Inpatient Acute Stroke Protocol Mount Auburn Hospital Acute Stroke Response System Start Date July 7, 2011

Agenda Outline of Acute Stroke Response System Triggers Responsibilities/ Expectations of Primary and secondary Teams Members Documentation Case Examples

Purpose: Acute Stroke Response System Early recognition and action for in-patients who develop stroke symptoms. 2. To ensure rapid evaluation and treatment of stroke to reduce morbidity and mortality.

Evidence Quality of care for in-hospital stroke: Analysis of a statewide registry Suggests in-hospital strokes are under recognized or under reported Inpatient stroke eval times are twice that of recommended 25 minutes. Cumber et al Stroke. 2011 Jan;42(1):207-10. Epub 2010 Dec 2.

Timeline Activate “Stroke Alert” ASAP Primary Team at Bedside Goal: 5 minutes Stroke Recognition to CT Goal: 25 minutes If t-PA eligible, onset of symptoms to t-PA bolus Goal: 60 minutes

Clinical Symptoms of Stroke Sudden Onset of : Numbness / Weakness of Face, Arm or Leg, especially one side. Confusion/Change in Mental Status Speaking or Understanding speech Seeing out of one or both eyes Loss of Balance or Coordination Severe headache with no known cause

What to do if your patient has stroke symptoms Recognition of stroke signs and symptoms Communication to Primary team - Page primary team “Stroke Alert” Patient to head CT within 25 minutes of recognition of symptoms Diagnosis is made after the CT / MRI Treatment plan is made

Pull Green Acute Stroke Folder: Algorithum Triggers: Face: Does the face look uneven? Arm: Does the Arm drift down? Speech: Does their speech sound strange? Time: To page a Stroke Alert! Page Primary Team: Stroke Alert at bedside within 5 minutes Pull Green Acute Stroke Folder: NIHSS Is it a stroke? Is pt. T-PA eligible? Yes No Activate the burst page prepare patient to go to CAT Scan Call attending to update and get orders

Acute Stroke Response System Team 1 Stroke Alert: Patients Primary Response Team Patient’s in-house MD or PA Patient’s Nurse Primary Attending/Surgical Chief Resident Team 2 Acute Stroke Protocol Burst Page: Primary Response Team AND Neurologist Iv-Nurse Nursing Supervisor Transporter CT Tech Intensivist MICU Nurse

Primary Nurse Role ASSESSMENT OF PATIENT COMMUNICATION TO TEAM Identifies and Notes Neuro deficit Checks Vital Signs Does a Finger Stick Glucose Pulls the Green Acute Stroke Folder COMMUNICATION TO TEAM Text Page Primary Team “Stroke Alert”

Stroke Alert Page (Team 1) Using the In-house Paging System 1. Primary MD / PA 2. Text Message: Stroke Alert, Patient name, Room Number, Nurse name and call back number

Primary Team at The Bedside Uses Acute Stroke /TIA Triage Form Identifies Time Last Known Well and Onset of symptoms Performs the NIHSS Determines if patient is a stroke and t-PA eligible

Acute Stroke/TIA Assessment Orders

Chart

STROKE ALERT (NEUROLOGIST) Algorithum Caregiver identifies possible in-patient acute stroke STROKE ALERT (PRIMARY TEAM) Assessment with Acute Stroke/TIA triage orders Clinical stroke + Eligible for IV-tPA Clinical stroke + Not eligible IV-tPA ? clinical stroke + ? eligible IV-tPA Not a stroke ACUTE STROKE PROTOCOL STROKE ALERT (NEUROLOGIST) ATTENDING NOTIFIED

Acute Stroke Protocol Page If it’s determined that the patient is t-PA eligible: (Team 2) Acute Stroke Response Burst Page (7458) If not t-PA eligible, the patient needs a Head CT, but Team 2 (Acute Stroke Burst Page is not activated)

Roles and Responsibilities Patient’s Nurse: Obtain Blood Glucose Activate the Stroke Alert Monitor BP and Vital Signs Record last time seen without stroke signs & symptoms Pull Green Acute Stroke Folder Check IV is patent Primary Team MD/PA: Assess patient using Acute Stroke/TIA Triage order set in green folder Perform NIHSS If patient is potential IV-t-PA candidate, activate Acute Stroke Protocol Burst Page Prepare patient for transport to Cat Scan

Roles and Responsibilities Neurologist: call unit to confirm receipt of page and consult with primary responding MD/PA Neuroradiologist: Read CT scans/ other imaging and discuss with neurologist or page report to neurologist Intensivist: prepare for arrival of acute stroke patient and hand-off from responding physicians and consultants CT Tech: Clear CT scan and prepare for arrival of patient. Alert MRI of potential acute stroke patient. Beeper 6508 IV Nurse: Put in a 18 or 20 gauge angio catheter IV(not intima). Assist PCA in drawing stat labbs if needed. Both IV nurses will be on the stat page so whoever is closer and free can respond 6183 6072 No IV nurse available 11:30pm to 07:00am so Nursing Supervisor put in IV or gets resources to do so during this time

Roles and Responsibilities Nursing Supervisor: Determine availability of bed in MICU/SICU and notify staff of potential transfer. ? Plan if no beds available. Confirm availability of IV-t-PA in SICU pixis. Obtain t-PA from pharmacy if none available on unit. Be a resource to caregivers beeper 6102 6090 MICU Nurse: Begin preparation for IV-t-PA administration. Keep all t-PA packaging for return to pharmacy if NOT given. PCA: Draw stat labs if peripheral access present. Be available to assist nurse. Transporter: Stat to floor to transport patient and/or labs. Transporter remains with patient until released by MD. Beeper 6161 (alpha pager to be obtained and carried by dispatcher during days and by transporter evenings). No transporter available 11:30pm to 07:00am Night float PCA/unit coordinator will be added to burst page and will assist as needed. Beeper 6094

Documentation Acute Stroke Progress Note: RN Event Note AND MD/PA progress note Acute Stroke Triage form filled out After every Stroke Alert page complete a rL on line incident form

Attending Notification If the primary team member determines the patient’s symptoms are not consistent with an acute stroke, they will notify the patient’s attending physician that a Stroke Alert was activated and of the results of their assessment. If the primary team determines that the patient’s symptoms are consistent with an acute stroke, but the patient is not an IV -t-PA, they will send a Stroke Alert page to the on-call neurologist to discuss appropriate management.

Level of Care Needs If a higher level of care is needed the patient is transferred to an ICU or SDU. The Nursing Supervisor helps the Primary team with patient placement. The Primary Team calls the the Units to explain details of the case. The Primary Team assists with writing orders and completes the stroke packet.

Case Reviews 79 year old male admitted with dizziness, unsteady gait, CT Scan in ED negative for stroke. On tele with new Dx. Afib. Pt. on heparin bridge to start coumadin. Vital signs 98.8-110-145/82/20, last seen normal @ 06:30. Day nurse in to do vital signs and assess pt.@ 07:45, pt. is found to have left sided weakness with facial droop. Nurse notes neuro deficit, gets a set of vital signs, glucose and sends a text page to primary team: Stroke Alert, John Doe, room S431, Jane Smith RN x4300 MD/PA arrives uses the Acute Stroke/TIA Assessment Orders to determine t-PA eligibility

Case Review 44 year old female with Hx. of hypertension and diabetes admitted with hypertensive urgency, blood pressure 210/90 in the ED with a glucose of 215. Admitted to ST3, for blood pressure and glucose monitoring. On tele, with q4 vital signs and FS. Pt. Calls for the nurse and states,”I have a severe headache and don’t feel well all of a sudden”. Nurse does vital signs, glucose ?

Questions If you have any questions please contact: - Oscar Soto. M.D., Neurology ....................... x 2170 - Marie McCune, RN, Stroke Nurse .............. x 6090 - Nancy Couts, Stroke Coordinator ................. x 3313

Mount Auburn Hospital Stroke Service THANK YOU! Time Lost is Brain Loss