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Running head: TRANSLATIONAL RESEARCH Translation Research for Practice and Populations Western Governors University

BE-FAST

Professional Practice Description According to the Centers for Disease Control and Prevention (CDC), stroke is the leading cause of disability and the fifth leading cause of death in the United States (Stroke Facts, 2016, para. 1). Current practice in the hospital setting for identifying potential stroke victims utilizes FAST as a screening tool. F- facial droop- ask the patient to smile. Is the smile symmetrical? A- arm drift- patient is asked to hold both arms out with palms up. Is one arm drifting downward? S-speech- ask the patient to repeat a simple phrase, “The sky is blue in Boston.” Is the speech clear or slurred? Are they able to repeat the phrase? (American Stroke Association, n.d.). FAST is a simplified tool to identify strokes potentially eligible for the administration of alteplase (Harbison, Hossain, Jenkinson, Davis, Louw, & Ford, 2003, p. 807). Where the FAST lacks is in the identification of posterior circulation infarcts. FAST according to Nor, McAllister, Louw, Dyker, Davis, Jenkinson, & Ford (2004), “FAST is less sensitive in detecting posterior circulation syndrome strokes” (p. 1358). Posterior circulation strokes are hemorrhages or infarcts involving the brainstem, cerebellum, midbrain, thalamus, and temporal and occipital lobes. Symptoms associated with the identified areas are gait disturbance, dizziness, vertigo, nausea/vomiting, headache, and truncal and/or limb ataxia (Arch, Weisman, Coca, Nystrom, Wira, & Schindler, 2016, p. 670). Uncommon signs and symptoms of stroke on presentation to the emergency room (ER) can lead to prolonged treatment times. One study by Sarraj, Medrek, Albright, Martin-Schild, Bibers, Vahidy, Grotta, & Savitz (2015) compared the door-to-needle times of posterior circulation strokes to anterior circulation strokes and revealed delays in neurological evaluation and door-to- needle times as much as 20 minutes (p. 675).

Another opportunity, the window for large vessel occlusion treatment has been extended to 24 hours from the last known well (LKW) (Atchaneeyasakul, Liebeskind, Yavagal, Jadhav, Haussen, Budzik, Boafe, Hanel, Ribo, Cognard, Sila, Hassan, Smith, Saver, Nogueira, Jovin, and DAWN Investigators, 2019, para.1). Our current algorithm lacks consideration for potential thrombectomy candidates, in turn could lead to delay in neurology evaluation, advanced imaging, and treatment. Given the current environment in the ER, all resources should be utilized in the efficient and expediate treatment of stroke. Utilizing EMS to transport patient to cat scan (CT) and assist in obtaining weight of the patient for medication administration. Presently, EMS is directed to an ER room. The patient is removed from the EMS stretcher and placed on the ER stretcher. The patient is quickly seen by the ER doctor and Vascular Neurology and brought to CT by the ER nurse. Having the patient brought to room versus directly to CT is delaying imaging- which in turn delays the CT interpretation- which in turn then delays the treatment. The goals for CT imaging and interpretation as defined by American Heart and American Stroke Associations (n.d.)- time of arrival to CT is 25 minutes and time of arrival to CT read is 45 minutes (p. 7). Time loss is brain loss- minutes saved are brain cells saved. Massachusetts Office of Emergency Services (MaOEMS) has had a recent protocol change. If the patient has a (+) FAST, a FAST-ED is utilized to assist in identification of LVOs (Massachusetts Office of Emergency Medical Services, 2019, p. 45). A FAST-ED score of 4 or greater is approximately 67% sensitive for identifying LVOs (Gropen, Boehme, Martin-Schild, Albright, Samai, Pishanidar, Janjua, Brandler, & Levine, 2018, p. 813). FAST-ED score could be utilized to initiate additional imaging- such as CT perfusion (CTP). Presently, the neurologist will perform a national institute of health stroke scale (NIHSS) and a score of 6 or greater will

