CLINICAL ISSUES

An evidence-based practice approach to improving nursing care of

acute stroke in an Australian Emergency Department
Julie Considine and Bree McGillivray

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence
regarding prevention of early complications.
Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend con-
siderable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in
patient outcomes following stroke.
Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing
management of acute stroke.
Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time,
Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and
blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions.
Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease
in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure
(p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area
interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment
prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1%
(ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns).
Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise
patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recom-
mendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the manage-
ment of acute stroke.

Key words: Australia, emergency nursing, nurses, nursing, stroke

Accepted for publication: 12 March 2009

Introduction
Stroke is a significant and increasing health issue. World
Health Organisation data shows that 15 million people
worldwide suffer a stroke very year. Of these, five million
people die from stroke and five million people are left with
permanent disability placing a burden on families and
communities (Mackay & Mensah 2004). Awareness and
modification of risk factors such as hypertension and smok-
ing has resulted in a reduction in the incidence of stroke

Authors: Julie Considine, RN, RM, BN, GradDipNurs, MNurs, PhD,
FRCNA, Senior Research Fellow, Deakin University – Northern
Health Clinical Partnership, Burwood; Bree McGillivray, RN, BN,
GCertEmergNurs, Clinical Nurse Specialist, Emergency Department,
The Northern Hospital, Epping, Vic., Australia
Correspondence: Julie Considine, Senior Research Fellow, Deakin
University, 221 Burwood Hwy, Burwood, 3125 Vic., Australia.
Telephone: +61 3 9244 6175.
E-mail: julie.considine@deakin.edu.au

