ARTICLE IN PRESS

Feasibility and Efficacy of Nurse-Driven Acute Stroke Care

Shraddha Mainali, MD,* Sonja Stutzman, PhD,* Samarpita Sengupta, PhD,*

Amanda Dirickson, RN, MSN, ANP-C,* Laura Riise, RN, MSN, CCRN, SCRN,†
Donald Jones, RN, MM, BM, CEN,‡ Julian Yang, MD,§ and
DaiWai M. Olson, PhD, RN, CCRN, FNCS*

Background: Acute stroke care requires rapid assessment and intervention. Re-
placing traditional sequential algorithms in stroke care with parallel processing
using telestroke consultation could be useful in the management of acute stroke
patients. The purpose of this study was to assess the feasibility of a nurse-driven
acute stroke protocol using a parallel processing model. Methods: This is a pro-
spective, nonrandomized, feasibility study of a quality improvement initiative. Stroke
team members had a 1-month training phase, and then the protocol was imple-
mented for 6 months and data were collected on a “run-sheet.” The primary outcome
of this study was to determine if a nurse-driven acute stroke protocol is feasible
and assists in decreasing door to needle (intravenous tissue plasminogen activa-
tor [IV-tPA]) times. Results: Of the 153 stroke patients seen during the protocol
implementation phase, 57 were designated as “level 1” (symptom onset <4.5 hours)
strokes requiring acute stroke management. Among these strokes, 78% were nurse-
driven, and 75% of the telestroke encounters were also nurse-driven. The average
door to computerized tomography time was significantly reduced in nurse-
driven codes (38.9 minutes versus 24.4 minutes; P < .04). Conclusions: The use of
a nurse-driven protocol is feasible and effective. When used in conjunction with
a telestroke specialist, it may be of value in improving patient outcomes by de-
creasing the time for door to decision for IV-tPA. Key Words: Nursing—acute
ischemic stroke—systems of care—door to needle.
© 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Background and Significance

From the *Department of Neurology and Neurotherapeutics, Uni-
versity of Texas Southwestern, Dallas, Texas; †Hospital Accreditation
Services, American Heart Association, Dallas, Texas; ‡Department
of Nursing, Emergency Department, University of Texas Southwest-
ern, Dallas, Texas; and §Department of Neurology, Duke University,
Durham, North Carolina.
Received June 13, 2016; revision received November 7, 2016;
accepted November 9, 2016.
Grant support: This study was funded by UT Systems Grant #77035/
2000163500.
Address correspondence to DaiWai M. Olson, PhD, RN, CCRN,
FNCS, Department of Neurology and Neurotherapeutics, University
of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390-8897.
E-mail: daiwai.olson@utsouthwestern.edu.
1052-3057/$ - see front matter
© 2016 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.11.007
A typical acute ischemic stroke patient loses 1.9 million
neurons each minute.1 In comparison with the normal
rate of neuronal loss in brain aging, the ischemic brain
ages 3.6 years each hour without treatment.1 In 1995, in-
travenous (IV) tissue plasminogen activator (tPA) was
established as an effective treatment for patients with acute
ischemic stroke.2,3 Although the window for effective-
ness was extended from 3 to 4.5 hours4 from last known
normal, earlier treatment is associated with a signifi-
cantly higher likelihood of better outcomes.5,6 These findings
led to the development of national guidelines by the Amer-
ican Heart Association/American Stroke Association for
target door-to-treatment (DTT) time of 60 minutes for el-
igible patients.7 Despite the efficacy8,9 of thrombolytic
therapy, only 3.4%-5.2% of eligible patients with acute
ischemic stroke receive IV-tPA.10 In 2011, less than one-third

