Retrospective Study to Assess the Risk Factors in Ischemic Stroke Patients for Critical Care Intervention Post-Treatment with Intravenous Plasminogen Activator

Retrospective Study to Assess the Risk Factors in Ischemic Stroke Patients for Critical Care Intervention Post-Treatment with Intravenous Plasminogen Activator

Introduction

Ischemic stroke health condition is among the deadly diseases that health practitioners are working hard to find the appropriate treatment. Health practitioners use different procedures, such as endovascular therapy and plasminogen activator in acute stroke. Goyal, Demchuk, Menon, Eesa, Rempel, Thornton & Dowlatshahi (2015) claim that many victims of ischemic stroke rarely survive, while those who survive experience difficulties in regaining their functional independence. Studying the risk factors and patients profile equips health practitioners with vital knowledge in determining the treatment procedure that can reduce adverse post-treatment outcomes as well as strategize on the provision and right use of resources to improve patient care. As claimed by Faigle, Sharrief, Marsh, Llinas & Urrutia (2014), Ischemic stroke has claimed many lives, especially older adults aged 60 years and above. More importantly, despite the cost, experts suggest intravenous thrombolysis and tissue plasminogen activator are the most appropriate treatment approved for stroke. Thus, Faigle et al. (2014) reveal that patient profiling can help practitioners in identifying the patients that require critical care need and post-treatment from others to ensure the appropriate use of resources. Perhaps, practitioners will be in a better position to free resources for patients with high-risk factors by transferring those with less risk factor from critical care units (Jauch, Saver, Adams Jr, Bruno, Connors, Demaerschalk & Scott, 2013). As claimed by Nishijima, Shahlaie, Echeverri & Holmes (2012), patients profile, which assists in separating patients as per their need, can help in the management of the available resources and reduce the cost of treatment.

Background

Many Saudi Arabians are experiencing a financial crisis as they treat Ischemic stroke patients, yet the majority do not survive, while survivors end up with disabilities. Consequently, health experts have tried hard to discover suitable treatment and also find ways to minimize treatment costs so that many can afford such treatments. Notably, several health practitioners have identified intravenous tissue plasminogen activator in conjunction with critical care intervention to be among the best treatment for ischemic stroke. Inversely, the procedure is expensive, which calls for further strategies to reduce the cost. Eventually, the research identified the existing gap in evaluating risk factors, which can be done through patient profiling to improve patient care while minimizing treatment costs. Thus, the research intends to fill that gap by conduction and retrospective study on risk factors of ischemic stroke patients.

Literature Review

The elderly population is at high risk of ischemic stroke, which is devastating, expensive, deadly, and also causes disability. However, the disease can also affect younger people. According to Sadeghi-Hokmabadi, Farhoudi, Taheraghdam, Hashemilar, Savadi-Osguei, Rikhtegar & Mirnour (2016), ischemic stroke is the second illness in the world claiming many lives. More so, burden-wise is ranked sixth and expected to worsen further by the year 2020. For that matter, scholars have written about various treatment methods that health professionals use to treat acute stroke. Goyal et al. (2015) suggest that endovascular treatment on top of standard care is among the best stroke therapy. It uses thrombectomy and thrombolysis technology, which is an expensive process for ordinary people to afford.

