Date of Award
Spring 6-7-2024
Scholarly Projects
Projects: SPU Access Only
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
Faculty Chair
Dr. Heidi Monroe
Faculty Reader
NA
Faculty Reader
NA
Executive Summary
Executive Summary
Title: Evaluating Consent With Emergency Treatment of Ischemic Stroke
Background & Significance: According to the American Stroke Association (ASA) (n.d.), stroke is currently the leading cause of disability and the fifth cause of death in the United States. According to the ASA (n.d.), 87% of all strokes are ischemic in nature, meaning a vessel in the brain is obstructed, limiting oxygen to the surrounding portions of the brain and causing the potential for disability and death. Previous research tells us that ‘time is brain’ and that faster treatments for acute ischemic stroke patients correlate with better patient outcomes (Powers et al., 2019). One of the treatments offered for those in the community suffering from an ischemic stroke is emergent mechanical thrombectomy, also known as endovascular treatment. The evaluation of these patients is expedited at every possible turn in the hopes of preserving as much brain tissue as possible (ASA, n.d.). Current standard of care practice is to attempt to gain consent from the patient, who is often suffering from major stroke deficits and unable to understand, or the family of the patient who may not be present; two-physician emergency consent is typically utilized when informed consent cannot be obtained in a timely manner; in these emergent situations, it is assumed patients would want an intervention that would likely prevent further disability, reverse current deficits or prevent death (Lindley et al., 2021).
Problem & Purpose Statement: The problem is that emergency treatment for ischemic stroke could be delayed due to attempts to gain consent from a patient who may not have the capacity to understand or the next of kin who may not be available for consent, both of which take valuable time. When there are delays in endovascular treatment for ischemic stroke patients, outcomes are worse (ASA, 2019). Using two-physician emergency consent instead of attempting patient or family consent needs to be researched to measure if time to treatment is reduced and patient outcomes are improved. This project evaluated if there was a difference in arrival to treatment times of ischemic stroke patients undergoing mechanical thrombectomy for patients who had a patient or family consent versus a two-physician emergency consent. It was designed as a pilot study to identify limitations and recommendations for carrying out a larger study in the future.
Methods: This project was a quantitative study; the numerical values of arrival to intervention time were utilized for analysis. The arrival to puncture times were separated into the two categories of patient or family consent and two-physician emergency consent. These data points were then used for comparison via independent t-test. Type of arrival, age, and sex were used as demographic data.
Results/Outcomes: This pilot project found that there was no statistically significant difference between the times from arrival to treatment for the different groups, two-physician emergency consent versus patient or family consent. The 54 patients with two-physician emergency consent (M = 53.5, SD = 47.3) compared to the 289 patients with patient or family consent (M = 73.1, SD = 88.9) did not demonstrate significantly more or less time from arrival to treatment. The p value was 0.12; therefore, it is not significant because it does not reach the threshold of p less than 0.05. The study failed to reject the null hypothesis that there is no difference or association between variables that is any greater or less than would be expected by chance. The variance of two-physician emergency consent was 2241, while the variance of patient or family consent was 7906; therefore, the ratio of the larger variance to the smaller variance was less than four, meaning the variances are approximately equal and a student t-test should be performed. This means that between the groups, the variance was similar to the differences within each individual group. Although the sample sizes of each group, 54 and 289, are greatly different in size, their variance within them was approximately equal, meaning the variation is what one would expect by chance.
Sustainability: The possibility of future work in this area is achievable as the stroke program coordinator already collects most of the data utilized for this study. However, manual chart audits must be conducted when determining which type of consent was used for each patient. This process took anywhere from one to five minutes per patient. Most of the patient consent forms were easy to find in the chart and could be determined quickly. While it is unfortunate this data cannot be automatically generated from the electronic medical record as the rest can, the time taken to find this information was reasonable. The Regional Director of Stroke Services and Director of Neurointerventional Surgery continue to be interested in this practice question and believe the potential answer could be of value to the Comprehensive Stroke Center in further decreasing the arrival to treatment times for endovascular intervention patients. However, the facility would need to assess if and how a future study would be most beneficial to evaluate and improve their current practice.
Implications: The first recommendation for a future study would be to obtain a larger sample size in order to give more rigor to results. This would decrease the likelihood of a type two error which can occur when there is not enough power to find an association that truly exists. A second recommendation would be to only evaluate ‘direct admit’ patient charts as these patients have an increased likelihood of increased time taken for the consent process. Patients deemed a ‘field admit’ come from an outside facility where there is added time for providers to gain consent from family over the phone while waiting for the patient to arrive. Lastly, a third party could document the specific amount of time taken when a provider gains consent from a patient, family, or when utilizing two-physician emergency. This pilot study did not directly aim to reduce death and disability of ischemic stroke patients. However, the hope is that evaluating if added time is taken during the consent process and potentially reducing that time would have an impact on patient outcomes. It is possible that just posing this question and educating on its results will have an impact on those involved in the process of obtaining consent. Physicians may attempt to eliminate any barrier that could slow the consent process in their own practice. They may also move to two-physician emergency consent earlier than they have in the past. Finally, the goal of this pilot study was to support the idea of a future study to further evaluate if consent plays a role in the difference of arrival to treatment time. Results discussed here suggest that further research is needed to fully explore this question.
References:
American Stroke Association. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke. https://www.stroke.org/-/media/Stroke-Files/Ischemic-Stroke-Professional-Materials/AIS-Toolkit/Guidelines-for-Mangaging-Patients-with-AIS-2019-Update-to-2018-Guidelines.pdf
American Stroke Association. (n.d.). About stroke. https://www.stroke.org/en/about-stroke
Lindley, R. I., Kane, I., Cohen, G. & Sandercock, P. A. (2021). Factors influencing the use of different methods of consent in a randomized acute stroke trial: The third international stroke trial (IST-3). International Journal of Stroke, 17(5), 553-558. https://doi.org/10.1177/17474930211037123
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., Brown, M., Demaerschalk, B. M., Hoh, B., Jauch, E. C., Kidwell, C. S., Leslie-Mazwi, T. M. Ovbiagele, B., Scott, P. A., Sheth, K. N., Southerland, A. M., Summers, D. V., Tirschwell, D. L., & the American Heart Association Stroke Council. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50(12), 344-418. https://doi.org/10.1161/STR.0000000000000211
Recommended Citation
Driscoll, Sara Colleen Babcock, "Evaluating Consent With Emergency Treatment of Ischemic Stroke" (2024). Doctor of Nursing Practice (DNP) Scholarly Projects. 68.
https://digitalcommons.spu.edu/shs_dnp/68
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