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2016: pp ■■–■■ 1
 ARTICLE IN PRESS
2 S. MAINALI ET AL.
of the patients treated with IV-tPA received it within the
recommended 60-minute window from hospital arrival.11
Specialized stroke training is required to facilitate timely
administration of IV-tPA. However, access to providers
with specialized stroke training is often limited to larger
urban stroke centers. An estimated 22.3% of Americans
have access to a primary stroke center within 30 minutes,
43.2% within 45 minutes, and 55.4% within 60 minutes.6,12
The use of telestroke consultation, in conjunction with
education and training of healthcare providers in acute
stroke management, is necessary to increase the rate of
IV-tPA use at community hospitals that lack on-site spe-
cialized stroke expertise.13 In such hospitals with limited
resources, it may be necessary to train nurses to lead a
stroke management protocol using a telestroke consult
in order to avoid delays in IV-tPA administration. Telestroke
systems have evolved as a way to provide adequate care
to stroke patients, especially those in remote locations
without access to stroke specialists.14 Although practice
recommendations were published in 2009,15 and further
defined for use in acute stroke-ready hospitals in 2013,16
there are no specific guidelines for the practice of stroke
care via telestroke.
Stepwise approaches, however, take longer to execute
and suffer from bottlenecks. The success of parallel pro-
cessing in reducing the time spent in the repair pit, as
seen in the “pit-stop” model in automobile racing, has
given us an insight to restructure the traditional step-
wise approach to stroke care into a parallel processing
approach. The automotive pit crew manages to com-
pletely refuel a high performance racing car and change
all four tires in a remarkable 12-14 seconds using par-
allel processing. We decided to adapt this model to the
care of stroke patients using telestroke consultation with
nurses as the primary code drivers.
Methods
QCI-Nurse-driven Acute Stroke CARe (QCI-NASCAR)
is a prospective, nonrandomized, feasibility study of a
quality improvement initiative conducted over the course
of 7 months. The project was reviewed and approved by
the institutional review board at the University of Texas
Southwestern. The University of Texas Southwestern
Medical Center has been collecting stroke care metrics
for admitted patients, and this served as the baseline data
for our project. Emergency department (ED) acute stroke
admissions were designated as level 1 through level 3,
and all patients included in this analysis were enrolled
from direct ED visits and telestroke consults. Level 1 strokes
are defined as stroke onset within 0-4.5 hours of symptom
onset, level 2 strokes are defined as stroke onset within
4.5 hours to 8 hours from symptom onset, and level 3
strokes as stroke onset within 8-72 hours from symptom
onset. In strokes with an unknown symptom onset, the
last known normal time is used.
The definitions used in this project include the follow-
ing: door-to-CT (DTCT) scan time, defined as the amount
of time from patient entering the ED to first entering the
computed tomography (CT) scanner. Door-to-physician
time (DTMD) referred to the amount of time from patient
entering the ED to the first evaluation by a physician.
Door-to-decision time (DTDT) is the amount of time
between when the patient entered the ED to when the
decision to treat or not to treat with tPA occurred. DTT
time17-19 is the amount of time between when the patient
entered the ED to when the treatment (IV-tPA) was pro-
vided to the patient. The primary outcome of this quality
care and improvement (QCI) project was to assess the
feasibility and efficacy of the nurse-driven, parallel pro-
cessing protocol, as well as to examine the impact on stroke
code time metrics compared with a non-nurse-driven pro-
tocol. Hence, the primary outcome measure for this was
changes in DTDT and DTT times.
The first 3 months of this study were dedicated to de-
veloping the NASCAR protocol. Protocol education (run-
in phase) was done over a 1-month period and
implementation occurred over the subsequent 6 months.
All results presented in this study are from the imple-
mentation phase. At the time of this study, there were
no data available to support endovascular revascularization
therapy, which is why a protocol for endovascular
revascularization therapy referral was not included in the
study.
Prior to implementing the QCI-NASCAR protocol, cham-
pions (team leaders) were identified to represent each
clinical discipline involved in acute stroke code, namely
nurses, ED physicians, stroke specialists, laboratory tech-
nicians, radiologists, and pharmacists. Bedside nurses in
the ED were identified as the empowered “drivers” of
the stroke code with defined roles such as getting a CT
scan and initiating telestroke consultation. Other members
of the team worked simultaneously to evaluate the patient
(ED physicians), establish IV lines (other nurses), and obtain
home medication list, as well as prepare IV-tPA, if indi-
cated (pharmacist). A run-sheet (Fig 1) was developed
to facilitate data collection. The run-sheet contained
information on the stages of stroke code and the respon-
sibilities of each team member, task completion times,
and any protocol violations. Nurses, ED staff, laborato-
ry, pharmacy, and radiology staff were trained on the
QCI-NASCAR protocol during a 1-month run-in
phase.
During the implementation phase, at the end of each
stroke code, the nurse who was selected as the protocol
driver was responsible for documenting the task com-
pletion times on the run-sheet, and note protocol violation
if any. The designated nurse driver was also asked to
fill out a questionnaire on the back of the run-sheet (Fig 1,
back page). The questionnaire focused on the nurse driv-
er’s perspective on the level of involvement each had in
running the stroke code. The questionnaires were scored
 ARTICLE IN PRESS
FEASIBILITY AND EFFICACY OF NURSE-DRIVEN ACUTE STROKE CARE 3

