Recommendations for Endovascular Care of Stroke Patients

The field of neurointerventional radiology (NIR) therapy, including acute ischemic stroke intervention, endovascular intracranial aneurysm management, and treatment of intra- and extracranial large-vessel disease, has evolved over the past 18 years. To support this specialized advanced care, nursing standards of care for staff that provide direct patient care in NIR suites and intensive management of this high-risk patient population are proposed in this document.

In 2014-2015, five large international clinical research trials of acute ischemic stroke compared IV tissue plasminogen activator (tPA) as the standard of care with endovascular treatment in conjunction with IV tPA for large-vessel occlusion in select patients, and were published in the New England Journal of Medicine. These studies individually and collectively demonstrated improved outcomes for patients who undergo acute endovascular treatment for large-artery occlusions, and this was subsequently recommended by the American Heart Association/American Stroke Association [1,2,3,4,5,6]. Concurrently, the treatment approaches for both ruptured and unruptured cerebral aneurysms have evolved, and scientific recommendations include endovascular as well as surgical approaches for definitive treatment [7,8]. The recommendations for the treatment of both symptomatic and asymptomatic carotid stenosis also have evolved and now include endovascular carotid artery stenting as well as carotid endarterectomy as treatment options [9].

There are a variety of both acute and non-acute patient conditions that are treated in the NIR suite (Table 1). In this document, we propose recommendations for structuring the staffing and care for this high-risk patient group while in the neurointerventional laboratory. This document includes recommendations for staff qualifications, staffing models, data collection, periprocedural assessment and care of the patient, groin/access management, common complications, and transition of care in the periprocedural handoff situations.

Staffing models will vary depending on the institution, availability and/or requirement of anesthesia, and volume of after-hours cases. Academic institutions will often have neurointerventional fellows who are able to assist the interventionalist. In private hospital settings, the interventional radiology technologist will often be scrubbed in with the physician and serve as the first assistant on the case. Suggested staffing models for NIR room coverage for academic and private hospital settings are listed in Table 2.

The registered nurse (RN) is an essential component of the neurointerventional team. The nursing and technologist responsibilities for neurointerventional procedures are similar to the duties performed by nurses and technologists in interventional radiology and cardiac interventional laboratories. The NIR nurse is assigned the role of either the circulating nurse or the conscious sedation nurse; the radiology technologist can also be assigned the role of circulator. Regardless of the position assigned, the role of the nurse and technologist in the NIR suite is to provide optimal patient safety.

The primary function of the circulator role is to ensure fluidity of the case. This is made certain by thorough examination, detailed documentation, point-of-care testing (POCT), and providing the interventionalist with the tools needed throughout the case. If the circulator role is assigned to the technologist, the neurologic assessment will be performed by the sedation nurse.

The primary difference between an NIR nurse and a general interventional radiology nurse is the ability to perform a detailed neurologic examination as defined by the organization. The circulator will be responsible for assessing the patient before and after the procedure if the procedure is scheduled with anesthesia. If the case does not require the presence of an anesthesiologist, the responsibility for pre- and postprocedural examination will be with the conscious sedation nurse.

Through certification and experience, the nurse will be able to pick up subtleties that indicate a change in neurologic status that may influence the patient's outcome. Should a complication occur during the procedure, the pre- and postprocedural examination could identify its severity. In addition, quick notification of the physician of changes in examination results will lead to faster response times for further intervention, potentially improving outcomes. The NIR nurse should also be experienced and proficient in caring for patients during emergent neurologic events such as the need for urgent external ventricular drain (EVD) placement or an acute intracranial pressure (ICP) crisis. These skills would include the ability to deliver hyperosmolar therapy and emergent blood pressure control management in an acute emergency.

The circulator is responsible for detailed documentation throughout the case. While this aspect of the job may seem tedious, the documentation includes extremely important data used in outcome measurements. In the field of vascular neurology, time is of the essence in the majority of cases. When dealing with acute ischemic stroke, documenting groin puncture, clot retrieval, and reperfusion times can provide accurate retrospective data to help identify opportunities to improve the procedural process and reduce treatment durations.

