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The National Institutes of Health Stroke Scale (NIHSS) is accepted as the definitive clinical examination to assess stroke severity. This project examined barriers to implementation and NIHSS use by registered nurses on a stroke/neurovascular Unit. Staff members were surveyed to determine nurse-perceived barriers to the routine use of the NIHSS. Su...
Contexts in source publication
Context 1
... patients (Goldstein, Bertels, & Davis, 1989;Lyden et al., 1999). It was designed by a group of stroke research neurologists to document the severity of neurologic deficits in acute stroke patients (Brott et al., 1989). It consists of 11 elements that reflect the wakeful- ness, vision, and motor, sensory, and language function of stroke patients (Fig. ...
Context 2
... the onset, the CNS and a staff nurse discussed potential barriers to NIHSS implementation on the unit but were not clear as to where problems existed. They created a survey with items relating to opinions and beliefs regarding use of the NIHSS, based on oral feedback and information from published literature (Tables 1-3). Interventions could be formulated to address concerns that the survey revealed. ...
Context 3
... quality of inpatient care for stroke patients is a matter of national importance. More than 700,000 people in the United States experience a stroke every year, and as many as 30% are permanently disabled. In 2005 the projected direct and indirect costs of stroke in the United States were $56.8 billion (American Heart Association, 2005). Interventions aimed at improv- ing assessment and outcome of acute stroke could positively affect physical, psychological, and financial healthcare measures. To standardize and optimize stroke patient care, some hospitals have established inpatient stroke units. These geographically defined units are staffed by physicians, nurses, and rehabilitation personnel skilled in the care of stroke patients. Several studies have demonstrated the effectiveness of stroke units in decreasing mortality and morbidity from stroke; the positive effects may persist for years (Alberts et al., 2000; Cavallini, Micieli, Marcheselli, & Quaglini, 2003). A comprehensive approach to patient care is created when staff members working within a stroke unit consistently and routinely use a validated and standardized tool for neurologic assessment in combina- tion with recognized treatment and management guide- lines (Criddle, Bonnono, & Fischer, 2003). Routine use of such a tool can improve medical documentation and internal communication between healthcare providers. Additionally, use of a standardized tool for initial neuro- logical assessment and the periodic monitoring of neuro- logical status provides a measure by which to analyze the delivery and quality of care (Spilker & Kongable, 2000). This article addresses the value of using a standardized neurological assessment tool in the care of stroke patients and the integration of such a tool into the practice of reg- istered nurses staffing a stroke/neurovascular unit. Thorough neurological assessment of patients experienc- ing acute stroke is critical for accurate diagnosis, treat- ment, and care throughout hospitalization. Published guidelines for the early management of patients with ischemic stroke (Adams et al., 2003) detail the goals asso- ciated with early care, including observation for changes in patient condition that might prompt initiation of medi- cal or surgical interventions and facilitation of measures aimed at improving outcome after stroke. Consistent use of a standardized assessment tool designed for stroke patients assists in the achievement of these goals. The National Institutes of Health Stroke Scale (NIHSS) is a well-validated, reliable scoring system for use spe- cifically with stroke patients (Goldstein, Bertels, & Davis, 1989; Lyden et al., 1999). It was designed by a group of stroke research neurologists to document the severity of neurologic deficits in acute stroke patients (Brott et al., 1989). It consists of 11 elements that reflect the wakeful- ness, vision, and motor, sensory, and language function of stroke patients (Fig. 1). The initial neurological examination of the acute stroke patient establishes the baseline stroke sever- ity and can help identify individuals at greatest risk for hemorrhagic complications after thrombolytic therapy. Scores ≥20 have been associated with symptomatic intra- cerebral hemorrhage (NINDS t-PA Stroke Study Group, 1997). NIHSS scores have been shown to strongly predict outcome after stroke and therefore can help guide deci- sions related to aggressiveness of care and disposition (Adams et al., 1999; Schlegel et al., 2003; Weimar, Konig, Kraywinkel, Ziegler, & Diener, 2004). After the initial assessment and determination of acute treatment, the focus of assessment shifts to moni- toring for neurological change or deterioration. The condition of approximately 25% of patients worsens during the first 24–48 hours after stroke (Adams et al., 2003), although neurological decompensation can occur later as well. Stroke-related neurological changes can occur rapidly, and often they result in irreversible brain