1. Process to Improve Stroke Care Reduce time to brain imaging Partner with EMS to improve skills & early identification Enhanced ED response & evaluation through training & competency assessments Develop Stroke Alert Decrease door to needle time Critical access/rural hospital transfer

2. Door to Needle - 2009

3. Reduce time to brain imaging 1. Ongoing review of data 2. Look at process & flow 3. Encourage staff input 4. Celebrate improvements & thank direct care staff

4. Partner with EMS 1.Provide EMS with stroke education 2.Stroke alert Train-the-Trainer Program offered in MI 3.Stroke info cards developed for EMS services

5. Partner with EMS 4. Stroke criteria developed for hospital notification at time of transport 5. ED supervisor, CT scan & lab staff notified if criteria met 6. Criteria: last known well, age, gender, s/s & ETA

6. Enhanced ED response 1.Educate and reeducate ED staff 2.Every stroke considered for tPA 3. Educate triage nurses 4.Mock stroke codes 5.Developed pocket cards with emergent guidelines for staff to carry

7. Enhanced ED response 5.Reinforced appropriate use of Stroke Alert beeper 6.Ongoing ED resident education 7. Optional stroke rotation for ED residents

8. Develop Stroke Alert 1.Triage immediately to ED based CT scanner 2.Draw blood & NIHSS 3.Notify Stroke Team 4.Bring clot box & infusion pump to CT

9. Develop Stroke Alert 5. Interpret images & treat immediately 6. Nurses provides tPA bolus & resident injects 7. Nurse programs IV pump & initiates infusion 8. Electronic access to tPA protocols anywhere in hospital

10. Decrease door to needle times 1.Stroke Team challenged to decrease door to needle time to 45 minute target 2.Individual patient treatment times are reviewed monthly 3.Celebrate successes

11. Decrease door to needle times 1.Follow up on failures or extended times 2.Verify triage time, time CT completed and administration of drug

12. Critical access/rural hospital transfer 1. Educate all ED staff on stroke 2. http://NIHSS- English.Training.Campus.nethttp://NIHSS- English.Training.Campus.net 3. Everyone is a thrombolytic therapy candidate until excluded 4. Assess & treat emergently

13. Critical access/rural hospital transfer 5.Partner with a stroke center for support 6. Set up transfer protocol 7. Notify center with NIHSS, last known well time, pertinent health history, pertinent labs, & CT results 8. Review exclusion/inclusion criteria with referral physician

14. Critical access/rural hospital transfer 9. Start tPA if appropriate criteria met 10. Transfer with appropriate staff while tPA infusing 11. Send copy of imaging & labs 12. Accepting hospital re-evaluates patient & reviews labs/imaging

15. Critical access/rural hospital transfer Telemedicine is an effective method to provide expert care to stroke patients in rural areas. Robotic evaluation is another option in rural areas. Stroke. 2007; 38: 1655-711. Seminars in Neurology. 2005; 25:337-44

16. Critical access/rural hospital transfer The “drip and ship” method of delivering tPA has been safe and efficacious. “Drip and ship: protocols use telemedicine consultation or robotic evaluation to determine eligibility before tPA is started and the patient is transferred. Neurology Today. 2009; 9: 2,13-14 Neurology. 2005; 64: 154-6.

17. Hippocratic Oath “First, do no harm” To do nothing is doing harm.