Specific documentation points to consider in NIR cases are the following:

• Time in the room

• Preprocedural examination (National Institutes of Health Stroke Scale [NIHSS] score)

• Start of anesthesia or intubation time

• Groin puncture time

• Initial Thrombolysis in Cerebral Infarction (TICI) score

• Time of completion of each pass and TICI score after each pass

• Device deployment (i.e., stents/stent retriever/aspiration device/coils/balloons)

• Implant information (lot numbers/serial numbers/size of implant/location of implant)

• Medications administered intra-arterially by the surgeon

• POCT information (activated clotting time [ACT]/VerifyNow)

• Intakes and outputs (heparin flush/contrast)

• Time successful reperfusion is achieved

• Closure device (time of deployment/type)

• Postprocedural examination

The circulator is responsible for running POCT when directed by the physician. POCT typically includes ACT (heparin) and VerifyNow (P2Y12, glycoprotein IIb IIIa inhibitors, and acetylsalicylic acid). Being proficient with these forms of testing will assist the interventionalist in completing the case as safely as possible. Providing the interventionalist with accurate results will determine if additional anticoagulant therapy is required prior to deployment of stents or flow diverters or angioplasty.

The circulator should be proficient in the devices and products used in the NIR suite. Just as in the operating room, the circulator is expected to obtain products that are needed throughout the procedure and provide the interventionalist with them. Quick retrieval of products can positively influence the time to recanalization and hopefully improve outcomes. From shorter anesthesia duration to decreased time to reperfusion of the brain, a speedy response to the interventionalist's needs can result in better outcomes and improve patient safety.

The sedation nurse is responsible for providing conscious sedation and monitoring the patient in the absence of anesthesia personnel. Nurses in this capacity should be certified via the institutional protocol to administer conscious sedation. When a nurse is placed in this role, it must be the only responsibility assumed by that person [10,11,12]. The conscious sedation nurse will work in conjunction with the circulator. Similar to when anesthesia personnel are involved in a case, theirs is a single defined role; the conscious sedation nurse should function in the same manner. It is imperative for patient safety that the conscious sedation nurse remains at the patient's bedside and does not assume the responsibilities of a circulator. The nurse should also be familiar with agents to reverse sedative medications if indicated.

Before the procedure, the conscious sedation nurse should review the patient's history, allergies, and prescribed medications. Assessments include preprocedural examinations, review of the laboratory work, and ensuring NPO status. Any deviations or concerns should be addressed and relayed to the physician. Finally, the nurse should review the Mallampati score and American Society of Anesthesiologists (ASA) classification (Tables 3, 4); should complications occur, this information will allow for quicker handoff and intervention from anesthesia [13,14].

After arriving at the NIR suite, a baseline set of vital signs including pulse, blood pressure, respiratory rate, and SaO₂ should be obtained. At the start of the case and after sedation has been administered, vitals are to be documented every 5 min. In addition, once the patient is sedated, the level of sedation should be charted as well [15]. The provider performing the sedation/anesthesia on the patient should be familiar with the depth of the sedation given to the patient [15]. Sedation levels are noted in the Practice Guidelines set up by the ASA, as seen below (Table 5). By remaining at the patient's bedside, adverse effects from medications for intraprocedural complications can be noticed promptly and reported to the interventionalist. The conscious sedation nurse may be asked to assess the patient's neurologic status throughout the procedure, communicating any changes or differences from baseline examination results.

Postprocedural care may vary from institution to institution, depending on staffing and patient flow. Whether the conscious sedation nurse remains at the patient's bedside, or handoff is made to a recovery nurse, the frequency of monitoring does not change. A postprocedural neurologic examination must be completed by the conscious sedation nurse. The interventionalist is made aware of the neurologic examination and is also included in the handoff communication with the recovery nurse. Vital signs are monitored every 15 min for a total of 30 min. If reversal agents have been required, vital sign monitoring may be extended to 2 h. The patient may then be admitted to the desired unit, or discharged if specified criteria have been met [10]. While discharge criteria are facility specific, in order to be discharged patients should at a minimum have returned to their baseline mental status, have hemodynamic stability, and be able to ambulate, urinate, and tolerate food and drink [11].

Whatever the level of sedation, the responsibility remains the same. The conscious sedation nurse is expected to recognize and respond to hemodynamic changes and medical emergencies. The nurse should have a detailed understanding of anatomy and physiology, cardiac arrhythmias, and the pharmacology and side effects of the medications being administered. With the advanced cardiac life support (ACLS) certification, a nurse should have proficiency in airway management and hemodynamic monitoring [12].

The interventionalist determines the type of anesthesia used during emergency or elective procedures. Typically, if the procedure requires catheters to be entered intracranially, general anesthesia is used. At times, primarily in emergent situations, moderate sedation can be used, depending on the physician's comfort and the patient's cooperation.