initiate the CTP order and imaging. NIHSS takes approximately three to four minutes to perform. Key Stakeholders The key stakeholders in the process change from FAST to BE-FAST are EMS, the hospital’s EMS coordinator, ER MDs and the nurses, Vascular Neurology, Stroke Nurse Program Manager, CT, and the medical practice council (MPC). In order to have a successful transition, stakeholders must be identified and involved early in the process to get buy-in. Key Stakeholder Role EMS They are the first professional medical contact. Including early in the process will improve communication, increase transparency, and create trust on both sides. Improving communication will increase our stroke alerts and documentation and transmission of the FAST-ED score prior to EMS arrival to the hospital. A FAST-ED score ≥ 4 from EMS will be utilized for additional imaging and to triage patients. It’s not unusual to receive three stroke alerts all within 10 minutes of each other. Obtaining FAST-ED score early- the emergency Brain Attack team can prioritize the patients. EMS Coordinator The EMS Coordinator is the point of contact for all the EMS services. Meets with EMS services on a monthly basis to

cleared and left cleared for the inbound stroke patient. MPC MPC is the final approval of all policies and algorithms. Representation on the MPC are varied members of the hospital- risk management, quality and safety, department directors and chairs, and patient advocacy. Evidence Critique Table Source Evidence Strength (I-VII) and Evidence Hierarchy Arch, A., Weisman, D., Coca, S., Nystrom, K., Wiralll, C., & Schindler, J. (2016). Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke, 47 (3), 668-673. https://doi.org/10.1161/strokeaha.115. Level IV Nonexperimental Aroor, S., Singh, R., & Goldstein, L. (2017). BE-FAST (balance, eyes, face, arm, speech, time): Reducing the proportion of strokes missed using the FAST mnemonic. Stroke, 48 (2), 479-481. https://doi.org/10.1161/strokeaha.116. Level IV Nonexperimental Kaps, M., Grittner, U., Jungehulsing, G., Tatlisumak, T., Kessler, C., Schmidt, R., Jukka, P., Norrving, B., Rolfs, A., & Tanislav, C. (2014). Clinical signs in young patients with stroke related to FAST: Results of the sifap1 study. BMJ, 4 (11) Level IV Nonexperimental

https://doi.org/10.1136/bmjopen-2014- Gropen, T., Boehme, A., Martin-Schild, S., Albright, K., Samai, A., Pishanidar, S., Janjua, N., Brandler, E., & Levine, S. (2018). Derivation and validation of the emergency medical stroke assessment and comparison of large vessel occlusion scales. Journal of Stroke and Cerebrovascular Disease, 27 (3), 806-815. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.10. Level IV Nonexperimental Sarraj, A., Medrek, S., Albright, K., Martin-Schild, S., Bibars, W., Vahidy, F., Grotta, J., & Savitz, S. (2015). Posterior circulation stroke is associated with prolonged door-to-needle time. International Journal of Stroke, 10, 672-678. https://doi.org/10.1111/j.1747- 4949.2012.00952.x Level IV Nonexperimental Evidence Summary In the retrospective analysis of “Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services” the purpose was to evaluate missed stroke diagnoses and opportunities for advanced treatment. The analysis concluded a missed stroke diagnosis by the ER MD and neurologist presented with symptoms not often associated with a stroke diagnosis, “difficulty in walking (41%), dizziness (34%), visual changes (31%), dysmetria (29%), headache (21%), and nausea/vomiting (16%)” and posterior circulation strokes were more than twice as likely as anterior strokes to initially be misdiagnosed (Arch et al, 2016, p. 670).

cohort was to evaluate the efficiency and effectiveness of a newly developed tool used in the identification of large vessel occlusions and comparing with other established identification tools. The Emergency Medical Stroke Assessment (EMSA) is a shortened or modified NIHSS- E- eye movement, M- motor assessment (face, arm, or leg weakness), and SA (slurred speech or aphasia) (Gropen et al, 2018, p. 807). The goal of the EMSA is to help EMS and ER providers accurately identify stroke patients with large vessel occlusions who may be candidates for thrombectomy. The conclusion of the study- EMSA was able to more accurately identify strokes when compared to with the 3-item stroke scale (3I-SS) and the Cincinnati Prehospital Stroke Scale (CPSS) and similar results compared to the Rapid Arterial oCclusion Evaluation (RACE) scale, and Field Assessment Stroke Triage for Emergency Destination (FAST-ED). I think what was most important that came from this study that I’ve used in having the hospital moving to utilizing EMS’s FAST-ED was the sensitivity and accuracy in the identification of large vessel occlusions- which will save minutes in getting the patient directly CT. Minutes saved are brain cells saved- elimination in redundancy. The last research article I reviewed was, “Posterior Circulation Stroke is Associated with Prolonged Door-to-Needle Time” was a cross-sectional study (Sarraj et al, 2015). The purpose of their study was to measure the prevalence and evaluate the difference in the treatment of patients with posterior circulation strokes and anterior circulation strokes. At the conclusion of the study it was noted there is a time difference of up to twenty minutes in the delivery of alteplase between the two groups with posterior circulation strokes lagging (Sarraj et al, 2015, p. 675). The study reasoned the difference was due to the delay in the activation of neurology to evaluate the patient.