damage. It is therefore important to have a comprehen- sive neurological assessment tool that objectively tracks changes and provides a standardized means for clear communication among caregivers. The NIHSS provides a numerical value for comparison from one time period to the next (Lyden et al., 1999). During a stroke patient’s hospitalization, the NIHSS can also be used to help identify clinical findings that might put the patient at risk for complications. For instance, dysarthria and facial weakness can indicate that the patient may have difficulty swallowing. Identifi- cation of motor weakness and ataxia can alert the staff to fall risk (Spilker et al., 1997). Despite evidence that the NIHSS is valid and reli- able, there has been reluctance to adopt it within clinical settings. Some users believe that scale completion is too time consuming when compared to standard neu- rological assessments (Lai, Duncan, & Keighley, 1998). Other detractors perceive a lack of interrater reliability in scoring on certain questions, particularly the ques- tions for ataxia and dysarthria assessment (Lyden, Lu, Levine, Brott, & Broderick, 2001). Others cite a “hemi- spheric bias” within the NIHSS, because 7 of the points are directly related to measurement of language (a left- hemisphere function) and only 2 points are related to neglect (a right-hemisphere phenomenon). Hence, the NIHSS may underestimate stroke severity in the right hemisphere (Woo et al., 1999). In addition, although many components of the NIHSS are part of a standard neurological assessment, training is required for reliable use of the tool (Andre, 2002). Although there are some limitations to use of the NIHSS, studies have demonstrated that it can reliably measure stroke severity. The interrater variability of users decreases with the use of videotaped training and certification (Criddle et al., 2003; Meyer, Hemmen, Jack- son, & Lyden, 2002). The NIHSS becomes easier and less time consuming to administer as it is made a standard part of nursing practice and provides a language health- care providers can use to communicate stroke severity (Criddle et al., 2003). When compared with other stroke scales (e.g., the Scandinavian, Mathew, and Orgogozo scales), the NIHSS was the most sensitive in detecting changes in stroke signs (Bessenyei, Fekete, Csiba, & Bereczki, 2001). Nurses on the stroke/neurovascular unit at Providence St. Vincent Medical Center (PSVMC) in Portland, OR, care for approximately 500 stroke patients per year. Nursing staff members used the standard neurological assessment tool portion of the graphics flow sheet to record patient neuro- logical status. They assessed level of consciousness, pupils, extraocular eye movements, and sensorimotor function. During the first quarter of 2003, the NIHSS was presented to unit staff nurses by the nurse manager as a tool for com- prehensive and concise neurological assessment of stroke patients and for clear and objective communication between healthcare professionals. Implementation of the NIHSS tool was discussed at a staff meeting, and staff members indi- cated by a show of hands that they were interested in using the NIHSS for patient assessment. A plan was created to use the tool to assess both ischemic and hemorrhagic stroke and transient ischemic attack (TIA) patients on admission, upon any significant neurological change, and on discharge. The NIHSS was already in use in the PSVMC Emergency Department, but only for patients who might be candidates for acute treatment with intravenous thrombolytics or enrollment in investigational protocols. Education on the NIHSS was provided to the nurses in various forms: in-service sessions on the pathophysiology and neuroassessment of stroke by the unit’s neuroscience clinical nurse specialist (CNS), viewing of a nationally rec- ognized videotape of a certified neurologist administering the NIHSS (Stroke Group, 1998), and real-time ...
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Citations
... These included baseline assessments of selfreported gender, age, race/ethnicity, partner status, pre-existing PTSS (Weathers et al., 1993; only individuals who self-reported a prior trauma, via the Life Events Checklist [Gray et al., 2004], had non-zero symptoms scores), and pre-existing depression (Kroenke et al., 2009). Stroke severity was assessed by patients' medical providers using the 11-item NIHSS, a clinical tool used to evaluate neurological status (Richardson et al., 2006). ...
Objective
Partners can be beneficial for patients experiencing stressful health events such as a stroke/TIA. During such events, however, partners may exacerbate early distress. The present study tested whether having a cohabiting partner modified the association between patients’ early perceptions of threat (e.g., feeling vulnerable, helpless) and longer-term posttraumatic stress symptoms (PTSS).
Methods
Participants (N = 328) were drawn from an observational cohort study of patients evaluated for stroke/TIA at an urban academic hospital between 2016-2019. Participants self-reported emergency department (ED) threat perceptions and PTSS secondary to the stroke/transient ischemic attack at three days and one-month post-event.