Due to the highly acute states of the patient population and the nature of NIR care, unplanned and unforeseen emergencies do occur. These can range from cardiac arrest to vessel perforation resulting in acute hemorrhage in the brain. The NIR nurse needs to be able to act quickly and have tools available for whatever emergency may arrive.

Every NIR suite should have emergency medical equipment available in the room, or in a central core region that is accessible. The crash cart should contain a defibrillator, an Ambu bag, and emergency cardiac medications. Should a code occur, the circulating RN will be responsible for calling the code per the department/hospital policy, obtaining the crash cart, and connecting the patient to the defibrillator. The nurse should also be prepared to perform the role designated by the code leader.

In the case of neurologic emergencies if vessel perforation and intracranial hemorrhage result, equipment needs to be available to address increased ICP and placement of an EVD as quickly as possible. Medications to reverse anticoagulants such as protamine and agents to reduce ICP such as mannitol should be readily available. There should be a daily log or checklist to ensure that a drain, craniotomy kit, and drainage system are present and accessible in the room. During this check, the expiration date and integrity of the kits/trays should be controlled as well. The circulator is responsible for obtaining the equipment and preparing it for the neurosurgeon's arrival. The circulator should also be prepping the drainage system with preservative-free normal saline in preparation for ICP monitoring once the EVD is in place.

Staffing levels can and will affect the patient's ability to receive appropriate care in the acute phase. Different staffing models are seen for “regular” working hours compared to “off-hours.” The so-called weekend effect, in addition to admission during off hours such as nights and holidays, can negatively impact mortality and outcome for stroke patients [16,17,18,19,20,21]. Several studies have been published which look at the effect staffing has on the mortality and functional outcome of stroke patients. During off-hours, patients are noted to wait longer for diagnostic imaging and admission [17,18]. An increase in the number of patients eligible for IV alteplase is often seen on the weekend - however, there are decreased odds of receiving the medication on the weekend [16,17,18]. Even with telemedicine, there is a technological delay when the physician is off site [20].

If there is a need to call in physicians, nurses, and technologists at night, an increase in the time to intra-arterial (IA) alteplase administration is seen [20]. An American study looking at clinical outcomes after intracranial thrombectomy on weekends versus weekdays showed an increase in moderate/severe disability during weekends in non-teaching hospitals [22]. A study from Canada showed that delays are minimized with the presence of an in-house stroke call team 24/7 [21].

Solutions to this staffing dilemma include transferring the patient to a comprehensive stroke center, where there is more consistent staffing on weekends [23]. Ideally there should be a 24/7 stroke coverage at large interventional stroke centers that would include access to stroke specialists, stroke teams, and organized systems of care [19,23,24]. To further decrease delays, around-the-clock interventional team coverage is essential and an angiography tray should always be ready for use [21].

A stroke team led by advanced practice nurses has been shown to be efficient, accurate, and safe for treating stroke patients in the emergency department (ED) with a 24-h staffing model [25]. Pharmacists should also be considered part of the care team. The pharmacy resident is able to help determine the inclusion criteria for IV alteplase administration, assist with its administration, and help monitor for adverse effects [26,27].

Ongoing staffing assessments should be conducted at each site to determine the best regular hours for staffing with consideration that this may not be a traditional 8:00-5:00 schedule. Certified comprehensive stroke centers are required to have an interventionalist available 24/7. Facilities with high numbers of endovascular treatment may also consider 24/7 coverage by the interventionalist or establishing a response time (Table 6).

As in any area of specialty nursing, the NIR nurse is required to maintain certifications and compliance as part of hospital standards. Each nurse must be able to demonstrate competency in performing conscious sedation and radiation safety (including maintenance of the dosimeter badge) through education and a written examination. These examinations are defined and often provided by the institution. The nurse will also be required to maintain a certification in ACLS/basic life support and in use of the NIHSS. This examination is specific to the neurologic patient population cared for in an NIR suite and must be renewed every 2 years. The nurse must provide documentation of the certification for this examination, as well as for the others mentioned above.

POCT performance in the angiography suite also requires competencies and daily quality controls. The nurse will be required to complete a written examination for each POCT device (ACT/VerifyNow) annually. Each device must have a quality control that is run each shift and documented in the designated log. Performing quality checks promptly at the start of each shift, or upon arrival while on-call, will ensure accurate results and decrease delays.

Depending on your institution, continued education specific to stroke may be required. For those centers that are comprehensive stroke centers, the nurse requires at least 8 h of continuing education in the area of stroke each year [23]. This can be completed through accredited meetings, journals, and lectures.