138  2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
doi: 10.1111/j.1365-2702.2009.02970.x
Clinical issues
however the absolute number of strokes continues to rise as a
result of ageing populations and increased life expectancy
(Mackay & Mensah 2004).
In the Australian context, 48,000 Australians have a stroke
each year (Victorian Department of Human Services 2007).
Of these strokes, 70% are first ever strokes and 30% of these
people will have another stroke within one year (Victorian
Department of Human Services 2007). Of those who survive
initial stroke injury, 9000 Australians die within one month
of stroke, one-third of patients with stroke die within
12 months and 78% of deaths from stroke occur in patients
older than seventy-five years (Victorian Department of
Human Services 2007). In the next 10 years more than half
a million people in Australia will suffer a stroke (National
Stroke Foundation 2006). In addition, stroke is a leading
cause of disability in Australia (National Stroke Foundation
2006). During 2005/2006 Victorian public hospitals man-
aged almost 12,000 episodes of stroke and just over 2800
episodes of Trans-ischaemic attack (TIA) (Victorian Depart-
ment of Human Services 2007). It is predicted that the
incidence of acute stroke will continue to increase by 2Æ7%
annually (Victorian Department of Human Services 2007).
An important part of acute stroke management and
decreasing stroke-related mortality is preventing complica-
tions within the first 24–48 hours (Bhalla et al. 2001,
Pendlebury & Rothwell 2004, Lees 2005, Anderson et al.
2006). The current climate of prolonged time spent in the
Emergency Department (ED) means that many aspects of
stroke management are now the responsibility of emergency
nurses. The ED at The Northern Hospital (TNH), Mel-
bourne, Australia manages over 65,000 patients per year
(Northern Health 2007). Observations of current emergency
nursing practice at TNH suggested variability in management
of patients with stroke in our ED. Further assessment of 2006
ED data for 113 patients with ED discharge diagnosis of
stroke confirmed variation in care. For example, triage
category allocation was spread across all five Australasian
Triage Scale categories (Cat 1 = 4Æ4%, Cat 2 = 19Æ5%, Cat
3 = 51Æ3%, Cat 4 = 21Æ2% and Cat 5 = 3Æ5%) suggesting
variability in perceived urgency of treatment and potentially
significant knowledge deficits among triage nurses. There was
also variability in terms of waiting times to see medical staff:
80% of patients (n = 90) were seen within one hour and 70%
of patients (n = 80) were seen within 30 minutes. The
average length of ED stay was 11 hours however 20% of
patients were in the ED for over 20 hours before transfer to
an inpatient unit highlighting the need for prevention of
complications to commence in the ED and for ED manage-
ment of acute stroke to be evidenced-based. Observations of
current practice also showed variability in frequency of vital
 2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
Evidence-based practice in improving nursing care of acute stroke
sign monitoring and that the intervals between vital sign
assessment increase the longer the patient is in the ED.
It is important to note that the focus of this paper is on
emergency nursing management of acute stroke. Although
the use of thrombolysis as a treatment option for acute stroke
is discussed in most stroke guidelines (Royal College of
Physicians 2004, Anderson et al. 2006, Adams et al. 2007,
National Stroke Foundation 2007, Victorian Department of
Human Services 2007), most current evidence does not
support the use of thrombolysis in acute ischaemic stroke
beyond three hours (Hacke et al. 1995, Clarke et al. 1999,
2000, Kothari et al. 2001, National Stroke Foundation 2003)
to 4Æ5 hours after symptom onset (Hacke et al. 2008,
Wahlgren et al. 2008). Further, it may be argued that for
patients who are ineligible for thrombolysis, the management
of fundamental aspects of stroke care is vital to optimising
outcomes for stroke survivors.
Aims
The aim of this study was to improve the emergency nursing
care of acute stroke by enhancing the use of evidence
regarding prevention of early complications.
Methods
Study design
A prospective pre/post-test design was used. The outcome
measures were elements of emergency nursing care known to
impact on outcomes of stroke survivors. Data were collected
using by medical record audit. The intervention for the study
was a guideline for the emergency nursing management of
stroke, the implementation of which was supported with
tutorials. Pre-test data were collected from January–March
2007 and post-test data were collected between August–
October 2007.
Setting
The study was conducted at The Northern Hospital: a
peripheral hospital 30 km north of Melbourne, Australia.
TNH is a 300 bed acute care campus of Northern Health.
The ED at TNH manages over 65 000 patients per year
(Northern Health 2007). During 2005/06, Northern Health
managed 404 admissions for acute stroke (Victorian
Department of Human Services 2007). The ED at TNH does
not routinely offer thrombolysis as an emergency treatment
option for acute ischaemic stroke due to lack of specialist
neurology and neurosurgical services, specialist neuro-
imaging capability and high dependency unit facilities.
139
J Considine and B McGillivray
Pre-hospital triage of patients with stroke by paramedics
tends to result in transport of patients who may be eligible for
thrombolysis to specialist centres. As a result of pre-hospital
triage, patients with stroke who present to TNH tend to be
older with a high incidence of pre-morbid risk factors,
particularly diabetes and smoking.
Participants
Participants were patients with an ED discharge diagnosis of
stroke (ICD-10 code I64). Pre-test data were collected for all
patients with an ED discharge diagnosis of stroke from
1 January–31 March 2007 (n = 64). The guideline was
implemented in July 2007 and a period of one month
was allowed for normalisation of practice. Post-test data was
collected for all patients with ED discharge diagnosis stroke
from 1 August–31 October 2007 (n = 41).
Ethical considerations
This study was approved by the Human Research and Ethics
Committee at TNH.
Intervention
The intervention for the study was a guideline for the
emergency nursing management of stroke that was imple-
mented in June 2007. Details of the guideline development
and content are presented elsewhere (McGillivray &
Considine 2009). The guideline was based primarily on
the Institute for Clinical Systems Improvement (ICSI)
Diagnosis and Initial Treatment of Ischemic Stroke Guide-
line (Anderson et al. 2006). The evidence presented in the
ICSI Guideline was augmented by evidence-based recom-
mendations from other key documents related to stroke
management: Australian National Stroke Foundation
Guidelines (National Stroke Foundation 2003), meta-
analyses related to stroke management (Hajat et al.
2000), outcome studies (Weir et al. 1997) and local
pressure injury and venous thromboembolism assessment
and prophylaxis policies that supported the ICSI recom-
mendations. The guideline was designed to be a summary
document that accompanied usual ED nursing documenta-
tion: this decision was pragmatic and aimed to increase
clinical utility of the guideline.
Guideline implementation which was supported by a
tutorial on stroke care delivered during nursing education
time. An overview of the evidence contained in the guideline
was presented during the 30 minute tutorial and the rationale
for changes in emergency nursing care of stroke discussed.
Importantly, the tutorials provoked robust discussion and
140  2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
debate about changes to practice and this level of interaction
facilitated emergency nurses’ understanding of the rationale
for the recommendations made in the guideline. It was also
important for the tutorials to emphasise the important
influence of nursing care of outcomes for patients with acute
stroke.
Tutorials were used previously in ED at TNH by Considine
and Brennan (2006) to promote uptake of evidence and
change practice related to paediatric fever management
practice in the ED at TNH. Adaptation of the ICSI Guideline
(Anderson et al. 2006) and development of the tutorial
occurred in conjunction with the ED Clinical Nurse Educa-
tors, Emergency Physicians, allied health personnel (speech
pathologists, physiotherapy and dieticians) and physicians
from the inpatient medical unit that specialises in stroke
management. The tutorial was delivered on eight occasions
and captured 48 emergency nurses. The guideline was also
placed in the nursing communications folder and on the desk
top of all computers in the ED and was promoted by the
researchers and ED Clinical Nurse Educators.
Procedure/data collection
One of the researchers (BM) collected following data by
medical record audit:
• demographic data: patient age and gender;
• ED system data: time of arrival, triage category, waiting
time, mode of arrival and ED length of stay;
• specialist referrals: assessment by stroke unit, speech
pathology, physiotherapy, dietician and occupational
therapy;
• nursing assessment data: vital sign assessment, oxygen
saturation and blood glucose monitoring, IV fluid regimes;
• frequency of oral intake prior to swallowing assessment;
• risk management: documentation of nil orally status, tim-
ing of swallow assessment, IV fluid regimes, venous
thromboembolism risk assessment and interventions,
pressure injury risk assessment and interventions.
Data analysis
Data analysis was performed using the computer software

