|Year : 2019 | Volume
| Issue : 4 | Page : 121-126
Emergency nurses' knowledge about tissue plasminogen activator therapy and their perception about barriers for thrombolysis in acute stroke care
Priya Baby1, PR Srijithesh2, Jesna Ashraf3, Deiva Kannan1
1 College of Nursing, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
3 Clinical Nursing Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Submission||04-Apr-2019|
|Date of Decision||15-Sep-2019|
|Date of Acceptance||16-Dec-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Priya Baby
National Institute of Mental Health and Neurosciences, College of Nursing, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Thrombolytic therapy using tissue plasminogen activator (t-PA) has been proven to be a cost-effective means of treating acute stroke. However, several factors lead to the underutilization of this treatment. This study was undertaken to assess the knowledge of emergency nurses regarding t-PA therapy and to identify the barriers perceived by them in the utilization of thrombolysis in acute stroke.
Materials and Methods: A cross-sectional survey was conducted among 30 nurses working in the emergency department of a tertiary level public hospital in India. A self-administered questionnaire was used to assess their knowledge and perceived barriers.
Results: Against a total score of 26, the score of the sample ranged from 13 to 22 with a mean score of 17.9 ± 2.4. The mean accuracy rate of the questions was 68.6 ± 25.3. Three major categories of barriers were identified in the efficient utilization of thrombolytic therapy. These were patient-related barriers, organizational barriers, and behavioral barriers. “Unaffordability of t-PA therapy due to financial constraints” and “patients not reaching the facility in the window period” were the two topmost barriers for thrombolysis identified by the nurses.
Conclusion: Ongoing continuing nursing education is essential to fill the knowledge gap of nurses regarding thrombolysis. Sufficient measures need to be taken at prehospital, institutional, and personnel levels to mitigate the barriers for thrombolysis so that no eligible patients are left without the benefits of the treatment.
Keywords: Acute stroke, barrier, emergency department, knowledge, nurses, thrombolytic therapy
|How to cite this article:|
Baby P, Srijithesh P R, Ashraf J, Kannan D. Emergency nurses' knowledge about tissue plasminogen activator therapy and their perception about barriers for thrombolysis in acute stroke care. Int J Non-Commun Dis 2019;4:121-6
|How to cite this URL:|
Baby P, Srijithesh P R, Ashraf J, Kannan D. Emergency nurses' knowledge about tissue plasminogen activator therapy and their perception about barriers for thrombolysis in acute stroke care. Int J Non-Commun Dis [serial online] 2019 [cited 2021 Jun 19];4:121-6. Available from: https://www.ijncd.org/text.asp?2019/4/4/121/274459
| Introduction|| |
Stroke has emerged as an epidemic in the developing world, causing high mortality and morbidity. As the volume of world's population is concentrated more in the developing countries like India, the major brunt of stroke is borne by these countries. The preventive health-care services are not fully developed in these middle-income countries, adding to the severity of the problem. Stroke not only poses a huge burden on the medical care system but also disturbs the socioeconomic milieu of the country owing to the relatively younger age at which it strikes the population.
Majority of the acute stroke events are ischemic in nature. In the treatment of acute ischemic strokes, early thrombolytic therapy using tissue plasminogen activator (t-PA) is a potential treatment for improving long-term outcome., It is proven as a cost-effective way of reducing the mortality and disabilities associated with acute ischemic stroke. However, the use of thrombolytic therapy in developing countries is very low when compared to the developed nations. In India, only a very small number of eligible patients receive t-PA therapy. There are several factors which contribute to the underutilization of this treatment in acute stroke patients. Several hospital factors, including those related to nursing personnel, can cause preventable delays in thrombolytic therapy. This is particularly true due to the overstrained emergency care system in the public hospitals, where nurses play a critical role in identification, triaging, and initiation of t-PA therapy. A systematic review about the perceptions of health professionals regarding barriers and enablers of implementing contemporary stroke management, recommends studies from developing countries in this aspect. Hence, this study was undertaken to assess the knowledge of emergency nurses' about t-PA therapy and to identify the barriers perceived by them in the utilization of thrombolysis for acute stroke patients in the emergency department.