It should be noted that the RN working in the NIR suite is not certified to operate the angiography equipment. This is restricted to radiology technicians and physicians who have undergone credentialing and certification. An RN would be practicing out of the scope of practice by operating the equipment.

Lastly, as the field of NIR advances, there will be new devices that are approved and become available. Despite the level of interaction with the device, the nurse and technologist are expected to be proficient in the device's function and use. Clinical and sales representatives from the device company will be available to provide training on such devices. A training log should be developed and maintained by the department, documenting that an in-service training has been completed. The log should be readily available for review.

Many stroke scales exist with varying levels of validation and reliability. The stroke team will determine the standard expectations for neurologic examination and documentation at your institution. Stroke recognition begins in the prehospital setting, with stroke scales used to accurately identify patients with large-vessel occlusions.

FAST. The Face Arms Speech Time (FAST) examination developed by the American Stroke Association is a quick and easy scale used to identify signs and symptoms of stroke in patients inside or outside the hospital. The FAST examination does not differentiate between small- and large-vessel occlusions [27] (Table 7). It was originally developed to be used for public education campaigns but has also seen an increase in use among in-hospital personnel.

LAMS. Developed for prehospital personnel, the Los Angeles Motor Scale (LAMS) stroke assessment is a validated, widely used tool shown to have good interrater reliability and good correlation with the NIHSS [28] (Table 8). The LAMS is validated to predict the presence of a large-vessel occlusion; a score ≥4 indicates that the likelihood of a large-vessel occlusion is increased 7-fold [28].

RACE. The Rapid Arterial Occlusion Evaluation (RACE) scale is the first validated tool for detection of large-vessel occlusion in the prehospital setting [29] (Table 9). A score ≥5 on the RACE scale has an 85% sensitivity and 65% specificity in detecting large-vessel arterial occlusions [29]. The RACE scale has a similar predictive value to the NIHSS [29].

C-STAT. Originally developed as the Cincinnati Prehospital Stroke Severity Scale (CPSSS), the name was changed to Cincinnati-Stroke Triage Assessment Tool (C-STAT) in order to prevent confusion with the Cincinnati Prehospital Stroke Scale (CPSS) (Table 10). The C-STAT was developed to predict the presence of severe acute ischemic stroke or large-vessel occlusion. A score ≥2 on the C-STAT has an 83% sensitivity and 40% specificity in detecting large-vessel arterial occlusions [30].

ESI. The Emergency Severity Index (ESI) is a tool that can be used to help triage patients upon arrival at the ED [31]. The ESI uses a 0-5 scoring system, with 0 being the most severe injury or illness (Fig. 1). The ESI would place all stroke patients at level 2, which means “needs immediate assessment” [31]. For all patients with an acute presentation of acute neurologic symptoms, there should be specialized checklists, protocols, and other tools in place for the triage nurse to identify stroke patients and initiate a stroke alert [27]. The initial patient assessment in the ED should focus on assessing the ABCs and vital signs and making a neurologic assessment [27]. All patients presenting with stroke symptoms should have cardiac monitoring in place [27]. The triage nurse or charge nurse in the ED should assume the responsibility to initiate a stroke alert based on the patient's presenting conditions, i.e., whether IV alteplase is an option versus endovascular therapy. The stroke alerts can be titled differently in order to help the team anticipate the needs of the patient arriving. The patient designated as a stroke alert should receive q15-min vital sign and neurologic checks for at least 1 h in order to evaluate the neurologic status.

NIHSS. The NIHSS is a valid and reliable tool used to determine stroke severity and treatment options and to predict patient outcomes. It is commonly used in both clinical and research trial settings as a standardized quantitative assessment of neurologic deficit severity. The NIHSS should be completed within the first 10 min of the stroke patient's arrival at the ED [23,32,33]. The NIHSS is useful across all levels of healthcare provision and presents a way to standardize assessment with high interrater reliability and to quantify the patient's baseline assessment and subsequent assessments [27,32,33] (Table 11). Posterior circulation strokes can be missed when the NIHSS alone is used and a score of 0 does not rule out that a stroke is occurring [34]. It is recommended that NIHSS users undergo formal training and certification through the American Stroke Association or similar organizations who offer certification [32]. A competent practitioner should use the NIHSS before and after an intervention is performed, and upon admission to the intensive care unit; several abbreviated versions of the NIHSS exist and should be used for further neurologic assessments [32].

