In-Hospital Stroke: A Train-Wreck or a Well-Oiled Machine? State-of-the-Art Stroke Nursing Symposium. January 31, 2012

Transcription

1 In-Hospital Stroke: A Train-Wreck or a Well-Oiled Machine? State-of-the-Art Stroke Nursing Symposium January 31, 2012 Christy Casper, ANP Ethan Cumbler, MD Alex Graves, ANP

2 Objectives Define in-hospital stroke and review the challenges that prevent optimal care Describe broad quality improvement methodology related to in-hospital stroke Develop action plans and tools for your hospitals

3 Case Presentation 43 year old man POD #2 after GI surgery 10:00 am Nurse checks on patient and he says he suddenly feels: The room is spinning I feel like I am going to throw up Wow, I see two of you I am hurting Action: Bowel sounds are active. VSS. Gives promethazine 25 mg, Fentanyl 50 mcg 11:15 am Patient hits call light, still not feeling well, lightheaded Nurse calls the physician listed on post-procedure orders No answer after 2 attempts Nursing eventually tracks down correct physician Action: VSS, BP higher 150/90. Verbal order for Zofran IV, 500 cc NS 1:00 pm (3 hours after onset) Pt complains of severe vertigo Nurse calls back physician who evaluates Action: Orders non-contrast head CT

4 Case Presentation 2:20 pm (4 hours, 20 min) CT is completed. Delays Waiting for transportation to be arranged Pt arrives at CT but needs to wait for another patient. 3:30 pm (5 hours, 30 min) Head CT read as negative for bleed, result called to primary MD. Based on continued symptoms, neurology called for consultation 4:10 pm (6 hours, 10 min) Neurologist sees the patient after clinic, exam is suggestive of stroke. Recommends MRI/A with DWI 4:45 pm MRI/A with diffusion ordered What do you think that showed?

5 Case Presentation 5:15 pm MRI no longer available as technician has gone home 5:25 pm Order changed to CT angiogram 6:30pm (8 hours, 30 min) Study read as subtle cerebellar infarcts Basilar artery thrombosis on CTA

6 In-Hospital Stroke Definition Stroke in a patient originally admitted for another diagnosis or procedure.

7 Background Between 4-17% of all strokes occur in patients already hospitalized for other reasons Translates to 35,000-75,000 in-hospital strokes annually Kimura K, Minematsu K, Yamaguchi T. Characteristics of In-Hospital Onset Ischemic Stroke. Eur Neurol 2006;55: Dulli D, Samaniego EA. Inpatient and Community Ischemic Strokes in a Community Hospital. Neuroepidemiology 2007;28:86-92.

8 What are some of the barriers? Confounding factors in the inpatient Pain medications Sedatives Anesthesia Blood sugar Electrolytes Underlying neurologic disorders

9 Other barriers? Providers not familiar with rapid stroke assessment protocol Providers not aware of acute treatment options Opposition from primary team Change of shift Time of day/week Nurse uncertainty Imaging not available 24/7 Location of the t-pa Patient location

10 In-Hospital Stroke: When and Where? Occur on average 6.2 days into hospitalization Admitting Diagnosis Cardiovascular (24%) Neurology/Neurosurgery (15%) Hematology/Oncology (8%) Orthopedic/trauma (7%) Gastrointestinal (7%) Respiratory (5%) Cumbler EC et al. In-Hospital Stroke Alert Program to Improve Process Quality for Cerebrovascular Accidents Occurring During Hospitalization Presented National Society of Hospital Medicine Symposium, Chicago Il, April 2009 Farooq MU et al. In-Hospital Stroke in a Statewide Stroke Registry. Cerebrovasc Dis 2008;25:12-20

11 Patient Characteristics In-hospital strokes are more likely to have prior dx of cardiac disease Afib, CHF, cardiomyopathy, CAD Community stroke are more likely to have atherosclerotic risk factors: Smoking, HTN, hyperlipidemia Park JH et al. Comparison of the Characteristics for In-hospital and Out-of-hospital Ischaemic Strokes. Eur J Neur 2009;16: Iguchi Y et al. In-hospital Onset Ischemic Stroke may be Associated with Atrial Fibrillation and Right-to-left Shunt. J Neurol Sci 2007;254:39-43 Kimura K, et al. Characteristics of In-Hospital Onset Ischemic Stroke. Eur Neurol 2006;55:

12 OUTCOMES Prognosis is worse for in-hospital strokes Stroke severity is higher Functional outcome is worse, half as likely to return home + In-hospital mortality 15-19% compared to community mortality of 2-7% Cardioembolic strokes associated with worse outcomes (2x) Less treatment with thrombolysis* Greater co-morbid Illness Infection causes majority of deaths Other complications (ie: DVT etc) *Park JH. Eur J Neur 2009 Kimura K. Eur Neurol 2006 Dulli D. Neuroepidemiology Farooq MU. Cerebrovasc Dis 2008