Results
Cohabiting partner status modified the association of ED threat with early PTSS. Patients with a cohabiting partner exhibited a positive association between ED threat and early PTSS, B = 0.12, p < .001; those without a cohabiting partner did not, B = 0.04, p = .067. A cohabiting partner was protective only for patients who initially reported low levels of ED threat, as patients with a cohabiting partner who reported low levels of ED threat also had lower early PTSS, B = -0.15, p = .016; at high levels of ED threat, a cohabiting partner was not protective, B = -0.02, 95% CI [-0.14, 0.09], p = .68. ED threat was associated with PTSS at one month, B = 0.42, p < .001, but cohabiting partner status did not modify the association.
Conclusions
ED threat perceptions were positively associated with early PTSS only for patients with a cohabitating partner. For patients who do not initially experience a stroke/TIA event as threatening, cohabiting partners may help patients maintain psychological equanimity.
... The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome [4]. However, a criticism of the NIHSS relates to its validity in certain non-dominant-hemisphere stroke syndromes. ...
Background and purpose
The National Institutes of Health Stroke Scale (NIHSS) has been found to be biased toward the left hemispheric and motoric functions providing minimal assessment to the right hemispheric language and cognitive functions. The need to complement the role of the NIHSS is necessary in accurate and rapid assessment of AIS patients and better management. We hypothesized that combining the NIHSS with a quantitative analysis of Spoken Picture Description scale of Comprehensive Aphasia Test (SPD-CAT) could provide valuable data regarding side, site, and size of stroke.
Subjects and methods
Eighty-six AIS patients presented within 48 h of onset of stroke were enrolled from Stroke Units of Ain-Shams University Hospitals (ASUHS). Clinical Assessment with NIHSS and SPD-CAT were correlated with the radiological MRI Brain lesions of stroke regarding (site, side, size/volume and lesion volume percent to the whole brain volume “LV% WBV”).
Results
Total and subscale scores of NIHSS and SPD-CAT have a highly statistically significant correlation with the ischemic “LV% WBV.” Quantitative analysis (content units) of SPD-CAT may help in prediction of the lobar site of the stroke with higher significance in the tempro-parietal and brainstem regions. Right hemispheric strokes have clinically and statistically significant scores on SPD-CAT in comparison to NIHSS scores. Also, the left to right ratio of content units of information carrying words (ICWs) in SPD-CAT gives a significant difference between right and left hemispheric strokes. Recording and analysis time of SPD-CAT makes it easy and rapidly applicable in emergency room (ER) and stroke units.
Conclusion
Combining the quantitative analysis of NIHSS and SPD-CAT can better predict the side, size, and site of AIS within reasonable time table and without urgent MRI for AIS assessment and management.
... Stroke was diagnosed according to the definition given by Sacco et al. (20), that is, either with direct evidence from neuroimaging or clinical stroke lasting >24 h. In addition to the Trial of Org 10,172 in Acute Stroke Treatment (TOAST) classification (21), modified Rankin scale (mRS) (22), and National Institutes of Health Stroke Scale (NIHSS) (23,24), stroke was differentiated into ischemic and hemorrhagic and according to localization of the stroke. Dysphagia diagnoses were carried out in a two-step procedure. ...
Stroke-associated pneumonia is a major cause for poor outcomes in the post-acute phase after stroke. Several studies have suggested potential links between neglected oral health and pneumonia. Therefore, the aim of this prospective observational study was to investigate oral health and microbiota and incidence of pneumonia in patients consecutively admitted to a stroke unit with stroke-like symptoms. This study involved three investigation timepoints. The baseline investigation (within 24 h of admission) involved collection of demographic, neurological, and immunological data; dental examinations; and microbiological sampling (saliva and subgingival plaque). Further investigation timepoints at 48 or 120 h after baseline included collection of immunological data and microbiological sampling. Microbiological samples were analyzed by culture technique and by 16S rRNA amplicon sequencing. From the 99 patients included in this study, 57 were diagnosed with stroke and 42 were so-called stroke mimics. From 57 stroke patients, 8 (14%) developed pneumonia. Stroke-associated pneumonia was significantly associated with higher age, dysphagia, greater stroke severity, embolectomy, nasogastric tubes, and higher baseline C-reactive protein (CRP). There were trends toward higher incidence of pneumonia in patients with more missing teeth and worse oral hygiene. Microbiological analyses showed no relevant differences regarding microbial composition between the groups. However, there was a significant ecological shift over time in the pneumonia patients, probably due to antibiotic treatment. This prospective observational study investigating associations between neglected oral health and incidence of SAP encourages investigations in larger patient cohorts and implementation of oral hygiene programs in stroke units that may help reducing the incidence of stroke-associated pneumonia.
