Nursing Grand Rounds Is My Patient Having a Str…Strrr…Strroook…..Stroke? Erin Rindels, RN, BSN, CNRN Stroke Nurse Coordinator Nicole Flowers, RN, BSN Staff Nurse, CRU team 2 Jessie Franklin, RN, BSN Staff Nurse, 4RC

Purpose Provide information on stroke Review code stroke criteria Discuss code stroke activations

Stroke Facts Leading cause of death Leading cause of disability 795,000 strokes a year Every 40 seconds someone has a stroke ~ 80% are preventable with risk factor modification

Stroke Facts Kills more than twice as many American women every year than breast cancer Women have greater disability after stroke than men 1.9 million brain cells die each minute of a stroke For every 12 minutes without treatment, a pea-sized piece of brain dies

Types of Strokes

Number of Stroke Patients at UIHC Stroke Type 2007 2008 2009 2010 Qtr1 Ischemic 344 348 391 94 ICH 181 175 174 39 SAH 93 105 119 22 TIA 56 41 42 5 Total 674 669 726 160

Code Stroke Activations at UIHC Type 2007 2008 2009 2010 Qtr 1 Stroke 219 233 248 65 Symptoms, no stroke 125 134 123 37 Inappropriate 21 20 9 1 Total 365 428 435 121

Where do code strokes originate? Location 2010 Jan Feb Mar Apr Outside Hospital 16 20 24 ETC 18 11 17 Inpatient 7 8 5 4 Total 41 44 36 45

What is the criteria for activating a code stroke? Any one of the following symptoms, occurring within the last 6 hours & symptom is still present: Sudden numbness or weakness of face, arm or leg, especially on one side of the body Sudden trouble seeing in one or both eyes Sudden confusion, trouble speaking or understanding Sudden trouble walking, dizziness, loss of balance or coordination

TPA criteria Ischemic stroke TPA (Activase) only FDA approved treatment Approved in 1996 Last time normal vs. symptom onset time IV TPA treatment 0-3 hrs & 3-4.5 hrs

TPA contraindications (0-3 hrs) Minor or rapidly improving symptoms Stroke or head trauma in last 3 months Major surgery in last 14 days Known history of ICH Sustained BP > 185/110 Aggressive treatment necessary to lower blood pressure Possible SAH GI or urinary tract hemorrhage in last 21 days Arterial puncture at noncompressible site within 7 days Received heparin within 48 hours and elevated PTT PT greater than 15 sec or INR greater than 1.7 Platelets less than 100,000ml Serum glucose less than 50 mg/dL

TPA contraindications (3-4.5 hrs) Greater than 80 yrs. old. NIH Stroke Scale score greater than 25 History of diabetes AND stroke Taking anticoagulation therapy

Other treatment options for those not eligible for IV TPA Endovascular – NIR 4.5 – 6 hrs of onset (sometimes up to 12 hrs) Intra-arterial TPA Mechanical thrombolysis

What do I do if patient meets criteria? Recognize that the patient meets the criteria Activate for all patients who meet the criteria, regardless of TPA eligibility Call 199, request Code Stroke activation Communicate with patient’s primary team Assist with patient evaluation Document event in narrative notes

Who is notified when a code stroke is called? Operator sends a text page to: Stroke team (physicians, nurse coordinator) CT tech 6JC, SICU, ETC charge RNs Pharmacy Interventional radiology Admission and Transfer Center Nursing Supervisor

What happens when a code stroke is called? Stroke team responds to examine patient Stroke team obtains history, completes NIH stroke scale CT ordered Labs, EKG reviewed or ordered

What happens when a code stroke is called? CT, 12-lead EKG, and labs need to be completed and interpreted within 45 TPA should be started within 60 minutes for those eligible

What should I do once a code stroke is called? Contact primary team to come to bedside Provide history to stroke team Help with transport Keep patient NPO until pass swallow screen Start TPA if ICU bed not available

Str…Strrr…Strroook….Stroke Bring attention to speech deficits Several recent delayed or missed activations Common theme was a speech deficit A staff nurse experience

Documentation Speech will be added to the neuro brief WDL and neuro WDL in Epic “speech clear & appropriate for developmental level” Minimum assessment policy will be updated to match brief WDL

3RC Code Stroke Symptoms recognized & reported to RN by Megan Yoder, NA Code Stroke called (NIH=14) Endovascular procedure Discharged with no deficits (NIH=0) Lisa Hughes, RN given a Daisy Award

4RC Code Stroke A staff nurse experience

References Adams, H.P.,Jr., del Zoppo, G., Alberts, M.J., Bhatt, D.L., Brass, L., Furlan, A., Grubb, R.L., Higashida, R.T., Jauch, E.C., Kidwell, C., Leyden, P.D., Morgenstern, L.B., Qureshi, A.I., Rosenwasser, R.H., Scott, P.A., & Wijdicks, E.F.M. (2007). Guidelines for the early management of adults with ischemic stroke. Stroke, 38:1655-1711. American Heart Association. Heart Disease and Stroke Statistics 2010 Update At-a-Glance. At: http://www.americanheart.org/presenter.jhtml?identifier=1200026. Hacke W, Kaste M, Bluhmki E et al. N Engl J Med 2008:359:1317. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. Centers for Disease Control and Prevention National Center for Health Statistics National Vital Statistics System. National Vital Statistics Report. Volume 57, Number 14. Deaths: Final Data for 2006. April 17, 2009.