| Materials and Methods|| |
A cross-sectional survey was conducted among nurses working in the emergency department of a tertiary level public hospital in India. Written permission was sought from the head of nursing services of the hospital for conducting the survey. The survey included only nurses who voluntarily consented to participate. The departmental scientific review and ethics committee approved the study. The sampling technique used was purposive sampling. Nurses who were working in the emergency department during the study were included. The nurses who did not have a minimum of 1-year work experience in the emergency department were excluded from the study. Of the 36 nurses working in the emergency department of the hospital, 30 nurses were eligible to participate in the study, and hence, they were included. A written informed consent was obtained from the nurses who participated in the survey. Confidentiality and anonymity were ensured throughout. Data were collected in February 2018.
A self-administered questionnaire was used to assess the knowledge of various aspects of thrombolytic therapy. The American Heart Association/American Stroke Association guidelines were applied in the preparation of the questionnaire. The questionnaire was validated by four nurses and one neurologist who are experts in the field of stroke care. The panel of experts suggested modifications in the questionnaire and consensus was reached before finalizing the tool. The questionnaire had two main parts. The first part consisted of sociodemographic variables such as age, gender, years of experience, and educational qualification. Educational qualification was categorized into diploma, graduate, and postgraduate degrees. The second part of the questionnaire had two subsections. The first subsection was knowledge regarding t-PA, which included eight multiple-choice questions (MCQ). The questions were about the dosage of t-PA, window period, side effects, technology used for synthesis of t-PA, and status of approval of t-PA for clinical use. A score of one was given for correct response, and a score of zero was given when the response was wrong or when the question was left unanswered. The second part was knowledge regarding situations of concern for thrombolysis. It consisted of 18 clinical scenarios explaining a virtual patient's clinical condition. Of the 18 scenarios, 9 were situations where thrombolysis was either contraindicated or further probing into the patient condition and management was required before a decision regarding thrombolysis could be made. The other nine were situations in which thrombolysis could be done without any concerns. For every clinical scenario, nurses had to make a dichotomous response, i.e., whether the situation is of concern for thrombolysis or patient can be thrombolysed without concerns. For every correct response, nurses were given a score of one. If the response was wrong, a score of zero was given. When no response was made, it was considered as a wrong response and a score of zero was given.
The third part of the questionnaire consisted of a list of commonly identified barriers for thrombolysis. A list of six commonly identified barriers for thrombolysis was prepared by the researchers based on the literature review. The nurses were asked to rank them from most important to least important barrier based on their perception. They were also given the option to identify and rank any barrier which was not listed.
Descriptive and inferential statistics were used for analysis. All the demographic variables except “total years of experience” were normally distributed. Hence, mean and standard deviation (SD) was used to describe these variables. “Total years of experience” was described using interquartile range and median.
The mean and SD of the knowledge scores were used as measures of central tendency, as the data were normally distributed. Accuracy rates were calculated for each item in the knowledge questionnaire. The accuracy rate is the percentage of correct responses obtained for an item divided by the number of responses. The mean accuracy rate of “situations of concern for thrombolysis” and “situations of no concern for thrombolysis” were compared using independent samples t-test.
Pearson's correlation was used to find the correlation between knowledge score and age. Spearman's rho was used to find the correlation between knowledge score and total years of experience. The association between knowledge score and educational qualification was tested using ANOVA. Independent samples t-test was used to find the association between gender and total knowledge score.
