2. INTRODUCTION TO THE
STROKE PROGRAM

3. Objectives: Familiarize with the Stony Brook Stroke Program
Discuss emergency assessment and expected time targets for acute stroke patient
Verbalize location of Stroke Program’s guidelines, protocols and references
Verbalize stroke core measures and quality measures per Joint Commission and New York State Department of Health

4. Stroke STATISTIC
Stroke is a leading cause of serious long-term disability in the US. Approximately 3% of males and 2% of females reported that they were disabled because of stroke
Stroke is the No.3 cause of death in the United States, >140,000 people die/year
Each year, approximately 795,000 people suffer a stroke. About 600,000 of these are first attacks, and 185,000 are recurrent attacks.
On average, every 40 seconds, someone in the United States has a stroke
American Heart Association Heart Disease and Stroke Statistics At-a-glance

5. Transient Ischemic Attack (TIA)
TYPES of Cases reportable to
Joint commission and New York STATE
Transient Ischemic Attack (TIA)
Brief episodes of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral infarction

6. STROKE PROGRAM Certifications Awards
Designated New York State Stroke Center
Joint Commission Comprehensive Stroke Center
Awards
AHA/ASA Get-With-The-Guidelines Stroke Gold Plus and Target:Stroke Honor Roll award for administration of IV tPA in 60 minutes or less for at least 50% of eligible patients
Healthgrades one of America's 100 Best Hospitals for Stroke Care

7. STROKE PROGRAM Stroke interventions available:
IV tPA administration – within 0-3 hours and hours treatment window for eligible patients
Mechanical Thrombectomy – up to 24 hours of last known normal for eligible patients
Aneurysm and AVM treatment
Carotid disease interventions
Multiple on-going clinical trial for stroke including but not limited to:
Minimally invasive evacuation of intracerebral hemorrhage (MIND Trial)
Hydrogen and minocycline stroke study (H2M)
Confidence trial for carotid stent

8. Stroke Program
Accepts transfer of stroke patients from surrounding hospitals
Cerebrovascular Center
2 Mobile Stroke Units
Neuro Critical Care Unit
Stroke Service
Stroke Program Coordinator
Stroke Program Navigator
Stroke Quality/Data Specialist
Physical Therapy
Occupational Therapy
Speech Therapy
Social Work
Case Manager
Stroke Support Group – 2 meetings monthly
Community outreach programs for stroke education/blood pressure screening

9. Stroke Practice Guidelines and Protocols
Stroke Program
Stroke Practice Guidelines and Protocols
Accessible through the Stony Brook Medicine Intranet under Quick Links: Stroke – Code BAT
Contains the Clinical Practice Guidelines and Protocols that the program follows in the assessment and management of stroke patients
Contains stroke-related compliance data for core measures and quality measures
Contains links to website for cerebrovascular-related CMEs and articles

11. NEW time target recommendations from AHA/ASA Target Stroke Initiative:
Acute Stroke Assessment
Current target response times:
* Refer to IV tPA (Alteplase) Eligibility Criteria, Criteria for Endovascular Intervention
NEW time target recommendations
from AHA/ASA Target Stroke Initiative:
Door to IV tPA administration: 45 minutes
Door to Revascularization for Mechanical Thrombectomy: within 60 minutes for patients transferred from an outside hospital OR 90 minutes for patients presenting directly
Patient needs to be evaluated immediately if with acute signs and symptoms of stroke and have CT Head completed faster than 25 minutes
Door to revascularization for Mechanical Thrombectomy: <120 minutes

12. Stroke Program
CODE BAT (Brain Attack Team) – mobilizes the Stroke Team to bedside for emergent assessment of a patient with acute stroke symptoms
Code BAT is called for patients with last known well within 6 hours as per New York State recommendation
“Code BAT CT Head” is ordered STAT to rule-out ICH
If indicated, a STAT “Code BAT CT Angiogram Head/ Neck” is ordered to evaluate vessels. CT Perfusion study will be ordered if needed to evaluate perfusion mismatch for patients with large vessel occlusion
Only the assessment of blood glucose level precede the administration of IV tPA (rt-PA) unless there is a suspicion of abnormal hematologic or coagulation test.
Refer to PC0078 Code BAT Brain Attack Team for Acute Stroke Adult and Pediatric
Refer to Code BAT Emergency Department Process Flow
Refer to Code BAT Inpatient Units Process Flow
Refer to ED Stroke Process Flow

