Education to improve stroke awareness and emergent response.

Introduction

Stroke is a leading cause of death and disability in the United States. It effects three million persons living with stroke, and touches one of every four families. Stroke costs 30 billion dollars annually in health care costs,[9] lost income and productivity, and countless

other personal losses and family impact.[7] Although this disease is so devastating and the impact is so widespread, the attitude of the general population and the health care community has been nihilistic. in the National Institutes of Neurological Diseases and Stroke (NINDS) rt-PA Stroke Trial, only 5% of the population sought medical treatment for stroke in under three hours.[13] Treating centers required system alterations and staff education before treatment could be provided in less than three hours. This article reviews reasons for delays in treatment and offers approaches to stroke education which may facilitate early diagnosis and intervention.

Reasons for Treatment Delays

Historically, there has been no treatment available for ischemic stroke other than stabilization and prevention of further stroke and secondary complications. This led to a "wait and watch" attitude by medical personnel. The stroke patient was often triaged for care after "more emergent" patients were evaluated and treated. For example, a patient with an abdominal stab wound (less than 5% mortality)[12] might be rushed in for treatment, while a stroke patient (20% mortality) would wait for care. Recombinant tissue plasminogen activator (rt-PA) is now available as the first treatment option for acute ischemic stroke. The NINDS t-PA Stroke Trial demonstrated that patients treated with rt-PA were 30% more likely to have little or no disability at three months following treatment.[11] The Food and Drug Administration (FDA) has now approved the use of rt-PA for stroke within three hours of symptom onset.

While there are many reasons a patient may delay seeking treatment, at least three reasons can be identified related to deficient information about stroke.[4] These are:

* symptoms aren't recognized

* the patient/family think the symptoms will go away

* the patient/family think that nothing can be done or it is not an emergency.

Large national surveys of the general public and also stroke survivors support the finding of a lack of adequate stroke information in these two groups.[1,5] In one study, just over 50% of patients seeking medical care recognized that they were having a stroke. In 39%, it took a witness or bystander to recognize the stroke. In the remainder of patients, the healthcare provider was the first to recognize the stroke.[2] In another study of stroke admissions in three emergency departments within varied geographic locations, the mean time to physician contact was 13.4 [+ or -] 2.3 hours, and only 8% of patients were previously educated about stroke.[6] Lack of patient recognition of and response to symptoms are key factors in treatment delay.

Other critical factors which impact acute intervention are response times of Emergency Medical Systems (EMSs) and Emergency Departments (EDs).[3,8] When a 911 operator gets an emergency call, the operator is responsible to prioritize the call and dispatch a transport team to the scene. The transport team must recognize the impact of the problem and take appropriate action. Delays in transport could result in time wasted between the symptom onset and the treatment initiation. In the NINDS rt-PA Stroke Trial, personnel interacting with EMS systems noted that protocols prioritized persons exhibiting stroke symptoms later than persons having cardiac symptoms.

In the ED, triage personnel determine the initial priority of treatment. In these settings, persons with stroke symptoms were often identified as lower priorities than other medical emergencies. Delays occurred in obtaining necessary lab specimens, computed tomography (CT) scans and rapid assessments by physicians.

These facts imply that education is fundamentally necessary to improve recognition of symptoms and emergent response. People should be aware that treatment is increasingly available within three hours of symptom onset. Increased awareness of the emergent nature of stroke and knowledge of treatment should prompt many more persons to seek medical attention sooner, and medical teams to respond faster. In effect, many more patients would be eligible for treatment.

Education efforts to reduce risk compliment information on recognition of stroke and emergent action, because many of the risk factors for stroke are controllable (Table 1). Information on stroke risk, symptoms and treatment should be provided to those likely to experience stroke, the general public and the emergency and medical communities who may witness and intervene when stroke occurs.

Table 1. Risk Factors for Stroke

Hypertension (treated or untreated)
Age (increases with age after 55)
Race (African American greater than Caucasian)
Gender (male greater than female)
Previous stroke or transient ischemic attack
Cardiac Disease
Diabetes
Smoking
Sedentary lifestyle
Hypercholesterolemia

Approaches to Stroke Education

In the NINDS rt-PA trial, a recruitment coordinator was responsible for stroke education at every study center. Although the role of a recruitment coordinator is not new to clinical trials, the stringent treatment time factor (within 3 hours after onset) limited the usefulness of traditional methods of recruitment, and posed a challenge. The potential audience for screening was extremely broad - any adult who could have a stroke. The goal of the educators was to "encourage early presentation to the emergency department following the onset of stroke."[10]

Although the methods used were individualized from center to center, strategies focused on:

* promotion of recognition of stroke onset, emergency response and risk factor reduction

* outreach to a wide range of audiences of all educational and economic levels

* development of cost-effective, broad-based educational opportunities throughout the community and more remote referral areas, using a variety of media and methods

* maximization of available resources to obtain these goals

A comprehensive community needs assessment was the first step in preparation for a community education program. Coordinators investigated unique characteristics of their communities and developed strategies for reaching target populations. In some communities the focus was mainly with the EMS or ED staff. For example, one coordinator spent much time in the triage area of the ED, screening patients and providing individual instruction to both the ED personnel and the EMS. Strategy development and modification was an ongoing process. Personnel identified and implemented timesaving processes. For example, study paperwork and equipment were prepackaged and made accessible so that time was not wasted searching for needed supplies. Tasks were prioritized so that only necessary functions were initiated before the patient was taken to the CT scan to avoid delays.

