Holistic stroke care and how to develop stroke unit

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Holistic stroke careand how to develop stroke
unit

• Tasanee Tantirittisak MD.
• Prasat Neurological Institute
• Bangkok, Thailand

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The Continuum of Stroke Care

Links in the chain of successful stroke
intervention
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Health promotion risk factors management

• Stroke awareness
• Primary prevention
• Public education
• Stroke signs and symptoms
• Stroke risk factors

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Stroke awareness stroke alert

• Identified high risk patients and control risk
  factors
• Healthy life style campaign
• High fiber, low salt
• Regular exercise
• Education of stroke signs and symptoms and how to
  do when they have stroke
• Arrange transferal system

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Campaign media
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Public educations
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Public education of stroke S/S
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Stroke Symptoms
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Pre hospital care

• Signs and symptoms recognitions
• EMS system
• Time is brain

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EMS

• Ability to assess clinical S/S of stroke and make
  accurate diagnosis
• Coordinate between patient and the right hospital
• Shorten time of transportation to hospital

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Cincinnati Prehospital Stroke Scale
Facial Droop Instruction Ask patient to smile o
Normal Both sides of face move equally o
Abnormal One side of face does not move as well
Arm Drift Instruction Ask patient to close eyes
and extend both arms straight out for 10
seconds o Normal Both arms move the same or not
at all o Abnormal One arm does not move or
drifts down
Speech Instruction Ask patient to say You cant
teach an old dog new tricks. o Normal Patient
says correct words without slurring o
Abnormal Patient slurs words, says wrong words,
or is unable to speak
Kothari RU, et al. Cincinnati Prehospital Stroke
Scale reproducibility and validity. Ann Emerg
Med. 199933373-8.
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Time is Brain
Time loss is....brain loss
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Time is Brain

• ????????????????????? 130 ??????????
• ???? 1 ??????????????????? ????????????????????
  ???????????????? 1.9??????? ??????????????????????
  ??????????????????????? 13.8 ????????????
• ???????????????????? ????????? ???????????????????
  ????????????????? 12 ????????
• ?????????????????????????????????????
  ??????????????????????????????????????????????????
  ???????????? 3.6 ??

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Acute stroke care

• 4 evidence-base of acute care
• Thrombolytic treatment in lt 3 4.5 hours of
  onset
• ASA in 48 hours of onset
• Stroke unit care
• Hemicraniectomy of massive infarction in 48 hours

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Stroke Fast Track
Consider Thrombolytic Treatment
Onset lt4.5hr CT neg Inclusion Exclusion
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Stroke Fast Track

• Thrombolysis treatment is time dependence.
• 3 hours time window is importance.
• Special pathway or fast track is necessary to get
  the treatment in time.
• Good detection for the patients is crucial.
• Education for public is necessary.
• Co-ordination with EMS is consider.
• Satellite systems.
• Telephone/ telemedicine

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How to develop stroke fast track

• Professional personals
• Good detectors
• Prompt investigations and treatment
• Monitoring and early detected complication
• Good data collection and quality improvement

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??????????????????????????????????????????????????

• ????????????????????????????? 24 ???????
  ???????????????????
• ??????????? ?????????????????????????/??????????
  ??????????????????????????????????????????????????
  ????
• ???????????????
• CT brain
• ????????????????????????????? BS, CBC,
  Coagulogram, electrolyte, BUN, Cr
• ????????????????????????????????????? ???? FFP,
  CRP, Plt. conc.??? PRC
• ?? ICU ???? stroke unit ??????????????????????????
  ???????????????????????????????
• ???????????? rt-PA ?????????????????????????

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NIH-recommended Emergency Department Response
Times
DTN 60 min the golden hour for evaluating and
treating acute stroke
15 min Stroke team notified (including
neurologic expertise)
T0 Suspected stroke patient arrives at stroke
unit
10 min Initial MD evaluation (including
patient history, lab work initiation, NIHSS)
25 min CT scan initiated
45 min CT labs interpreted
60 min rt-PA given if patient is eligible
IDEALLY performed prehospital

• NINDS NIH website. Stroke proceedings. Latest
  update 2008.

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NINDS and ACLS Recommended Stroke Evaluation
Time Benchmarks for Potential Thrombolysis
compared PNI Thailand
Time Interval Time PNI
Door to doctor 10 min 6.6
Access to neurological expertise 15 min 6.6
Door to CT scan completion 25 min 10.30
Door to CT scan interpretation 45 min 10.30
Door to treatment 60 min 49
Admission to monitored bed 3 hrs 1.36
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Stroke unit

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  ???????????????????????? ??????????????
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  ??????????????????????

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Stroke unit

• Aim to avoid systemic complications and to
  rapidly detect deteriorating stroke as changes in
  patient's assessment often occur in the first few
  hours after onset
• Stroke unit patients have increased therapeutic
  contact with nurses and therapy staff, compared
  to those treated in general medical wards.

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??????????? stroke unit

• Increase nursing contact
• Early detection of deterioration
• Prevent complications
• Swallowing test, bed sore, DVT prophylaxis
• Educations
• Decrease LOS
• Decrease mortality, morbidity and cost

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?????????? stroke unit

• ???????
• ????????????????????????????????????????????
  ??????????? 4 ???????????
• Stroke unit

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???????? ??????????????? ????? ???????
????????????????????????????????????
?????? ????????????????
???????? ???????????????????????????????????????????????????????????????? ??????????????????????
Infusion pump / Syringe pump ??????????????????????????????????????????????????? ?????????????????? ????????????????????????????? / ??????????????????????????????????? ?????????????????????????????????????????
??????? defibrillation ?????????????????????????????????????????????????????
?????????????????????????????????? ??????????????????????????????????????????????????????????
EKG monitor ????????????????????

