Looking for the Silver Lining

Aug 01, 2018

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I think we’ve all had to go back and rethink stroke. In the past five years, there have been major significant advances in what we can do for patients with stroke. The landscape is changing so fast that no one can keep up.

DaiWai Olson

In an unexpected turn of events earlier this year, the American Heart Association (AHA)/American Stroke Association (ASA) rescinded its recently released guidelines about early management of patients with acute ischemic stroke (AIS). The organizations published a correction in which large parts of the document were deleted, and they later published revised guidelines. DaiWai Olson, professor of neurology and neuro- surgery at the University of Texas (UT) Southwestern in Dallas; director of the Neuroscience Nursing Research Center at UT Southwestern Peter O’Donnell Jr. Brain Institute; and editor of Journal of Neuroscience Nursing, led multiple sessions at this year’s National Teaching Institute & Critical Care Exposition (NTI) in Boston on “Why and How the New 2018 Ischemic Stroke Guidelines Will Change Your Practice.” He spoke with us about the controversy surrounding the release of the initial guidelines and what bedside nurses need to know about the revised guideline.

How long have you been a nurse?

I started nursing in 1986 with an associate degree. I started at a hospital in Davenport, Iowa. I got my bachelor’s degree and spent about 20 years at Duke University in Durham, North Carolina, and got my PhD from the University of North Carolina at Chapel Hill. I was recruited to join the faculty here at UT Southwestern about five years ago.

Let’s talk about the AHA/ASA AIS guidelines.

There was an early release of material in January. They were published online in February. The print publication is dated March 1, and in April — I think it was April 16 — they deleted a bunch of material. They retracted almost 100 pages.

Was it pretty obvious that there was going to be an immediate correction?

Not at all. I was surprised when they retracted. I was also surprised at what they retracted — and what they didn’t. It wouldn’t surprise me if there are more changes yet to come. In fact, it would surprise me if there’s not. I anticipate that over the next several years these guidelines will be revised several times.

In your presentation about the guidelines at NTI, what key items did you focus on?

Those that most directly impact nursing practice or those that were most directly impacted by nursing practice. Let me give you an example of what I didn’t focus on. If there was a recommendation that physicians should do a certain surgical procedure, or should not do a certain surgical procedure, I didn’t focus in on that. But I did focus in on things like there’s a recommendation that a validated tool should be used to evaluate stroke, and the nurses are the ones who are going to be using that tool. So that seemed like an important one to share with nurses. I mean, there’s, what, 217 recommendations? And I had an hour. I had to pick and choose.

So if you look through the guidelines, you’ll see, “Hospital stroke teams need to collaborate. We need to write protocols.” Well, nurses write protocols. That’s what we do. We’re really good at that. So that’s going to be a nursing thing. Multiprofessional QI. Well, nurses are part of the multiprofessional team. Telestroke. Nurses are the ones who get the robot ready. We interact strongly. We get that telestroke moving. We interact with the physician on the other end of it.

“Primary stroke centers need to get the patient ready for thrombectomy.” Well, that’s the nurse. The nurse gets the patient ready. “Mechanical thrombectomy needs to be done at a comprehensive stroke center.” That means if you’re a nurse at a comprehensive stroke center, you are going to get patients into your stroke center from outside, so you’ve got to get protocols. You’ve got to figure out: How am I going to get these patients here? When they get here, how am I going to provide care for them? Where are they going to go? If you don’t work at a CSC, you’ve got to think about: OK, any patient who’s eligible for mechanical thrombectomy — and based on the new evidence, that population is growing — it’s going to be sent out. So if I’m a nurse at a hospital that doesn’t do thrombectomy, I’ve got to figure out how I can facilitate an intrahospital transfer, because it’s going to happen. “Use the National Institutes of Health stroke scale.” That’s an easy one. “Don’t look for zebras on CT. Don’t look for zebras on MRI.” That means we’re going to be doing fewer CT MRIs. That could affect staffing.

So that was my decision-making process — what are the ones that really affect us?

Tell us your thoughts on the release, the retractions, where we are right now and where this might go.

I think there’s actually a silver lining to all of this. There were I think 217 recommendations, and when they came out, it put everybody into a flurry. I think we’ve all had to go back and rethink stroke. In the past five years, there have been major significant advances in what we can do for patients with stroke. The landscape is changing so fast that no one can keep up.

When the guidelines came out, they were supposed to provide us with an up-to-date status, but, in part because the landscape is changing so fast, you can’t put something out that’s up-to-date because new evidence comes out every week. The other piece is when this controversy that resulted in the retractions happened, I think a lot of people went back and really started reading the guidelines deeper. There’s a lot of information, and the authors did an excellent job of at least stating, “Here are the references we used to make this recommendation.” A lot of people have now gone back and said, “Wait, wait, wait.”

What do you mean?

Instead of me just saying, “Oh, the AHA recommended A, B, C. I’m going to do that,” there’s a lot more critical thinking, and they’re turning to folks like nurses, and they’re saying, “OK, this is the recommendation from the AHA, and here’s all of the evidence that the authors used to make this decision. How do we interpret this within our own practice?” Most of these guidelines aren’t simple mandates. So, putting any particular guideline into practice at your hospital requires that you really know how nursing and medicine and radiology and lab and pharmacy work.

When this was all unfolding, was the feedback immediate?

Yes, immediate and strong. It was, in many ways, science the way science should be. It was an open debate.

Let’s talk a little more about you. What do you like to do in your spare time?

In my spare time, I set these sort of weird, big, lofty goals. Three years ago, we completed the high-to-low challenge, which is you go to the top of Mount Whitney — the highest point in the continental U.S. — and you walk to the lowest point in the United States, which is in Death Valley. So it’s about a 184-mile hike, and you do that straight. And then next week, I’m doing the Miami to Key West challenge, which is you start in Miami and you kayak to Key West. It’s just under 200 miles of ocean kayaking.

When did you do the Whitney to Death Valley?

We did it in July. Yeah, it was 126 in Death Valley. My feet were bleeding for three weeks afterward.

So you said that’s like 180-some miles?

Hundred and 84.

How many miles before you really start to feel the climate change?

Well, you start at Mount Whitney’s parking lot, which is about 9,000 feet elevation, and it’s a little cooler, and we started off at about sunset and hiked through the night. And so of course it’s cold, and there’s snow at the top. It took us 12 hours to get to the top, and then when you get to the top, that’s where you start. So it’s 12 hours of hiking to 14,000-plus feet of elevation, and then you get to start the hike, and there’s changes. By the way, if you look at it, it’s not all downhill. You go from 14,000 down to about 6; then you go up to 7; then you go down to 2; then you back up to like 8. So, you’re going up and down to finally end — because there are a couple of mountain ridges to go over before you get to Death Valley. You couldn’t get on a skateboard and go downhill. It took six days.

What’s the time frame for the Miami to Key West challenge?

It’s just under 200 miles. The record is three days, and we’re not going for the record, because I’m 56 years old. It’s my son-in-law and myself in the kayak, and my brother, who’s also a critical care nurse, is our road crew. We’re hoping for five days. That’s my goal. So our first stretch is going to be about 28 hours, and then we’ll probably try to sleep for like four or five hours before we head off again. But the first stretch is really fairly long. We’ve got about 28 hours of paddling.

Wow! It sounds grueling.

It’s going to be fun.