1. 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

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

3. 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

4. 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

5. Types of Strokes

6. 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

7. 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

8. 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

9. 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

10. 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 & hrs

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 4RC Code Stroke
A staff nurse experience

23. 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:
American Heart Association. Heart Disease and Stroke Statistics 2010 Update At-a-Glance. At:
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 April 17, 2009.