SPSS 14.0 for Windows (SPSS Inc., Chicago, IL, USA) Pre-
test and post-test data were compared to determine if
prevention of early complications improves ED manage-
ment of stroke. In addition to descriptive statistics (per-
centages, means, standard deviations), non-parametric data
were compared using chi-square and Mann–Whitney
U-tests and parametric data were compared using indepen-
dent samples t-test (Polgar & Thomas 1991).
Clinical issues Evidence-based practice in improving nursing care of acute stroke

Results Table 2 Median number of repeated nursing assessments by group

A total of 104 patients were recruited to the study: 63 Pre-test Post-test

patients in the pre-test group and 41 patients in the post- Mdn (IQR) Mdn (IQR) p*
test group. As the study data were not normally distrib-
Respiratory rate 8 (5–13) 12 (6–19) 0Æ009
uted, medians and inter-quartile ranges are presented and Heart rate 8 (5–12) 11 (5Æ75–19) 0Æ022
non-parametric analyses were used to compare groups. Blood pressure 8 (5–11) 12 (5Æ75–19) 0Æ032
There were no significant differences in the gender or age Temperature 4 (2–5) 4 (2–6Æ5) 0Æ310
distribution of both groups: males comprised 49Æ2% of the Glasgow Coma Score (GCS) 4 (3–8) 7 (3Æ5–9Æ5) 0Æ163
pre-test group (n = 31) and 56Æ1% of the post-test group SpO2 5 (3–10) 10 (5Æ5–19) 0Æ001
Blood sugar level (BSL) 4 (2–5) 4 (2–6Æ5) 0Æ310
(n = 23) (v2 = 0Æ472, df = 1, p = 0Æ492). Patients in the
pre-test group had a median age of 75 years [Inter-Quartile *Mann–Whitney U.
Range (IQR) = 59–82] and post-test group patients had a
median age of 66 years (IQR = 58–77) (U = 1087Æ0,
Table 3 Risk assessment and interventions by group
p = 0Æ174). This between-group difference in median age
was not statistically significant. There was no significant Pre-test Post-test
between-group difference in the proportion of patients
n % n % p*
arriving by ambulance (54Æ0 vs. 53Æ7%) (v2 = 0Æ001, df = 1,
p = 0Æ975) or who required interpreting services (27Æ4 vs. Nil orally 27 52Æ9 20 66Æ7 0Æ227
status documented
14Æ6%) (v2 = 2Æ326, df = 1, p = 0Æ127).
Swallow assessment 12 46Æ2 28 87Æ5 0Æ003
This study had three major findings following implemen- prior to oral intake
tation of the ED stroke guideline. First, there was significant VTE assessment 22 40Æ7 11 34Æ4 0Æ557
21Æ4% increase in triage to Australasian Triage Scale (ATS) VTE interventions 35 64Æ8 21 65Æ6 0Æ939
category 2 following implementation of the stroke guideline Pressure area assessment 21 38Æ9 16 47Æ1 0Æ450
and significant 15Æ6% decrease in triage to ATS category 4 Pressure area interventions 13 24Æ1 18 52Æ9 0Æ006