MEND. The Miami Emergency Neurologic Deficit (MEND) examination includes assessment items that will identify posterior stroke symptoms often missed by the NIHSS [34,35] (Table 12). The MEND examination can be used by prehospital and in-hospital personnel and includes a scoring component to quantify the severity of the neurologic deficit [35]. The ability to use this examination across all aspects of stroke care is beneficial for improving communication throughout the continuum of care. The MEND examination was developed by the University of Miami and is taught as part of their Advanced Stroke Life Support Course. Organizations should pick an assessment or triage scale and train their personnel accordingly. The use of multiple scales at an organization is not recommended. An overview of the different neurologic assessments or tools is presented in Table 13.

Neurologic and vital sign assessments should occur at a minimum every 30 min for patients waiting to receive endovascular treatment [25,32] (Table 14). Blood pressure measurement during the reperfusion therapy procedure is recommended every 5 min [25]. Postprocedural vital sign monitoring may follow the same guidelines as reperfusion treatment with an alteplase infusion: q15 min for 2 h, q30 min for 6 h, and q1 h for 16 h.

IV alteplase is a recommended standard of care for acute ischemic stroke patients who meet inclusion and exclusion criteria, and, therefore, signed informed consent is recommended but not required. The process of obtaining consent can be tricky when different cultures and languages are involved in comprehension of the process [36]. If the patient is unable to consent, the assumption of consent for IV alteplase for ischemic stroke has been endorsed by the American Academy of Neurology and the American Heart Association/American Stroke Association [37]. A study published in 2014 found that older adults were no less likely to desire IV thrombolytic therapy when unable to consent then when asked directly; however, assumption of consent should only be applied when informed consent cannot be obtained [37]. Endovascular treatment is now considered a standard of care by the American Stroke Association for large-vessel occlusions and should follow the same consent process as IV alteplase [6].

In an acute situation, every attempt at obtaining either verbal or written consent should be made prior to the intervention. In non-acute situations, verbal or written consent should be obtained prior to the intervention. Treatment should not be withheld in an emergency because of an inability to obtain consent. After every attempt has been made to gain consent from the patient or family, the provider should clearly document the reason consent was not obtained and the need for emergency treatment. This documentation is an important component of comprehensive stroke monitoring and review for certification.

Before any cerebral endovascular procedure, a standardized time-out should be performed [38]. The time-out should involve the following personnel: the individual performing the procedure, the anesthesia provider (if applicable), the nurse, the radiology technologist, and any other personnel participating in the procedure from the beginning [39]. During the time-out, the care team should actively communicate and agree on the following:

• Correct patient identity

• Correct site

• Procedure to be performed

• Allergy

• Creatinine, INR, and platelet count

• Review of medication list

If the patient requires a second procedure and the personnel in the room changes, a second time-out should be performed [39]. Documentation of the time-out should be made according to the organization's standards and policy [39]. The time-out is an important component of comprehensive stroke monitoring and review for certification.

Air embolism is a complication that may occur in the following situations [40]:

• Air in pressurized flush bags connected to arterial lines

• Bubbles in syringes that form when contrast or saline are drawn up

• Disconnected stopcocks or loose rotating hemostatic valves that may allow air to enter the circulatory system when blood pressure falls

• Rupture of balloons that have not been adequately degassed prior to inflation

• Air bubbles in contrast injectors

• Air bubbles in flush tubing that connects pressure bags to arterial lines

Quick identification is important for treatment of air embolism. Treatment includes [40]:

• Termination of the connection between the offending arterial line and the patient

• Elevating the patient's blood pressure

• Ventilation with 100% oxygen

• Hyperbaric oxygen therapy

Postprocedural care and attention to the access site is the responsibility of the NIR nurse, fellow, and NIR physician team. Although the femoral approach is the most common and preferred method of accessing cerebral vessels, the vasculature of patients may impede the ability to use the femoral artery. When the patient has a tortuous vasculature in the lower extremities, the radial and/or brachial arteries are often considered a good alternative to the femoral artery [41]. If the vertebral artery is the target vessel, the radial approach will be beneficial for quicker access [42].

At the conclusion of the procedure, sheath removal and access site management must be addressed. In the past, manual compression for 15-20 min was the gold standard, until vascular closure devices became available [43,44]. Vascular closure devices have been found to be safe and effective at achieving hemostasis and decreasing the duration of bed rest required [43,44,45,46]. Vascular closure devices work by three different methods: suture closure, collagen plugs, and staples/clips [44]. If a vascular closure device cannot be used, manual compression should be considered [44]. The ACT level should be checked prior to sheath removal, and mechanical pressure held for 60 min or manual pressure for 30 min. Complications may occur with any hemostatic technique; they are outlined in Table 15[45]. Complications with the femoral access approach are outlined in Table 16 [42,45].

