Where the brain and spine meet … at the beach!
CANN 42nd Annual Meeting and Scientific Sessions
June 14–17, 2011
Vancouver, BC
Oral presentation abstracts | Poster abstracts
Online registration is available now!
Abstracts for oral presentations
Wednesday, June 15
A1
An adolescent’s complex brain tumour journey
Serena Slater, Debbie Meldrum, Tina Primiani
When a healthy, intelligent, high achieving adolescent is struck with the diagnosis of a brain tumour, many aspects of her life can take a drastic turn. By exploring one such complex case, involving unanticipated post-operative difficulties and uncertain pathology, we discuss some of the challenges of interdisciplinary care management. In this case, anxiety, chronic pain, social isolation, and complex family dynamics did not always allow the patient to follow a usual illness trajectory and challenged the care givers in a way that obliged them to explore new avenues of practice and to push the existing system. The complexity of this case helped identify certain missing links in the organization and prompted the interdisciplinary team members to reevaluate and modify their approach. The implications for nursing practice, for such cases with unpredictable outcomes, have provided some guiding lessons for the care of all patients.
B1
Not Just Your “Garden Variety” Atherosclerosis: One Woman’s Story
Shannon Nearing
Ischemic stroke accounts for approximately eighty percent of all strokes (Heart and Stroke Foundation, 2011). The etiology for ischemic stroke, particularly in older adults, is often associated with vascular changes resulting from atherosclerotic disease. In younger adults the mechanism is often unclear and may be due in part to rarer processes. Radiation induced vascular injury is one such phenomenon. Radiation induced “iatrogenic” injuries to large arteries may result in stenotic and/or occlusive vasculopathy which in the past was considered to be relatively rare.
Using a case study format, the author will present the story of a 43 year old woman with a history of breast cancer who presented with multiple ischemic infarcts in the brainstem and cerebellar hemispheres. The dilemmas faced in determining the etiology and best treatment option for this young woman will be outlined. The clinical presentation, diagnostic tests, pharmacotherapy, treatment options and the implications for nursing practice will be highlighted. The author will conclude with a brief update on what is known to date about the effects of radiation on the vasculature.
The intent is provide the neuroscience nurse with essential information, which will be of benefit when communicating with, and educating patients and their families with respect to a diagnosis of radiation induced vascular disease.
C1 & C2 (double session)
Anti-epileptic drugs: Principles of Management
Margo DeVries-Rizzo
Antiepileptic drugs (AEDs) are used commonly in the care of neuroscience patients. Although primarily used to treat epilepsy, neuroscience nurses will often encounter AEDs when caring for other neurological conditions as well. Additionally, as patients have become more complex, often with multiple co-morbidities, the amount of information nurses need to know to practice safely and effectively has grown exponentially. Understandably, gaining knowledge about AEDs and principles of management is an essential aspect of nursing care.
Although antiepileptic drug literature is vast and daunting, the approach to understanding AEDs and their use can be practical and straightforward. This presentation will be a comprehensive overview of principles of management of antiepileptic drugs with a focus on practical implications for nursing. Broad principles of how an AED is chosen, basic principles of pharmacotherapy, adverse effects, and nursing implications will be discussed. Participants will have the opportunity to work through case studies throughout this presentation to apply their knowledge.
This presentation will be beneficial to any nurse working with anti-epileptic drugs regardless of the clinical setting. Additionally, as nurses are consistently educating patients and others, information shared in this session will be beneficial for empowering patients to participate in the management of their health condition.
D1
Using Telehomecare Technology to Understand the Needs of Patients and Caregivers Following Acquired Brain Injury
Sonya Canzian, J. Dabbs, Jane Topolovec-Vranic, Diane Duff, L. Mitchell, A. Michalak, Mina Singh, Dawn Tymianski, Linda Yetman, A. Nathens
Many family members and individuals with moderate or severe acquired brain injury (ABI) note social isolation, insufficient support, monitoring, education and access to specialized health providers following discharge to the community. Telehomecare (THC) provides a technological bridge for clinicians, patients, and family caregivers to address these identified needs. The purpose of this study was to use THC technology to explicate the needs and concerns of individuals who have ABI and their family caregivers during the first six months post discharge from acute care or rehabilitation facilities.
A prospective observational mixed-methods study of five dyads of patients and their primary family caregivers was conducted. Participants were interviewed and received THC assessments with a research nurse at specific time intervals.
The team identified challenges early on in the implementation of the study protocol. Difficulties were encountered with the use of the telehomecare equipment, operationalizing the definition of moderate to severe ABI in the acute phase, and obtaining consent from the participants in the acute care setting. However, the qualitative and quantitative data obtained from the participants have been rich and revealing of the participant experience of life after discharge. Primary caregivers identified that their role required a significant amount of time and dedication, resulting in high levels of physical and emotional stress and burden. Depression and altered psychosocial patterns were also noted in the patient group.
Findings from the study have enhanced our understanding of the stresses and coping mechanisms of patients and caregivers following ABI. Early support and education for caregivers and patients may be beneficial in reducing the stress experienced during the transition. While THC has been successfully utilized for other patient populations, special considerations are required for ABI. The information obtained in this study will be utilized to design services which can be delivered via THC to best address the needs of patients and families post-discharge.
This presentation will describe the research process and findings to date.
A2
Shaken Baby Syndrome: Never by Accident
Arbelle Manicat-Emo, Semira Amin, Una Karanovic
Perhaps one of the more emotion provoking and controversial patient populations that neuroscience nurses may encounter in their practice is infants and younger children diagnosed with “Shaken Baby Syndrome”. “Shaken Baby Syndrome” or non-accidental injury is a collective term for the internal head injuries such as subdural haemorrhages and cerebral oedema an infant or young child sustains from being violently shaken leading to seizures, neurological impairment and unfortunately death. Other injuries may include retinal haemorrhages and bone fractures. This presentation will discuss the incidence and epidemiology of “Shaken Baby Syndrome”, mechanism, signs and symptoms, and its nursing and medical management. As well, the ethical, practical and legal implications in particular for neuroscience nurses will be explored. Many neuroscience nurses possess specialized knowledge and clinical experience in caring for patients with head trauma. This expertise enables neuroscience nurses to play a vital role in the prevention, identification, assessment and management of infants who sustain this fatal form of child abuse. Bound by their moral obligation to protect and advocate for those they care for, neuroscience nurses will need to work collaboratively with the other members of the interprofessional team to address the special needs of these infants and their families. Moreover, neuroscience nurses must practice with sensitivity and objectivity as these patients become involved in the complex process of child welfare and criminal investigation.
B2
Enrolment in Research: Trials and Tribulations
Libby Kalman, Victoria Riediger, Jemini Abraham, Anne Cayley, Relu Wiegner
As stroke nurses working within a regional stroke centre we have a responsibility to provide optimal stroke care, which includes participating in clinical research trials. Clinical trials we are participating in or have developed are both qualitative and quantitative in nature involving methods such as interventional, observational or needs surveys of patients with stroke and TIA. Within our centre we have a dedicated nurse who is our research coordinator who maintains all the research studies. The physicians and nurses within our stroke team are expected to continuously screen and enrol clients into research studies. This occurs across the spectrum of care; during in-patient consultations, after hours while on-call and during follow-up visits in the stroke prevention clinic. Our aim is to provide a literature review surrounding the barriers and facilitators with patients’ enrolment in research trials. A comparison will be made between the findings from the literature and our experiences with enrolment. Patient enrolment is an important component of conducting quality research and bringing evidence practice to the bedside.
