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Stroke Systems of Care: Prehospital and Initial Management of Stroke June 2014 prepared by Karen Ellmers, RN, MS, CCNS OHSU Stroke Program Coordinator.

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Presentation on theme: "Stroke Systems of Care: Prehospital and Initial Management of Stroke June 2014 prepared by Karen Ellmers, RN, MS, CCNS OHSU Stroke Program Coordinator."— Presentation transcript:

1 Stroke Systems of Care: Prehospital and Initial Management of Stroke June 2014 prepared by Karen Ellmers, RN, MS, CCNS OHSU Stroke Program Coordinator

2 Objectives Describe stroke levels of care. Review case study of initial stroke management. Discuss stroke quality improvement measures.

3 Stroke Levels of Care Acute Stroke Ready Hospital Primary Stroke Center Comprehensive Stroke Center Higashida, R., et al. (2013). Stroke 44.

4 Acute Stroke Ready Typically small facilities serving small cities or rural populations. Stroke patient population volume low. Limited staffing & bed availability.

5 Acute Stroke Ready Receives patient from EMS or other mode: –Initial triage and diagnosis –Establish telemedicine link –Acute stabilization –Acute treatment –Transfer as needed based on level of care needed

6 Acute Stroke Ready Recommended elements: –At least 2 staff members able to be at patient bedside within 15 minutes, 24/7 –Able to do rapid brain imaging within 45 minutes –IV thrombolytic protocol with goal of door to needle within 60 minutes –Written transfer protocols –Telemedicine link within 20 minutes Schwamm, LH (2009). Stroke 40(7):

7 Acute Stroke Ready Possible performance metrics: –Stroke severity –Time to first brain imaging –Door to needle time for thrombolytics –Time to initiation of anticoagulation reversal –Time to initiation of telemedicine link –Time to transfer, when indicated Schwamm, LH (2009). Stroke 40(7):

8 Telestroke

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10 Stroke, 2011; 42:

11 Primary Stroke Center Mostly urban and suburban Typically 300+ stroke patient admissions per year Same level of care 24/7/365 All attributes of acute stroke ready, plus….

12 Primary Stroke Center Collaboration with EMS providers. Access to stroke treatment & destination protocols. Provide support to remote area hospitals. Transfer protocols to primary or comprehensive stroke center, when needed.

13 https://multco.us/health/providers/emergency- medical-serviceshttps://multco.us/health/providers/emergency- medical-services, Section 10 Treatment Protocols, updated 12/13; downloaded 6/20/14.

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15 *Patient example from electronic medical record test environment

16 Primary Stroke Center Neuroimaging—24/7 basis: –Able to obtain brain image within 25 minutes and interpretation within 20 minutes of completion. Advanced imaging: –MRI with diffusion –Vascular imaging (MRA, CTA, carotid doppler) –Cardiac imaging (TTE, TEE, or cardiac MRI)

17 Primary Stroke Center Laboratory Services: –Stroke labs within 45 minutes from order on 24/7 basis. –ECG and chest x-ray within 45 minutes from order, when clinically indicated. Outcome and quality improvement activities. Community educational programs.

18 Primary Stroke Center Neurosurgeon available within 2 hours of need identified. Or written transfer plan to facility with this capability. Operating room capability 24/7.

19 Primary Stroke Center Stroke Units –Does not require specific enclosed unit, but must be a unit where majority of patients are admitted where staff have annual education & specialized experience in caring for the stroke patient.

20 Primary Stroke Center Written Care Protocols:

21 Primary Stroke Center Rehabilitation Services: –Speech Language Therapy –Physical Therapy –Occupational Therapy Assessment and early initiation of a plan.

22 Primary Stroke Center, Metrics Stroke Core Measures Volume of Ischemic, TIA, ICH & SAH admits Acute Stroke workup times: –Door to CT –Door to lab results –Door to EKG & CXR IV tPA volume, door to needle times

23 Must show that you deliver care based on these published guidelines.

24 Comprehensive OHSU Certified! Effective March 2013 The Joint Commission has officially certified OHSU as a Comprehensive Stroke Program. OHSU is the first in the Pacific Northwest to receive this certification.

