Stroke Protocol Time Lost Is Brain Lost!. Objective: Improve patient care & outcomes Offer a standard of care Increase efficiency Meet accreditation recommendations.

Slides:



Advertisements
Similar presentations
JCAHO EXPECTATIONS FOR PRIMARY STROKE CENTER
Advertisements

3/28/2017© 2009, American Heart Association. All rights reserved.
GUSTO-IV AMI G lobal U se of S trategies T o Open O ccluded Coronary Arteries in AMI.
Stroke Workshop Case Scenario.
Controversies in the management of Pulmonary Embolism
Heather M. Prendergast, MD, MPH EMRA/FERNE Case Conference: Legal Issues in the ED Management of Acute Ischemic Stroke Patients.
B.A.P.E.T Brain Attack Protocol & Emergency Treatment By: Nicole Florentine, Christina Lauderman Erin Patrick, & Kara Sharp.
Advanced Adult Intravenous Calculations
THROMBOLYSIS Alteplase: indications and contra-indications Dr Ken Fotherby, New Cross Hospital.
TPA… SMART or not SMART? That is the Question. Sarah Parker, MD.
Hyperacute Stroke Treatment: Inclusion and Exclusion Criteria
Canadian Best Practice Recommendations for Stroke Care (Updated 2008) Section # 3 Hyperacute Stroke Management Canadian Best Practice Recommendations for.
Disclosures: Maximo C. Kiok, M.D. Medical Director of Stroke Program Trinity Health System.
STROKESTROKESTROKESTROKE. Why Change? Improve Mortality Improve Mortality Devastating and Life Altering Devastating and Life Altering Cost expense of.
Target: Stroke Building on Success A national quality improvement initiative of the American Heart Association/American Stroke Association to improve.
The cursor must be over the text in the question boxes to have the answers open correctly.
ED TIA Patient Case Presentation Transient Ischemic Attack Patient Update: The Optimal Management of Emergency Department Patients With Suspected Cerebral.
Ann M. Hoff, MD ETC Physician Trinity Health. American Stroke Association  Guidelines for the Early Management of Adults with Ischemic Stroke (2007)
E. Bradshaw Bunney, MD Legal Issues in the ED Management of Acute Ischemic Stroke Patients.
Quality Improvement in the Emergency Department Creating the culture so it’s second nature Jonathan A. Edlow, MD Associate Professor of Medicine Harvard.
Anticoagulation in Acute Ischemic Stroke. TPA: Tissue Plasminogen Activator 1995: NINDS study of TPA administration Design: randomized, double blind placebo-controlled.
Spotlight A Stroke of Error. This presentation is based on the December 2014 AHRQ WebM&M Spotlight Case –See the full article at
Brain Single-Photon Emission CT With HMPAO and Safety of Thrombolytic Therapy in Acute Ischemic Stroke Proceedings of the Meeting of the SPECT Safe Thrombolysis.
Mid America Stroke Network Founded By: Saint Louis University Hospital (SLU Hospital)
Seeing a Stroke Developed by: K. Banasky, RN, BSN Educator GCH Emergency Services.
What can we do to cut down the time it takes to give a clot dissolving drug (tPA)?
T-PA in Treatment of Acute Stroke: What We Know From NINDS 2004 vs 2000 Sidney Starkman, MD Departments of Emergency Medicine and Neurology, UCLA UCLA.
Process to Improve Stroke Care Reduce time to brain imaging Partner with EMS to improve skills & early identification Enhanced ED response & evaluation.
 Describe the major signs and symptoms of stroke  Classify stroke and type specific treatments  Apply 8 d’s of stroke care  Follow suspected stroke.
Healthcare Facilities Accreditation Program (HFAP) Primary Stroke Certification Troy Repuszka, RN, BScN July 16, 2009.
Stroke Alert at Lutheran General Hospital, Park Ridge, IL
Acute ischemic stroke: Not a moment to lose By Julie Miller, RN, CCRN, BSN, & Janice Mink, RN, CCRN, CNRN Nursing2009, May ANCC contact hours.
Dripping and Shipping Theda Clark Medical Center Appleton Medical Center Sheila Barr, RN Kristin Randall, RN Stroke Program Coordinators.
T. P.A. tissue Plasminogen Activator Presented by: Kelly Banasky, RN, BSN GCH Emergency Services Educator.
Administering Thrombolysis Early Management
Stroke and the ED Kurian Thomas, MD Department of Neurology.
The Evolving Management of Pediatric Stroke Christopher A. Miller, MD July 21, 2012.
10 May 2005 CASES - Original article available at CASES (Canadian Alteplase for Stroke Effectiveness Study) The CASES Investigators.
S TPA and Appropriate documentation for contraindications: A conversation with The Joint Commission and a Physician Perspective Shyam Prabhakaran, MD,
Stroke and Code Brain Attack “Act Fast When the Brain Attacks”
Treatment of Ischaemic Stroke The American Heart Association American Stroke Association Guidelines Stroke. 2007;38:
STROKE Lalith Sivanathan 2015 ADVANCED CONCEPTS IN EMERGENCY CARE (EMS 483)
Subarachnoid Hemorrhage. Etiology Spontaneous (primary) subarachnoid hemorrhage usually results from ruptured aneurysms. A congenital intracranial saccular.
Case 60 F with PMH HTN, DM, CVA presented to UNC ED CC: seizure. Per the daughter the pt was walking and all of a sudden fell and her whole body started.
Primary Stroke Center EMS Training Union Hospital, Inc. Terre Haute Union Hospital, Inc. Terre Haute.
Protocol Nichol McBee, MPH, CCRP BIOS Coordinating Center Johns Hopkins University.
11 WAYS TO DECREASE DOOR TO NEEDLE TIME YOU CAN DO IT FASTER Jeff Nickel, MD FACEP ED Medical Director Parkview Regional Medical Center.
Dr Payam Sasannejad, Neurologist Assistant Professor of mums Intravenous thrombolytic therapy in acute ischemic stroke.
{ Challenging Case Presentations From South Texas Methodist Hospital REGIONAL SYSTEMS OF CARE DEMONSTRATION PROJECT: MISSION: LIFELINE™ STEMI SYSTEMS ACCELERATOR.
“Door to Needle (DTN) Time in Stroke Thrombolysis” Audit Care of the Elderly Department Dr Nikoletta Petrou, Foundation Year 1 Doctor Dr Prasanna Aghoram,
Simon Howard Medical Management of Acute Stroke. Fast Recognition of Stroke With sudden onset neurological symptoms: 'FAST' should be used to screen for.
ACUTE STROKE TREATMENT: An introduction Dec.2014
Adult Stroke 2010 AHA Guidelines for CPR and ECC
Outpatient DVT assessment & treatment Daniel Gilada.
Management of Acute ISCHEMIC stroke
Inpatient Acute Stroke Protocol
Advances in Treatment for Acute Stroke
ACLS CVA.
Code Stroke Code Stroke: Medical Directive (PCS-MD-25) ETA: 13 minutes.
Rapid Reversal of Warfarin Therapy in Patients with Intracranial / Intraspinal Bleeding Mount Auburn Hospital Blood Bank, Emergency Department, Critical.
Clinical Audit of Head CT in Stroke Alert Cases: Role of Radiology Resident and CT Technologist Awareness in improving Head CT reporting time K Hooda,
Code Stroke Process 3. MD evaluation < 10 minutes Brief neuro exam
ED STROKE ALERT Competency
Performance Improvement: Emergency Management in Acute Cerebrovascular Patients Current US Guidelines Lisa A. Shultz, MD Medical Director, Lourdes Stroke.
GHS Outpatient Enoxaparin Program
Extended Window Thrombectomy
Calculate Well’s score for PE (BOX1)
Jennifer E. Fugate, DO, Alejandro A. Rabinstein, MD 
The Multi-arm Optimization of Stroke Thrombolysis (MOST) Trial
MOST Study Update and Protocol Refresher
Presentation transcript:

Stroke Protocol Time Lost Is Brain Lost!

Objective: Improve patient care & outcomes Offer a standard of care Increase efficiency Meet accreditation recommendations To establish a stroke protocol

Assessment Define and recognize the signs of stroke. FAST EXAM Positive ? <10minutes from arrival time No Yes CAT SCAN Within < 25 minute from arrival time. Radiologist Reading within 45minutes from arrival Time. Neurology Is there a hemorrhage is present ? Notification of possible stroke Follow up care As needed No Yes Follow up care As needed tPA Candidate? Yes No ICU ? Stroke I will admit you to the ICU. ED attending will decide whether to activate stroke team based on this information. Time Lose = Brain Lose We will assess you while you’re in the ICU and may order other test Like: Labs or a MRI……….. tPA Given Stroke Protocol Flow Chart Images Sent <60 minutes from arrival

Assessment Define and recognize the signs of stroke. FAST EXAM Positive? <10 minutes form arrive ED attending will decide whether to activate stroke Protocol based on results of FAST Exam Follow up care As needed No Yes Stage 1 Cat Scan Within <25 minutes from arrival time Active Stroke Protocol via Operator Key Purple Arrow = Staff Communication Blue Arrow = Patient Care/Flow * Do not delay sending the patient to CT scan in order to complete the ECG, or chest x-ray unless specifically requested by physician. Ideally, labs should be drawn prior to going to CT. Operator will Page: CT Department Radiologist Neurology Lab Respiratory

Assessment Record time of patient’s Arrival to ED Record time of Fast exam within <10 minutes of arrival time.

