Post-Thrombolytic Care Steps Up the Step-Down Unit.

n 1995, the National Institute of Neurologic Disorders and Stroke trial was published, prompting alteplase approval for acute ischemic stroke treatment. Since 1995, there have been quite a few changes in managing stroke patients post alteplase, including administration inclusion and exclusion criteria. With a few exceptions at high-performing academic centers, postalteplase patients are admitted to a critical care area for frequent monitoring during the first 24 hours regardless of stroke severity. The latest ischemic stroke guidelines from the American Heart/ American StrokeAssociation encourage treatment with alteplase in patients with mild but disabling symptoms regardless of the stroke severity score. Although this is good news for stroke patients, wewere facedwith challenges in critical care bed availability. Often, patients with a low stroke severity score who received alteplase would be prioritized admission to critical care over a patient with higher acuity and a greater need for critical care–level nursing care. Our organization is in the Midwest and composed of 1 comprehensive stroke center, 4 primary stroke centers, 5 affiliate hospitals, and vascular neurology coverage through telemedicine for 28 facilities across the state. Our comprehensive stroke center houses a 32-bed integrated stroke unit (ISU), a 32-bed neurocritical care unit (NCCU), and a 32-bed general neurology unit. As alteplase volumes increased, we saw an opportunity to expand the scope of care and knowledge by empowering the step-down registered nurses (RNs) to care for low-severity stroke scale patients on the ISU.