On the other hand, Faigle et al. (2014) claim that Intravenous tissue plasminogen activator as the best treatment, which is also expensive. Besides, implementation of such therapy remains a challenge due to financial burden, prolonged time taken to transfer patients to the emergency department, shortage of proper facilities, and fear of side effect by both physician and patients, and more importantly, thrombolytic therapy efficiency doubts (Sadeghi-Hokmabadi et al. 2016). Additionally, both treatment requires critical care and close follow up. Thus, in the event of large numbers of such patients, the quality of care reduces, which increase mortality rate. Hence, the need to update the patient profile by recording risk factors of every patient to identify and separate those who need critical care services from others (Jauch et al., 2013). Nishijima et al. (2012) reveal that patient profiling will enable practitioners to utilize resources according to patient needs, thereby improving patient care. Concurrently, it is significant to update patients’ treatment/health history, bearing in mind that a slight mistake in the update can lead to a substantial impact on the patient because practitioners relay on them when determining the treatment procedure of a patient. On that note, there are some cases where practitioners give patients intravenous tissue plasminogen activator to treat acute stroke yet the patient is suffering from stroke mimic, which adds extra treatment cost to reverse on top of the expensive acute treatment (Goyal, Male, Al Wafai, Bellamkonda & Zand, 2015). According to Dong, Cao, Ren, Nair, Parker, Jahnel & Upadhyaya (2015), it is crucial to note that risk factors together with stroke subtypes affect the outcome of intravenous tissue plasminogen activator treatment. For example, a patient with a risk factor (diabetes mellitus) has a high chance of registering a negative intravenous treatment results, which can even lead to death or more complications. As claimed by Sadeghi-Hokmabadi et al. (2016), it is paramount to consider patients’ risk factors, especially in developing countries where there are no adequate facilities so that the few available can handle patients of high need.

Subsequently, many nurses understand risk factors and patients profiling, which help in decongesting critical care units by giving critical patients priorities. According to Löwhagen Hendén, Rentzos, Karlsson, Rosengren, Sundeman, Reinsfelt & Ricksten (2015), stroke patients getting overall anesthesia for endovascular treatment should as well receive post-treatment in critical care unit since their neurological results are worse than for those getting conscious sedation. Philip-Ephraim, Charidimou, Williams, Otu, Eyong & Ephraim (2015) reveal that patient profiling is vital in improving patients care because it helps in identifying and analyzing different risk factors ranging from tradition to novel. For example, patients’ profiles can help in evaluating the effect of post-treatment for antiplatelet therapy patients who mostly react negatively with tissue plasminogen activator when the ischemic stroke occurs (Xian, Federspiel, Grau-Sepulveda, Hernandez, Schwamm, Bhatt & Bettger, 2016). On that account, after analyzing such factors, the practitioner can be in a better position to come up with the most appropriate procedure and avoid medication error that would harm the patient, despite many advantages of intravenous plasminogen activator in stroke treatments. Hence, the need for proper research on patient profiling.

Nevertheless, health policymakers should come up with programs such as training that can help people counter stroke illnesses. As revealed by Palazzo, Brooks, James, Moore, Alexandrov & Alexandrov (2016), stroke requires early intervention therapy such as zero degree head on the bed, which of course, will need close monitoring. Hence, the need to address patient profiling to facilitate the creation of enough room in the critical care unit for patients with high demand. It can as well help patients with high post-treatment risk, such as Pneumonia, which is among the leading causes of post-stroke treatment death due to its comorbidity. Arboix (2015) suggests that people should seek proper treatment for cardiovascular diseases because it causes stroke and reoccurrence to a previously healed patient. However, researchers should study further on some non-modifying risk factors such as age and sex, which limit patients to receive intravenous tissue plasminogen activator (Madsen, Khoury, Alwell, Moomaw, Kissela, De Los Rios La Rosa & Ferioli, 2015). For example, women suffering from hypertension have illegibility limits to receive tissue plasminogen, which leaves them undertreated, yet hypertension is a risk factor to acute stroke. Philip-Ephraim et al. (2015) claim that if people observe a healthy lifestyle, they can minimize occurrences of stroke by fighting against contributing factors such as cardiovascular illnesses. However, adequate assessment of risk factors associated with Ischemic stroke patients under intravenous plasminogen activator therapy calls for more research.