Cat Scan Within <25 minutes from arrival time Images sent Radiologist Reading within <45minutes from arrival Time. Stage 2 Neurology Is there a hemorrhage present? Fast Exam Positive Yes No Follow up care As needed tPA Candidate?

Indications New symptomatic ischemic stroke with clearly defined onset Non-contrast CT showing NO intracranial hemorrhage or well-established acute infarct Patient should be evaluated by an in-house neurology Fellow or Resident

Guidelines for Use of Intravenous tPA in Acute Ischemic Stroke Approved FDA use for LESS than 3.0 hours from initial symptoms Off-label use for 3 to 4.5 hours The only FDA approved treatment for ischemic strokes is tissue plasminogen activator (tPA, also known as IV rtPA, given through an IV in the arm ).

Contraindications (risks must be weighted against anticipated benefits) Age < 18 CT scan findings (intracranial hemorrhage, or major acute infarct signs) Suspicion of subarachnoid hemorrhage (even if head CT is negative for hemorrhage) Recent (within 3 months) major surgery or trauma (discuss with Attending) History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor (May consider IV tPA in patients with CNS lesions that have a very low likelihood of hemorrhage, such as small unruptured aneurysms or benign tumors with low vascularity) Known bleeding diathesis  Current use of oral anticoagulants with INR > 1.7 or PT > 15 seconds  Use of heparin within 48 hours preceding onset of stroke AND prolonged aPTT at time of presentation  Platelets <100,000  Internal hemorrhage (GI hemorrhage, urinary tract hemorrhage) < 3 weeks  Dabigatran use in the past 48 hours (if last dose >48 hours, confirm normal renal function [creatinine clearance >50 mL/min] and normal coagulation [aPTT, INR, platelet count] before tPA administration).  Low molecular weight heparin use (i.e.- Lovenox) in the past 24 hours.  Persistent systolic BP >185 mm Hg or diastolic BP >110 mm Hg despite treatment.

tPA Candidate? tPA Given ICU I will admit you to the ICU. YES No Follow up care As needed We will assess you while you’re in the ICU and may order other test Like: Labs or a MRI……. Stage 3 <60 minutes from Arrival

- Estimated Weight (lbs) Conversion to Kilograms (Kg) Total iv t-PA Dose (mg) at 0.9 mg/kg t-PA Bolus (mg) *10% of total* t-PA Bolus (ml) Discard Dose t- PA (Not for infusion) Infusion Dose (mg) Infusion Rate (ml/hr) tPA Dose Chart

Administration  The stroke fellow may utilize a phone consultation with the stroke attending prior to administering IV tPA  Administer tPA in monitored setting (unit bed or emergency room)  Mix two 50 mg tPA vials with 50 mL normal saline each --> one mL solution contains one mg tPA for a total of 100mg in 100mL of solution.  Estimate total body weight (if not measured on admission)  Calculate TOTAL tPA DOSE: 0.9 mg per kg (not to exceed 90 mg total dose) - Give 10% as IV bolus - Give other 90% as IV infusion over 60 minutes  Vital signs and neuro checks at least every 15 min for first 2 hours (including NIHSS scores- document in SCM note).  Treat systolic BP if it rises to >180 mm Hg or diastolic BP >105 mm Hg for more than 15 minutes  Avoid BP decrease <160/ 85 mm Hg

Assessment Define and recognize the signs of stroke. FAST EXAM Positive? <10 minutes form arrival Follow up care As needed Cat Scan Within <25 minutes from Arrival Images Sent Radiologist Reading within <45minutes from arrival time. Neurology Is there a hemorrhage present? Follow up care As needed tPA Candidate? tPA Given < 60 minutes from Arrival ICU YES NO YES NO YES

The Clock is Ticking Time Lost Is Brain Lost! tPA is on the way!

References Pöder, U., Dahm, M. F., Karlsson, N., & Wadensten, B. (2015). Standardised care plans for in hospital stroke care improve documentation of health care assessments. Journal Of Clinical Nursing, 24(19/20), doi: /jocn Read, S. J., & Levy, J. (2006). Effects of care pathways on stroke care practices at regional hospitals. Internal Medicine Journal, 36(10), doi: /j x Rymer, M. M., Anderson, C. S., Harada, M., Jarosz, J., Ma, N., Rowley, H. A., &... Bornstein, N. M. (2014). Stroke service: How can we improve and measure outcomes? Consensus summary from a global stroke forum. Acta Neurologica Scandinavica, 130(2), doi: /ane.12256