Building an Emergency Response to Acute Stroke

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1 Great Lakes Stroke Network August 2006 Building an Emergency Response to Acute Stroke Wende N. Fedder RN, BSN, MBA Director, Stroke & Neurovascular Services Alexian Brothers Hospital Network Elk Grove Village, IL

2 Objectives 1. Resolving Stroke Response Challenges in a Community Hospital System 2. Initial experience with building an emergency response for stroke 3. Approaches to Professional Training for In-Hospital emergency and in-hospital clinicians and EMS

3 Background Third leading cause of death in the U.S. Approx. 700,000 people suffer strokes each year Incidence increases with age Mortality from stroke increases with age Frequent cause of disability Pre-hospital care has been primarily supportive

4 Stroke Alert Our experience Alexian Hospital Network has 2 acute care hospitals that were both certified by JCAHO in June 2005 We describe the first year experience building a acute stroke team at one of the community hospitals UIC Collaboration with Alexian Brothers Hospital Network EMS collaboration with NSA in July 2005 Coverdell IL CAPTURE Stroke Registry

5 Challenge: Develop an Acute Stroke Response Team Using Evidence Based Medicine in a Community Hospital

6 Acute Stroke Management Teams Ensure maximal perfusion and oxygenation of the brain regardless of underlying pathology (SAH, ICH, ischemic stroke) General Emergent Management of Patients with Stroke, Including BP management. Lewandowski C

7 Stroke is a Medical Emergency-Time is Brain!

8 BAC Recommendations-- --Stroke Centers Alberts et al JAMA 2000 June Multidisciplinary group; AAN, ACEP, AANS, AHA, NSA AANN, NIH, ASNR, SBC

9 Institute for Health Care Improvement- 100,000 Lives Campaign Campaign to make health care safer and more effective Mission to avoid 100,000 needless deaths between January 2005 and July 2006, and every year thereafter. Over 2800 U.S. hospitals have joined Promote development of Rapid Response Teams Complete details found at

10 Challenges How will the ED respond to the Stroke Alert? How will Neurology/INR be involved? How will Internal Medicine Physicians be involved? Will the Rapid Response Team involvement lessen the clinical skills of the non-icu staff? How to educate cardiac cath lab and OR? How to approach a Stroke Log and PI? How to educate EMS?

11 Multi-disciplinary Team Members Stroke Medical Director (Physician Champion) Stroke Administrative Director Quality Manager Interventional Neuroradiology Advanced Practice Nurse Data Manager/Abstractor Physician Leadership: ED, Neurology and Neurosurgery Staff Leadership Nurse Leadership: ED, ICU and Stroke Unit Director Leadership Therapy (OT, PT, SLP) Physiatry (if available) Interventional Neuroradiology Administrative Director Lab Administrative Director, Radiology Pharmacy RRT (ICU RN, Intensivist) Primary Care Physicians

12 What Is the Goal of Acute Stroke Team? Assess ABC s and neurologic function Stabilize Assist with communication Assist with accurate symptom onset and medical history Assist with transfer to CT Assist with review of inclusion/exclusion criteria tpa, and other treatments Educate and support Organize information communicated to the patient s physician. Acute stroke research studies Support family

13 How We Will Save the Ischemic Penumbra: Guidelines for Emergent CT and IV Thrombolysis (The Golden Hour ) Goal Target Times Minutes Presentation to CT Completion 25 Presentation to CT Interpretation 45 Presentation to IV thrombolysis 60

14 Immediate General Assessment Assessment Goal: in first 10 minutes Assess ABCs, vital signs Provide oxygen by nasal cannula Obtain IV access; obtain blood samples (CBC, lytes, coagulation studies) Obtain 12-lead ECG, check rhythm, place on monitor Check blood sugar; treat if indicated Communicate with Stroke Team: neurologist, radiologist, CT technician Perform general neurologic screening assessment (NIHSS) Transport to CT Start Protocols!

15 Source: University of Cincinnati College of Medicine

16 Source: University of California at Los Angeles Stroke Center

17 Differential Diagnosis Drug overdose Hyper and Hypoglycemia Seizure ( with persistent paralysis) Cervical / Head Trauma Intracranial Mass Migraine ( with persistent neuro signs) Meningitis/Encephalitis Post cardiac arrest ischemia

18 Initial Steps How To Engage senior leadership support. Determine the best structure for the team. Provide education and training. Establish criteria and mechanism for calling the Stroke Alert. Use a structured documentation tool. Establish feedback mechanisms. Measure effectiveness.