D2
Endovascular Aneurysm Repair: The RCH Experience
Mary Anne Enriquez
Royal Columbian Hospital has a thriving Neuroscience Department, which added an Endovascular program starting April 2008. The intent of this presentation is to analyze data collected on the endovascular neurosurgical patients. This retrospective study will look at all endovascular repairs of aneurysms from April 2008 to April 2010, ruptured and non-ruptured, focusing on requirements of care such as: Admission disposition, critical care unit length of stay, length of hospitalization, post procedure complications, subarachnoid haemorrhage grade, and discharge disposition. This presentation will also refer to best practice guidelines for the management of aneurysms and SAH, specifically referring to RCH protocol. This data is currently being collected as part of an ongoing 5 year study of the Cerebral Endovascular service. There will also be discussion of the successes of this service, and the overall impact on the critical care and neurosciences units and nurses.
A3
Growing Teratoma Syndrome and secondary malignancy
Emily Jewels
BC Children’s Hospital sees approximately 30 new diagnoses of brain tumors per year. Approximately 6% are germ cell tumors.
Typically across Canada aggressive surgery is not considered up front due to the location and the highly responsive nature of germinomas to chemotherapy and radiation. Treatment includes an initial biopsy if serum and CSF tumor markers are not diagnostic, followed by radiation and chemotherapy. There is a 2nd look option for surgery if needed, but our experience has been that these tumors post chemotherapy can be very challenging to resect, thus the complications may outweigh the benefit of resection.
In the past year we have had 2 cases initially diagnosed with germ cell tumors that were treated with chemotherapy and radiation. During chemotherapy they were found to have ‘growing teratoma syndrome’, and underwent a partial resection. Post completion of treatment, both patients relapsed and unfortunately both developed a secondary high grade malignancy at the primary site.
This presentation is a brief review of these unusual cases including their pathology and treatment. It will also discuss the implications that this may have on the current treatment approach, how this impacts our nursing practice and the support we give to families in these unique situations.
B3
End-of Life Care Following an Acute Stroke: The Nurses Perspective
Janice Nesbitt, Dr. Susan McClement, Dr. Marie Edwards, Dr. Mike Harlos
Cerebral vascular accidents (CVAs) rank as the third leading cause of death in Canada with more than 50,000 of these events occurring annually (Heart and Stroke Foundation (HSF), 2008). In Canada, 75% of patients experiencing a stroke will be left with some degree of disability, while fifteen percent will succumb to the event (HSF, 2008). The evidence base from which to provide end-of- life care to patients dying from a CVA is currently limited, and there is a dearth of research examining the experiences of nurses charged with the responsibility of caring for these patients. In order to begin to address this gap in the literature, a qualitative study, using van Manen’s interpretive phenomenology (van Manen, 2007) was conducted to examine and describe the lived experiences of nurses working on an acute neurosciences unit in a tertiary hospital. Nine nurses were interviewed, and a follow-up focus group was conducted to confirm the interpretation of the data. This presentation will discuss the essence of nurses’ lived experience in caring for these patients. Implications for education, practice, and future research arising from the study will be presented.
C3
Pearls for success: strategies for assessment of the deteriorating client
Dawn Tymianski
For any neuroscience nurse, good neurological assessment of the client comes with experience, repetition, intuition, married with the ability to reconcile client’s verbal symptoms. Furthermore, the neurological exam relies on our ability to correlate the signs and symptoms to its anatomical position. Correlation facilitates timely assessment, diagnosis, treatment and outcomes.
Nurses are also required to assess the deteriorating neurological client. Deterioration can be defined as a change in GCS of 2–3 points over a short course of time. This assessment is different as acute, rapid deterioration can have fatal consequences, such as in acute hydrocephalus or haemorrhage. Secondly, we lack the luxury of time to complete a thorough assessment. Good, rapid assessment is indispensible and therefore should be completed in order to diagnosis, predict outcomes, and, must go beyond the Glasgow Coma Score.
The neurological assessment must be practical, efficient and brief in order to produce a high yield of information. Two key questions are always asked, ‘what is the lesion’, and ‘where is the lesion’. Through case presentations and critical thinking, this session will identify and describe the assessment of eloquent areas and their prognostic importance. Eloquent areas for discussion include cortical function, midbrain and brainstem. Furthermore, systemic influence, such as fever and electrolyte disturbances and their impact on LOC will also be discussed. Attendees can contribute at the end of the session with their own experiences. Therefore, this session will help guide the nurse to ask the right questions, assess key neurological areas, fostering critical thinking and improve outcomes in the deteriorating client. Through the ability to answer these questions, the nurse is on the path to efficient, accurate assessment.
D3
ABCD of CJD: The Big Picture of Creutzfeldt-Jakob Disease
Rolande D’Amour
Creutzfeldt-Jacob disease (CJD) is a rare prion disease that is incurable, transmissible, and always fatal. Prion diseases affect humans as well as animals. In the 1980’s, the “Mad Cow Disease” (MCD) epidemic in the United Kingdom created awareness of prion diseases worldwide. Unfortunately, this epidemic resulted in the dissemination of inaccurate information in the public as well as in health professionals who sometimes feel unprepared to work with CJD patients. This situation has a terrible effect on the families who feel they are left to themselves to face the stigma and fear associated with this difficult disease. It also causes frustration in nurses who feel unprepared to work with CJD patients. Although CJD is a rare neurodegenerative disease, with rapid onset and decline, neuroscience nurses who deal with all forms of dementia may have the opportunity to work with a suspect CJD patient. Therefore, it is of utmost importance that they have an understanding of prion diseases and the particular needs of this patient population.
The purpose of this presentation is to increase awareness about CJD as well as foster reflective practice in neuroscience nurses. It will generate new insights and knowledge about the disease as well as the particular needs of the CJD patients and their family.
A4
A Systematic Review of Halo Pin Site Care—A Journey Towards Best Practice
Erin Vandeven, Kaitlin Flynn, Helene Nobel, Sandy Melo, Herta Yu, Shobhan Vachhrajani
Objective: In our pediatric neurosurgical setting, there are inconsistencies in the provision of halo pin site care due to a lack of formal institutional protocol directing our care and teaching. In an attempt to develop a teaching tool for nurses and families it was discovered that the Orthopedic and Neurosurgical services had differing protocols regarding pin site care. This systematic review aims to evaluate existing published pin site care practices and determine which approach may best prevent pin site complications.
Methods: Published surgical and nursing literature was systematically searched using standard electronic journal databases. Search criteria included halo fixation, halo traction, skeletal pins, pin site care and complications. Article inclusion was determined by group consensus. Our group consists of four pediatric neurosurgical nurses, a neurosurgical nurse practitioner and a senior neurosurgical resident with clinical epidemiology training.
Results: Titles, and subsequently abstracts, from the adult and pediatric literature felt to discuss either pin site complications or pin site care protocols were retained for full text review. At present, 29 articles have been identified and will be appraised using methodology devised by the Critical Appraisal Skills Programme (CASP). An evidence-based summary of best halo pin site practices will be created.
Dissemination and Knowledge Transfer: Results of this review will be disseminated during the CANN 2011 Scientific Session. This audience will provide an ideal cohort for knowledge transfer and implementation of review results. Such a discussion will also promote translation of this knowledge into best practices for halo pin site care.