Figure 1. Final version of the run-sheet. The figure shows the front and the back page of the run-sheet that was used to collect data. The front page of
the run-sheet contained information on the stages of stroke code and the responsibilities of each team member, task completion times, and any protocol
violations. The back page of the run-sheet contained a questionnaire measuring nurse drivers’ perspectives on how involved they were in running the
stroke code, and were scored on a scale of 1-10 with 1 being “minimal involvement as code driver.”

on a scale of 1-10, with 1 being “minimal involvement
as code driver.” Stroke codes were designated as “pri-
marily nurse-driven” if the score for question 2, “I felt
like this stroke code was nursing-driven,” was greater
than or equal to 7, and not primarily nurse-driven if the
score was less than or equal to 6. In addition, the nurse
drivers were asked to complete a short survey that pro-
vided their opinion on factors helping or hindering the
efficient execution of nurse-driven stroke code. The primary
outcome of this study was to determine if a nurse-
driven acute stroke protocol is feasible and assists in
decreasing DTDT and DTT times. We used the time of
administration of the bolus as the DTT time. In the event
that the bolus was not documented, we used the time
the infusion was started as the DTT.
Monthly meetings were held between the champions
of the different disciplines to ensure proper execution of
the QCI-NASCAR protocol. Necessary feedback was given
to the members of the stroke code team via e-mail. Data
analysis was centered on determining the factors asso-
ciated with the best practice of the management of
acute stroke. Data were abstracted from the run-sheets
into an electronic spreadsheet, which was imported
directly into SAS v 9.3 (SAS Institute, Cary, NC, USA)
for analysis.
Results
During the 6-month implementation phase of the QCI-
NASCAR protocol (May 2014 to October 2014), a total
of 153 stroke codes were analyzed, including 57 level 1
stroke codes, 14 level 2 stroke codes, and 82 level 3 stroke
codes. The mean score for the question 2 portion of the
run-sheet, “I felt like this stroke code was nursing-
driven” (Fig 1), was 7.9 (standard deviation = 2.7, range
1-10), indicating involvement of nurses as primary code
drivers. Out of the 57 level 1 strokes, 45 (78%) were pri-
marily nurse-driven.
The mean overall National Institutes of Health Stroke
Scale (NIHSS) score on admission to the ED was 4.4 (stan-
dard deviation = 5.74). For the population of patients treated
during the QCI-NASCAR protocol, the mean NIHSS score
for primarily nurse-driven codes was 5.0, and those not
primarily nurse-driven was 4.1 (P = .35). Although the mean
overall DTCT scan time was 33.18 minutes for the whole
population, the DTCT in nurse-driven codes was 24.4
 ARTICLE IN PRESS
4 S. MAINALI ET AL.
Table 1. Results for the key outcome measures*

Variable Nurse-driven codes Non-nurse-driven P value

Door-to-CT (all stroke codes) 24.4 [29.9] min (n = 57) 38.9 [47.0] min (n = 96) .04
Door-to-MD (all stroke codes) 16.1 [26.6] min (n = 57) 35.6 [63.7] min (n = 96) .03
Door to MD (level 1 stroke codes) 9.8 [19.1] min (n = 25) 14.4 [17.2] min (n = 32) .36
Door-to-MD (level 1 telestroke) 10.5 [19.8] min (n = 22) 13.5 [16.2] min (n = 14) .64
Door-to-decision (level 1 stroke codes) 43.5 [18.1] min (n = 25) 149.6 [234] min (n = 32) .04

Abbreviation: CT, computed tomography; SD, standard deviation.

