INPATIENT ACUTE STROKE PROTOCOL. Mount Auburn Hospital Acute Stroke Response System

Transcription

1 INPATIENT ACUTE STROKE PROTOCOL Mount Auburn Hospital Acute Stroke Response System

2 AGENDA Outline of Acute Stroke Response System Triggers Responsibilities / Expectations of Primary and secondary Teams Members Documentation

3 PURPOSE: ACUTE STROKE RESPONSE SYSTEM 1. Early recognition and action for in-patients who develop stroke symptoms. 2. To ensure rapid evaluation and treatment of stroke to reduce morbidity and mortality.

4 EVIDENCE Quality of care for in-hospital stroke: Analysis of a statewide registry Suggests in-hospital strokes are under recognized or under reported Inpatient stroke eval times are twice that of recommended 25 minutes Cumber et al Stroke Jan;42(1): Epub 2010 Dec 2.

5 TIMELINE 1. Activate Stroke Alert ASAP 2. Primary Team at Bedside Goal: 5 minutes 3. Stroke Recognition to CT Goal: 25 minutes 4. If t-pa eligible, onset of symptoms to t-pa bolus Goal: 60 minutes

6 ACUTE STROKE RESPONSE SYSTEM TEAM 1 Stroke Alert: Patients Primary Response Team Patient s in-house MD or PA Patient s Nurse Primary Attending/Surgical Chief Resident TEAM 2 Acute Stroke Protocol Burst Page: Primary Response Team AND Neurologist Neuroradiologist Iv-Nurse Nursing Supervisor Transporter CT Tech Intensivist MICU Nurse

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8 CLINICAL SYMPTOMS OF STROKE Sudden Onset of: Numbness / Weakness of Face, Arm or Leg, especially one side. Confusion/Change in Mental Status Difficulty Speaking or Understanding speech Difficulty Seeing out of one or both eyes Loss of Balance or Coordination Severe headache with no known cause

9 ALGORITHUM Triggers: Face: Does the face look uneven? Arm: Does the Arm drift down? Speech: Does their speech sound strange? Time: To page a Stroke Alert! Page Primary Team: Stroke Alert at bedside within 5 minutes Pull Green Acute Stroke Folder: NIHSS Is it a stroke? Is pt. T-PA eligible? Yes Activate the burst page prepare patient to go to CAT Scan No Call attending to update and get orders

10 PRIMARY NURSE ROLE ASSESSMENT OF PATIENT Identifies and Notes Neuro deficit Checks Vital Signs Does a Finger Stick Glucose Pulls the Green Acute Stroke Folder Team 1 Using the In-house Paging System 1.Primary MD / PA 2.Text Message: Stroke Alert Patient Name, Room# Nurse Name, Call back #

11 STROKE ALERT PAGE TEAM 1 Using the In-house Paging System 1. Primary MD / PA 2. Text Message: Stroke Alert, Patient name, Room Number, Nurse name and call back number

12 PRIMARY TEAM AT THE BEDSIDE Uses Acute Stroke /TIA Triage Form Identifies Time Last Known Well and Onset of symptoms Performs the NIHSS Determines if patient is a stroke and t-pa eligible

13 ACUTE STROKE/TIA ASSESSMENT ORDERS

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15 ALGORITHUM Caregiver identifies posible inpatient acute stroke STROKE ALERT (PRIMARY TEAM) Assessment with Acute Stroke/TIA triage orders Clinical stroke + Eligible for IV-tPA Clinical stroke + Not Eligible IV-tPA? Clinical stroke +? Eligible IV-tPA Not a stroke ACUTE STROKE PROTOCOL STROKE ALERT (NEUROLOGIST) ATTENDING NOTIFIED

16 ACUTE STROKE PROTOCOL PAGE If it s determined that the patient is t-pa eligible: TEAM 2 Acute Stroke Response Burst Page (7458) If not t-pa eligible, the patient needs a Head CT, but Team 2 (Acute Stroke Burst Page is not activated)

17 ROLES AND RESPONSIBILITIES Patient s Nurse: Obtain Blood Glucose Activate the Stroke Alert Monitor BP and Vital Signs Record last time seen without stroke signs & symptoms Pull Green Acute Stroke Folder Check IV is patent Primary Team MD/PA: Assess patient using Acute Stroke/TIA Triage order set in green folder Perform NIHSS If patient is potential IV t-pa candidate, activate Acute Stroke Protocol Burst Page Prepare patient for transport to Cat Scan

18 ROLES AND RESPONSIBILITIES Neurologist: Call unit to confirm receipt of page and consult with primary responding MD/PA Neuroradiologist: Read CT scans/ other imaging and discuss with neurologist or page report to neurologist CT Tech: Clear CT scan and prepare for arrival of patient. Alert MRI of potential acute stroke patient. Beeper 6508 IV Nurse: Put in a 18 or 20 gauge angio catheter IV(not intima). Assist PCA in drawing stat labs if needed. Both IV nurses will be on the stat page so whoever is closer and free can respond Beeper 6183 or 6072 No IV nurse available 11:30pm to 07:00am so Nursing Supervisor put in IV or gets resources to do so during this time

19 ROLES AND RESPONSIBILITIES Nursing Supervisor: Determine availability of bed in MICU/SICU and notify staff of potential transfer. Determine plan if no beds available. Confirm availability of IV-t-PA in SICU pixis. Obtain t-pa from pharmacy if none available on unit. Be a resource to caregivers beeper 6102 or 6090 MICU Nurse: Begin preparation for IV-t-PA administration. Keep all t-pa packaging for return to pharmacy if NOT given. PCA: Draw stat labs if peripheral access present. Be available to assist nurse. Transporter: Stat to floor to transport patient and/or labs. Transporter remains with patient until released by MD. Beeper 6161 (alpha pager to be obtained and carried by dispatcher during days and by transporter evenings). No transporter available 11:30pm to 07:00am Night float PCA/unit coordinator will be added to burst page and will assist as needed. Beeper 6094

20 LEVEL OF CARE NEEDS If a higher level of care is needed the patient is transferred to an ICU or SDU. The Nursing Supervisor helps the Primary team with patient placement. The Primary Team calls the the Units to explain details of the case. The Primary Team assists with writing orders and completes the stroke packet.

21 DOCUMENTATION RN / MD / PA event note Acute Stroke Triage form filled out After every Stroke Alert page complete a rl on line incident form

22 ATTENDING NOTIFICATION If the primary MD / PA determines the patient s symptoms are not consistent with an acute stroke, they will notify the patient s attending physician that a Stroke Alert was activated and of the results of their assessment.

23 QUESTIONS If you have any questions please contact: - Oscar Soto, M.D., Neurology... x Marie McCune, RN, Stroke Nurse... x Nancy Couts, Stroke Coordinator... x 3313

24 Mount Auburn Hospital Stroke Service THANK YOU! Time Lost is Brain Loss