Presentation on theme: "Liz Mackey, Stroke Nurse Practitioner, Western Health Melbourne"— Presentation transcript:
1Liz Mackey, Stroke Nurse Practitioner, Western Health Melbourne Lizzie Dodd, Clinical Practice Consultant, Acute Stroke Unit Coordinator, The Queen Elizabeth Hospital SA HealthApplication of the National Institutes of Health Stroke Scale and common pitfalls
2Aims Introduction to the National Institutes of Health Stroke Scale Common pitfalls of the NIHSSDiscuss how the NIHSS can be incorporated into practicePatient assessmentCommunicationDecision makingStroke trial recruitmentReporting outcomesCase examplesTraining options
3National Institutes of Health Stroke Scale 15-item neurologic examination stroke scaleRatings for each item are scored with 3 to 5 gradeswith 0 as normal, and there is an allowance foruntestable items. Range 0 – 42Mild 0-7Moderate 8-16Severe > 16The single patient assessment requires less than10 minutes to complete.
4National Institutes of Health Stroke Scale A trained observer rates the patient’s ability to answerquestions and perform activities.The evaluation of stroke severity depends upon theability of the observer to accurately and consistentlyassess the patient
5National Institutes of Health Stroke Scale Evaluates the effect of stroke on:Level of consciousnessExtraocular movement
7Pitfalls of the NIHSS Three main pitfalls in using the NIHSS: Items with poor reliabilityDominant-hemisphere strokesLessened weighting for posterior circulation strokes
8Pitfalls: Items with poor reliability The NIHSS contains FOUR items which are widely acknowledged to have poor reliability1a Loss of Consciousness4 Facial Palsy7 Ataxia10 DysarthriaPotential issues if not scored accurately include:Communication difficulties between practitionersDecision making errors (eg in thrombolysis or trial recruitment)Difficulties assessing patient outcomesRef 12.
10Pitfalls: dominant hemisphere strokes Communication / language impairments in dominant hemisphere strokesHigher scores for more deficits related to language / communication impairmentsTendency for dominant hemisphere strokes to receive a higher rating, approximately 4-points more for the same size stroke, compared with non-dominant hemisphere strokes.Items affected particularly:1b LOC Questions,1c LOC Commands,9 Best language,10 DysarthriaRef 13, 14
11Pitfalls: Posterior circulation Lessened weighting for vertebro-basilar (posterior circulation) strokesItems include:1a LOC3 Visual fields4 Facial palsy5&6 Motor7 Ataxia8 Sensory10 DysarthriaOther elements that provide more information about the posterior circulation receive no score e.g.diplopiadysphagiagait instabilityhearingnystagmus Ref 12 Another downside is the lessened weighting for posterior circulation strokes, a problem for nearly all neurological deficit scales. Though some items related to the verterbo-basilar system can be scored (e.g. LOC, visual fields, facial palsy, sensory, motor, dysarthria and ataxia), other elements receive no score (e.g. diplopia, dysphagia, gait instability, hearing, and nystagmus).
12Why should we bother doing NIHSS? Whose job is it to do this?
13Why should we bother doing NIHSS? Well-validated, reliableTime efficient & standardised brief neurological examinationAssesses degree of neurological deficitPredictor of mortality & functional outcomes (short- and long-term)Clinical Guidelines for Stroke Management 2010 (NSF p.55)“Stroke severity should be assessed & recorded onadmission by a trained clinician using a validated tool(e.g. NIHSS or SSS)”Facilitates:Communication (clinicians, patients, care givers)Identification of location of infarctEarly understanding of prognosisSelection for interventions / trialsIdentification of potential for complicationsRef 1-9
14NIHSS use in everyday clinical practice Emergency DepartmentWho?Why?Rapid assessment & decision making:Location of strokeThrombolysisPatient management & prognosisFacilitate coordination of careAdds to the picture of the stroke subtypeTACI, PACI, LACI, POCI, haemorrhageTrial recruitmentCommunication when referring to other teamseg. neurointervention, neurosurgeryFacilitates communication to patients and families / care givers
15NIHSS use in everyday clinical practice Thrombolysis decision making:Baseline differences in NIHSS scores can affect the response of stroke patients to intravenous tissue plasminogen activatorRisk of haemorrhage is considerable among patients with high NIHSS scores:US FDA labelling: use intravenous tissue-type plasminogen activator in patients with NIHSS scores >22 with caution.Ref 2,10Thrombolysis decision making:The NIHSS is widely used in current clinical practice. 29 These baseline differences in NIHSS scores can affect theresponse of stroke patients to intravenous tissue plasminogen activator, which is the only FDA-approved medical therapy toreduce disability after acute ischemic stroke. Moreover, federal drug labeling for intravenous tissue-typeplasminogen activator incorporates the NIHSS. Because the risk of hemorrhage is considerable among patientswith high NIHSS scores, FDA labeling indicates the decision to treat with intravenous tissue-type plasminogen activator inpatients with NIHSS scores >22 should be made with caution. Therefore, the AHA/ASA advocates that efforts continue to focuson how to collect and incorporate the NIHSS into a revised version of the 30-day measures.