Based on the ranking of barriers done by the nurses, mean rank for each barrier was calculated using the Friedman test. The barriers were then arranged in the ascending order of mean rank obtained. Thus, the perceived barriers of thrombolysis were ranked in the order of their importance.
| Results|| |
The sample characteristics are described in [Table 1]. The areas of MCQ and the accuracy rates for each question are shown in [Table 2]. The highest accuracy rate (100%) was for the question regarding the most important side effect of t-PA, and the lowest was for the question regarding the technology used for synthesis of t-PA (30%). The accuracy rate was low for questions related to window period.
|Table 2: Accuracy rate of questions regarding tissue plasminogen activator|
Click here to view
The clinical scenarios and the accuracy rate for each scenario are given in [Table 3]. The mean accuracy rate for the nine “situations of concern for thrombolysis” was 60.4 ± 28.7. The mean accuracy rate for the nine “situations of no concern for thrombolysis” was 83.7 ± 15.5. The accuracy rate was significantly lower for “situations of concern for thrombolysis” than “situations of no concern for thrombolysis” (P = 0.05).
|Table 3: Accuracy rate of questions regarding contraindications for thrombolysis|
Click here to view
Against a total score of 26, the knowledge score of the sample ranged from 13 to 22 with a mean score of 17.9 ± 2.4. The knowledge score was found to have a significant negative correlation with age (r = −0.41) (P = 0.02). The total years of clinical experience were found to have a negative correlation with knowledge scores, though it was not statistically significant (P = −0.21) (P = 0.24). There was no significant gender difference in the knowledge scores. There was a significant association between educational qualification of the nurses and their total knowledge score. The graduate and postgraduate nurses were found to have significantly higher knowledge scores than the diploma holders in a subgroup analysis [Figure 1].
|Figure 1: The association between total knowledge scores and educational qualification of nurses|
Click here to view
Nurses ranked the various barriers for thrombolysis in the order of their importance. A mean rank was obtained for each perceived barrier, and the barriers were arranged in the ascending order of the mean rank. Three major categories of barriers for thrombolysis were identified. These are patient-related barriers, organizational barriers, and behavioral barriers. Among these, the patient-related barriers occupied the top places in the ranking list. “Unaffordability of t-PA therapy due to financial constraints” and “patients not reaching the facility in the window period” were identified as the topmost barriers. The perceived barriers and their ranking are listed in [Table 4].
|Table 4: Ranking of the barriers as perceived by emergency nurses for thrombolysis in acute stroke|
Click here to view
| Discussion|| |
The findings of the study throw light into the specific areas of knowledge deficit of nurses regarding thrombolytic therapy. Limited knowledge was displayed in areas such as “what is considered window period” and “the importance of administering t-PA as early as possible even when it is within the window period.” More than half of the nurses gave wrong responses in these areas. For triaging patients in the emergency department and initiating t-PA therapy, the knowledge about window period and the concept of “time is brain” is imperative for the nurses. In a similar study conducted among various hospital staff, it was seen that knowledge about thrombolysis and window period is considerably low in them. Only 30% of the nurses knew that t-PA is prepared by genetic engineering technique. However, this knowledge about the drug can be helpful while counseling the patients and convincing them about the reason for a high cost of the drug. All the nurses were aware that bleeding is the most important side effect of thrombolytic therapy. Nurses showed lesser knowledge in identifying situations of concern for thrombolysis when compared to situations of no concern for thrombolysis. This is an important concern and a major area that requires education for the nurses since major errors can happen if screening for thrombolysis eligibility is inappropriate.
Graduate and postgraduate nurses were having significantly higher knowledge levels than the diploma holders. Another finding was that as the age increased, there was a significant drop in the knowledge scores. In our setting, the newly joined nurses are mostly graduates or postgraduates. Thus, the diploma nurses were elder when compared to their counterparts. This explains the observation that nurses with higher age were low on knowledge scores. However, this is a very critical thing to be addressed as experienced nurses are an asset to any emergency department, but inadequate knowledge can nullify their effects. Continuing nursing education, especially focusing on acute stroke care, is imperative to boost the knowledge levels of the nurses. Adequately equipped nurses can initiate workflows in acute stroke care which has proven to significantly reduce the door to needle time.
The most important barrier identified by the nurses for thrombolysis is the financial constraint of the patients to afford the cost of t-PA. The unaffordability of t-PA has been recognized as a major reason for reduced thrombolysis rates in public sector hospitals in developing countries. Public hospitals in India mostly cater to the health needs of the less privileged population. Hence, policies to reduce the burden of cost of thrombolysis can allow more eligible patients to receive the treatment. As acute stroke strikes unexpectedly, the patient's family may find it difficult to arrange for the huge cost required for the treatment. Thrombolytic therapy in acute stroke has proven to be cost-effective in terms of cost-saving generated by avoiding the huge cost of caring the disabled for years to decades., Taking into consideration the financial burden a stroke patient levies on the economy of the country, it is a considerable option to waive off the treatment cost for thrombolysis in acute stroke.
“Patients not reaching the hospital within window period” is another major barrier identified. This finding is supported by several studies. Poor recognition of stroke symptoms,, lack of knowledge about the availability of thrombolytic therapy, and improper health-seeking behaviors  are the reasons for delayed presentation. The first point of contact for the patient is usually a general physician who may fail to refer them to a facility with thrombolysis. In a study conducted in India, it was found that 66% of the acute stroke patients were not informed about the option of thrombolytic therapy by the initial medical contact. A systematic approach initiated in the community to spread awareness about acute stroke as a medical emergency is necessary. Moreover, the primary care providers should also be involved in the networking so that referrals to appropriate centers are made.
The most important in-hospital barrier identified by the nurses is the difficulty in fast-tracking acute stroke patients. Delay in getting computed tomography scan and laboratory test results significantly impact the eligibility rates for thrombolysis. Hospitals can ensure a fast-tracking route for acute stroke patients to reduce the door to needle delay. An efficient triage system as well as bypass protocols for imaging and laboratory can address the in-hospital delays.
Lack of caregiver support and their denial to give consent for thrombolysis is also a major factor perceived by the nurses, as cause for underutilization of thrombolysis. This mostly stems from the lack of knowledge about t-PA and fear of bleeding. Denial of treatment is usually seen in patients with milder strokes and who do not want to take the risk of bleeding. Even though our medical care system mostly follows a paternalistic model; appropriate counseling of the patients with a balance between principle of liberty and coercion is required to tackle this issue. The barriers perceived by the nurses in this study is similar to barriers for thrombolysis faced by eligible patients.
This study highlights the areas of knowledge lacunae about thrombolytic therapy among nurses. It also brings out the barriers for thrombolysis as perceived by nurses. However, the major limitation of the study is the small sample size. As this survey was conducted in a single hospital, the findings may not be generalizable. Hence, future study in a larger sample is recommended.
| Conclusion|| |
Thrombolytic therapy using t-PA is a cost-effective and viable treatment option available for acute ischemic stroke. Nurses working in the emergency department are the key personnel in triaging stroke patients and initiating thrombolytic therapy. It is highly suggested to have stroke specific continuing education programs in emergency departments. Several strategies including community education, concessional rates for thrombolysis, and fast-tracking protocols for acute stroke patients in the emergency department should be initiated to allow optimal utilization of thrombolysis.
We would like to thank all the nursing officers of the emergency department who participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Feigin VL. Stroke epidemiology in the developing world. Lancet 2005;365:2160-1.
Wasay M, Khatri IA, Kaul S. Stroke in South Asian countries. Nat Rev Neurol 2014;10:135-43.
Durai Pandian J, Padma V, Vijaya P, Sylaja PN, Murthy JM. Stroke and thrombolysis in developing countries. Int J Stroke 2007;2:17-26.
Bowen A; Stroke TIWPF. National Clinical Guidelines for Stroke. 2nd
ed. London: Clinical Effectiveness & Evaluation Unit, Royal College of Physicians; 2004.