25 Comprehensive Stroke Center Health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology. Advanced neuroimaging capabilities, such as MRI and various types of cerebral angiography, 24/7/365, most within 30 minutes of clinical need. Surgical and endovascular techniques, including clipping and coiling of intracranial aneurysm, carotid endarterectomy and stenting, and endovascular treatments for ischemic stroke. Infrastructure and programmatic elements such as a dedicated neuro intensive care unit staffed with neurointensivists. Post hospital care coordination. Extensive data collection and peer review process. Participation in stroke research. Everything we’ve discussed so far, plus……

26 Comprehensive Stroke Center Increased data collection requirements. Examples: Ischemic stroke –% of patients who received IV tPA in ≤ 60 minutes from arrival –% who arrive in less than 6 hours of onset who were considered for endovascular tx –90 day modified Rankin scores Hemorrhagic stroke –Initial severity scores documented (ICH & SAH) –Procoagulant reversal times for ICH –Median time from admit to surgical or endovascular tx for aneurysm –% of patients who receive nimodipine within 24 hours of admit Serious complication and mortality rates for CEA, aneurysm coiling & clipping, carotid stents, thrombectomies, decompressive cranis, ventriculostomies, EVD’s & transduced lines, cerebral angiograms. Follow-up calls on complex stroke patients within 7 days of discharge.

27 Comprehensive Stroke Center Enhances the ability to analyze and optimize how patients move through the system (EMS on through back into community). –It allows for more team thinking of how we all work together to provide an efficient & optimal patient experience, rather than just thinking in silos about what occurs in and would work best for my own department. Regular communication among stakeholders through an organized committee/advisory group structure helps to reinforce the team concept, helps to identify common goals, sets clear priorities, and builds positive working relationships.

28 Stroke Systems of Care Does it make a difference? –Compared to general hospitals, Primary Stroke Centers have: Higher tPA treatment rates Lower death rates Improved outcomes –Being certified by an independent licensing body increases effectiveness of overall stroke care. –The focus is on the entire continuum. Higashida, R., et al. (2013). Stroke 44

29 The Power of Data The Get With the Guidelines-Stroke database allows for analysis of trends and identification of performance improvement projects of our internal performance and ability to benchmark with over 2400 other hospitals. Data can be extracted and shared with direct care providers. –A way to show how their efforts impact care in a positive manner. –Motivation to improve in areas needing attention. We have over 4500 patients in our database. Our Stroke Advisory group selects & monitors the annual performance improvement (PI) projects. PI efforts are coordinated by the Clinical Nurse Specialist, but all members of the team are involved in developing & implementing systems solutions. Data is reported up through organizational chain, plus to the Joint Commission.

30 Stroke Core Measures STK-1VTE Prophylaxis initiated by hospital day 2 STK-2Discharged on Antithrombotics STK-3Anticoagulation for Afib STK-4 % who arrive in ED w/in 120 minutes of onset who received tPA w/in 3 hours of onset STK-5Antithrombotics started by hospital day 2 STK-6LDL> 100 discharged on a statin STK-8Patient/family stroke education provided STK-10Assessed for rehab needs PSC-7Bedside swallow screen prior to any PO PSC-9Tobacco cessation provided during hospital stay Power of Data

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36 Mrs. Smith a 60 yr old is working alone at the dry cleaning shop she owns with her husband, who had just left to get lunch. She suddenly falls behind the counter There is vomiting and silence………… Case Study

37  Two customers come into the shop and find Mrs. Smith laying face down in vomit, on floor unable to move with out any one else around.  They called 911.

38 Time 911 Call Received 14:47.17 Time EMS Dispatched 14:47: 57 Time EMS Enroute 14:48:17 Time EMS at Pt Side 14:55 Case Study

39 Screening for stroke / Scores compared Cincinnati Prehospital Stroke Scale LA stroke screen Facial droopYes Arm driftYes GripNAYes SpeechYes Prescreening questions (seizures, glucose, age > 45, new onset symptoms 24hrs), ambulatory at baseline NoYes

40 Stroke Symptoms Sudden numbness or weakness of the face, arm, or leg (especially unilateral). Sudden confusion, trouble speaking or understanding speech. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance or coordination. Sudden severe headache with no known cause.