16NIHSS use in everyday clinical practice Acute Stroke Care UnitWho?Why?Facilitate coordination of careCommunication of changesRecruitment to trialsWhen?At intervals during acute stay:Thrombolysis: NIHSS at 2-hours, 24-hours, discharge
17NIHSS use in everyday clinical practice Follow-up in Outpatient ClinicCommunication of changesAudit of outcomes for thrombolysis
18NIHSS use in everyday clinical practice Stroke trial recruitmentMost stroke trials require NIHSS to be > 4 or < 26
19NIHSS use in reviewing hospital morbidity & mortality performance Growing interest in ensuring stroke severity is accurately quantifiedBy scoring stroke costs to health services are potentially more accurately identifiedi.e. adjustment for stroke severityFonarow et al (2014): “Stroke severity has been documentedto be a key mortality risk determinant in acute ischemic stroke.Prior analyses demonstrated that stroke severity, as quantified by theNIHSS, was the strongest predictive variable for in-hospital and 30-daymortality and substantially improved the performance of a model basedon clinical variables without stroke severity”Ref 2
20NIHSS use in reviewing hospital morbidity & mortality performance Fonarow et al (2012):Among hospitals ranked in the top 20% or bottom 20% of performers by theclaims model without NIHSS scores, 26.3% were ranked differently bythe model with NIHSS scores.Of hospitals initially classified as having “worse than expected” mortality,57.7% were reclassified to “as expected” by the model with NIHSS scores.Ref 11
27FREE training viahttps://secure.trainingcampus.net/uas/modules/trees/windex.aspx?rx=nihss-english.trainingcampus.net
28Boehringer Ingelheim training offer In hospital group training and accreditation for NIHSS (can be a 2 hour session or 2 x 1 hour sessions = 1 hour to train + 1 hour for exam)BI sponsor paper exams ($25 each), everyone gets booklet ($3 each), a DVD for the department ($50 worth)The DVD does the teachingGet sent to the National Stroke Association in Colorado for official processing and accreditation, certificates will be providedBenefits are that a group of doctors/nurses can do training in one in-house session, (no need to do it at home)
29Examples of Apps for NIHSS Canopy MedicalTranslatorAndroidhttps://itunes.apple.com/us/app/canopy-medical-translator/id ?mt=8
32References Clinical Guidelines for Stroke Management 2010 (NSF) Fonarow GC, Alberts MJ, Broderick JP, Jauch EC, Kleindorfer DO, Saver JL, Solis P, Suter R, Schwamm LH. Stroke Outcomes Measures Must Be Appropriately Risk Adjusted To Ensure Quality Care of Patients: A Presidential Advisory From the American Heart Association/American Stroke Association Stroke. published online February 12, 2014Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N, RemondaL, Schroth G, Arnold M, Mattle HP. Predictors of early mortality after acute ischaemic stroke. Swiss Med Wkly. 2010;140:Chang KC, Tseng MC, Tan TY, Liou CW. Predicting 3-month mortality among patients hospitalized for first-ever acute ischemic stroke. J Formos Med Assoc. 2006;105:Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, Hernandez AF, Peterson ED, Fonarow GC, Schwamm LH. Risk score for in-hospital ischemic stroke mortality derived and validated within the Get With The Guidelines–Stroke Program. Circulation. 2010;122: Johnston KC, Connors AF Jr, Wagner DP, Knaus WA, Wang X, Haley EC Jr. A predictive risk model for outcomes of ischemic stroke. Stroke. 2000;31:
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3410. Fonarow GC, Liang L, Smith EE, Reeves MJ, Saver JL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH; on behalf of the GWTG-Stroke Steering Committee & Investigators. Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care. J Am Heart Assoc11. Fonarow GC, Pan W, Saver J et al “Comparison of 30-Day Mortality Models for Profiling Hospital Performance in Acute Ischemic Stroke With vs Without Adjustment for Stroke Severity” JAMA, July 18, 2012—Vol 308, No12. Meyer BC, Lyden PD. "The Modified National Institutes of Health Stroke Scale (mNIHSS): Its Time Has Come" Int J Stroke August ; 4(4): 267–27313. Lyden P, Claesson L, Havstad S, AshwoodT, Lu M. Factor analysis of the national institutes of health stroke scale in patients with large strokes. Arch Neurol. 2004;61:14.Woo D, Broderick J, Kothari R, et al.,Group Nr-PSS. Does the national institutes of health stroke scale favor left hemisphere strokes. Stroke. 1999;30: