NAS-Care study under way at two Texas hospitals

The Nursing-driven Acute Stroke Care (NAS-Care) study was launched in two East Texas hospitals this summer. Good Shepherd Medical Center in Marshall, TX completed training, and recently entered the intervention stage.  At the second hospital, researchers began collecting baseline data in June.  (The name of this hospital cannot be released yet, as the staff is currently blinded to the study.)

Stroke protocol team as fast as a “racing pit crew”

From left to right: DaiWai Olson, PhD, RN (Co-Investigator); Michelle Provencher, RN, BSN, MS (Lead Research Coordinator); Mark Goldberg, MD (Current PI); Julian Yang, MD (Study Author and Former PI); Linda Hynan, PhD (Statistician)

From left to right: DaiWai Olson, PhD, RN (Co-Investigator); Michelle Provencher, RN, BSN, MS (Lead Research Coordinator); Mark Goldberg, MD (Current PI); Julian Yang, MD (Study Author and Former PI); Linda Hynan, PhD (Statistician)

NAS-Care is based on the pilot study, Quality Care Improvement with Nursing-driven Acute Stroke CARe (QCI-NASCAR, which was originally conducted at UT Southwestern Medical Center’s St. Paul University Hospital in 2013.  The study has expanded to Lone Star Stroke (LSS) Partner Institution hospitals that utilize telestroke technologies to reach underserved stroke patients from rural areas.

The QCI-NASCAR project, performed at St.Paul University Hospital, was so-called after protocol author, Dr. Julian Yang asked, “If a pit crew can change a stock car in 13 seconds, why can’t we run a stroke code in under an hour?”  He hypothesized that hospitals should be able to speed-up the process by getting all hands on deck for patients needing immediate care while brain tissue is dying. To test this hypothesis, a “pit stop” workflow model was implemented and nurses were placed in the driver’s seat. Ultimately, the nurse-driven protocol for telestroke encounters resulted in lower door-to-CT scanner times and increased workflow consistency.

For more background, see the QCI-NASCAR scientific poster, presented at the International Stroke Conference in February 2015.

Momentum builds for faster nurse-driven stroke code

The Lone Star Stroke NAS-Care study, led by principal investigator, Mark Goldberg, MD, is building on QCI-NASCAR’s momentum with a multi-institutional trial. The trial aims to answer questions such as “Can a nurse-driven protocol significantly and reproducibly lower stroke code metrics for telestroke encounters to national guideline parameters?” and ” Will the protocol and tools developed previously scale to help bring more stroke patients from the front door to the CT scanner and back for tPA treatments as quickly as possible?”

Three phase investigation

Phase 1: Blind spot data gathering

The trial is made up of three phases. In the first, the LSS NAS-Care research team will gather data from medical charts for three months. In this behind-the-scenes phase, everyone at the partner institution will be blinded to the study, with the exception of the stroke coordinator and a few key people in administration.

Phase 2: Driver’s Education

In the second study phase, blinders will come off and nurses will be asked to take the wheel. Michelle Provencher, RN, BSN, MS, an emergency room nurse and lead research coordinator for the NAS-Care study, revised the run sheet used in the QCI-NASCAR pilot study. The run sheet is a checklist used to guide nurses through the telestroke encounter. Since the first version used in the original QCI-NASCAR study, the run sheet has been enhanced based on extensive nurse feedback.

The sheets are introduced to nurses at NAS-Care study sites in a two-fold education plan. First, the nurses are asked to watch the NAS-Care “Time is Brain: Racing to the Finish” lecture video.

Lead Study Coordinator Michelle Provencher (far right), trains nurses at Good Shepard Medical Center.

Lead Study Coordinator, Michelle Provencher (far right), trains nurses at Good Shepard Medical Center in Marshall, TX.

Second, nurses train with on-site mock codes and learn how to use the run sheets. They practice using the sheets from top to bottom, beginning with the nurse’s decision between two options; to send a patient directly to CT, or to a hospital room for stabilization. Good Shepherd Medical Center in Marshall, TX, was the first to complete both training steps in June 2015. Their lecture and mock-code training session were filmed, and will be shared with future research teams and for new staff orientation.

Phase 3: Taking the wheel

In the third NAS-Care study phase, researchers collect data for six additional months. At this point, the hospital care team is aware they’re being monitored by researchers as they use the run sheets during telestroke encounters. Researchers will be watching to determine if nurses are running stroke codes more efficiently in the last three months of the six-month intervention phase than they did during the first three months.

Would the nurses welcome more charting?

“What I think is really interesting is not knowing what type of reaction we’d get from the nurses,” said Provencher.

As it turns out, nurses at Good Shepherd were enthusiastic about the run sheet. One nurse said, “This is really going to help! I can just glance at it and I know what needs to be done with the patient.” In fact, they soon began using the first page of the sheet as part of their medical record.

Part of the reason for establishing LSS was to introduce research and technology to rural areas that may never have been exposed to it otherwise. With the NAS-Care study, this goal is being realized and clinicians are proud to take part.

The nurses’ reactions to the research study itself have also been rewarding.

“They were excited to participate in research because they’d never worked anywhere that offered it,” said Provencher.

It’s never been done before

Until now, no one has studied how the acute stroke process differs in an environment where a stroke patient is seen through a virtual visit rather than in-person by an on-site neurologist. For many sites involved, NAS-Care will be the nurses’ first opportunity to participate in clinical research.