role, she says, includes doing an ongoing assessment of their conditions and reporting the results to the physician, medication administration by oral, IV, or via feeding tube, and overseeing the care associated with activities of everyday living including: assisting patients with eating, transfers to the toilet or in and out of bed, helping them change into night clothes, showering/bathing, wound care, tracheostomy care, incontinence care, and bladder catheterizations for those who need it.
Cabello says that the greatest reward for her in her job is “job satisfaction—knowing that I have given the best care I can to a patient.”
If you’re considering this type of nursing work, Cabello says that you must be compassionate. “Care for each patient as if they were your own loved one. That is what will cause you to give special attention to all your duties.”
“Nurses are vital team members of the health care team and are the ones on the frontline in providing direct care for patients. The stroke patients on the unit are still at the phase of their illness where they are at a high risk for a stroke progression,” says Cabello. “The nurse’s strong assessment skills coupled with identification of sudden changes in the patient’s condition can lead to the quick treatment and health care management of the patient.”
Our Nurses of the Week are Kaile Neuschatz and Kelsey Halbert, both registered nurses and Stroke Nurse Navigators at Yale New Haven Hospital. As stroke nurse navigators, it is their job to provide continuity of care for stroke patients from the acute care phase to the recovery care phase to optimize outcomes for the patient.
Suffering a stroke sends a patient on a path to medical treatment, rehabilitation, and home care which can be a confusing process. This is where stroke nurse navigators come in, helping guide those who have suffered a stroke attack through their entire treatment and recovery process. Stroke patients are seen by countless providers so a stroke nurse navigator is there to provide a familiar face throughout the entire care process.
Halbert tells the New Haven Register, “Although we’re not active members of the treatment team…our relationship with those patients begins when they roll through the door [of the emergency department].” Quality of life outcomes for stroke patients are greatly improved the more quickly they are treated, which is why the stroke nurse navigator begins their work even before a stroke is definitively diagnosed.
Navigators have been part of the health care team in pediatrics and oncology for some time at Yale New Haven Hospital, but became part of the stroke care team in May 2016. The hospital serves a low-income urban population that is more susceptible to illnesses like heart disease, high blood pressure, and diabetes – all risk factors for stroke. Karin Nystrom, advanced practice registered nurse and manager of Yale New Haven’s Stroke Center, says:
“Because we are one of two comprehensive stroke centers in Connecticut, our patient population tends to be more complex, which necessitates the importance of the navigator role, because patients have so many complicated co-morbidities or illnesses that complicate their stroke.”
To learn more about Neuschatz and Halbert and the role of the Stroke Nurse Navigator, visit here.
Anne M. Cabello, RN, BSN, CRRN, was only 12 years old when she experienced a mild stroke. Luckily for her, with good, acute rehabilitative care—as well as, she says, much love, prayers, and support—she made a full recovery. This experience, though, led her to become a rehabilitation nurse when she grew up.