Jivan K, Ranchod K, Modi G. Management of ischaemic stroke in the acute setting: Review of the current status. Cardiovasc J Afr 2013;24:86-92.
Demaerschalk BM, Yip TR. Economic benefit of increasing utilization of intravenous tissue plasminogen activator for acute ischemic stroke in the United States. Stroke 2005;36:2500-3.
Kamal N, Sheng S, Xian Y, Matsouaka R, Hill MD, Bhatt DL, et al
. Delays in door-to-needle times and their impact on treatment time and outcomes in get with the guidelines-stroke. Stroke 2017;48:946-54.
Baatiema L, Otim ME, Mnatzaganian G, de-Graft Aikins A, Coombes J, Somerset S. Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: A systematic review. Implement Sci 2017;12:74.
Jauch EC, Saver JL, Adams HP Jr., Bruno A, Connors JJ, Demaerschalk BM, et al
. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.
Mellon L, Hasan H, Lee S, Williams D, Hickey A. Knowledge of thrombolytic therapy amongst hospital staff: Preliminary results and treatment implications. Stroke 2015;46:3551-3.
Harper JP. Emergency nurses' knowledge of evidence-based ischemic stroke care: A pilot study. J Emerg Nurs 2007;33:202-7.
Zhou Y, Xu Z, Liao J, Feng F, Men L, Xu L, et al
. New standardized nursing cooperation workflow to reduce stroke thrombolysis delays in patients with acute ischemic stroke. Neuropsychiatr Dis Treat 2017;13:1215-20.
Boudreau DM, Guzauskas GF, Chen E, Lalla D, Tayama D, Fagan SC, et al
. Cost-effectiveness of recombinant tissue-type plasminogen activator within 3 hours of acute ischemic stroke: Current evidence. Stroke 2014;45:3032-9.
Joo H, Wang G, George MG. A literature review of cost-effectiveness of intravenous recombinant tissue plasminogen activator for treating acute ischemic stroke. Stroke Vasc Neurol 2017;2:73-83.
Brainin M, Teuschl Y, Kalra L. Acute treatment and long-term management of stroke in developing countries. Lancet Neurol 2007;6:553-61.
Abraham SV, Krishnan SV, Thaha F, Balakrishnan JM, Thomas T, Palatty BU. Factors delaying management of acute stroke: An Indian scenario. Int J Crit Illn Inj Sci 2017;7:224-30.
] [Full text]
Pandian JD, Kalra G, Jaison A, Deepak SS, Shamsher S, Singh Y, et al
. Knowledge of stroke among stroke patients and their relatives in Northwest India. Neurol India 2006;54:152-6.
] [Full text]
Pandian JD, Jaison A, Deepak SS, Kalra G, Shamsher S, Lincoln DJ, et al
. Public awareness of warning symptoms, risk factors, and treatment of stroke in Northwest India. Stroke 2005;36:644-8.
Panwar A, Veeramalla M, Valupadas C, Ramesh K, Owais M, Muriki R. Barriers to stroke thrombolysis. J Clin Diagn Res 2017;11:OC01-5.
Ghandehari K, Foroughipour M, Pourzadeh A, Taheri M, Abbasi M, Gorjestani S, et al
. Thrombolysis in stroke patients: Problems and limitations. Iran J Med Sci 2010;35:145-8.
Vahidy FS, Rahbar MH, Lal AP, Grotta JC, Savitz SI. Patient refusal of thrombolytic therapy for suspected acute ischemic stroke. Int J Stroke 2015;10:882-6.
Pandian JD, Khurana D, Kaul S, Sylaja PN, Padma V, Arora D, et al
. Intravenous thrombolysis in India: The indo-US stroke project. Stroke 2015;46:AWMP25.
[Table 1], [Table 2], [Table 3], [Table 4]