*Reported as mean [SD] and (n).

minutes (P = .04). Further, the mean DTDT was 95.33
minutes for all level 1 strokes treated during the study.
There was a significantly shorter DTDT for level 1 stroke
codes that were primarily nurse-driven using this model
(43.5 minutes) compared with stroke codes primarily con-
ducted using the traditional model (149.6 minutes; P = .04,
Table 1). None of the patients received IV-tPA in the tra-
ditional codes; therefore, comparison could not be made
regarding DTT times between the two groups.
There were a total of 45 telestroke consultations, out
of which 34 were primarily nurse-driven (75%). Overall,
the DTMD time in telestroke consults was 14.1 minutes.
In primarily nurse-driven codes, the DTMD time was 9.8
minutes compared with 14.4 minutes when not primar-
ily nurse-driven (P = .36) (Table 1). There were only three
IV-tPA cases in the study period and all three codes were
nurse-driven. It was also noted that the mean DTCT time
improved in the second half of the study period com-
pared with the first half, although the difference was not
statistically significant (38.04 minutes versus 27.88 minutes;
P = .15).
Discussion
Multiple factors hinder the timely administration of IV-
tPA in acute stroke, including patient-related factors
(delayed recognition of symptoms and delayed presen-
tation) and hospital-related factors (delay in activation
of stroke code in the ED, lack of stroke-trained nursing
staff, delay in notifying the pharmacy and CT techni-
cians, delay in decision making due to lack of in-house
stroke specialists, and so on). Various stroke awareness
programs,20-22 as well as quality improvement projects,23-25
have been implemented across the nation to improve the
target treatment times. In this quality improvement study
at University of Texas Southwestern Medical Center, we
assessed the feasibility and efficacy of a nurse-driven pro-
tocol in acute stroke care.
We found that the NIHSS scores between nurse-
driven and non-nurse codes were similar. This suggests
that stroke severity was not associated with staff behavior
(i.e., staff did not treat patients differently because they
perceived a greater sense of urgency based on stroke
severity). In the primarily nurse-driven codes, it was noted
that both the DTCT and DTDT times were significantly
reduced compared with non-nurse-driven codes. Simi-
larly, in telestroke encounters, nurse drivers were able
to obtain physician consultation in a shorter time period,
although the difference between nurse-driven and non-
nurse-driven codes for this variable was not statistically
significant. Although we saw only three cases of IV-tPA-
eligible stroke codes during this study, all three were
successfully driven by a nurse who supports the feasi-
bility of a nurse-driven protocol.
This was a study carried out at a single site and there-
fore had a small sample size of 153 patients, out of which
only 57 were within the IV-tPA treatment window. The
decision to include all stroke codes is both a limitation
and benefit. The focus on early DTCT and DTDT is clearly
aimed to increase reperfusion therapy for stroke pa-
tients eligible for IV-tPA therapy.26 Therefore, the driving
force to improve stroke care is toward level 1 stroke
(symptom onset <4.5 hours). However, the benefit of in-
cluding all stroke patients in this QCI is that this creates
a more sustainable change by changing stroke care for
all stroke patients, not simply an added element of care
for level 1 stroke.27
The sample size for the number of nurses is not
known because we did not require documentation of the
“driver” (primary care nurse) and the identity of the
driver was not provided in more than half of the stroke
codes. Also, only three IV-tPA cases were identified in
the entire study period, limiting the analysis in this group
of patients. Because of a lack of sufficient nursing feed-
back, it is also not entirely clear what factors hindered
or helped the nurse drivers to run the stroke code using
this model.
Despite these limitations, our study suggests that the
nurse-driven protocol may be (1) feasible, because there
were 78% level 1 strokes, and 75% of the telestroke en-
counters including three tPA cases that were primarily
run by nurses; and (2) efficacious, because the nurse-driven
codes showed significantly improved DTCT and DTDT
in this study. Our experience with this protocol at a single
site suggests that ED nurses could be effectively trained
to be the primary code drivers using this model. This is
 ARTICLE IN PRESS
FEASIBILITY AND EFFICACY OF NURSE-DRIVEN ACUTE STROKE CARE
especially useful in community hospitals that lack on-
site specialized stroke expertise.
Conclusions
Our study shows that effective teamwork using a par-
allel processing model can increase efficiency in the
management of acute stroke patients and demonstrates
the feasibility of a nurse-driven protocol. Implementa-
tion of such protocol could be very useful in rural
community centers that lack on-site specialized stroke ex-
pertise, where a busy ED physician may be responsible
for managing multiple patients at the same time. In such
settings, training of nurses to run the stroke code could
be very useful.
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