Accounting for 700,000 deaths per year and occurring every three minutes in the United States (Harvey, 2004), cerebral vascular accidents (CVA) are common life-threatening/ life-changing emergencies treated in hospitals across the nation. A CVA, also known as a
stroke or ‘Brain Attack’, is an affliction of the brain and comes in two varieties, ischemic and hemorrhagic. Each form of CVA results in damage to brain tissue. A hemorrhagic CVA occurs when bleeding in the brain, brought on by a ruptured blood vessel, occupies the tight spaces in and around the brain applying pressure to cerebral tissue depriving it of oxygen and causing neurological damage. In ischemic CVA brain tissue damage is caused due to a blockage of blood through a cerebral artery which also deprives the brain tissue of oxygen and causes neurological damage. Ischemic CVA may be caused by thrombus, which is blockage due to arterial plaque and atherosclerosis of cerebral arteries leading to gradual narrowing and occlusion of an artery over time. A second form of ischemic CVA occurs when an embolus, such as a clot, blocks a cerebral artery having traveled from another location of origin in the body.
The result of any of the above pathologies is a variety of neurological impairments including hemi-paresis, expressive aphasia, and altered level of consciousness. Response to current treatments may range from complete recovery to life long impairment to death. It is important, therefore, that we study our approach to the treatment of strokes in hopes of improving outcomes for a greater number of the patients who come to us seeking medical and rehabilitation care.
Among studies that have examined ways to improve our approach to acute stroke care are a 2005 study of the efficacy of promoting evidence based practice with regards to stroke treatment protocols and a 2002 study of the effect that increased team work focused activities have on staff attitudes about team work. While the 2005 study is more clear in its goal of improving the actual stroke treatment process, the 2002 study also aims to improve patient outcomes by seeking out ways to create a more cohesive, and therefore more effective, treatment team. We will look at the 2002 study Can Staff Attitudes to Team Working in Stroke Care be Improved? and then move on to the 2005 study Promoting Evidence Based Practice. Implementing the American Stroke Association’s Acute Stroke Program.
A descriptive contrast between the typical approach to a stroke rehabilitation team and a football team is provided by Gibbon et al. (2002):
The contrast is often made between rehabilitation, where team members spend nearly all their time carrying out their individual professional roles and only meet together for a short time each week, and football, where nearly all the week is spent practicing teamwork in preparation for one 90-minute game. (p. 106)
Gibbon et al. (2002) state that the variety of type of care providers in the stroke rehabilitation setting was itself a barrier to team cohesiveness, as each discipline operated under their own professional boundaries and may in fact harbor professional jealousies towards one another. These multi disciplinary professionals often do not operate under the same protocols and in effect speak different professional languages. This can lead to negative perceptions of one another and have a negative impact on care. In their 2002 study, Perspectives of Caregivers of Stroke Survivors: Implications for nursing, Moore, Maiocco, Schmidt, Guo, & Estes (2002) note that family care givers main complaint about the health care team is discontinuity and a lack of communication.
Gibbon et al. (2002) studied the effect that a team coordinated approach would have on health care staff attitudes toward team work. They applied two interventions to the daily routines of four different stroke units. The first intervention was the use of integrated care pathways of care, which involved all staff agreeing on a single plan of care with set time frames and responsibilities. The second intervention was the use of a single set of team notes which the health care team used to chart and communicate with one another. These two interventions were designed to force the professionals on the unit to work together. They measured four qualities, team vision, participant safety, task orientation, and support for innovation, both before and after implementation of the two interventions.
Unfortunately, the results of the study showed that the interventions had little or no positive effect upon teamwork when measured by the four defined standards of team work attitudes. One group actually showed a decline in all four areas. It seems that there is much more to the complicated process of establishing effective team work than imposed collaboration. The authors even concede, “ The assumption that the process of developing and implementing integrated care pathways and team notes might improve team working could be wrong.” (Gibbon et al., 2002, p. 110)
In their 2005 study, Promoting Evidence Based Practice. Implementing the American Stroke Association’s Acute Stroke Program, Kavanagh, Connolly, & Cohen (2005) examined the effect that evidence based practice had upon patient outcomes when applied to implementation of protocols for CVA treatment outlined by the American Stroke Association (ASA). A multi disciplinary team was assembled in an urban city community hospital in California with the goal of implementing a the new CVA care protocols based on those provided by the ASA. Using the process of evidence based practice laid out by Rosswurm & Larrabee (1999) the team enacted a system of finding areas in which improvements were needed, linking problems with interventions and outcomes, synthesizing the best evidence, designing a change in practice based on the basis of evidence, and implementation and re-evaluation of the new practice. (as cited in Kavanagh et al., 2005, p. 137).
Nine outcomes were used as standards including time from ED arrival to imaging work up, administration of IV tissue plasminogen activator ( IV-Tpa), and discharge disposition. IV-Tpa is a medication that may reopen an occluded artery involved in an ischemic stroke provided that it is administered within a three hour window that begins at the onset of symptoms. (Miller & Elmore, 2005). These outcomes were noted during a pilot study before the implementation of evidence based practice and also after nine months of evidence based practice. The results of the nine month study showed a marked improvement in many areas such as shorter door to imaging time and a higher frequency of IV-Tpa use for ischemic strokes.
The application of evidence based practices appears to have a positive effect upon patient outcomes. Perhaps this dynamic approach to patient care also improves multidisciplinary teamwork, as it is in its own nature to respond to input from each of the caregivers who participate in its process. This, of course, could be the subject of another study.
Gibbon, B., Watkins, C., Barer, D.,Waters, K., Davies, S., Lightbody, L., Leathley, M. (2002). Can staff attitudes to team working in stroke care be improved?. Journal of Advanced Nursing, 40 (1), 105-111.
Harvey, J. (2004). Countering “brain attacks”. Nursing Management, 35 (8), 27-33.
Kavanagh, D., Connolly, P., Cohen, J. (2006). Promoting evidence based practice. Implementing the American Stroke Association’s Acute Stroke Program. Journal of Nursing Care Quality, 21 (2), 135-142.
Miller, J., Elmore, S. Call a stroke code! (2005). Nursing2005, 35 (3), 58-63.
Moore, L. W., Maiocco, G., Schmidt, S. M., Guo, L., Estes, J. (2002). Perspectives of caregivers of stroke survivors: Implications for nursing. Medsurg Nursing, 11 (6), 289-295.