The radial artery approach for endovascular therapy has advantages and disadvantages, which are detailed in Table 17 [41,42]. Hemostasis after radial approach is achieved using two different methods: manual compression or a compression device [42]. For patients who are not on anticoagulant therapy, 10 min of manual compression is usually recommended to achieve hemostasis [42]. For patients who are receiving anticoagulants, use of a compression device for 2 h may be necessary to achieve hemostasis [42].

Sheath removal should be performed by specially trained personnel. It is equally important for the bedside nurse caring for the patient after the endovascular intervention to understand what complications to assess for and how to assess the puncture site. The frequency of vascular access assessment should be included in the postprocedural order set and mirror the neurologic and vital sign assessments.

There are many opinions regarding early ambulation, with general agreement that the earlier the patient is able to ambulate, the fewer complications they will experience. Several studies looked at sheath size, mode of hemostasis achievement, and ambulation time. Some older studies recommended 4-6 h of bed rest, while more recent studies have found that ambulation 2-4 h after sheath removal is safe [47,48] (Table 18).

The use of pressure dressings after sheath removal was common; however, a recent study showed a decreased risk of complications when a transparent dressing is used [49]. If manual compression is the closure method, a pressure dressing is reasonable; if a collagen plug or the clip closure method is used, a transparent dressing will result in fewer complications.

The transfer of a stroke patient's imminent healthcare responsibility from one department to another, as well as from one healthcare provider to another, highly impacts the success and outcomes for the neurovascular patient. Ineffective communication has been proven to contribute to 20-24% of medical errors, as well as to 43% of researched malpractice issues. It is also known that communication breakdowns are the primary root cause of more than 60% of the 2,000 sentinel events analyzed by The Joint Commission (TJC) [50]. As a result of TJC-released patient safety data, in 2006 TJC required and released a National Patient Safety Goal aimed at improving the effectiveness of caregiver communication [51].

Handoff involves the transfer of essential information when the responsibility for patient care shifts from one healthcare provider to another. When handoffs are effective, there is a seamless transition of critical information that results in improved continuity of patient care [50]. The most important function of safe handoffs is information processing, i.e., making sure that essential data are transferred for patient safety [50]. The use of structured tools for handoffs, as well as bedside reports and rounds, are recommended. A model for standardizing handoffs has the potential to result in improvement of patient care [52].

(1) SBAR: Situation, Background, Assessment, and Recommendation

(2) Six Sigma - Define, Measure, Analyze, Improve, and Control [53]

After the patient has arrived at your facility, it is the responsibility of the acute stroke response team to communicate to patient providers the emergent plan of care for the stroke patient. If available, the acute stroke advanced practice provider (APP) is the core communicator responsible for delivering care in the ED, ensuring effective communication with the nurses and healthcare providers in the ED, following the patient through the emergent treatment period, and communicating with the neurologist, interventionalist, and admitting hospitalists. The acute stroke APP also communicates with, and delivers the patient to, the critical care unit or step-down unit after mechanical thrombectomy or alteplase administration. The APP performs the handoff at the bedside to the admitting unit's bedside nurse. Both the critical care nurse and the stroke response APP concurrently complete an NIHSS assessment to adequately understand the patient's neurologic examination results. In the absence of APPs, a stroke response team RN (trained in acute stroke care) may be utilized to fulfill the above role. Some facilities already utilize neurocritical care (NCC) RNs to help with this role.

Examples of personnel involved in the stroke process handoff:

• Stroke network neurologist, transfer center RN

• Acute stroke response team, advanced practice nurse

• Neurologist, neurointerventionalist, hospitalist - admitting physician

• Nurses of each unit (ED, NIR, NCC, stroke unit, and operating room)

• APP NCC/neurointensivist

Consistent information is necessary for adequate communication and handoff for this high-risk patient population. Examples of required information to adequately transfer care and provide effective care for the stroke patient are the following:

• LKW (last known well)

• NIHSS score and neurologic deficits

• Allergies

• Medications given

• Anticoagulant/antiplatelet use

• Procedures done (alteplase, interventional radiology, etc.)