B4
Stroke Rehabilitation Comes Home
Michael Suddes, Megan Booi, Tyler Burley, Nelly Chow, Katherine Churchward, Darren Knox, Lisa Patel, Luchie Swinton (on behalf of the Calgary Stroke Program Early Supported Discharge)
Despite advances in acute stroke care, the optimization of rehabilitation services for people affected by stroke still presents the best opportunity to realize opportunities in reducing the burden of stroke for the individual, family and the health care system.
Properly resourced community-based stroke rehabilitation services that promote early supported discharge from acute care are cost efficient, clinically effective, significantly reduce length of hospital stay and have been shown to significantly enhance community reintegration when compared to traditional inpatient care. Early Supported Discharge (ESD) services involve providing trans-disciplinary, patient-centered rehabilitation services in-home to stroke survivors who have been discharged from facility care but still require rehabilitation to maximize their independence.
Although this model of care is not widespread yet in Canada it has been adopted in many countries and this approach is a best practice recommendation from the Canadian Stroke Strategy.
This presentation will describe the development, implementation and impact-evaluation at a client and system level of an innovative ESD service in the Calgary Zone of Alberta Health Services, alongside the role of neuroscience nurses within the team and the implications for neuroscience nursing practice.
C4
Engaging Nurses in “Transforming Care at the Bedside” (TCAB) on a Neuroscience Unit
C. Bouchard, J. Lizotte, N. El Hachem, L. Fabijan, M. Stewart
Transforming Care at the Bedside (TCAB) is an innovative program of rapid-cycle problem-solving which helps nurses, their health team colleagues and patient representatives to systematically discuss and experiment with changing patient care processes and work environments in order to increase patient safety, reduce wasted time and increase professional satisfaction. Initiated in the United States in 2002 by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI), TCAB ‘s four-step process has enabled better clinical outcomes, reduced nurse turnover and lower costs in over 200 American and European hospitals.
In August 2010, the McGill University Health Centre (MUHC) launched TCAB on five pilot units including a neuroscience unit at the Montreal Neurological Hospital. The implementation process includes considerable staff learning and active support from Nursing leadership, as well as ongoing analysis of the impact of staff problem-solving on patient care and nursing work satisfaction. It is an effective method of inspiring excitement while reinforcing staff creativity to uncover and try new solutions.
The aim of this presentation is to share the results of the first eight months of TCAB on a neuro unit where the team has been involved in a dynamic learning process to re-define their work in a re-designed patient-centered unit.
D4
“Nursing 24/7”: Daughters Caring For a Neurologically Impaired Parent
Arbelle Manicat-Emo, Beverly Espedido, Dzigbordi Bankas
Caring for a parent who has been severely impaired by a neurological event is challenging for the family members affected particularly for the adult child caregivers. In situations where daughters are involved, the burden of caring for the parent often falls on them largely in part to the traditional role of the daughter becoming a mother. The stress of caring for the neurologically impaired parent may increase substantially when the daughter is a neuroscience nurse. “Knowing too much” can either be an advantage or disadvantageous especially if the diagnosis is less than favourable. Advocating for the patient takes on a different context when the patient is one’s own mother or father and the roles of nurse and daughter become entangled. Studies have shown that nurses providing care for their own relatives have specific needs with regard to their dual role as a health care professional and family caregiver. The personal stories of three neuroscience nurses’ lived experiences of each caring for their own parent who has been neurologically impaired by either a stroke or brain haemorrhage will be shared while exploring the concepts of caregiver burden and compassion fatigue. By using their stories to generate dialogue and advocacy among their peers within the greater neuroscience nursing community, it is the hope and intent of these nurses that this discussion can lead to further awareness, and the development of effective supports and innovative care interventions for health care professionals as family caregivers.
Thursday, June 16
A5
Collaboration of APNs to Improve Care for Children with Progressive Neurologic Conditions and Their Families
Andrea Neufeld, Lisa Pearlman
Brain tumours are now considered the leading cause of cancer death in children. Unfortunately, for some children disease progression occurs despite aggressive neurosurgical and adjuvant treatment. Tumour pathology and surgical inaccessibility may limit treatment options and outcomes.
This presentation examines the formation of collaborative relationships in caring for these children and their families between a Paediatric Neurosurgical Advanced Practice Nurse and a Palliative Care Nurse Practitioner. We recommend early involvement of palliative care teams with children/families who have palliative brain tumor diagnosis, and those with recurrent metastatic brain lesions and leptomeningeal disease to assist with identification of goals of care and support with pain and symptom management decisions. The intent of this presentation is to emphasize the importance of advance care planning, symptom management, identification of sources of emotional, spiritual and physical support, creation of memories and exploration of the child’s legacy as end of life approaches. We will be presenting a case-based approach to illustrate the benefits of partnership and collaboration between these two advanced practice nurses in meeting the complex family-centered needs of these children and their families.
B5 & B6 (double session)
Sustaining Best Practice Nursing Care Across the Acute Stroke Continuum
L. Kelloway, T.L. Green, M.P. Lindsay, on behalf of the National Stroke Nursing Council
Nursing care across the stroke continuum is based upon awareness and understanding of the complexities of cerebrovascular disease, understanding of current best practices and translation to the practice setting. Major contributions to stroke nursing knowledge and practice arise from nursing and interprofessional research. The National Stroke Nursing Council has continued to play an active role in the 2010 update process for the Canadian Stroke Strategy Best Practice Recommendations as part of their ongoing commitment to address and highlight nursing-sensitive care activities. Key areas of focus for nurses within the 2010 stroke best practices include stoke unit care, inpatient management of oral care, incontinence, mobilization and nutrition issues. Nurses also play a significant role in patient and family education and support throughout the stroke continuum. Demonstrating the impact that nursing has on stroke patient care through ongoing measurement and monitoring is key to sustaining and improving best practice initiatives within the clinical setting.
The focus of this presentation is to facilitate nurses’ acquisition of knowledge related to evidence informed practice and to prepare nurses to assume a leadership role in the management of interprofessional care of stroke patients and their families.
Expected Outcomes of the Presentation:
- Increase awareness of evidence informed practice that supports stroke nursing practice
- Facilitate understanding of the utilization of measurement and monitoring to support implementation of best practice care.
- Provide education related to stroke best practices within the acute stroke setting.
- Provide opportunity to develop networks and linkages with nurses in practice and with the National Stroke Nurses Council
C5
Neuroscience Nursing in Qatar: A descriptive exploratory study of practice and educational needs
Dr. Diane Duff, Dr. Alice Gaudine, Isabelle Kelly, Lisa Moralejo, Elizabeth Young, Aisha Yousif, Amal Karib, Areej Salah Hassan, Maroua Bouafif, Munachiso Bob-Ume, Sailanie Caleja, Taibah Ahmed, Yassmin Hussein
There are no articles available in the scholarly literature on international education initiatives for neuroscience nurses, nor are any papers on neuroscience nursing in the Middle East indexed. A specialty assessment tool, the International Neuroscience Nursing Practice Assessment Tool (INNPAT) was developed to describe the scope of neuroscience nursing practice, neuroscience resources and services. The INNPAT was developed using the Delphi method in April 2009 at the American Association of Neuroscience Nursing conference. The tool was designed to collect baseline data on neuroscience practice from key informants using a combination of observation, interviews, and focus groups. Data findings from this pilot study revealed system strengths and gaps in resources and neuroscience nursing practice. The tool is also being piloted in China, Uganda, and Tanzania in 2010–2011.