41 EMS to patient at 14:55:  Pt. is awake and talking  Glucose = 135  Pt had no signs of trauma but states she does not recall events surrounding the fall so cervical spine was immobilized.  LA Stroke Screen Positive for acute stroke.  Pt. stated last time she remembers being normal was at approximately 1330 when she finished her lunch  Code 3 to Hospital  Alerted Hospital of stroke patient Case Study

42 Arrival to Emergency Department Orders placed in advance of patient arrival EMS pulls into ED ambulance bay at 15:20 –Triaged EMERGENT & placed in a resus room –0-10 MINUTES Rapid ED eval MD/RN/Tech/Social Worker Acute Stroke Team Activation 15:28 Stroke Neurologist arrived in ED 15:32 –Door to Head CT 15:30 = 10 minutes –Door to Labs resulted minutes (some via POC) –EKG / Chest xray <23 minutes

43 Physician H&P:  60 yo female h/o DM2, HTN, A Fib not on coumadin. Who presents w L hemiplegia, R gaze and L neglect.  Was found down at work.  Last known normal  NKA; Meds: Asa, Metormin, Pravastatin  Vital signs on arrival BP 204/88 pulse 77, R 18 Temp 36.3  Sp02 100% weight 61.2 kg  Pt. denies any head traumas, no h/o systemic bleeds, no recent MI, no h/o strokes or ICH/SAH, no recent surgeries  NIHSS 19 Case Study

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45 Mrs. Smith’s NIHSS was 19 What the NIHSS score means in general terms:  NIHSS 1-7 = mild stroke  NIHSS 8-18 = moderate stroke  NIHSS > 18 = large stroke Case Study

46 tPA Inclusion/Exclusion for onset < 3 hours Inclusion criteria Diagnosis of ischemic stroke causing measurable neuro deficit > 18 yo Exclusion criteria Unknown onset time Imaging evidence of hemorrhage or stroke prior stroke or head trauma within 3 months History of previous ICH Intracranial neoplasm, AVM or aneurysm Recent intracranial/intraspinal surgery Arterial puncture are non-compressible site within previous 7days Active internal bleeding Platelets < 100,000 Current anti-coagulant use with INR > 1.7 Glucose < 50 BP > 185 /110 despite aggressive treatment to lower BP Relative exclusions Rapidly improving or minor symptoms Pregnancy Seizure at onset Major surgery or serious trauma in previous 14 days Recent GI/GU hemorrhage in previous 21 days Myocardial infarction in previous 3 months Exclusion for onset hours Same criteria as < 3h, plus > 80 yo Severe stroke (NIHSS >25) Oral anti-coagulation, regardless of INR History of diabetes History of prior stroke

47 Stroke Team Neurologist note  S/S consistent with R MCA, possibly due to atrial fibrillation (carotids not imaged yet).  Given the high NIHSS 19, it is likely that she has large vessel occlusion.  The patient meets criteria for tPA.  Potential benefits and risks, including bleeding and death discussed with the patient who wishes to proceed.  Pt consented for IV tPA and thrombectomy with stentriever.  1608 IR team activated.  1610 tPA started in ED. Case Study

48 –tPA 1610, 50 min after ED arrival and 2 hrs 40 min after last known well. –VS monitoring q5 min. in ED: 1555, BP 145/ , BP 162/78 –IV tPA –Total dose 0.9 mg/kg, max. 90mg: Mrs. Smith’s weight = 61.2 kg 5.5 mg bolus over 1 minute 49.5 mg over 1 hour via IV pump Total 55 mg Case Study

49 1638 pt. left ED to the Neurointerventional Angio suite, accompanied by Rapid Response Nurse stentriever obtained TICI 2a flow at 3 hrs 58 min after last known well. Pt was admitted to Neuro Intensive Care Unit at 1835.

50 Case Study Post tPA monitoring Neuro assessment & vital signs are to be monitored and documented every 15 minutes for 2 hours (starting from time bolus is given). Then every 30 minutes for next 6 hours. And hourly for next 16 hours. Observe for bleeding from puncture sites, urine, stool. Watch for signs/symptoms of intracerebral hemorrhage.

