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

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

3. 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.

5. 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 Jan;42(1): Epub 2010 Dec 2.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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”

12. 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

13. 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

14. Acute Stroke/TIA Assessment Orders

15. Chart

16. 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

17. 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)

18. 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

19. 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
No IV nurse available 11:30pm to 07:00am so Nursing Supervisor put in IV or gets resources to do so during this time

20. 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
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

21. 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

22. 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.

23. 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.

24. 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 /82/20, last seen 06:30. Day nurse in to do vital signs and assess 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

25. 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 ?

26. 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

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