1. Dripping and Shipping Theda Clark Medical Center Appleton Medical Center Sheila Barr, RN Kristin Randall, RN Stroke Program Coordinators

2. Objectives To understand the coordination of care between referring hospitals and primary stroke centers. To develop relationships with referral hospitals in administering tPA To develop teamwork philosophy with referral hospitals

3. Theda Care System 4 - Hospitals 17 - Family and Internal Medicine Clinics 1 - Fast Care location open 7 days a week

4. Theda Clark Medical Center Neenah, WI Primary Stroke Center since 2004 250 licensed beds One of the largest acute care facilities in the area Level 2 Trauma Center Theda Star

5. The Stroke Team Emergency Room EMS Neurology Neurosurgery Radiology Neuroradiology Stroke Unit Physiatry Physical, Occupational and Speech Therapy Rehabilitation Unit Transitional Rehab Outpatient Rehab Stroke Coordinators

6. Appleton Medical Center Appleton, WI 160 Beds Specialty oncology and cardiac Sister hospital with Theda Clark Medical Center Together they provide coordinated specialty care

7. New London Medical Center & Riverside Medical Center - Waupaca, WI Small rural community hospitals Both provide general acute care

8. Referrals to the Stroke Center Appleton Medical Center –Sent 56 patients from their ED to the Stroke Center – tPA cases - 3 New London Medical Center –Sent 24 patients from their ED to the Stroke Center –tPA cases - 1 Riverside Medical Center – Sent 12 stroke patients from their ED to the Stroke Center – tPA cases - 2

9. Rhinelander Manitowoc Green Bay Marinette Oshkosh Fond du Lac Waupun New London Shawano Waupaca Wild Rose Chilton Antigo Langlade Appleton Berlin

10. The referral process…. AMC to Theda Clark Patient presents to the hospital ED triage nurse/EMS documents stroke symptoms and determines the time of onset. Acute CVA worksheet initiated for those presenting within 8 hours of onset of symptoms.

11. Acute CVA worksheet Code Stroke ER\Code Stroke Worksheet.docCode Stroke ER\Code Stroke Worksheet.doc

12. tPA Candidate ED physician consults with neurologist. Standard tPA Orders Neurologist will order tPA dosage –Dosages: 0.9 mg/kg 0.6 mg/kg Max dose is 90 mg

13. tPA is a go……. STAT Labs: BMET, CBC, PT, PTT EKG Vital Signs every 15 minutes until infusion completed 2 IV sites established

14. tPA Candidates Nationally only 1-6 % of stroke patients arrive to the hospital in time to be considered for tPA! Theda Clark has a 5% rate of patients that received tPA.

15. tPA started… Order is sent to the pharmacy where is it dosed and mixed. RN administers the tPA –10% as a bolus over 1 minute –Remaining infused over an hour

16. Thrombolytic Precautions Strict bedrest for 24 hours Draw labs from capped IV – waste 8 mL blood first Keep all dressings on for 24 hours No heparin, aspirin, Coumadin, or other antiplatelets or anticoagulants for the first 24 hours after tPA Guiac all stool for occult blood Place Thrombolytic Precaution Sign over patient’s bed

17. The Decision to transfer The ED Physician and Neurologist talk….. –Neurologist recommends that the patient be transferred to the Stroke Center –Patient/family must agree to transfer –Transfer process is initiated by ED RN

18. Stroke Center here we come!!! Other treatment options for Ischemic Strokes –Intra-arterial tPA –MERCI Retrieval Device

19. Modes of transfer Theda Star Air medical staffed by RNs Ambulance

20. Transfer Process RN contacts EMS for a STAT transfer. Our Theda Star dispatch can help assist with making arrangements if the helicopter is needed. If tPA is completed, patient sent in ambulance with EMS personnel If tPA still infusing, an RN will ride along

21. Transfer process continue The stroke center is notified of admission of a stroke patient. Placement is determined by patient’s status: ICU vs Intermediate Neuro Unit Report is called over to the admitting RN Direct Admit to their room

22. Where do we go from here? In the process of developing a feedback letter to our referring hospitals to acknowledge accomplishments. We involve quality improvement when necessary. Moving towards a system wide electronic medical record

23. Billing Emergency Department Bill + MD Charges –If tPA started – ED bills for the charge Transfer Bill (EMS or Theda Star) Theda Clark Hospital Bill + MD Charges

24. Admission to the Stroke Center Established standing orders Mild, moderate, severe stroke pathways Testing: MRI/MRA, labs, TEE, ECHO Carotid Ultrasound Therapies: OT, PT, Speech

26. Any Questions….. Thank You! Contact Information: Sheila Barr or Kristin Randall Theda Clark Medical Center 130 Second Street Neenah, WI 54956 (920)720-7328