51 Case Study Post tPA monitoring: Can I transfer while infusing? The literature supports the initiation of IV tPA, using telemedicine support as needed, and transfer to regional stroke centers for further treatment, when indicated. Data suggests that drip & ship complication rates are comparable to non-drip & ship. It is considered a safe & effective method that can increase treatment rates in eligible patients and shorten time to treatment. Risk vs. benefit needs to be considered.

52 Case Study No hemorrhagic transformation at 24 hours. Admitted to Neurosciences ICU, then Neurosciences Acute Care Unit. Received Speech Therapy, Physical Therapy, Occupational Therapy, and Dietician assessments & treatments starting from day 1. Discharged to a skilled nursing facility on day 14. Progressed to Inpatient Rehabilitation, then home, where she continues outpatient therapy.

53 Case Study Stroke risk reduction –Written information on recommendations passed on to PCP. –Started on anti-coagulation for afib. –Adjusted blood pressure meds. –Provided stroke education to family. –Written information about stroke, plus warning signs/symptoms to call 911: Teachable moment with family

54 Truly an interdisciplinary effort! EMS Emergency Department Neurology Neurosurgery Interventional Neuroradiology Anesthesiology Intensivists Telemedicine Nursing –Managers –Educators –Staff nurses Radiology Laboratory Services Nutrition Services Rehabilitation Services Pharmacy Services Care Management Social Work Quality Improvement Stroke Program Coordinator Administration

55 Stroke Systems of Care From Higashida, R., et al. (2013). Stroke 44

56 Stroke Systems of Care Oregon –Senate Bill 375 passed in April –Establishes a Stroke Care Committee in the Oregon Health Authority. –To make recommendations for achieving continuous improvement in the quality of stroke care. –Encourages sharing of information and metrics. –First meeting took place May certified PSC, 2 certified CSC, the rest are acute stroke ready, or approaching that. It is estimated that 80-90% of the population has access to stroke neurologist evaluation via telemedicine.

57 Critical Success Factors The real goal is to try to prevent stroke and to return as many people as possible to their highest functional status.

58 Questions?

59 Q&A What are three recommended attributes of an acute stroke ready hospital? a. Urban, large hospital, telemedicine network. b. Inpatient rehabilitation unit, tPA ready, MRI capability. c. Provides initial triage & acute stabilization, tPA ready, written transfer plans.

60 Q&A What are three recommended attributes of a Primary Stroke Center? a. Hemorrhagic stroke capable, Neuro ICU, written transfer plans. b. Advanced neuro imaging, neurosurgeon available within 2 hours, full array of Rehabilitation Services. c. Endovascular capability, inpatient rehabilitation unit, tPA ready.

61 Q&A What are three requirements for a JC certified CSC? a.Surgical & endovascular capabilities, dedicated Neurosciences ICU, post hospital care coordination. b.Written transfer plans, tPA ready, CT capability. c.Initial triage & acute stabilization, ischemic strokes only, Rehabilitation Services.

62 Bibliography Acker, JE, Pancioli, AM, Crocco, TJ, et al. (2007). Implementation strategies for emergency medical services within stroke systems of care: A policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and Stroke Council. Stroke, 38: Alberts, M.J., et al. (2005). Recommendations for Comprehensive Stroke Centers. Stroke, 36: Connolly, E.S., et al. (2012). Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the AHA/ASA. Stroke, 43: Higashida, R., et al. (2013). Interactions Within Stroke Systems of Care: A Policy Statement From the American Heart Association/American Stroke Association. Stroke, 44: Jauch, E.C., et al. (2013). Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the AHA/ASA. Stroke, 44: Martin-Schild, S, Morales, MM, Khaja, AM, et al. Is the drip and ship approach to delivering thrombolysis for acute ischemic stroke safe? J EM Med 2011; 41(2), Morgenstern, L.B., et al. (2010). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guidelines for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke, 41, pp Pervez, MA, Silva, G, Masrur, S, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010; 41:e18-e24. Schwamm, L.H., et al. (2009). Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care: A Policy Statement from the AHA. Stroke, 40: Summers, D., et al. (2009). Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement from the American Heart Association. Stroke 40, (8), pp Wondwossen, GT, Chaudry, SA, Hassan AE, et al. Drip and ship thrombolytic treatment paradigm among acute ischemic stroke patients in the United States. Stroke 2012; 43: Xian, Y., et al. (2011). Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality. JAMA, 305(4):


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