... 49,50 These weaknesses may explain the alarmingly low NIHSS completion rates (12-28%) in acute stroke settings. 51,52 Overall, the assessment validity and prognostic value of performing a neurological examination in isolation has been challenged by the view that other assessment methods and measures be included, 53 like concurrent physiological observations such as EEG. 54 ...
Background: Early and objective prediction of functional outcome after stroke is an important issue in rehabilitation. Electroencephalography (EEG) has long been utilized to describe and monitor brain function following neuro-trauma, and technological advances have improved usability in the acute setting. However, skepticism persists whether EEG can provide the same prognostic value as neurological examination.
Objective: The current cohort study examined the relationship between acute single-channel EEG and functional outcomes after stroke.
Methods: Resting-state EEG recorded at a single left pre-frontal EEG channel (FP1) was obtained from 16 adults within 72 h of first stroke. At 30 and 90 days, measures of disability (modified Rankin Scale; mRS) and involvement in daily activities (modified Barthel Index; mBI) were obtained. Acute EEG measures were correlated with functional outcomes and compared to an early neurological examination of stroke severity using the National Institute of Health Stroke Scale (NIHSS). Classification of good outcomes (mRS ≤1 or mBI ≥95) was also examined using Receiver Operator Curve analyses.
Results: One-third to one-half of participants experienced incomplete post-stroke recovery, depending on the time point and measure. Functional outcomes correlated with acute theta values (rs 0.45–0.60), with the strength of associations equivalent to previously reported values obtained from conventional multi-channel systems. Acute theta values ≥0.25 were associated with good outcomes, with positive (67-83%) and negative predictive values (70-90%) comparable to those obtained using the NIHSS.
Conclusions: Acute, single-channel EEG can provide unique, non-overlapping clinical information, which may facilitate objective prediction of functional outcome after stroke.
... The National Institute of Health Stroke Scale was developed out of a need to standardize neurological assessments of the complex stroke patient. 20,21 Clinical practice standards helped to optimize the stroke process as part of the pathway to disease-specific certification. 22Y25 The Colorado Stroke Alliance task forces published their work on optimizing stroke care systems, emphasizing a standardized approach, which led to significant improvement in overall stroke quality 23 As neuroscience nurses were adopting new practices of neurological evaluation using structured processes for assessment with the National Institute of Health Stroke Scale tool to meet the needs of complex patients and advancing technology, the need for a more sophisticated level of specialized nursing education and national certification became evident. ...
Over the past 50 years, the Journal of Neuroscience Nursing (JNN) has grown from a neurosurgical focus to the broader neuroscience focus alongside the professional nursing organization that it supports. Stroke care in JNN focused on the surgical treatment and nursing care for cranial treatment of conditions such as cerebral aneurysm, carotid disease, arteriovenous malformation, and artery bypass procedures. As medical science has grown and new medications and treatment modalities have been successfully trialed, JNN has brought to its readership this information about recombinant tissue plasminogen activator, endovascular trials, and new assessment tools such as the National Institute of Health Stroke Scale. JNN is on the forefront of publishing nursing research in the areas of stroke caregiver needs and community education for rapid treatment of stroke and stroke risk reduction. The journal has been timely and informative in keeping neuroscience nurses on the forefront of the changing world of stroke nursing.
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Acute ischemic stroke is inadequately treated in the USA and worldwide due to a lengthy history of neuroprotective drug failures in clinical trials. The majority of victims must endure life-long disabilities that not only affect their livelihood, but also have an enormous societal economic impact. The rapid development of a neuroprotective or cytoprotective compound would allow future stroke victims to receive a treatment to reduce disabilities and further promote recovery of function. This opinion article reviews in detail the enormous costs associated with developing a small molecule to treat stroke, as well as providing a timely overview of the cell-death time-course and relationship to the ischemic cascade. Distinct temporal patterns of cell-death of neurovascular unit components provide opportunities to intervene and optimize new cytoprotective strategies. However, adequate research funding is mandatory to allow stroke researchers to develop and test their novel therapeutic approach to treat stroke victims.