(Table 1). Second, there was increased frequency of repeated *Chi-square.

assessments of respiratory rate, heart rate, blood pressure and
oxygen saturation (Table 2). There was also a non-significant
vs. 26Æ1%, n = 6) (v = 2Æ390, df = 1, p = 0Æ122) and median
increase in median number of Glasgow coma score assess-
time to speech pathology assessment decreased by 93Æ5 min-
ments.
utes. The median time for speech pathology assessment for
Third, there were significant improvements in risk man-
the pre-test group was 25Æ7 hours (IQR 17–52Æ9) and
agement. There was a 41Æ3% increase in patients who
24Æ1 hours (IQR 14Æ6–66Æ7) for the post-test group
underwent a swallow assessment prior to oral intake
(U = 332Æ000, p = 0Æ816).
(p = 0Æ003) and 13Æ8% increase in documentation of nil
orally status (Table 3). There was no change in the frequency
of risk assessments for venous thromboembolism or pressure Discussion
areas however there was a significant 28Æ8% increase in the
The results of this study highlight three major areas of
frequency of documentation of pressure area interventions
practice change following implementation of the ED stroke
(p = 0Æ006) (Table 3). In addition, the frequency of speech
guideline so the discussion to follow will focus on the
pathology assessment in ED increased by 16Æ1% (n = 3, 9Æ7
importance of these changes in clinical practice for ED
patients with acute stroke. The first major finding of this
Table 1 Distribution of ATS categories by group study was a significant shift in triage decision making with
Pre-test Post-test
increased triage to Australasian Triage Scale category 2 (seen
within 10 minutes) and decreased triage to Australasian
n % n % p* Triage Scale category 4 (seen within 60 minutes). This finding
ATS 1 0 0 4 9Æ8 0Æ011 is important as it suggests increased perception of urgency of
ATS 2 8 12Æ7 14 34Æ1 0Æ009 stroke care by emergency nurses and acknowledgement that
ATS 3 39 61Æ9 19 46Æ3 0Æ118 stroke is a medical emergency (National Stroke Foundation
ATS 4 16 25Æ4 4 9Æ8 0Æ048
2007). Further, triage of patients with actual or potential
*Chi-square. stroke as high acuity is the first step in facilitating early