13 Discontent is merely the first necessity of progress Thomas Edison

14 Acute Stroke Response Results of Survey on Brainwave 3 response patterns to new neurologic deficits in the hospital Traditional Nurse notes symptoms Call to primary MD Primary MD decides how to proceed Rapid Response Triage Nurse notes symptoms General medical rapid response team evaluates If consistent with CVA, neurology or stroke team consulted Direct Activation of Acute Stroke Team Nurse notes symptoms Acute stroke team activated Summary of 2009 Responses to Brainwave Survey- Cumbler E, Personal Communication

15 Individual Brilliance Is Inadequate In the Absence of System Organization

16 QI Principles

17 Staff Education

18 Inpatient Stroke Alert Program Code Gray Code Stroke Code Neuro Code Brain Attack Any staff member can trigger a stroke alert Single alert number Rapid mobilization of staff Acute Stroke Team or stroke trained Rapid Response Team Authority to proceed with evaluation Cumbler EC, et al. Stroke Alert Program Improves Recognition and Evaluation Time of In-Hospital Ischemic Stroke. J Stroke and Cerebrovasc Dis 2010;19: Nolan S, et al. Code Gray An Organized Approach to Inpatient Stroke. Crit Care Nurs Q 2003;26:

19 PDSA PLAN DO STUDY ACT

20 Continuous Process Improvement Process Map Identification of: unreliable steps and reliably slow steps Solutions to Barriers -System Re-engineering

21 Stake-holder Buy-in Who are your key stakeholders?

22 Standardization January 15 th 2009, 3:27 pm US Airways Flight 1549 suffered multiple bird strikes after takeoff from LaGuardia airport Both engines lost thrust Pilot Captain Sullenberger Did Capt. Sullenberger first rely on memory or instinct to respond? Neither Within 16 seconds of the bird strike Captain Sullenberger requested the Quick Reference Handbook checklist for loss of thrust on both engines

23 In-Hospital Stroke Checklist Optimal Process Codified Exactly what needs to occur By whom When How

24 Measurement In-Hospital Stroke Response Times Minutes Minutes from Stroke Alert to CT Scan p< Stroke Alert Number Pre-intervention Intervention rollout Post-intervention Time to CT Time to Thrombolysis CT Goal tpa Goal Beware the Hawthorn Effect!

25 Closing the Loop Planning the Next PDSA Cycle

26 Now what

27 Step 1 Create a detailed Process Map Identification of slow, unreliable or wasteful steps Identify insufficiencies

28 What does your process look like? Observation Difference between ED and in-hospital alerts Interview Floor staff: RNs, CNAs, medical staff, hospital manager, clerks Hospital Operator Stroke neurologist, resident Radiology: radiologist, CT tech Transport service staff Lab tech MET members Pharmacy EVERYONE

29 Treatment Timeline 0 min 10 min 15 min 25 min 45 min 60 min Stroke symptoms identified and Stroke Alert called Initial stroke evaluation: patient history, lab work initiation, and NIHSS assessment Stroke Team arrival CT scan obtained CT and labs interpreted Activase (t-pa) given if patient is eligible

30 Interview Questions Who calls the alert? Who is notified? Who responds? Who stays with the patient? Who places the orders? Who draws the labs? Who transports the patient? Who can give t-pa? Transportation department is responsible for moving patients to radiology IV access Ordering labs and CT Communication with the CT tech T-PA can only be given by an ICU nurse

31 Process Map: Pre-Intervention Who does what? When? How? Are there consistencies? Dashed line = unreliable steps Add times What s occurring simultaneously vs sequential?

32 Step 2 System Redesign Create NEW process map From symptom recognition to t-pa administration Data-driven

33 NEW Process Map Transportation RN & Stroke Team member go to CT IV access Attempts > 10 minutes STOP go to CT Ordering labs & CT Similar to a CODE, order & explain later Stroke Alert Panel (order set) Communication with CT CT added to Stroke Alert page T-PA only given by ICU nurse Call a MET for t-pa administration T-PA kit grab and go

34 Step 3 Create Tools Detailed checklists Exact steps by whom, how, what order Highlight benchmark times Review with stakeholders (multiple times) 2 versions (physician and nurse) Name-badge and pocket sizes Availability

35 Hospital-wide education

36 Set a GO-LIVE date for process change Meet with the Nurse Educators Give each educator a packet for their unit with: Overview of process changes and reasons why Checklists for all staff Ask for sign-off from all RNs on each unit Offer to present at a staff meeting, lunch CE New-hire orientation Present at Charge Nurse Council Meet with environmental and dietary services

37 Step 4 Provide Feedback Real time feedback Review the process Handout checklists summary ALL treatment cases EVERYONE involved Request staff inform you of barriers experienced Request suggestions for future process improvement

38 Example Feedback Form

39 Results Change in Median Response Time p< Minutes from Stroke Alert to CT Scan Pre-intervention Intervention rollout Post-intervention Pre-intervention 9/08 2/09 Intervention 3/09 5/09 Post-intervention 6/09 11/09

40 Results Reduction of Variability in Time to Evaluation

41 Thank you!