Summary

Ischemic stroke is a deadly and expensive disease, which propelled experts to write more on its treatment procedure, suggesting intravenous plasminogen activator as one of the best therapy. Besides, patients react differently to stroke treatments, especially those who have existing conditions such as diabetes mellitus, which calls for proper post-treatment. Further, policymakers should encourage early intervention, set training, and enhance patient profiling. However, researchers have not adequately addressed the risk factor issue, and it is an essential element that can help in combating the disease by decongesting the critical care units and managing the available resources.

Theoretical Framework

The conceptual framework shows the process improvement plan to reduce ischemic stroke risk factors.

According to Reed & Card (2016), plan-do-study-act (PDSA) is crucial in the health sector because of its contribution to improving the quality of health. First, it helps nurses to plan a research/activity, in this case, the stroke treatment. After planning, then nurse gets into the second stage of executing the plan, such as a review of patient profiling while recording the information. The third step is where the practitioner analyzes the data collected, training effect, and comparison of research information to make decisions. Finally, the fourth step where implementation takes place, such as the proper use of health resources. Additionally, the researcher identifies issues that need a further address, and the process continues until when they address the topic adequately. Nurses should adopt PDSA since it assists in timely planning for pre-treatment, ongoing treatment, and post-treatment, especially in an ischemic stroke where patients react differently to treatments (Reed & Card, 2016).

Methodology

Objective: The research intends to carry out the study with the primary aim of improving the health of ischemic stroke patients. The researcher’s objective is to answer the clinical question. Does patient profiling improve proper resource utilization in ischemic stroke treatments? P- Ischemic stroke patients, I- patient profiling, C- no patient profile, O-proper resource utilization.

Philosophical stance: The researcher intends to use a retrospective study, which is common in medical research. The methodology allows the researcher to review and draw conclusions from existing studies.

 Research Design: The study will use a retrospective research design to allow the review of situations that have already taken place. Perhaps, this design is the most appropriate since the study involves post-treatments. Additionally, it is helpful because there will be a comparison of outcomes of patients under intervention and that with no interference.

Sample: the study intends to involve fifty scholarly articles, books, and journals. The investigator will randomly select at least seven years old academic reading materials concerning different health facilities in Saudi Arabia. Subsequently, the research will also compare the outcome where the patient profile was considered and results from less patient profiling.  

Instruments: The researcher will use both structured and none-structured to enhance the collection of in-depth information. The researcher will identify professional tools to interpret the question for better understanding.

Ethics: The researcher will ensure there is no hidden agenda as well as get consent approval from the Saudi Arabian authority before commencement. Additionally, he/she will observe a high level of confidentiality and disclosure of unauthorized information.

Procedure: The researcher will prepare questions. After that, liaise with the supervisor for clarity. The study will consider stroke ischemic patients and patients with other illnesses (subject control). Further, the medical records will help to retrieve patients’ profiles. The intended data will be risk factors such as modifiable and the effect it has on resource management as well as patient care.

Data Analysis: the study will use both qualitative and quantitative techniques to analyze the data. The investigator will use a statistical package for social science (SPSS) software to analyze quantitative data for clarity. Both quantitative and qualitative data will help to find out information such as financial issues, risk factor level, and the knowledge patients and nurses have concerning such factors and patient profiling.

Work Plan: The researcher will conduct a demo study to evaluate the effectiveness and efficiency of the questionnaires, which will take about three days. After that, the researcher will prepare final questions within two days, liaise with the supervisor to ensure the research is on the right track. After the supervisor’s approval, the research will seek permission from the Saudi Arabia governing body. The gathering for study materials will follow, which will take about five days. Eventually, the actual study will emerge, starting with the review of the questionnaires estimated to take three days and take about seven days to fill. After the collection of information, the researcher plans to take about 15 days to sort and analyze the data. Then, take ten days to prepare the report and 1-2 days for presentation. Thus, in general, the researcher plans to take about seven weeks to finalize the research. In conclusion, ischemic stroke is a deadly and expensive disease that calls for more research on how to combat it.