19 Initial Structure: Who is Going to Respond 24/7? (Existing Resources) Stroke Alert Structure: (2 teams) ED Team (Stroke Alert Called, RRT back-up) In-house-existing Rapid Response Team established Oct 2004 (Stroke Alert Called, ICU MD and RN respond to pt bedside) Interventional Neuro-Radiology Team and Neurologists on-call

20 Two Team Model: Who is the Stroke Alert Rapid Responder Team? In-house ICU Nurse (RRT) Intensivist (RRT) Transport ED ED physician ED RN RRT (backup) In all cases: Lab Tech, CT Tech, Pharmacy, Data Specialist (carried pagers)

21 Stroke Alert Launch What are initial steps to set up a Stroke Alert? Stroke Clinical Education: Existing RRT and ED were trained in acute stroke response House-wide education blitz Dec-Feb 2005 Stroke Alert Pagers: assigned to clinical staff and an Overhead Page was announced as backup. Stroke Alert Process: hospital operators were inserviced and assigned to keep a log of calls. February 2005, the Stroke Alert was launched

22 Modifications to In-house RRT Call Criteria Initial RRT call criteria included: Acute change in heart rate <40 or >130 bpm Acute change in systolic blood pressure <90 mmhg Acute change in respiratory rate <8 or >28 per min Acute change in saturation <90% despite O2 Acute change in urinary output to <50 ml in 4 hours Staff member is worried about the patient Acute change in conscious state Added: Any sudden neurologic change Sudden one-sided numbness or weakness Sudden change of vision Sudden difficulty speaking Sudden severe headache Sudden trouble walking New Stroke Alert System Pagers assigned to RRT (excluding respiratory) Lab Radiology/CT

23 Stroke Protocols An acute stroke code box for acute stroke protocols Protocols included: Stroke Response Flow Chart Stroke Alert Orders Admission Orders NIHSS Assessment Form Inclusion and Exclusion Criteria for Fibrinolytic therapy Stroke Log manual

24 First 6 months experience Acute stroke treatment outcomes after implementation over 6 month period showed increase utilization of: IV tpa Clot retrieval IA tpa Other acute interventions (acute neuroprotectant studies)

25 Stroke Alert Call Volume/Treatment Dec Feb Apr June August 20-Oct Baseline Combined ED And In-house Stroke Alerts Stroke Alert Calls Acute Intervention *Stroke Alert Launched Feb 2005 ABMC 350 I.Stroke/TIA admissions per year

26 Results of Stroke Alert Response Twelve months prior to Stroke Alert launch 2 patients were treated with IV tpa (based on financial data) In the first 6 months after Stroke Alert launch, 7 patients were treated with IV tpa and other acute therapies 4/7 (57%) of treated cases, were treated with IV tpa 3/7 (43%) of all treated cases received IA tpa, MERCI, or enrolled in SAINT II

27 Stroke Alert Results 14/63 (20%) stroke alert calls (In-house and ED) ruled in for ischemic stroke (primary diagnosis ICD-9 codes , , , , , , 434.0, , , , 436) Low Yield

28 Overall Results of Stroke Alert Response (continued) Increased use of stroke protocols in cases where the rapid response team intervened. Average monthly stroke alert calls 12/month Bonus! Additional benefits included, increased staff confidence to stroke response, assessment and action. Teachable moments from a well trained group of staff

29 Lessons Learned Get the word out initially and continuously! Communicate, communicate, and communicate! Hospital publications, newsletters, etc. Staff are encouraged to call even if they re unsure Be tolerant of false alarms. It s better to call than not Share stories-missed opportunity Case Studies!

30 Performance Improvement Each month, determine the location each code occurs from code logs and records. Establish a process to identify all calls to the Stroke Alert Team. One possible data collection strategy: Each call to the RRT should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and serve as the source of the data.

31 Professional Training

32 Stroke Education for Clinicians: Who Should Receive Stroke Education? EMS staff ED Neurologists/Interventional Neuroradiology Internal Medicine and Family Practice Radiology Lab Pharmacy RNs Hospital Operators!

33 How did we educate to prepare for Stroke Alert Launch? Staff were educated on criteria for calling a stroke through General hospital orientation, ACLS and CPR education, Physician CME, Nurse Unit meetings, Lunch and Learns EMS educated through 2 in-hospital CME Cincinnati/LAPSS scales Neuro-ICU training by physicians at UIC House-Wide Stroke Unit Open House

34 Physician Training Intensivists visited UIC Neuro ICU Stroke Program Medical Director gave multiple CMEs Physicians are developing a Neuroscience Clinical Conference to review recent cases ACLS and NIH SS certification

35 Hospital Staff NIHSS Training NIHSS Training Course NSA NIHSS Training Program $25 per exam Benefits: NSA keeps record of staff who successfully certified Good for nurses who are not as comfortable with computers Customer Service Challenge: US Mail more time intensive for certificates, no competency structure ASA On-Line Training Tool Free asa.trainingcampus.net. Benefits: Built in competancy Efficient Challenge: Computer logs out every 30 minutes, IT capability in hospital

36 EMS Training- Initial Approach Work with EMS from the beginning (even adding them to your planning team) EMS education in critical to the success of early identification and rapid transport to the hospital Stroke Education in Firehouses! Message Load and Go Provide feedback to EMS staff

37 Conclusion Developing and organized approach to acute stroke is critical for improved patient outcomes If we can be aware of neuro changes, we can improve the quality of our care. Rapid Response teambuilding to stroke through hospital-wide and EMS education can improve responses to critically ill neurological emergencies

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