Direct-to-CT. QuICR Webinar November

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Hilary Russell
8 years ago
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1 Direct-to-CT QuICR Webinar November

2 Our ER Camrose offers 24 hour Emergency Room Care to our community We serve an approximate city/county population of 26,000 people Our ER visits totaled 17,931 from April 1, 2014 to March 31, 2015 We are an 11 bed unit including 2 bed trauma room Each trauma bed has tele-stroke capability to stroke neurologist at UAH We have one doctor on call 24/7 We are staffed with 2 RNs, 1 LPN and a clerk from and 2 RNs and a clerk from Our hospital has an on-site radiologist We have on site CT from and CT is on call from We have no on site stroke neurologist

3 Stroke Specifics Last year SMH saw 61 strokes in ER, 16 of which required TPA Since January 2015, we have already seen 14 stroke patients requiring TPA Our best DTN time to date is 28 minutes (this time is reflective of the stroke neurologist from our Stroke Prevention Clinic being on site and attending this patient in ER) We are a primary stroke center Two tele-stroke monitors connecting us to stroke neurologist at UAH RNs trained in ACLS, NIHSS and TORBSST On site Heart & Stroke program Stroke Prevention Clinic held weekly with stroke neurologist CT and radiologist on site On call CT at night ( ) Radiologist on call from

4 EMS Support High paramedic complement ACLS crews available Excellent working relationship between EMS and ER staff

5 Critical Support Team We have recently developed a response team to come when called to any unit in the hospital for medical emergencies and/or workload issues. This team is comprised of one staff member from each of 4 units (day surgery, medical, surgical, maternity) When the Critical Support Team is needed, the unit that needs them calls our psych unit who in turn calls each unit asking for Critical Support Team to go immediately to Unit in need.

6 Door to CT Current What we like to see.. Pre-notification CT, radiologist, lab alerted Patient registered, labels made, Stroke labs entered Netcare accessed and printed RAAPID notified Heart and Stroke team Poten&al Stroke: Pa&ent Informa&on to Collect Time of Onset of Symptoms Blood Glucose Level Es&mated Time of Arrival Pa&ent Full Name Birth Date AHC/ULI Remember to No&fy ER Physician/Lab/CT

7 SWARM We generally rely on our paramedics assessment and send straight to CT with RN accompaniment if possible if ABCs cleared, vitals stable Physician will have a quick look if they are right there Patient identifier bracelet applied Chart ready and sent with patient to CT

8 Transport to CT Patient stays on EMS stretcher and on EMS monitor to CT EMS will go to ER to get ER stretcher for when patient comes off CT table RN stays with patient in CT if possible If patient on Coumadin, lab wants access to the patient prior to CT to draw the INR this is cumbersome and sometimes wastes time

9 Barriers Staffing If our department is busy (and more often than not we are), our physician can be busy and unavailable at the moment EMS enters the building so an immediate SWARM isn t possible When our RN is required to 1:1 any patient our staffing is significantly affected Leaves one staff to triage and keep an eye on the waiting room One staff to care for the other 10 patients We have to weigh the risk of sending RN to CT and may keep her if other patients in department are unstable CT on call during nights, live out of town so take approximately minutes to get to hospital and get CT up and ready

10 Barriers Con t Low numbers of TPA cases mean decrease confidence in process New staff and physicians decrease efficiency as we get very few TPA cases some staff have never done one Uncomfortable with process, urgency, equipment Many out of our control delays Waiting for RAAPID - Sometimes have to leave a message Waiting for stroke neurologist

11 Barriers Con t Variability based on past experience In the past, we have had negative experiences with the decision to pre-notify RAAPID and/or call stroke neurology ER physician insists on waiting to call RAAPID until he has assessed the patient RAAPID telling us not to call until we are ready to speak to stroke neurology Misunderstandings between the call to pre-notify and the call to speak to stroke neurology These negatives are remembered and make both staff and physicians tentative to make the pre-notification call

12 How will we improve? Developing a more detailed, up to date form for receiving EMS patch information Similar to Foothills template shown at EMS webinar Using Critical Support Team for all possible TPA to allow for 1:1 stroke care and not put rest of ER at risk

13 How will we improve? Providing staff with DTN Algorithm with clearly defined roles Person who takes patch does the pre-notifying Part of pre-notification includes calling for Critical Support Team Nursing to call RAAPID for pre-notification not physician Registration clerk role definition New system developed to enter unidentified patients in to Meditech

14 How will we improve? Considering developing a kit for Stroke Labs containing Vacutainer Access Device and tubes needed for bloodwork RN or EMS to get labs from IV site if possible

15 How will we improve? Conducting DTN simulation on November 10 2 scenarios Walk up EMS Try to be as real as possible including calling RAAPID and accessing stroke neurologist Have recorder to document times and identify barriers

A Collaborative Effort to Improve Emergency Stroke Care: Mobile Stroke Unit

A Collaborative Effort to Improve Emergency Stroke Care: Mobile Stroke Unit What can we do to cut down the time it takes to give a clot dissolving drug (tpa)? MOBILE STROKE UNIT! Mobile Stroke Unit Mobile