• Treatment and future plan of care

• Any complications

• Code status

• Family contact phone number

Stroke remains a major healthcare problem affecting over 795,000 Americans each year. Stroke is also a contributing cause of functional impairments in individuals, leading to a high number of patients requiring an institutional or skilled level of care [54]. Time from symptom onset to start of treatment is one of the most important data points in stroke care; thus, the overall speed of the revascularization process is an important and appropriate measure. It is estimated that for every 30-min delay in time to revascularization there is a 10% decrease in the likelihood of a good outcome of endovascular reperfusion therapy [55].

Endovascular therapy for both urgent and non-urgent neurologic conditions is often available at comprehensive stroke centers. Primary stroke centers may possess resources but often lack the patient volumes and around-the-clock resources necessary to pursue a comprehensive stroke center certification. To receive the designation of comprehensive stroke center, a certification must be obtained from an approved credentialing body.

There are three main certifying bodies for hospital stroke certification; this includes both primary stroke centers and comprehensive stroke centers, as well as the newest designation, acute stroke-ready hospitals. The certifying bodies are: TJC, the Healthcare Facilities Accreditation Program (HFAP), and DNV·GL Healthcare (DNV). The following are descriptions of these certifying bodies:

The HFAP mandates that comprehensive stroke centers provide care for complex stroke patients. Their infrastructure includes advanced treatments in key areas such as neurology, neurosurgery, and neuroradiology. Hospitals with accreditation from another organization may apply for stroke certification. Appropriately qualified clinicians conduct the certification review, and the certification is for a 3-year period, with a mid-cycle review at 18 months. HFAP certification requires all comprehensive stroke centers to provide quality care in the following interventional capabilities: carotid endarterectomy, stenting, IA reperfusion, endovascular ablation, etc. [56].

DNV, a certifying body for comprehensive stroke centers, encompasses the full spectrum of stroke care - diagnosis, treatment, rehabilitation, and education - and establishes clear metrics to evaluate outcomes. Comprehensive stroke centers are typically the largest and best-equipped hospitals in a given geographical area able to treat any kind of stroke presentation or stroke complication. DNV introduced its disease-specific standards and certification program for comprehensive stroke centers following the guidelines set forth by the Brain Attack Coalition and the American Stroke Association for treatment of the most serious stroke events [57].

With guidance from the Brain Attack Coalition, TJC initially developed a certification for primary stroke centers in 2003 and then developed an advanced certification for comprehensive stroke centers in 2012. Comprehensive stroke center institutions are hospitals that have specific abilities to receive and treat the most complex stroke cases including acute ischemic, intracerebral, and subarachnoid hemorrhage. TJC, with collaboration from the American Heart Association/American Stroke Association, has maintained a unique relationship, established in 2003 to promote the provision of excellent stroke care in hospitals all across the USA. The goal of establishing this advanced level of certification is to recognize the significant resources, staff, and training that are necessary for the treatment of complex stroke cases. In 2015, the acute stroke ready level of stroke certification also became available. We also anticipate that, over time, states, municipalities, and regions will develop a formal referral stroke system of care so that the most complicated cases will be identified, transferred, and treated at the centers best equipped to provide this kind of specialized care [57].

Centers can choose any certifying institution, and must meet the specific requirement of that agency in order to be certified. All the certifying bodies discussed above require a comprehensive stroke center to provide high-quality and time-efficient care for their stroke patient population. In order to capture endovascular treatment-specific stroke outcomes, metrics are collected, reviewed, and analyzed by each institution and reported to the comprehensive stroke center-certifying bodies. The following are measures that are examples of data capture for reporting [57].

Included population:

• Patients discharged with ICD-10-CM Principle Diagnosis Codes for Ischemic Stroke

• Patients with documented thrombolytic infusion therapy or mechanical endovascular reperfusion therapy

Excluded population:

• Patients less than 18 years of age

• Patients who have a length of stay more than 120 days

• Patients admitted for elective carotid intervention

Rationale for Measure Collection. Timely recanalization of an occluded intracerebral artery is a strong predictor of improved functional outcome and reduced mortality in patients with an acute ischemic stroke [55]. Trials of IA lytic agents and mechanical revascularization devices have historically required start of treatment as long as 6-8 h for anterior circulation strokes of the middle cerebral artery, with extended times from symptom onset for vertebrobasilar occlusions. At this time, administration of IV tPA within 3-4.5 h of the time last known well remains the recommended first-line approach [6]. However, the short therapeutic window and low rates of recanalization with IV tPA therapy have prompted investigation into alternative approaches via IA infusion of a thrombolytic drug or mechanical recanalization with clot thrombectomy. These other treatments are a consideration for patients in whom IV alteplase fails or is considered likely to fail, who are excluded from IV alteplase treatment, and/or who present with large-vessel occlusion that can be detected directly with brain imaging (noncontrast CT, CT angiography, or magnetic resonance angiography) or indirectly with an NIHSS score greater than 10 [57].