Additionally, the Neuroscience Nursing Education Maturity Model (NNEMM) was used to gauge the current level of neuroscience nursing education in Qatar. The NNEMM examines curriculum and competence, educational processes, pedagogy and didactics, learning materials, resources, design and development, teachers, nurses, institutional support, policy, certification, and teachnology.
The goals of the presentation are to highlight the strengths and gaps of neuroscience nursing in Qatar, the degree to which nurses in Qatar identify as “neuroscience nurses”, and the educational needs and preferences of neuroscience nurses in Qatar.
Both the INNPAT and NNEMM are suitable for collecting baseline data about neuroscience nursing knowledge and practice anywhere in the world, including Canada.
D5
The needs of family members of severe traumatic brain injured patients during critical care, acute care and community: A quantitative study
Alanna Keenan, Lynn Joseph
Severe traumatic brain injury (TBI) is a devastating injury, with significant associated morbidity. Increased levels of anxiety and depression in family members have been cited. (Kolakowsky-Hayher, et al., 2001)
The study’s purpose is to identify the associations between the patient’s severity of injury as measured by the Glasgow coma score, Post-traumatic amnesia, and Functional Independent Measures and the family member’s anxiety as measured by the State –Trait Anxiety and the needs of individual family members as measured by the Family Needs Questionnaire.
Data was collected at three distinct time periods 1) upon transfer from ICU; 2) on discharge from acute care; and 3) six months post discharge.
Forty-four survey sets were completed by 24 family members. Participants were primarily female (84%) with a mean age of 44 years. Family members were associated with 15 patients, 14 of whom were male. Ages ranged from 17 to 58 with the mean age of 30.7. All but three patients were injured as a result of a motor vehicle collision.
Qualitative results of the needs of family members during critical and acute care from the data, has been analyzed and published (CJNN, 2010, 32[3]). Further implications for neuroscience nurses are emerging from the quantitative data with respect to prioritization of family needs and the anxiety traits in relation to the patients’ recovery. Acknowledging a family’s anxiety and recognizing their needs are critical elements in caring for patients and their families have implications for neuroscience nurses.
A6
The Stigmata of Neurofibromatosis Type 1 (NF 1)
Herta Wai-Ham Yu, Patricia Rowe
Neurofibromatosis, both type 1 and 2, belongs to a group of disorders known as neurocutaneous syndromes. NF 1 is an autosomal dominant disorder affecting 1 in 3500 individuals in the general population. NF 1 is a progressive disorder with highly variable multisystem manifestations including the skin, musculoskeletal, and central nervous system. It is also associated with cognitive problems and learning difficulties. Anyone with the neurofibromin mutation will development the disease, however the expression is variable manifesting a different set of signs and symptoms for each individual.
NF 1 is complicated disorder with life threatening complications and psychosocial implications that truly requires a multidisciplinary approach to care. The clinical features, cosmetic disfigurement, and cognitive deficits, along with the ambiguity of manifestations, greatly impact on the patient’s and family’s quality of life. A diagnosis of NF 1 is a source of great anxiety. Nurses caring for these patients and families need to fully understand the manifestations and implications for each individual. This presentation will review the Pathophysiology of the disorder with case reviews to illustrate its complexity and implications for nursing care and support for these patients and families.
C6
Recruiting new nursing graduates directly into a Neuro Intensive Care Unit
Joanne Charbonneau, France Ellyson, Siva Moonsamy, Martha A. Stewart
Specialized critical care units such as the combined Neuroscience Intensive Care Unit and Post-anaesthesia care units (PACU) of the Montreal Neurological Hospital encounter challenges in terms of the recruitment and retention of nursing staff. Creative solutions are needed.In 2008, the Nursing leadership team of this unit developed an innovative and comprehensive orientation and integration program for a cohort of five new graduates nurses.As it was the first time hiring a group of new graduates into this unit, a great deal of planning took place to prepare the team and create the support structures and roles to increase the likelihood of success.
The program is divided into 2 phases and is based on Schoessler & Waldo’s (2006) Developmental Transition Model covering the first 18 months of practice. The first phase is the twelve weeks preceptorship period and the second phase is a continuing education program over the subsequent 15 months. Feedback from the new graduates has been very positive and all of them remain part of the nursing team.
This presentation will summarize the main features of this integration program including the planning, implementation and evaluation phases as well as lessons learned.
D6
What’s New in Neurosurgery Plumbing? The Pipeline Embolization Device (PED)
Aaron Gardner, Christina Cossette
Cerebral aneurysms occur in many different locations, shapes and sizes, ranging from low risk (less than five millimetres) to high risk giant aneurysms (greater that twenty five millimetres). Surgical and endovascular options are available for treatment, including clipping, coiling and stenting. A new approach to aneurysm treatment includes the placement of a Pipeline Embolization Device (PED). Many patients who are high risk for rupture or are not candidates for invasive surgical treatment remain candidates for this less-invasive approach. Endovascular placement of this device requires entry through the femoral artery with pre and post placement anticoagulation. Patients are generally hospitalized for 24-48 hours and are cared for post procedure in an observation/step down unit setting. In order to provide optimal nursing care to these patients nurses require knowledge of the procedure, post procedure nursing care and routine follow up. Possible complications will be reviewed and a case study involving a 31-year-old female with a PICA aneurysm will be discussed.
A7
Neurometabolic Clinic and Palliative Care: An Important Alliance in the Continuum of Care
Lisa Pearlman
The Children’s Hospital London Health Sciences Centre offers a Neurometabolic Clinic to children with progressive life-limiting neurodegenerative disorders. The focus of the clinic is to support children and their families from the time of diagnosis, through investigation and follow-up. Many of these children present with rare disorders that result in severe cognitive and neurological impairment which increases their risk for ongoing, life-threatening co-morbidities and multiple hospitalizations. In January 2009, the Children’s Hospital funded a paediatric palliative care service. The intent of palliative care is to optimize quality of life in children with life-limiting and life-threatening diseases. Since its inception, 25% of the palliative care referrals originate from the Neurometabolic Clinic providing a foundation for collaborative practice in both the hospital, clinical and home settings to meet the unique needs of this patient population from the time of diagnosis, through to end of life and in bereavement. The goals of this presentation are (1) to focus on the specialization of neuro-palliative care in supporting paediatric neuroscience patients who present with degenerative diseases and their families (2) to draw attention to the need for neuroscience nurses to explore goals of care and lead families into discussions about advance care planning, and (3) to provide neuroscience nurses with an overview as to the pain and symptom management needs of children with neurometabolic disorders.
B7
How-to guide on becoming a Stroke prevention champion in your nursing practice
Aline Bourgoin
It is well known that stroke is a leading cause of disability in Canada. Caring for stroke survivors is a costly burden to the health care system. A large number of strokes can be prevented through the management of modifiable risk factors. The nurse specialists working in the Stroke Prevention clinic are leaders in Stroke prevention care through the identification and teaching of the management of their patient’s modifiable risk factors.
Stroke Prevention care does not solely need to happen after a primary stroke event. It is known that there is an increasing prevalence of obesity, diabetes and hypertension in the Canadian population, most importantly in our youth. Stroke prevention teaching can be applied along the continuum of stroke care by many nursing disciplines (i.e., medicine, surgery…). This presentation aims to discuss the application of the 2010 Best practice guidelines for stroke into nursing practice as well as assist nurses to integrate risk factor counselling in their daily patient care.