Reference

Arboix, A. (2015). Cardiovascular risk factors for acute stroke: Risk profiles in the different

subtypes of ischemic stroke. World Journal of Clinical Cases: WJCC, 3(5), 418.

Dong, Y., Cao, W., Ren, J., Nair, D. S., Parker, S., Jahnel, J. L., & Upadhyaya, M. (2015).

Vascular risk factors in patients with different subtypes of ischemic stroke may affect their

outcome after intravenous tPA. PloS one, 10(8).

Goyal, N., Male, S., Al Wafai, A., Bellamkonda, S., & Zand, R. (2015). Cost burden of stroke

mimics and transient ischemic attack after intravenous tissue plasminogen activator

treatment. Journal of Stroke and Cerebrovascular Diseases, 24(4), 828-833.

Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J., & Dowlatshahi,

1. (2015). Randomized assessment of rapid endovascular treatment of ischemic stroke. New

       England Journal of Medicine, 372(11), 1019-1030.

Faigle, R., Sharrief, A., Marsh, E. B., Llinas, R. H., & Urrutia, V. C. (2014). Predictors of critical

care needs after IV thrombolysis for acute ischemic stroke. PloS one, 9(2).

Jauch, E. C., Saver, J. L., Adams Jr, H. P., Bruno, A., Connors, J. J., Demaerschalk, B. M., & Scott, P. A. (2013). Guidelines for the early management of patients with acute ischemic stroke: a

guideline for healthcare professionals from the American Heart Association/American Stroke

Association. Stroke, 44(3), 870-947.

Löwhagen Hendén, P., Rentzos, A., Karlsson, J. E., Rosengren, L., Sundeman, H., Reinsfelt, B.,

& Ricksten, S. E. (2015). Hypotension during endovascular treatment of ischemic stroke is a

risk factor for poor neurological outcome. Stroke, 46(9), 2678-2680.

Madsen, T. E., Khoury, J. C., Alwell, K. A., Moomaw, C. J., Kissela, B. M., De Los Rios La Rosa,

F., & Ferioli, S. (2015). Analysis of tissue plasminogen activator eligibility by sex in the Greater

Cincinnati/Northern Kentucky Stroke Study. Stroke, 46(3), 717-721.

Nishijima, D. K., Shahlaie, K., Echeverri, A., & Holmes, J. F. (2012). A clinical decision rule to

predict adult patients with traumatic intracranial haemorrhage who do not require intensive

care unit admission. Injury, 43(11), 1827-1832.

Palazzo, P., Brooks, A., James, D., Moore, R., Alexandrov, A. V., & Alexandrov, A. W. (2016).

Risk of pneumonia associated with zero‐degree head positioning in acute ischemic stroke

patients treated with intravenous tissue plasminogen activator. Brain and behavior, 6(2),

e00425.

Philip-Ephraim, E. E., Charidimou, A., Williams, U. E., Otu, A. A., Eyong, K. I., & Ephraim, R.

16. (2015). Serum Lipid Profile in Ischaemic Stroke Patients in Southern Nigeria. Alcohol, 24, 16.

Sadeghi-Hokmabadi, E., Farhoudi, M., Taheraghdam, A., Hashemilar, M., Savadi-Osguei, D.,

Rikhtegar, R., & Mirnour, R. (2016). Intravenous recombinant tissue plasminogen activator for

acute ischemic stroke: a feasibility and safety study. International journal of general

       medicine, 9, 361.

Reed, J. E., & Card, A. J. (2016). The problem with plan-do-study-act cycles. BMJ Qual Saf, 25(3),

147-152.

Xian, Y., Federspiel, J. J., Grau-Sepulveda, M., Hernandez, A. F., Schwamm, L. H., Bhatt, D. L.,

& Bettger, J. P. (2016). Risks and benefits associated with prestroke antiplatelet therapy

among patients with acute ischemic stroke treated with intravenous tissue plasminogen

activator. JAMA neurology, 73(1), 50-59.