• (A) Documentation of the date and time of arrival of the patient at your hospital

• (B) LKW documentation

• (C) NIHSS score documentation (if possible)

• (D) Documentation of INR and blood sugar, pressure, and platelets

• (E) Documentation of code status

• (F) Documentation of pre-modified Rankin Scale score

• (G) Documentation of the decision time for the vascular and interventional radiology procedure

• (H) Documentation of scanning utilized to make the decision for the vascular and interventional radiology procedure

• (I) Sedation documentation (Aldrete score) before/after the procedure

• (J) Vital sign and neurologic check documentation

• (K) Documentation of the time of groin puncture

• (L) Documentation of all catheters entering and exiting the body, with times documented

• (M) Documentation of the number of passes, with times documented

• (N) Documentation of the IA route of alteplase/mechanical endovascular reperfusion, with date and time of initiation

• (O) Reperfusion grade, time of reperfusion

• (P) Documentation of the site of occlusion (artery, distal, or proximal)

Documentation of the door-to-needle time is required by all certifying bodies.

Description. Ischemic stroke patients with a posttreatment TICI reperfusion grade of 2B or higher in the vascular territory beyond the target arterial occlusion at the end of treatment with IA thrombolytic (tPA) therapy and/or mechanical endovascular reperfusion therapy are assessed. The TICI reperfusion grade is used to measure cerebral reperfusion. There are four results of scoring: 0, no perfusion; 1, perfusion past the initial occlusion, but no distal branch filling; 2a, partial filling of occluded territory <50%; 2b, partial filling of occluded territory >50%; 2c, near-complete reperfusion with slow flow in distal cortical branches or presence of distal cortical emboli; and 3, full perfusion with filling of all distal branches [57,58].

Rationale for Measure Collection. TICI grading is used to measure cerebral reperfusion and provide adequate documentation of the outcome of the patient [57]. Other key components of patient data collection can be individualized from each institution's preference to utilize in the quality improvement process. The most important factor in comprehensive stroke care is that the evaluation and initial treatment of patients with stroke should be performed in a timely manner. Organized protocols should be utilized and implemented, as well as organized data collection completed, around the institution's process to ensure efficacy of care. An evaluation of process care points is essential for efficiency. An example of data process collection is presented in Table 19.

The required data can be collected under the specific requirements of the individual stroke care institution. For example, it may be collected by the NIR staff in electronic or paper format, or can also be included in what has been dictated by the physician to document the procedure and intervention. The data will be collected and analyzed by the stroke quality team and compiled for submission as required. Examples and possibilities of personnel who can serve as data collectors for the organization could include: quality outcome manager/personnel; personnel of individual departments such as neuroscience, nursing, NIR, or cardiology; stroke outcome manager/staff; or ED outcome manager/staff. Organizations could comprise homegrown databases or templates for maintaining all the data elements required.

Many institutions utilize the “Get with the Guidelines” Web-based data repository maintained by outcome scientists to compile the data required for both comprehensive and primary stroke center certification. This program also allows hospitals to compare their data with similar hospitals and other comprehensive stroke centers. An example of the metrics that are required for both primary and comprehensive stroke center certification by TJC can be seen in Table 20.

Despite the advances in the recognition and treatment of acute and non-acute neurologic conditions, stroke (all causes) remains the leading cause of disability in the USA and a significant contributor to mortality. The field of neurovascular diagnosis and treatment continues to expand rapidly, and institutions are recognizing the importance of providing this service to patients and families. The benefit for patients has been demonstrated in numerous research publications and is now endorsed by the American Heart Association/American Stroke Association clinical practice guidelines for care of both ischemic and hemorrhagic stroke [6,8,59]. The authors of this document have contributed from both personal and professional experience in the field during this time of immense growth. We sincerely hope that your team benefits from this resource.

A special thank-you to Lori Masaro, MSN, CNRN, SCRN, for starting us on this journey. Your leadership passion for neuroscience nursing is unending. Thank you for always being an advocate for nursing and for helping to make the profession amazing.

The authors have no disclosures and declare no conflict of interests. No funding was received for this paper.