C7
The Learning Curve: Nurses’ Perceptions of Transforming from Acute Medicine Nursing into Stroke Nursing on an Acute Stroke Cohort Unit
Trudy Robertson
Background: In 2009, an acute medical unit at a regional stroke centre began the process of cohorting acute stroke patients based upon best practice recommendations for stroke care (Canadian Stroke Network; Heart & Stroke Foundation of Canada, 2010). For many unit team members, the decision to convert 10 acute medicine beds to a stroke cohort unit was an exciting opportunity to improve care and outcomes for stroke patients. For unit nurses however, developing expertise in stroke nursing and meeting best practice standards on a busy medical unit was met with apprehension and pessimism. The process of transforming acute medicine nurses into stroke nurses required planning, ongoing educational support, and supportive leadership.
Objective: To explore nurses’ perspectives of their comfort, educational needs, and ability to attain competency in stroke assessment and care prior to the opening of a stroke cohort unit. The needs expressed by nurses and the efficacy of education workshops, team conferencing and National Institutes of Health Stroke Scale (NIHSS) education, were examined to help guide educational and care planning.
Design: This 1 year study involved a convenience sample of 37 novice to expert registered nurses on a 30 bed acute medicine unit at an urban tertiary care hospital. Qualitative and quantitative data was collected at 3 group stroke workshops. Pre and post workshop questionnaires were used to gain self assessment of competency in clinical stroke assessments such as gaze, visual fields, language and neglect. Qualitative focus groups were held following the workshops to gain insights into nurses’ beliefs and their needs for attaining individual, team, and unit success.
Results: Results showed both novice and expert nurses rated their stroke assessment competencies prior to the educational sessions as low. Following the sessions, improvement in self assessment of competencies, confidence and optimism for success of the cohort unit was documented. Unit nurses rated their greatest needs as supportive leadership and continuing stroke education. They placed great importance on adequate nurse:patient ratios, having their voices heard, and being involved in decision-making.
D7
Clearing the RUNWAY: Nursing care for patients with implanted subdural electrodes
Marjorie Ryan
A subgroup of epilepsy patients who are "refractory to medical therapy" and have had inconclusive results in terms of investigations aimed at finding a seizure focus require recording closer to the source. Surgically implanted subdural electrode grids assist in determining the precise area of the brain which triggers seizures therefore providing valuable information to the surgeon for his final surgery. It will guide him/her to approach with the least amount of trauma to the brain.
The challenges nurses face are like no other, including care of the patient with craniotomy directly from the Recovery Room; care of the ictal and postictal patient who is permitted to seize a number of times before treatment is initiated; maintaining a clean surgical site which includes the external leads; ensuring the safety of a seizing patient with external leads that are within reach of their hands.
The nurse needs to be proficient in their knowledge and skills to care for the patient. They are the first link to avoiding and\or minimizing adverse complications. Their skills and critical thinking can significantly impact the outcome of the final surgical resection which will be an intricate and gratifying event guiding the patient down the runway to their Flight to Freedom.
A8
Nursing Management of Patients with Cavernomas
Herta Wai-Ham Yu, Patricia Rowe
Cavernous malformations (CMs) are considered benign vascular lesions within the central nervous system (CNS). The vessels of CMs lack the supportive musculature in normal blood vessels making CMs prone to micro-haemorrhages. The aetiology is unknown with either sporadic onset presentations or familial/hereditary tendencies. The treatment choices remain controversial and may include surgical removal, medical management, or conservative observation.
In general, patients with CM are asymptomatic or have only mild symptoms. On the other hand, many patients who present to hospital suffer massive hemorrhages followed with severe generalized or focal neurological deficits. This devastating experience can create great stress and anxiety for patients and their family and require much support, education, and expert quality care from a team perspective. Nurses caring for these patients in the acute care environment are in the prime position to collaborate and mobilize various health care team members to best support and address the individual care needs of this group of patients and their families.
This presentation will provide a brief overview of the pathophysiology and natural history of CM from the adult literature and how it translates into the pediatric population. The purpose of this presentation is to use a pediatric case review to illustrate the experiences of this disease in paediatrics and promote a discussion regarding how nurses can best help support and care for this patient population.
B8
The 5 Ws of Patient Education: When, What, Why, Whom and How is it being delivered?
Andrea Cole-Haskayne, Heather Layton, Michael Suddes, Christianne Krassman, Pia Lawrence, Devika Kashyap
There is evidence that the information and support needs of people affected by stroke are often not well met. Consistently meeting these needs requires healthcare providers to overcome several challenges including: cognitive impairment post stroke, language disorders, fatigue, staff time constraints, availability of family members or caregivers; and the knowledge level, training, and confidence of staff in delivering education. Educational or support interventions have not traditionally been charted or documented in a consistent, comprehensive or timely manner, but are key to neuroscience nursing practice.
Based upon Canadian Stroke Strategy best practice recommendations, Accreditation Canada’s ‘Stroke Service of Distinction Award’ incorporates specific patient education standards. Improvement opportunities within our Stroke Program were identified in the process of successfully being assessed against these standards. This presentation will describe a quality improvement project.
We will present an overview of the evidence surrounding the need, structure and deliverables of the project, and outcomes with respect to evidence of quality improvements as measured by patient and staff satisfaction through surveys and focus groups, electronic charting compliance and qualitative data on the experience of patients and providers.
C8
Missing the Boat? Neuroscience Nurses and Chronic Disease Management
Nancy Thornton
Although neuroscience nurses typically encounter neurological conditions in an acute care context, many neurological conditions are chronic in nature, and successful treatment would benefit from a chronic disease management approach. There is evidence that chronic disease self-management can result in both improved health outcomes for people with chronic health conditions, and reduced health care costs (Lorig et al, 2001; Ahmed et al, 2010).
While this method of healthcare delivery is common for conditions like diabetes and asthma, it is not a framework typically used for neurological conditions.
The purpose of this presentation is to introduce the neuroscience nurse to:
- an overview of the “lived experience” of chronic illness as reported in the literature
- the power of our communications with people living with chronic illness
- key components of successful chronic disease self-management
- an argument for partnering with patients and families in chronic disease self-management
D8
Sleep Disordered Breathing Patterns in Neuro Patients
Linda Smith
Sleep disordered breathing patterns (SDBP) refer to phenomena of airway narrowing or collapse that occurs during sleep and includes disorders such as primary snoring, and obstructive and mixed sleep apnoeas. Patients with SDBP demonstrate symptoms during the day (excessive daytime sleepiness and poor performance in the workplace and for tasks that require optimal attention, such as driving a motor vehicle) and night (habitual loud snoring, choking during sleep, apnoea periods and abnormal motor activities). Untreated SDBP’s are associated with an increase in morbidity secondary to short term and long term consequences. Patients with a neurological disorder are at higher risk of developing sleep disordered breathing patterns as a consequence of their disease process (Chokroverty, 2010). As well, people with sleep disordered breathing patterns, are at higher risk of developing certain neurological conditions, i.e. stroke (ischemic and hemorrhagic) (Yaggi, et al, 2005: Yantis, Neatherlin, 2005), and traumatic brain injuries (Tregear, et al, 2009).
This session will review the conditions associated with sleep disordered breathing patterns including: primary snoring, obstructive, central and mixed sleep apneas, and narcolepsy. The signs and symptoms, pathophysiology, screening questions, and definitive testing strategies for diagnosis will be highlighted. The main focus of the presentation will examine the nursing implications and management strategies for adult neurosciences patients including, continuous positive pressure ventilation (CPAP) and bi-level positive pressure ventilation (BiPAP).