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J Considine and B McGillivray
diagnosis, treatment and referral to specialist services: these
factors are known to improve outcomes and prevent compli-
cations following stroke (Davernport & Dennis 2000,
National Stroke Foundation 2003).
The second major finding of this study was increased
frequency of repeated physiological assessments. Increased
physiological surveillance is a positive finding because control
of abnormal physiological parameters may be a neuropro-
tective strategy following stroke (Bhalla et al. 2001). The
median number of oxygen saturation assessments doubled in
the post-test group despite no real differences ED length of
stay suggesting increased frequency of assessment. Oxygen
saturation monitoring is important following stroke as
patients with acute stroke have lower oxygen saturation than
matched controls (Elizabeth et al. 1993) and hypoxia
increases cerebral injury following stroke (Bhalla et al.
2001, National Stroke Foundation 2003). Unfortunately,
there were no major changes to temperature and blood
glucose monitoring and this is an area of ongoing work for
the ED. Temperature monitoring following stroke is impor-
tant as hyperthermia is common in stroke patients due to
infection preceding stroke, stroke related damage to the
hypothalamus or as a result of thromboembolism (National
Stroke Foundation 2003). Early hyperthermia in acute stroke
increases risk of poor outcome, mortality and increased
infarct size (Bhalla et al. 2001, Lewandowski & Barsan 2001,
Anderson et al. 2006). One meta-analysis of hyperthermia
and stroke outcomes showed a 19% increase in mortality for
febrile patients (OR 1Æ19, 95% CI, 0Æ99–1Æ43) (Hajat et al.
2000) highlighting the importance of temperature control in
patients with acute stroke. Hyperglycaemia following stroke
is also associated with increased mortality and/or decreased
functional outcome (Weir et al. 1997, Bhalla et al. 2001,
Lewandowski & Barsan 2001, National Stroke Foundation
2003, Anderson et al. 2006) and blood glucose level over
8 mmol/l is a known predictor of mortality following stroke
(adjusted for age, stroke severity and stroke type) (Weir et al.
1997).
Finally, there were significant improvements in risk man-
agement, particularly related to safe swallowing. Documen-
tation of nil orally status increased by 13Æ8% indicating
increased awareness of nil orally status until swallowing is
assessed. There was also a 41Æ3% increase in patients who
underwent a swallow assessment prior to oral intake again
highlighting the importance of safe swallowing following
stroke. Impaired swallowing following stroke is associated
with increased mortality (Lewandowski & Barsan 2001) and
gag assessment is now known to be an unreliable indicator of
swallowing (Lewandowski & Barsan 2001, National Stroke
Foundation 2003). In addition, the frequency of speech
142  2010 The Authors. Journal compilation  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 138–144
pathology assessment in ED increased by 16Æ1% and median
time to speech pathology assessment decreased by 93Æ5 min-
utes. Although these differences in speech pathology assess-
ment did not reach statistical significance, it may be argued
that they are clinically significant. A key focus of the
guideline used in this study was early referral to speech
pathology and prior to guideline development, speech
pathology referral was ad hoc and dependent on individual
clinician knowledge and motivation. Speech pathology refer-
ral occurred mostly using telephone paging system which had
major limitations out of hours when speech pathologists were
not in the hospital. To coincide with implementation of the
guideline, an electronic allied health referral system was
activated on all ED computers. The increased incidence of
speech pathology assessment in ED and decreased time to
speech pathology assessment suggest that these changes were
effective although there is scope for further improvement in
facilitating speech pathology assessment.
A further finding related to risk management was increased
the frequency of documentation of pressure area interven-
tions. Pressure ulcer risk assessment and prophylaxis are an
important aspect of stroke care and patients with stroke are
particularly prone to pressure ulcers as a result of increased
age, immobility, incontinence, poor nutritional status, cog-
nitive impairment and diabetes (National Stroke Foundation
2007). The ED stroke guideline used in this study highlighted
existing organisational policies related to pressure ulcer
prevention.
Limitations
There are several limitations that should be considered when
interpreting the study findings. First, this was a relatively
small study conducted in one ED so the generalisability of
findings may be limited. Second, the study method was reliant
on nursing documentation as a proxy for care delivery and it
may be argued that documentation does not accurately reflect
actual practice. Observations of clinical practice would
suggest that documentation is under-representative of nursing
care; that is care is delivered but not documented. The
findings of this study may therefore under-represent actual
improvements in stroke management. Finally, the use of a
pre-test post-test design has limitations given that data
collection occurred over two different periods in time.
Although there were no major changes in staff or ED policies
during this time, the use of a control group would have been
an ideal study design. The model of emergency nursing care
delivery at TNH is team nursing: if staff were assigned to
control and intervention groups the need to work together
would make contamination of a control group unavoidable.
Clinical issues
Conclusion
Emergency nurses play a key role in acute stroke care and the
role of ED staff in stroke care will expand as the burden of
disease related to stroke results in increased service demand.
Further, increased emergency demand and decreased access
to inpatient beds may further increase the time patients spend
in ED following acute stroke making emergency nursing
management of acute stroke a fundamental factor in
optimising patient outcomes following stroke. The results
of this study have shown that an evidence-based guideline
can improve stroke care in the ED and decrease clinical risk
associated with acute stroke. Unfortunately, emergency
nursing care is under-represented in many guidelines for the
management of acute stroke and most guidelines focus on use
of thrombolysis as the key to ED management of acute
stroke. Irrespective of whether thrombolysis is a treatment
option for acute stroke, sound emergency nursing manage-
ment (accurate assessment and triage, rigorous physiological
surveillance, management of physiological abnormalities and
management of clinical risk) are fundamental to the health
outcomes of patients with acute stroke. As the continuum of
stroke care begins in the ED, detailed recommendations for
evidence-based emergency nursing care should be included
in all multidisciplinary guidelines for the management of
acute stroke.
Acknowledgements
This study was supported by a National Institute of Clinical
Studies (NICS) Emergency Care Nursing Grant. NICS is an
institute of the National Health and Medical Research
Council (NHMRC), Australia’s peak body for supporting
health and medical research.
Contributions
Study design: JC; data collection and analysis: BM, JC and
manuscript preparation: BM, JC.
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