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

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

5. Receives patient from EMS or other mode:
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. Recommended elements:
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. Possible performance metrics:
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

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. Section 10 Treatment Protocols, updated 12/13; downloaded 6/20/14.

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. Rehabilitation Services:
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 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
Everything we’ve discussed so far, plus……
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.

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

31. Power of Data

32. Power of Data

33. Power of Data

34. Power of Data

35. Power of Data

36. She suddenly falls behind the counter
Case Study
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…………

37. Case Study
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
Case Study
Time 911 Call Received 14:47.17
Time EMS Dispatched :47: 57
Time EMS Enroute :48:17
Time EMS at Pt Side :55
Just over half of all stroke patients use EMS access to health care; those who utilize EMS comprise the majority of patients presenting in the 3- 4 ½ hour TPA window.
• EMS use strongly associated with :
1. shorter time periods from symptom onset to hospital arrival
2. decreased time to initial physician examination, initial CT imaging, and neurological evaluation

39. Screening for stroke / Scores compared
Cincinnati Prehospital Stroke Scale
LA stroke screen
Facial droop
Yes
Arm drift
Grip NA
Speech
Prescreening questions (seizures, glucose, age > 45, new onset symptoms 24hrs), ambulatory at baseline No

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. Case Study 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

42. Arrival to Emergency Department
Case Study
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 :30 = 10 minutes
Door to Labs resulted minutes (some via POC)
EKG / Chest xray <23 minutes

43. Case Study 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 1330.
NKA; Meds: Asa, Metormin, Pravastatin
Vital signs on arrival BP 204/88 pulse 77, R 18 Temp 36.3
Sp % 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

45. What the NIHSS score means in general terms:
Case Study
Mrs. Smith’s NIHSS was 19
What the NIHSS score means in general terms:
NIHSS = mild stroke
NIHSS = moderate stroke
NIHSS > 18 = large stroke
What is the NIHSS and Why Do We Need It?
NIHSS is a validated tool that allows clinicians to:
Objectively quantify the clinical exam (both for determination of the use of tPA and in the acute phase)
Determine if the patients’ neurological status is improving or deteriorating;
Provide standardization in assessment; (from one person to the next – same thorough exam performed)
Communicate patient status: (nurses and MDS talking the same language)

46. Case Study 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
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
Case Study
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.
Stroke Team Neurologist

48. Case Study
tPA 1610, 50 min after ED arrival and 2 hrs 40 min after last known well.
VS monitoring q5 min. in ED:
1555, BP 145/105
1600, 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

49. Case Study
1638 pt. left ED to the Neurointerventional Angio suite, accompanied by Rapid Response Nurse.
1728 stentriever obtained TICI 2a flow at 3 hrs 58 min after last known well.
Pt was admitted to Neuro Intensive Care Unit at

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. Post tPA monitoring: Can I transfer while infusing?
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. Stroke risk reduction Case Study
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 2013.
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 2014.
13 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. What are three recommended attributes of a Primary Stroke Center?
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. What are three requirements for a JC certified CSC?
Q&A
What are three requirements for a JC certified CSC?
Surgical & endovascular capabilities, dedicated Neurosciences ICU, post hospital care coordination.
Written transfer plans, tPA ready, CT capability.
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):