13. Stroke Program
Future Plan- Implementation of Code CSI (Complex Stroke Intervention) to expedite assessment and treatment of complex stroke patients presenting to the Emergency Department

14. PRIMARY STROKE
CoRE MEASURES
STK-1 VTE prophylaxis on the day of or the day after hospital admission.
STK-2 Antithrombotic therapy at hospital discharge.
STK-3 Anticoagulation for Atrial fibrillation/flutter at hospital discharge.
LIPs must be mindful of the specific time period of the core measures for compliance.
Reason(s) must be documented in the medical record why elements of the core measures were not implemented for the patient.
STK-4 IV t-PA initiated at this hospital within 3 hours of time last known well.
STK-5 Antithrombotic therapy by the end of hospital day 2.
STK-6 Statin medication at hospital discharge.
STK-8 Patient and/or caregiver stroke education: activation of emergency
medical system, need for follow-up after discharge, medications
prescribed at discharge, personal risk factors for stroke, and warning
signs and symptoms of stroke.
STK-10 Rehabilitation services assessment

15. Comprehensive Stroke Core measures
CSTK 01 – NIH Stroke Scale score performed for Ischemic Stroke patients
CSTK 02 - Modified Rankin Score at 90 Days
CSTK 03a - Severity Measurement Performed : Hunt and Hess Scale performed for
SAH
CSTK 03b – Severity Measurement Performed: ICH Score performed for ICH patients
CSTK Procoagulant Reversal Agent Initiation for ICH patients
CSTK 05a - Hemorrhagic Transformation for IV t-PA patients
CSTK 05b - Hemorrhagic Transformation for IA t-PA and/or Mechanical Endovascular Reperfusion Therapy patients
CSTK 06 - Nimodipine Treatment Administered
CSTK 07 - Median Time to Revascularization
CSTK 08 - Thrombolysis in Cerebral Infarction (TICI) post-treatment reperfusion grade
CSTK 09 - Arrival Time to Skin Puncture
CSTK 10 - Modified Rankin Score at 90 Days: Favorable Outcome
CSTK 11 - Timeliness of Reperfusion: Arrival Time to TICI 2B or Higher
CSTK 12 - Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

16. Quality Measures AHA/ASA Quality Measures
- Dysphagia Screen before being given any food, fluids, or medication by mouth
RN or LIP completes bedside swallow evaluation using the Yale Swallow Protocol
If indicated, formal swallow evaluation by Speech Therapist
For patients who failed swallow evaluation: Order Aspirin per rectum or place NGT for patients who need Plavix or Brilinta
- Documented Lipid profile
- Intensive Statin Therapy Use (Lipitor ≥ 40mg, Crestor ≥ 20mg)
Additional New York State requirements
- Documentation of NIH Stroke Scale on discharge
- Annual 8 hours of cerebrovascular-related continuing education for Physicians, NP/PAs and RNs taking care of stroke patients

17. Stroke Program Stroke Quality/Oversight Meetings:
Cerebrovascular Conference – every 1st and 2nd Wednesday of the month, case-based discussion. Offers 1.0 CME credit.
Stroke QA/Peer Review – every 3rd Wednesday of the month, stroke case reviews and discussion. Offers 1.0 CME credit.
Code BAT meeting – every second Tuesday of the month at 3PM. Attended by EMS, ED, Stroke/Neurology, CVC/Neurosurgery, Radiology, Pharmacy, Neuroscience Administration.

18. For questions, contact:
THANK YOU !
For questions, contact:
Anne Froehlich, Stroke Program Coordinator:
Marret Anderson, Stroke Program Navigator:
Josephine George, Stroke Data Specialist:
Antonieta Rosenberg, Stroke Service NP: