Process to Improve Stroke Care

1
Process to Improve Stroke Care

• Reduce time to brain imaging
• Partner with EMS to improve skills early
• identification
• Enhanced ED response evaluation through
• training competency assessments
• Develop Stroke Alert
• Decrease door to needle time
• Critical access/rural hospital transfer

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Door to Needle - 2009
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Reduce time to brain imaging

• 1. Ongoing review of data
• 2. Look at process flow
• 3. Encourage staff input
• 4. Celebrate improvements thank
• direct care staff

4
Partner with EMS

• Provide EMS with stroke education
• Stroke alert Train-the-Trainer Program offered in
  MI
• Stroke info cards developed for EMS services

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Partner with EMS

• 4. Stroke criteria developed for hospital
• notification at time of transport
• 5. ED supervisor, CT scan lab staff notified
• if criteria met
• 6. Criteria
• last known well, age, gender, s/s ETA

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Enhanced ED response

• Educate and reeducate ED staff
• Every stroke considered for tPA
• 3. Educate triage nurses
• Mock stroke codes
• Developed pocket cards with emergent guidelines
  for staff to carry

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Enhanced ED response

• Reinforced appropriate use of Stroke Alert
  beeper
• Ongoing ED resident education
• 7. Optional stroke rotation for ED residents

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Develop Stroke Alert

1. Triage immediately to ED based CT scanner
2. Draw blood NIHSS
3. Notify Stroke Team
4. Bring clot box infusion pump to CT

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Develop Stroke Alert

• 5. Interpret images treat immediately
• 6. Nurses provides tPA bolus resident
  injects
• 7. Nurse programs IV pump initiates infusion
• 8. Electronic access to tPA protocols anywhere
  in hospital

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Decrease door to needle times

1. Stroke Team challenged to decrease door to needle
   time to 45 minute target
2. Individual patient treatment times are reviewed
   monthly
3. Celebrate successes

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Decrease door to needle times

1. Follow up on failures or extended times
2. Verify triage time, time CT completed and
   administration of drug

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Critical access/rural hospital transfer

• 1. Educate all ED staff on stroke
• 2. http//NIHSS-English.Training.Campus.net
• 3. Everyone is a thrombolytic therapy
  candidate until excluded
• 4. Assess treat emergently

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Critical access/rural hospital transfer

• Partner with a stroke center for support
• 6. Set up transfer protocol
• 7. Notify center with NIHSS, last known well
  time, pertinent health history, pertinent labs,
  CT results
• 8. Review exclusion/inclusion criteria with
  referral physician

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Critical access/rural hospital transfer

• 9. Start tPA if appropriate criteria met
• Transfer with appropriate staff while tPA
• infusing
• 11. Send copy of imaging labs
• 12. Accepting hospital re-evaluates patient
  
• reviews labs/imaging

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Critical access/rural hospital transfer

• Telemedicine is an effective method to provide
  expert care to stroke patients in rural areas.
• Robotic evaluation is another option in rural
  areas.
• Stroke. 2007 38 1655-711.
• Seminars in Neurology. 2005 25337-44

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Critical access/rural hospital transfer

• The drip and ship method of delivering tPA has
  been safe and efficacious.
• Drip and ship protocols use telemedicine
  consultation or robotic evaluation to determine
  eligibility before tPA is started and the patient
  is transferred.
• Neurology Today. 2009 9 2,13-14
• Neurology. 2005 64 154-6.

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Hippocratic Oath

• First, do no harm
• To do nothing is doing harm.