EMERGENCY EVALUATION OF THE ACUTE STROKE PATIENT. Angel Rochester, MD Associate Director of Critical Care & Trauma Associate Director of Chest Pain

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1 EMERGENCY EVALUATION OF THE ACUTE STROKE PATIENT Angel Rochester, MD Associate Director of Critical Care & Trauma Associate Director of Chest Pain

2 Greenville County EMS 800 Square Miles in Greenville County Busiest EMS organization in South Carolina 62,000 Annual Responses Over 500 Stroke transports per year Strong relationship with County Hospitals Involvement in Hospital meetings

3 EMS Stroke Screening EMS Dispatchers perform a pre-arrival stroke screen over the phone EMS Providers conduct a Cincinnati Stroke Scale upon arrival NIH Stroke Scale Pre-hospital Stroke Thrombolytic Check List

4 Standing Orders EMS Stroke/CVA/TIA Assessment: 1. Perform patient assessment. 2. Perform both Glasgow Coma Scale and Cincinnati Stroke Scale on patients who present with signs / symptoms of Acute Stroke. Determine blood glucose level, if hypoglycemic, follow Hypoglycemia Standing Order. Interventions: Follow Airway Management Standing Order. Establish IV at KVO rate follow Intravenous Infusion Initiation Standing Order. Monitor cardiac rhythm. All patients with new signs and symptoms of a stroke regardless of time onset are to be transported to a cardiac/stroke center (Greenville Memorial Medical Center or St. Francis Hospital Downtown). Notify the receiving facility as soon as possible of the STROKE ALERT. If Acute Stroke*, complete Prehospital Stroke Thrombolytic Check List and if time permits an NIH Stroke Scale If Major Stroke** and the patient meets the criteria, consider Rapid Sequence Intubation Standing Order. Contact Medical Control: Transport and continue BLS and ALS follow Standard of Care guidelines. Acute Stroke* = Involves onset of symptoms < 4 ½ hours Major Stroke** = Involves patient with an altered level of consciousness

5 Cincinnati Stroke Scale Facial Droop Normal: Both sides of face move equally Abnormal: One side of face does not move at all Arm Drift Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other Speech Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or mute

6 Stroke Distribution 8/1/2010-8/1/2011

7 GHS Referral Line Transfers GHS Satellites have a dedicated onsite STEMI/Stroke stretcher and Activation Line GCEMS has an ambulance stationed at Hillcrest and Greer Mobile Care Reach Access to surrounding counties

8 Greenville Memorial Emergency Department 90,000 Adults/yr 20,000 pediatrics/yr

9 Acute Stroke Decision Pathway Greenville Memorial Emergency Department EMS calls with possible stroke patient Signs and Symptoms of Acute Stroke? Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Patient presents to triage Yes Onset less than 4.5 hr Triage in room Print Form M10357, M10108, M10682 Stroke Alert page to notify neurologist, CT & Lab MD assesses patient, NIHSS (full initially) TPA criteria reviewed (M10357) Stroke orders started (M10357) LOD labs (CBC, PT/PTT, INR, BMP) LOD Head CT STAT EKG, continuous cardiac & O2 monitoring, CXR, fingerstick glucose, urine pregnancy, NPO including meds Register patient in REACH cart (per neurologist request) Consult neurologist via REACH telemedicine ED Physician Goal: <10 min Stroke Alert Page Goal: <15 min Labs drawn & testing started - Goal: <15 min CT complete - Goal: <25 min CT & labs resulted Goal:< 45 min No Onset greater than 4.5 hr Triage Stroke orders started Labs (CBC, PT/PTT, INR, BMP, fingerstick glucose, Head CT, EKG and continuous monitoring, NPO Assess using NIHSS (full initially, focused q 1 hr x 2 and then q2hr) Complete Dysphagia Screen Stroke Alert Process GMH TPA candidate? YES Neurologist to odiscuss risks/benefits w/ pt/family omake recommendations for tpa in person or via REACH & give order to ED RN RN to oadminister tpa, complete tpa orders M10682, transfer to GHS via Mobile Care or Med Trans ocomplete Dysphagia Screening tpa initiated Goal: <60 min NOT TPA candidate ED MD to document reason in IBEX Doctor Notes, NIHSS Neurologist recommendations in person or per REACH consult ED MD calls PCP or neurologist for admission or transfer. (Follow normal admit procedure) Complete Dysphagia Screening ED MD calls PCP or Hospitalist for admission or transfer (Follow normal admit procedure) Nurse completes Dysphagia Screen before any PO Intake/Meds

10 Accurate Weights

11 Acute Stroke Decision Pathway Greenville Memorial Emergency Department EMS possible stroke patient Signs and Symptoms of Acute Stroke? Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Patient presents to triage CALL THE STROKE ALERT WEIGH THE PATIENT / STRETCHER Yes Onset less than 4.5 hr Stroke Alert Page Goal: <15 min No Onset greater than 4.5 hr Triage in Critical Care Room Print Form M10357, M10108, M10682 Stroke Alert page to notify neurologist, CT & Lab ED Physician Eval Goal: <10 min Triage To Critical Care WEIGH THE PATIENT

12 Code Stroke MD assesses patient NIHSS (full initially) TPA criteria reviewed (M10357) Stroke orders started (M10357) LOD labs (CBC, PT/PTT, INR, BMP) LOD Head CT STAT EKG, continuous cardiac & O2 monitoring, finger stick glucose, urine pregnancy, NPO including meds Register patient in REACH cart (neurologist request) NOTIFY CT REACH PATIENT Consult neurologist via REACH telemedicine Labs drawn & testing started Goal: <15 min CT complete Goal: <25 min CT & labs reported/resulted Goal: 45 min

13 ORDER WHEN COMPLETED Candidate for tpa TPA candidate? YES tpa initiated Goal: <60 min Neurologist to odiscuss risks/benefits w/ pt/family omake recommendations for tpa in person or via REACH & give order RN (2 signatures confirm dose ) oadminister tpa, infuse 50 ML BOLUS NS AT THE END OF TPA TO AT THE SAME RATE AS TPA. Complete tpa orders M10682, o Complete Dysphagia Screening ovs q 15 minutes onihss Q15, then Q30, then Qhr CALL (5-PILL) NOTIFY PHARMACIST OF LOCATION, PATIENT WEIGHT, SCAN

14 Observation Unit Group My Hospital All SC Hospitals JC PSC Hospitals Time Period 07/01/ /30/ /01/ /30/ /01/ /30/2011 Ischemic stroke 621 (69.1%) 3414 (62.5%) (62%) TIA SAH ICH 116 (12.9%) 976 (17.9%) (17.8%) 37 (4.1%) 243 (4.4%) (4.4%) TIA/Stroke Workup as observation status Labs, MRI/MRA, Echo, Carotid U/S Risk factor identification/reduction NP managed with ED physician Neurology consult 124 (13.8%) 557 (10.2%) (11.2%) Stroke NOS 1 (0.1%) 85 (1.6%) 2947 (1.3%) No stroke related diagnosis 0 (0%) 163 (3%) 5159 (2.2%) Blank "Missing diagnosis" 0 (0%) 26 (0.5%) 2770 (1.2%) Total CVA/TIA Pts Total ALOS 7/ / / / / / / / / / / / Total 135 (53 ICD ) 1.15

15 Observation Unit TIA/Stroke Workup as observation status Labs, MRI/MRA, Echo, Carotid U/S Risk factor identification/reduction Neurology Consult NP managed with EM Physician Work up completed in hours, 365 days

16 Thank You Questions?

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