A9
Moyamoya: Some things do run in the family
Ivanna Yau, Patricia Rowe
Moyamoya disease is a unique cerebrovascular disorder characterized by progressive stenosis and/or occlusion of the internal carotid arteries and their main branches. Reduction in blood flow leads to the formation of abnormal dilated collateral vessels in attempt to re-establish perfusion. On angiography these vessels produce the unusual appearance described as a “puff of smoke”. It is becoming more widely recognized as a cause of stroke and/or transient ischemic attacks in both pediatric and adult patients. The incidence peaks in two age groups: children in the first decade of life and adults in their mid 40s. There is a 2:1, female to male predominance. High incidence is noted in Asia, especially in Japan. The natural history of untreated moyamoya disease is poor. The etiology of moyamoya disease is wide, although there has been a familial link in 10—15% of cases. This presentation will review: epidemiology, pathology, clinical presentation, diagnosis/testing, treatment options and natural progression of the disease. Our focus will primarily be on familial moyamoya disease. We will share our experience with a family that has multiple members with moyamoya disease, the impact that this diagnosis has had on them, and explore some strategies for nurses to help support families with this diagnosis.
B9
Social disadvantage and stroke prevention
Sarah Flogen
People who experience an episode of neurovascular impairment, such as slurred speech or sudden weakness, may be experiencing a transient ischemic attack or minor stroke. The risk of recurrent stroke in the week after a TIA or minor stroke is 10%. The urgent goal of treatment for patients with these symptoms is stroke prevention through patient self-management of risk factors. Standardized recommendations for lifestyle change are provided to a population that, in Ontario, is socially and economically diverse. The socially disadvantaged are known to carry more burden of disease, are asked to modify risk factors and change their lifestyle, yet without the social or financial means to do so. This presentation will empirically examine and describe the preliminary findings of a doctoral research study that explores the experience of socially less advantaged Torontonians who experience a possible TIA or minor stroke as they navigate the stroke system and the standardized recommendations they receive. Participants who attend this presentation will gain insights into the experience of less advantaged people, and begin to critically evaluate the recommendations made to TIA patients.
C9
Improving Oral Care on Acute Neuroscience Inpatient Units: An Interdisciplinary Collaboration
Christianne Krassman, Kevin Lindland, Andrea Cole-Haskayne, Pia Lawrence, Burke Lintell, Sandra Jensen, Brenda Pullar
The acute neuroscience patient population is often unable, for physical and/or cognitive reasons, to perform adequate oral care. Poor oral hygiene in this population leads to increased presence of respiratory pathogens in oropharyngeal secretions, thus placing neuroscience patients at increased risk of developing aspiration pneumonia.
This interdisciplinary team was formed to develop and pilot an evidence-based oral care protocol on two acute inpatient neuroscience program units. The team’s project plan includes: adoption of an oral cavity assessment tool to identify frequency of oral care required; identify patients who are at risk for aspiration and provide them with suction-based care; provide nursing staff with education on the impact of poor oral hygiene; training of nursing staff by dental hygienists on provision of effective oral care to dependent patients; access to necessary oral care supplies; and incorporate documentation of oral assessment and care in unit patient care flow sheets.
The presentation will discuss the important role oral hygiene plays in ensuring positive outcomes for hospitalized neuroscience patients, as well as display the adapted oral assessment tool, algorithm to determine aspiration risk, flow sheet documentation, and quantitative data collected on the care delivered over the 6 month pilot period.
D9
DIPG: a Pediatric Brain Tumour in an Adult
Jodi Dusik Sharpe
Diffuse Intrinsic Pontine Glioma, or DIPG, is a high grade, malignant, brainstem tumour typically presenting in children between the ages of 5–10 years. Symptom presentation to diagnosis is of short duration given the rapid growth of these tumour cells. Considered a WHO grade 4 tumour, the prognostic outlook is grim with limited treatment options. Surgical excision is contraindicated given the anatomical structures whereby the tumour invades, and less than 25% of patients with a DIPG have a surgical biopsy for pathological diagnosis. Diagnosis is determined by a patients neurological status and radiographic imaging. Diffuse Intrinsic Pontine Glioma, four words that carry a devastating diagnosis with a challenging sequelae of neurological symtomatology. The nursing implications holistically encompass caring for the patient and their family, assessment of and interdisciplinary management of neurological compromise and adjuvant therapy; and eventual palliation. Though rarely observed in the adult population, this presentation will follow the clinical course of a 23 year old man and his family who face this devastating and lethal diagnosis with determination and perseverance.
A10
Lived Experience, Difficulties and Needs of Patients with Myotonic Dystrophy According to Disease Severity and Living Situation: Implications for Nurse Case Manager
Maud-Christine Chouinard, Cynthia Gagnon, Danielle Maltais, Melissa Lavoie
Nurses working with patients suffering from Myotonic Dystrophy Type 1 (DM1) can only partially understand what it is like to live with this complex neuromuscular disorder. Little is known about lived experience, difficulties and needs of the DM1 patients. Furthermore, their experience can vary greatly depending on the disease’s severity and on their conditions of living. The objective of this study was to describe how the disease affects the lives of DM1 patients according to the severity of the disease and the types of household. Within the context of a descriptive qualitative approach, 38 participants representing the different DM1 phenotypes and kinds of household were interviewed. Interview transcripts indicate that most of participants perceive having an adequate level of autonomy even if they say that they have poor health. The most troublesome problems that they live with are physical pain, fatigue and hypersomnolence; but these problems vary according to the disease severity. Participants living alone greatly depend on their relatives for their activities of daily living. Participants living with other people have more opportunities to make outside activities. This presentation outlines the impacts of DM1 in the patients’ lives and emphasizes the importance of considering the patient’s perspective in the nurse follow-up.
B10
Stroke 101: Delivering stroke education for prevention of first stroke (primary) or subsequent stroke (secondary) in the community
Andrea Cole-Haskayne, Ev Glasser, Michael Suddes
Stroke 101 is an educational program developed and delivered by neuroscience nurses in alignment with current best practice standards, and a goal of the Alberta Provincial Stroke Strategy, ‘to reduce the rate which individuals have stroke in Alberta’ Stroke 101 is a 2 hour interactive workshop delivered in the community in partnership with Chronic Disease Management (CDM) services. The class covers: types of stroke, recognizing and reacting to the signs of stroke, and risk factors. Participants assess their risk, and initialize development of a personalized action plan to reduce their risk. Maximum class size of 20 enhances interaction allowing participants to obtain feedback.
Stroke 101 has proven to be a popular program with those who are at risk of stroke or wanting to learn more about stroke and how to prevent it. Evaluation feedback from 9 cohorts has been overwhelmingly positive.
The purpose of this presentation is to present the outcomes, successes and challenges of this new program and describe initiatives aimed at increasing recruitment.
C10
Climbing that Mountain to Patient Adherence: Motivational Interviewing (MI)
Cheryl Mayer
Changing behaviour requires time, effort and motivation. Yet, for many of our clients/patients who have suffered a stroke, wishing to adopt healthier lifestyles (changing diet, smoking cessation, substance abuse, medication/regimen adherence, physical activity), change seems to be out of reach. For the relatively cognitive intact person, MI is a directive, client-centered counseling style for eliciting behaviour change by helping clients explore and resolve ambivalence (Miller, 1997). Compared with nondirective counselling, the style is focused and goal-directed. By seeking to understand the client’s frame of reference through reflective listening, by expressing acceptance and affirmation, and by monitoring the degree of readiness to change, the neuroscience nurse is able to facilitate behavioural change needed to live well with, not only stroke but with any condition. Neuroscience nurses deal each day with patients who are resistant to following a regimen(s). Motivational Interviewing, as a patient-centered communication style, adds one more strategy to the neuroscience nurse’s tool box to help facilitate the shifting of the client/patient’s behaviour from ambivalence and dependence to insight and independence. The presentation will focus on the benefit of using a communication style such as motivational interviewing when promoting adherence to regimens within the neuroscience patient population.
D10
Pre-emptive Spasticity Management: For Therapists and Nurses in Acute Neurosciences
Tina Moran
Spasticity as a result of brain or spinal cord injury is a significant problem. Adverse effects related to spasticity include functional impairment, pain, contracture and pressure sores. These in turn significantly restrict a patient’s ability to return to activities of daily living, and make nursing care tasks such as bathing and changing extremely difficult. Research to date has been primarily focused on the efficacy of treatment once a contracture or other significant symptoms have formed. Traditional pre-emptive treatments, such as systemic medication and stretching, have had limited success in preventing contractures and pain. There is also a gap in the research for this pre-emptive stage. In Acute Neurosciences at Royal Columbian Hospital we have been trialing a new pre-emptive approach with our acquired brain injury patients who are at risk for spasticity. Our pre-emptive approach includes the use of physical devices, such as cast boots, alternative positioning and pre-emptive botox. The success of this approach is dependent on neuroscience nurses, therapists, and physiatry working as a team. These interventions are patient specific and often require 24/7 application; thus nursing plays a significant role in supporting the success of this pre-emptive approach. So far, anecdotally we have had successful clinical results. We are now moving forward with a formal research study. This purpose of this presentation is to discuss our innovative approach to spasticity management, and to shift focus from the traditional corrective approach to a primarily pre-emptive approach.
B11
An inpatient stroke protocol that provides safe and effective emergency care
Cathy McKim, Dawn Bien-Aime
Stroke is a medical emergency. Treatment with the fibrinolytic agent tPA can significantly improve the health outcomes of stroke patients. In Canada, stroke thrombolysis with tPA was approved for use in 1999 and has since become standard of care for the treatment of ischemic strokes within 4.5 hours of symptom onset.
At The Ottawa Hospital, a Stroke Code process in the Emergency has been in effect for more than a decade. The Emergency Department protocol has had a tremendous impact on the quick access to this time-dependent therapy. However, recognizing that the emergency department is not the only location within the hospital where stroke may present, members of the stroke team realized that a similar emergency response was required for inpatients that experienced an acute ischemic stroke. Neuroscience nurses are part of the team that provides therapy to all eligible stroke clients, and as such require an expanded knowledge base related to emergency stroke treatment.
This presentation will review Stroke Code rationale, inclusion/exclusion criteria, delivery and monitoring procedures that have evolved into the Inpatient Stroke Code protocol within The Ottawa Hospital.
C11
When the Right Brain goes Wrong… the Wheels are not Turning Right
Isabelle Martineau, Karen Mallet
The brain is the most complex part of the human body. Although the two hemispheres seem to be mirror images of each other, the functions attributed to each half of the brain are very distinct. Each hemisphere has functional specializations meaning that one hemisphere exerts more control over a particular function than the other does. This phenomenon is called brain lateralization.
The brain hemisphere in which the main language abilities reside, which includes the formulation and understanding meaning of words and sentences, is usually referred to as the “dominant” hemisphere. For the vast majority of right-handed persons, and actually many left-handers, this type of language abilities lateralizes to the left hemisphere.
While the communication deficits concomitant with left hemisphere damage can be identified by difficulties of phonological, synthetic, and semantic language known as aphasia, the communication problems following right hemisphere damage are often less perceptible. As a result, these deficits may go undiagnosed, attributed to confusion or as being emotional in origin. This presentation will explore the domains of the right hemisphere, from perceptual, communication, and cognition and the effect of dysfunction on the lives of patient with right hemispheric strokes. Nursing approaches to caring for these patients will be examined.
D11
MuSK antibody Myasthenia Gravis: How is it different?
Wilma J. Koopman, Mike W. Nicolle
Acquired myasthenia gravis (MG) is a rare autoimmune disorder of neuromuscular transmission. In most cases, the acetycholine receptor (AChR) is the target of the autoimmune attack, whereas in others it may be non-AChR components such as the muscle-specific tyrosine kinase (MuSK) receptor. Fluctuating skeletal muscle weakness is the hallmark of MG. The clinical features may vary in AChR and MuSK positive disease. Management of MuSK positive MG patients is often difficult due to its preferential bulbar involvement and increased severity compared to MG associated with AChR antibodies.
The aim of this presentation is to highlight the clinical features, and treatment challenges of MuSK positive MG. A case of a young woman with MuSK MG will be used to illustrate this relatively new entity. Treatment of this condition includes immunosuppressive agents (Prednisone, Azathioprine, and Mycophenolate) and Intravenous Immunoglobulin and plasmapheresis. Despite years of treatment, this individual’s clinical course progressed such that she was dependent on BiPAP for up to 16 hours per day to support her chronic respiratory involvement. Rituximab has been used in refractory MG although is not funded in Ontario. Following application and lobbying of government officials funding for Rituximab was received. This presentation will conclude with our experience of using Rituximab in MG and the implications for neuroscience nurses who provide care to these individuals.
Abstracts for poster presentations
Stroke Early Supported Discharge Team
Shy Amlani, Gillian Turner
Early rehabilitation of stroke patients is a widely held and well-documented tenet of stroke care (Stroke. 2008). However, it may not be appropriate for many patients who have experienced stroke to remain in hospital once through the acute stroke phase. The Stroke Early Supported Discharge (SESD) program provides rehabilitation to stroke survivors in their homes. Appropriately resourced SESD programs are cost efficient and clinically effective, significantly reducing length of acute hospital stay (Lancet, 2005). A systematic review of randomized control trials of similar programs identified that stroke patients demonstrated equal, if not better recovery, as a result of receiving treatment in their own homes rather than in hospital, and that hospital length of stay was decreased on average by one week (Shepard et al., 2010). In the Edmonton Zone, more than 90% of patients report positive outcomes on this program. While the Edmonton Zone SESD was not structured to have nursing on the team, we believe the work of the SESD has a significant, positive impact on stroke nurses, as they are able to discharge stroke patients to their home environment more quickly, knowing that the SESD team is there to provide the necessary bridge between acute care and community reintegration.
Adverse Effects and Quality of Life in Individuals Treated with IVIG for a Myasthenia Gravis Crisis
Wilma Koopman, Nicole LeBlanc, Kurt Kimpinski, Michael Nicolle
In myasthenia gravis (MG), antibodies against acetylcholine receptors (AChRs) impair neuromuscular transmission, producing muscle weakness. Although variable in its presentation, the clinical hallmark of MG is that of fatigable weakness of skeletal muscles. Bulbar involvement produces difficulty chewing, dysphagia, and dysphonia. Respiratory involvement, which is a result of weakness of the diaphragm and intercostal muscles, results in exertional dyspnea and orthopnea. Individuals with bulbar and/or respiratory involvement would be considered to be in crises.
