The Middletown Press (Middletown, CT)
WHEN TIME IS BRAIN
Nurse navigators help patients in stroke recovery
NEW HAVEN » Suffering a stroke sends a person onto a formidable and confusing path through medical treatment, rehabilitation and home care.
Registered nurses Kaile Neuschatz and Kelsey Halbert help guide those who have suffered an often-devastating attack, assisting doctors and other health care providers by “focusing on the gaps,” as Neuschatz said. “We want continuity of care to optimize outcomes for the patient.”
Their job titles are apt: Neuschatz and Halbert are stroke nurse navigators at Yale New Haven Hospital.
“Although we’re not active members of the treatment team … our relationship with those patients begins when they roll through the door” of the emergency department, Halbert said.
“We provide support to the neurologists and the emergency department nurses for the initial coordination of care, which also allows us to start an education process with the patient,” he said. “There’s a lot of activity going on, so we can alert the patient” about what’s going to happen.
“We can continue educating them to discuss stroke and what their expected hospital course is going to be, especially for the first 24 hours,” Halbert said. “They will be seen by countless providers, so it’s nice to establish a familiar face.”
Navigators have been part of the health care team in pediatrics and oncology for some time. They became part of the stroke care team in May 2016. The two nurses begin their work even be
fore stroke is definitively diagnosed.
“Every minute matters. Time is brain,” Neuschatz said. With every minute that goes by, 1.2 million neurons are lost.
“The outcome for the quality of life for the patient will be improved if they access care and treatment more quickly,” she said.
Stroke is always a complex condition, with symptoms that can range from vision loss to paralysis. Nurse navigators are an especially valuable addition to the medical team at Yale New Haven. The hospital serves a low-income urban population, which is more susceptible to illnesses such as heart disease, high blood pressure and diabetes, all risk factors for stroke.
“Because we are one of two comprehensive stroke centers in Connecticut, our patient population tends to be more complex, which necessitates the importance of the navigator role, because patients have so many complicated co-morbidities or illnesses that complicate their stroke,” said Karin Nystrom, an advance practice registered nurse who is manager of Yale New Haven’s Stroke Center. Hartford Hospital is the state’s other comprehensive stroke center.
Stroke, which hits 795,000 people per year, is the fifth-leading cause of death in the United States, according to the Centers for Disease Control and Prevention, with more than 130,000 deaths per year, one-fifth of total deaths. Most strokes, 87 percent, are ischemic strokes, caused by a blockage in a blood vessel leading to the brain, according to the National Stroke Association. Stroke also can be caused by a burst blood vessel in the brain.
Signs of a stroke include sudden weakness, especially on one side of the body, confusion, difficulty speaking, trouble with vision, balance, coordination or a sudden headache, according to the stroke association.
One problem is that a patient may be suffering a stroke without realizing it.
“There are many symptoms that can mimic a stroke and while we have identified many common symptoms that we educate the public about, these are often ignored or unrecognized by the patients, and so a key part of the education process is reinforcing stroke warning signs and the importance of coming to the hospital,” Nystrom said.
Because the brain is so complex, each patient suffering a stroke will have a unique set of symptoms. The nurse navigators are ready to take on whatever challenges that must be met.
“You can’t see inside your skull,” Neuschatz said. “These events can have so many different consequences requiring all the different resources,” including speech therapy, physical therapy and occupational therapy. Long-term effects of a stroke include mobility, speech, cognitive ability and other functions, which can require months of rehabilitation.
The first task of the nurse navigators is to educate the patient and family members about what to expect.
“We also help coordinate the care based on what the first findings from their first workup is and coordinate with different departments to expedite their care, especially if there is an urgent intervention that takes place,” Halbert said.
Whether surgery is needed or not, the patient will then be admitted to the hospital.
“Once they get admitted, the medical team does a standard workup and part of our role is to help [patients] understand why we’re doing these tests and what the test results mean,” Neuschatz said. “The brain is very complicated. Problems in various areas can cause different symptoms for the patient, so we help them understand their diagnosis.”
Transitions
Nystrom said the navigators “provide a seamless transition from the acute phase of care to the recovery care phase.”
“The recovery process from stroke can be very long and frustrating for a patient and family,” Neuschatz said. “The stroke team works closely with lots of other teams … to help patients with mobility and adapting back to normal life.”
In addition to physical and occupational therapists, other caregivers are brought in. For example, “stroke can affect swallowing abilities, so we work with speech pathologists and nutritionists to optimize a patient’s diet and safe swallowing,” Neuschatz said.
They also help arrange brain scans “and are available to answer any questions they might have or concerns that are directed to the doctors. We maintain ourselves as a resource for them,” even after discharge, Halbert said.
If the patient is sent to a rehabilitation facility, “we try to really smooth the transition from the hospital to wherever they’re going afterwards so no aspects of their care are missed,” Neuschatz said. The navigators have visited rehab centers in the area as well and know the services offered at each.
Going home is often the hardest transition.
“When a patient is going from rehab to home, I think there’s a lot of fear,” Neuschatz said. “It’s very scary.” Family caregivers have concerns about physically caring for the patient, including giving medications.
“We explain … the process of stroke recovery care and that it’s usually longer than we want … every patient is different,” Neuschatz said. “Sometimes a daughter will need to cry on your shoulder and we have the time to offer that support.”
“We’ll call many of them a couple of days after they’re home to see how they’re doing, to make sure they understand what happened to them and that they’re following their discharge instructions, that they’re taking their medications and basically to see how they’re doing,” Halbert said.
The navigators help set up visiting nurses and physical therapy at home, and keep the patient’s primary care doctor informed of the patient’s progress — or help find a primary physician if the patient doesn’t have one. They help make appointments at a stroke clinic or to have their blood drawn. Many of the tasks are simple but they help keep the patient on the way to a faster recovery.
“One of our goals is to help prevent readmission of patients, so some of these issues that might seem smaller might be very critical for the patient,” Neuschatz said.
“Because the patient experience is very individual, there’s not a template or list that every patient will follow in order,” Halbert said. “We identify needs unique to each patient.”
Both Neuschatz and Halbert have worked in intensive-care units and said serving as a nurse navigator is very different but gratifying in its own way.
“I always wondered what happened to patients after they left and now I know,” Halbert said.
Neuschatz said that “after caring for critically ill patients for so long, I became more interested in helping people stay well outside the hospital.”
“After you have a stroke you are four to five times more likely to have another stroke, so much of the education that we do is focused toward secondary stroke prevention,” Halbert said.
“We help empower the patients to make changes in their life,” such as quitting smoking, treating high blood pressure and high cholesterol, Neuschatz said. “They can take concrete actions; they can change their diet; they can quit smoking.”
Neuschatz said more younger people are suffering strokes, because of rising diabetes rates and illicit drug use, in addition to the other factors. Risk factors can be inherited as well.
All along the way, the nurse navigators are in frequent contact with patients, connecting them with resources such as a support group for stroke survivors and their caregivers, which meets on Yale New Haven’s St. Raphael campus.
“We have a large patient population that had strokes and a large population that are at risk for stroke, so it becomes very important to have a care team that provides the seamless transition of care from hospital to rehab facility to home to the stroke clinic so that they can be optimally cared for in the community,” Nystrom said.