The one thing all these studies have in common is the need for rapid recognition of stroke and activation of the stroke system of care and as early as possible in the process. The FAST screening tool for facial droop, arm drift, and speech issues screens for strokes in the anterior and middle cerebral territories neglecting the posterior cerebral territories. “Time is brain” (Saver, 2006). For every minute that passes almost 2,000,000 brain neurons are lost (Saver, 2016, p. 265). For every thirty minutes that a large vessel is occluded not allowing blood and nutrients like glucose to get to the brain- the brain ages 3.6 years (Saver, 2016, p. 265). The faster we can accurately identify potential stroke patients and the quicker we activate neurology it will improve the patient’s outcome, by getting the proper resources to the patient quickly. Evidence-Based Practice Recommendation A retrospective analysis of our EHRs was performed on confirmed strokes that presented to the hospital from January 2018 to end of December 2018. We are an academic facility with 354 beds with a comprehensive stroke certification. Annually we evaluate approximately 1500 patients for stroke with 1100 acute stroke codes in the ER and remaining in-hospital. Patients were initially identified utilizing a self-maintained stroke and brain attack access database log and cross-referenced with the discharge international classification of disease tenth revision (ICD-10) codes. ICD-10 codes captured were I60 (subarachnoid hemorrhages), I (intracranial hemorrhages), and I63 (ischemic strokes). Informed consent was not required- personal patient identifying information was not utilized in the review of the EHRs. Approval by the institutional review board (IRB) was also not required since this was a quality improvement endeavor.

Brain Attack- Emergency Department Policy: A “Brain Attack” is a code used to activate a specific algorithm designed to evaluate any patient experiencing neurological changes (Figure 1). This algorithm is used for any patient presenting from outside the hospital through triage or ambulance, as well as in-hospital patients. Purpose: The patient experiencing neurological changes will present to the emergency department either through triage or through an Emergency Medical Service (EMS). All patients presenting by EMS stroke alert with EMS, will be evaluated on their arrival through our Brain Attack algorithm. When this patient presents through triage, the RN will immediately evaluate the patient using the BE-FAST scale (Figure 2). The exam includes evaluating for loss of balance or coordination, loss or change of vision, facial droop, arm drift, and/or difficulty with speech, as well as determining the exact time the patient was last known to be well (LKW). If the LKW is within 4.5 hours, the ‘Brain Attack’ is initiated with the aim of expediting further evaluation and treatment of the patient with a possible acute cerebrovascular attack. If the patient is determined to have an acute ischemic stroke (AIS), and is eligible to receive tPA, the goal is to also expedite the administration of tPA within 45 minutes of arrival to the emergency department, according to the published American Heart Association guidelines. When a patient is presenting beyond a

LKW of 4.5 hours, but less than 24 hours, an ED provider then determines the NIHSS. If the NIHSS is greater or equal to 6, a Brain Attack is also initiated to select potential candidates for mechanical thrombectomy. Procedure: I. Triage a. When the EMS providers activate a stroke, the charge nurse obtains the FAST-ED score and will initiate a Brain Attack by calling x2300. The RN will also provide their respective location of the Brain Attack within the emergency department. i. Upon arrival, the patient is registered, and the RN will initiate the ED Brain Attack order set ii. The ED MD and Neurology MD will meet at the patient’s bedside to ensure the patient is hemodynamically stable for transport to the CT scanner. The patient will remain on the EMS stretcher to expedite this transfer. b. If ER/Triage Activation, the triage RN pages Brain Attack (2300) and initiates the Brain Attack order set. II. Assessment and Decision a. The Patient is assigned an emergency index severity (ESI) level of 1. An initial set of vital signs, including the blood pressure, pulse rate, pulse oximetry, as well