Intravenous immunoglobulin (IVIg) is used to treat MG crises. Although there is considerable evidence that IVIg is an effective treatment, there is little evidence of how it works in MG. This study will report the findings related to the adverse effects and quality of life in patients in MG crisis following the administration of IVIg.
A total of 21 patients (14 males, seven females) were studied. Self-reported adverse effects and quality of life (as measured by SF-36) were reported prospectively at baseline and three defined intervals after treatment (10 days, 28 days, and 12 weeks). The most commonly reported adverse effects were fever, headache, and back pain, each of which improved over the course of the study. Quality of life results are pending. Nurses caring for MG patients during a crisis requiring treatment with IVIG will be able to use the results of this study to educate and support their clients and families.
Telestroke in Alberta: RNs Help to Bring Stroke Care Close to Home for Albertans
Shy Amlani, Ashfaq Shuaib, Josephine Amelio, Colleen Taralson
Nursing practice in Telehealth is consistent with the philosophy and approach of primary health care, enhancing the application of principles of the Canada Health Act such as comprehensiveness, universality and accessibility (Canadian Nurses Associaiton). We hope to demonstrate the importance of stroke clinic nurses in Telestroke follow-up visits.
Nurse coordinators in the Edmonton Stroke Prevention Clinics incorporate Telestroke visits into the daily clinic schedule. The nurse coordinators are responsible for full medical histories, background on the presenting concern, reviewing patient medications, recording vital signs taken at the peripheral sites and gathering information on the current status of the patient. They provide extensive teaching on risk factor management and may refer the patient for appropriate follow-up with other healthcare providers. Nurse coordinators will also ensure that the physician orders are processed and executed.
Since 2003–2004, the number of Telestroke visits has grown from 20 per year to 500. Ninety-seven per cent of patients are satisfied with the quality of care they receive through Telestroke. Patients report a greater sense of control in scheduling, significant monetary and time savings, and reduced stress. Telestroke delivers both clinical and administrative results. The nurse coordinators in Edmonton’s three Stroke Prevention Clinics are working to ensure Telestroke visits become as routine and effective as face-to-face encounters.
“MUST-TOC”—MUltiple Sclerosis Team for Transition of Care: Pediatric to Adult Setting
Diane Lowden, Amit Bar-Or, Diana D’addio, Heather Davies, Marie‑Emmanuelle Dilenge, Dale Macdonald, Sarah Meffe, Serena Slater, Genevieve Tousignant
Up to 10% of individuals with multiple sclerosis (MS) experience their first symptoms before the age of 18 (Venkateswaran & Banwell, 2010). Children with MS approaching adulthood need to build skills in self-management of symptoms and treatments, achieve developmental tasks independently and acquire expertise within a new health care system, in preparation for transfer to the adult setting. In our tertiary care health centre, a multidisciplinary, cross-site team of pediatric and adult MS specialists, including neurologists, clinical nurse specialists (CNS) and social workers have developed a coordinated program to transition adolescents from the pediatric to adult MS program, with the support of a hospital transition advisor. The CNSs have had a key role in identifying gaps in service, suggesting evidence-based strategies to support transition rather than transfer and using their knowledge of adolescent to adult development in nursing assessments and interventions with individuals and families. An algorithm detailing age-related actions and responsibilities of team members provides guidance for a consistent and coordinated transition plan. Joint MS clinics, held with the neurologists and CNSs, enhance the efficacy of information transfer, facilitate the development and sharing of care plans, and enable the implementation of new therapeutic alliances with adolescents prior to transfer. Age-appropriate transition checklists assess the readiness for transfer and detail the self-care skills to be developed. Future initiatives planned with the MUST-TOC group include the development of a “Patient Passport” of health information and a satisfaction questionnaire. This novel program has provided a way to ensure that transition occurs by design rather than by default for adolescents with MS and their families.
Improving Oral Care on Acute Neuroscience Inpatient Units: An Interdisciplinary Collaboration
Christianne Krassman, Kevin Lindland, Andrea Cole-Haskayne, Pia Lawrence, Burke Lintell, Sandra Jensen, Brenda Pullar
The acute neuroscience patient population is often unable, for physical and/or cognitive reasons, to perform adequate oral care. Poor oral hygiene in this population leads to increased presence of respiratory pathogens in oropharyngeal secretions, thus placing patients at increased risk of developing aspiration pneumonia.
This interdisciplinary team was formed to develop and pilot an evidence-based oral care protocol on two acute inpatient neuroscience program units. The team’s project plan includes: adoption of an oral cavity assessment tool to identify frequency of oral care required; identify patients who are at risk for aspiration and provide them with suction-based care; provide nursing staff with education on the impact of poor oral hygiene; training of nursing staff by dental hygienists on provision of effective oral care to dependent patients; access to necessary oral care supplies; and incorporate documentation of oral assessment and care in unit patient care flow sheets.
The poster presentation will discuss the important role oral hygiene plays in ensuring positive outcomes for hospitalized neuroscience patients, as well as display the adapted oral assessment tool, algorithm to determine aspiration risk, flow sheet documentation, and quantitative data collected on the care delivered over the six-month pilot period.
In-hospital strokes: Where are they, and how can we improve care?
Andrea Cole-Haskayne, Nancy Newcommon, Michael Suddes, Nandavar Shobha, Kelly Roy, Michael D. Hill
Everyday in Canada, patients admitted for a variety of conditions suffer devastating strokes. Minimal literature exists on in hospital stroke, although evidence suggests that access to hyperacute care and other best practices is poorer for these individuals (Canadian Stroke Strategy, 2010).
Extensive stroke education based on best practice recommendations has been done with EMS, emergency room, stroke unit and neurosciences staff. Education for health care providers working in other specialties has been historically focused on areas thought to have a high incidence of in-hospital stroke.
In an effort to better understand where our in hospital strokes were occurring, a review of administrative databases was conducted to identify all patients admitted with a secondary diagnosis of stroke from April 2002 to March 2009. Most in hospital strokes at our three acute hospitals occurred on general medical units (28.1%), cardiology (11.1%) and cardiac surgery (10.5%).
This poster will present our findings and our education plan to focus resources on those areas where in-hospital stroke is more prevalent. The goal is that nurses and other staff will be aware of current stroke best practice recommendations, recognize and respond to in-hospital stroke earlier and prevent complications, thereby improving patient outcomes.
Self-Efficacy for Motivational Interviewing Among Health Care Providers
Cheryl Mayer, Gina Tomaszewski
As neuroscience clients move toward the chronic stage of illness, ambivalence for change becomes a hurdle. Clients are either not ready to change or unsure of how to incorporate change into their daily routines. Motivational Interviewing (MI)is a directive, client-centred counselling style for eliciting behaviour change by helping clients explore and resolve ambivalence (Miller, 1997). The effect of health care providers’ confidence to communicate with patients after attending a three-day certificate program in Motivational Interviewing was examined. This was a quasi experimental design in which health care providers (N=35), of which 16 were registered nurses from the Southwestern Ontario region, completed questionnaires immediately after day two and day three. The Health Promotion Counseling Self-Efficacy Scale (Tresolini, Saluja, & Stritter, 1995) was adapted and used to capture the participants self-report of self-efficacy. Overall, self-efficacy levels for both knowledge and ability to apply strategies used in motivational interviewing increased. The certificate program implications for neuroscience nursing practice include an increase in the nurses’ knowledge and ability to use motivational interviewing in nursing practice.