In some centers, patient education was a priority because patients waited a significant amount of time before seeking treatment. Coordinators provided community information through distributing educational reading materials, lectures and presentations at health fairs and screenings, work site wellness programs, senior centers, churches, community organizations, neighborhood special events and other gatherings of people at risk for stroke.

Educational offerings through television, radio, newspapers, bulletin boards and other printed media were developed and distributed whenever possible. The use of a local or national celebrity to help champion the cause was beneficial toward attracting attention to programs. The information conveyed to public audiences was simple and consistent: "the warning signs of stroke are..." or "stroke is an emergency, call 911."

The medical community received information regarding the emergent nature of stroke and the critical time to treatment factor. Symptom recognition and rt-PA therapy were reviewed to underscore the availability of treatment for patients that met the protocol criteria.[11]

Professional correspondence, letters and presentations at professional meetings provided a forum for distribution of information. When possible, continuing medical education (CME) credits or continuing educational units (CEUs) were offered to the medical community.

Outcomes

There were no standardized approaches to evaluate quality and effectiveness of education efforts at the eight study centers. Anecdotal observations suggest a trend toward improved awareness. At the onset of the education process, information on stroke was often absent or limited to "after your stroke" advice for the lay public. in most cases, medical personnel were in need of education about stroke assessment and management, and were receptive and often enthusiastic toward educational offerings.

Overall, study recruitment for the NINDS rt-PA Stroke Trial exceeded expectations. Patients were recruited more quickly than anticipated, and as time went on, more people could recognize the basic stroke symptoms or knew of the trial. Health care providers were more likely to respond rapidly after participating in training sessions. Patient recruitment would increase following training sessions. Trained ED and EMS personnel would inquire to the stroke teams about outcomes of patients that they had transported or triaged. This may in part be due to the educational approaches used. Education programs required repeated sessions to reinforce the principles, and,to reach new contacts.

Lay awareness improved as more programs were developed within the community. At one study site, an informal telephone survey was conducted, which verified an increased awareness in their target area. Subjective assessments from education coordinators identified an overall lack of stroke awareness upon contact with the target audiences. However, this lack of awareness showed signs of diminishing. Inquiries from the public about rt-PA treatment were noted at all centers. Patients had picked up the descriptive term "brain attack" for stroke, and were using it to describe what happened to them. Audiences demonstrated learning of information presented through appropriate questions and comments. They also verbalized confidence that they had learned helpful information from educational sessions.

In many cases, the 911 stroke response and triage protocols were changed to move stroke calls to top priority in triage and transport, similar to policies used with myocardial infarction. Personnel were encouraged to review their policies and eliminate actions which would prevent delays in transport.

More evaluation is needed to determine which methods are most effective in influencing the various target populations to achieve the desired responses. Benefits from broad-based educational efforts were not fully realized by the end of the trial. Outcomes of educational efforts could be assessed by tracking changes in trends related to the prevalence and natural history of stroke and related risk factors, as well as increased hyperacute response to stroke warning signs.

Summary

We have learned important lessons in developing stroke education programs. We utilized strategies and models successful in application to other chronic illnesses. While the programs developed at the eight NINDS rt-PA stroke trial centers provide a sample, further exploration and refinement in the stroke education process is needed. Recently, a national approach to stroke education has been put forward by health promotion agencies such as the National Stroke Association, the American Heart Association, and the National Institutes of Health. These organizations have recognized the need for increased public stroke awareness now that promising treatments are available. With rt-PA treatment, 30% more people responding in time could result in 12,000 additional patients treated. The need is great. The message must be simple. "Stroke is an emergency. Time is brain."

References:

[1.] American Heart Association, 1995.

[2.] Barsan WG, Brott TG, Olinger CP et al: Identification and entry of the patient with acute cerebral ischemia. Ann Emerg Med 1988; 17:1192-1195.

[3.] Bratina P, Greenberg L, Pasteur W, Grotta JC: Current emergency department management of stroke in Houston, Texas. Stroke 1995; 26:409-414.

[4.] Brott TG: 7he Case for ASAP. Through the Literature. National Stroke Association, 1994.

[5.] Dupont/NSA Survey of Stroke Awareness in America. National Stroke Association, 1989.

[6.] Feldmann E, Gordon N, Brooks JM et al: Factors associated with early presentation of acute stroke. Stroke 1993; 24:1805-1810.

[7.] Heart and Stroke Facts: 1996 Statistical Supplement. American Heart Association, 1996.

[8.] Lyden PD, Rapp K, Babcock T, Rothrock J: Ultra-rapid identification, triage and enrollment of stroke patients into clinical trials. J Stroke Cerebrovasc Dis 1994; 4:106-113.

[9.] Matcher DB, Duncan PW: Stroke. Clinical Updates 1994; 3.9.

[10.] The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: The NINDS t-PA Stroke Dial Manual of Procedures.

[11.] The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581-1587.

[12.] Unpublished data, University of Cincinnati, reported in National Stroke Association Community Presentation Guide.

Sheila Daley, Janet Braimah, Sharion Sailor, Gail L. Kongable, Carol Barch, Karen Rapp, Patti Bratina, Judith Spilker, Rosario Donnarumma and the NINDS rt-PA Stroke Study Group

Questions or comments about this article may be directed to: Sheila Daley RN, BSN, Coordinator, Stroke Education Program (STEP), K-11 Neurology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, Michigan 48202.