i. If the LKW ≥ 3 hours- Neuro MD will verbally consent for off label tPA use and document verbal consent in the patient’s EHR ii. Goal BP prior to the initiation of tPA is SBP < 185 mmHg and DBP < 110 mmHg. If the BP is above specified parameters, the ED MD or Neurology MD will be notified to appropriate intervention. Once goal is achieved tPA may be initiated. iii. tPA dosing is 0.9 mg/kg (not to exceed 90 mg). The first 10% is administered as a bolus over 1 minute via a syringe. The remainder 90% of the total dose is administered directly from the vial with vented tubing over 60 minutes. Refer to NPG 1124 tPA Preparation and Administration Policy. iv. Vital signs and neuro checks after the administration of tPA are as follows:  Every 15 minutes from the initiation of tPA bolus for the following 2 hours  Every 30 minutes for the following 6 hours  Every hour for the following 16 hours v. Notify provider (ED MD or Neurology MD) for SBP ≥ 180 mmHg or DBP ≤ 110 mmHg- manage BP per provider (ED MD or Neurology MD) orders. If neuro status worsens or any changes in neuros- stop t-PA immediately, notify provider (ED MD or Neurology MD). Anticipate a stat head CT order.

*Neurology MD will call neurointerventional radiology if the patient is a candidate for thrombectomy. IV. Transfer patient to ICU or PCU as soon as a bed is available. Reference American Stroke Association. (n.d.) Retrieved from https://www.strokeassociation.org/ American Heart Association (n.d.). Phase III target: Stroke. Retrieved from https://www.heart.org/-/media/files/professional/quality-improvement/target-stroke/ target-stroke-phase-iii/ts-phase-iii-5-6-19/final5619-target-stroke-phase-3-brochure.pdf? la=en&hash=6D2B8193E1C5487071586C65ECA23A6993059FCD Arch, A., Weisman, D., Coca, S., Nystrom, K., Wiralll, C., & Schindler, J. (2016). Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke, 47(3), 668-673. https://doi.org/10.1161/strokeaha.115. Aroor, S., Singh, R., & Goldstein, L. (2017). BE-FAST (balance, eyes, face, arm, speech, time): Reducing the proportion of strokes missed using the FAST mnemonic. Stroke, 48(2), 479-481. https://doi.org/10.1161/strokeaha.116.

with face arm speech test (FAST) in acute stroke patients. Stroke, 35(6), 1355-1359. https://doi.org/10.1161/01.STR.0000128529.63156.c Sarraj, A., Medrek, S., Albright, K., Martin-Schild, S., Bibars, W., Vahidy, F., Grotta, J., & Savitz, S. (2015). Posterior circulation stroke is associated with prolonged door-to-needle time. International Journal of Stroke, 10, 672-678. https://doi.org/10.1111/j.1747- 4949.2012.00952.x Wolters, F., Li, L., Gutnikov, S., Mehta, Z., & Rothwell, P. (2018). Medical attention seeking after transient ischemic attack and minor stroke before and after the UK face, arm, speech, time (FAST) public education campaign: Results from the oxford vascular study. Journal of the American Medical Association, 75(10), 1225-1233. https://doi.org/10.1001/jamaneurol.2018. Contact: Stroke Nurse Program Manager Approved by:

Practice Change Model I chose, Kotter and Cohen’s Model of Change, “Eight Steps for Successful Change” (Melnyk & Fineout-Overholt, 2019, p. 434). The change to the algorithm and the usage of a new stroke identification tool would be organizational wide. Kotter and Cohen’s model, I felt was better suited to an organizational change by providing a step-by-step guide. It is also the desired model of change used at my organization- so I have familiarity with its practice. The following two tables includes Kotter and Cohen’s eight steps, justification, and how each step will be implemented. Step Justification/Implementation Step 1- Increase urgency As a manager of the stroke program I need to create a sense of urgency and present compelling evidence the need for change to prompt movement from the current state to the future. The need for accurate and rapid identification of potential stroke patients by moving from the