... used by health professionals with various levels of training. 103,104 Some literature suggests that the NIHSS is weighted more toward language deficits, hence giving higher scores to left compared with right hemispheric ischemic strokes with equivalent volumes of infarct. 105 Although the NIHSS was developed by the investigators of the original 2 NINDS alteplase trials, the exclusion criteria for minor stroke were not based purely on the NIHSS. ...
Purpose:
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods:
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results:
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
... Richardson et al. [37] argued that consistent and routine use of validated and standardized tools for neurological and functional assessment of stroke survivors in conduction with well established treatments and management guidelines complement effective patient care. Thus, routine use of stroke scales can improve medical documentation and internal communication between health care professionals. ...
Introduction: Stroke recovery is a major issue of concern for the surviving patient and family but its rate varies from person to person. Existing prognostic models for stroke recovery are commonly based on stroke level of neurological deficit on admission. Aim: The aim of this discussion paper was to review stroke progression and analyse the trajectory of stroke recovery. It also addressed the value of using standardized neurological assessment tools in routine stroke care and the integration of easy to use assessment tools into everyday nursing practice. Methods: Medline and Google Scholar databases were searched using combinations of the following keywords: scale, stroke, rehabilitation and nursing from 2000 onwards. Results: Popular scales used in stroke practice and research, including attempts to evaluate patient progress after stroke can be divided as follows: i) Neurological deficit scales ii) Functional outcome iii) Global outcome scales iv) Health related quality-of-life scales. The assessment tools for discussion in this paper are the Scandinavian Stroke Scale (SSS) the Barthel Index of daily living (BI) and the modified Rankin Scale (mRS). All three measures are well established in the international literature as reliable and valid of stroke outcomes and have been used in numerous large scale studies. Due to the diversity of available outcome measures for acute stroke choosing one tool is challenging and using more than one scale implies that the scales are imperfect. Yet, consistent and routine use of validated and standardized tools for neurological and functional assessment of stroke survivors in conduction with well established treatments and management guidelines complement effective patient care. Conclusions: This paper argues that despite barriers to routine use of stroke scales as reported by some nursing staff, particular efforts should be made in nurse training to introduce and demonstrate the importance of stroke scales. Their use not only provides a reliable record of progress but also contributes to optimum patient care and outcomes. © 2015, Technological Educational Institute of Athens. All rights reserved.
... Pocket cards appeared to be a popular method of learning and reinforcing the practice change. This is consistent with previous literature demonstrating the effectiveness of pocket cards as part of educational strategies for implementation of new clinical practices and to improve health care provider knowledge (Blanco et al. 2005;Richardson et al. 2006;Mikhael et al. 2008). Pocket cards are inexpensive, easily implemented and readily available educational tools. ...
Successful implementation of practice change requires educational tools that engage and motivate clinicians.
To examine clinician usage and preference for different educational tools when a multifaceted strategy was used for implementation of new recommendations for managing newborns at risk of sepsis.
Seminars, web-based tutorial, handouts, pocket cards and web-based management algorithm were used to educate health professionals. Ninety-two clinicians attended seminars and completed feedback questionnaires that included three questions assessing knowledge of the recommendations. After 3 months, an electronic survey containing the same questions was sent to 41 key stakeholders (staff neonatologists, trainee physicians, nurse practitioners and respiratory therapists) who provided patient care during the implementation period. Compliance with recommendations was assessed by chart audit.
Seminar content was helpful to 97% of participants and 88% were comfortable using the recommendations. Response rate for the 3-month survey was 80%. The most frequently used and useful tools were pocket cards (76%) and seminars (76%); 79% continued to use the card. Only one respondent used the web tutorial and four used the algorithm. There was no significant difference in percent correct responses to the questions between the two timepoints (p > 0.05). Compliance with the recommendations was 83%.
When provided with different educational tools, clinicians prefer pocket cards and seminars - tools that are simple and readily accessed.
... 27 Nurses in the Stroke Unit should have experience and expertise in performing serial neurological assessments using the National Institutes of Health Stroke Scale or a similar validated tool. 91 There should be a written protocol that details how changes in a patient's status are detected, how they are documented, and how medical staff are notified of such changes. 92 For example, a standard protocol might include vital signs every 1 to 2 hours for 24 hours after admission and neurological checks (using the National Institutes of Health Stroke Scale or similar assessments) every 2 to 4 hours. ...
The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience.
We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices.
Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures.
Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.