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?????????? stroke unit

• ????????????????????????????????????????????
• ?????
• Stroke manager
• ??????
• ??????????? ????????????
• ???????
• ???????
• ????????

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Specialized team
???????????? ?????
????? ?????????????????????? ???????????????????? ????????????????? ??????????????????????????? ??????????????????????????? ????? ??????????????????
stroke director ??????????????????????? ???? ????????????? ???????????
?????? ???????????????????????? ??????? ?????? ???????????????????????????????????? ???????????????????????????????????????? ???????????????? ??????????????????????
?????????????????? ??????????????????????????????????????? ?????????????????????????????????????
??????????? ????????????????????????????????????????
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???????? ????????????????????????????????????????????????? ????????????????????????????????????????????
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??????? ?????????????????????????????????????????????? ??????????????????????????????? ????????????? ????????????????????????
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Care protocols
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Stroke care map

• Stroke care map with standing order
• Admit to stroke unit

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Nurse follow standing orders immediately
Doctor order stroke care map
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???????? care map ?????????????????
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Education (Patients and family)
??????????????????????? ?????????????????????
????????????? ?????????????? ?????????????????????
?????????????????????????????
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Set up stroke unit

• Education
• Training stroke nurses
• Continue education for team
• Patient education

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?????????????????????????????????

• 2 courses basic and advance
• Agenda
• Basic neuroanatomy
• Signs and symptoms of stroke
• Investigations in stroke
• Complications of stroke
• Scale and score
• Nursing care
• Development of stroke systems
• Rehabitlitation

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Discharge planning and patient transfer protocols
???????????????????????????????????????????????
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Data collection
?????????????????????????????? ??????????????????
?????
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Set up stroke unit

• Data collection
• Quality control
• Benchmarking

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???????????????????????????????????????????????

• ????????????????????????? (process)
• ????????????????????????? CT/MRI ????
• ??????????????????????????????????????????????????
  ???????????
• ???????????????????????????????????????? 48
  ?????????? ????????????????????
• ?????????????????????????????????????????????????
  (antiplatelet) ????????????????????????????
  (anticoagulant)???????????????????
• ?????????????????????????????????????????
• ??????????????????????????????????????????
• ???????????????????????????? Nifedipine
  sublingual
• ??????????????????????????????????????????????????
  ?????????????????????????????
• ??????????????????????????????????? Stroke unit
• ???????????????????????????????????????????????
• ???????????????????????? (gt37.5?c)
  ????????????????????????????????????????
• ??????????????????????????????????????????????????
  ????

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???????????????????????????????????????????????

• ??????????????????????? (outcomes)
• ????????
• ????????????????????????
• ??????????????????????????????
• ????????????????????
• ???????????????????????
• ???????? Re-admission ????? 4 ???????
• ???????????
• ???????????????????????? ?????????????????????
• ??????????????????????????????

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Death rate of stroke in PNI

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Length of stay
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Stroke Unit in PNI
Indicators Target Result 2006 Result 2007 Result 2008 Result 2009
Death rate lt1 0 0 0.45 0
Pneumonia lt5 0 0 1 2
UTI lt8 0 0.83 1 2
Bed sore lt0.5 0 0 0 0
Readmit lt3 2 2.6 2 2.2
LOS 10.4 days 4.4 days 3.95 days 3.6 days 3.6 days
Bathel index0 80 98.3 94.82 96.56 95.4
Satisfied score 85 90.78 90.85 90.94 91.94
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Rehabilitation

• Provide in-hospital multidisplinary service.
• Set goal and try to achieve it.
• Refer to collaboration rural care.
• Teaching caregiver for home care.
• Provide and educate setting house.

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Early rehabilitation

• Prevent joint stiffness
• Adequate secretion toilet
• Prevent DVT
• Good outcome

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Secondary prevention

• Control risk factors
• Antiplatelets / anticoagulant
• Vascular intervention if needs
• Exercise and rehabilatation
• Good diets

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Risk factor management

• Control modifiable risk factors.
• Public campaign and education
• Regular check up
• Secondary prevention of recurrent stroke.
• Home help care/ long term care for severe disable
  patients (include rehabilitation) and community
  support.

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Home health care

• Follow independent patients
• NG tube feedings adequate nutrition, feeding
  technique, NG tube care
• Prevent bed sore / wound care
• Respiratory care
• House adjustment for handicap person
• Home PT, OT

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Community Re-Engagement

• Assist
• Stroke survivor and family
• Develop and implement care plan
• Assess
• 6-weeks, 3-months and 1-year
• Health status
• Community participation
• Links to prevention services

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Satellite stroke systems
Rural hospital
Rural hospital
Rural hospital
Regional center
Rural hospital
Rural hospital
Rural hospital
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Roles of the Regional Centers

• Full continuum of care within a region
• Collaboration and strategic alliances
• Local and regional commitment
• Local and regional care plans
• Data and information
• Education of the public, clients and providers
• Provincial system of linkages

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  ??????????????????????? ? ???

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?.????? 13.??.??????? ?.??????? 14.
??.???????????? ?.??????? 15.??.???????
?.??????? 16.??.?????????? ?.???????? 17.??.???
??????? ?.???????? 18.??.???????
?.???????? 19.??.???????? ?.???????? 20.??.??????
?.??? 21.??.????? ?.????? 22.??.??????????????????
? ??????????????????????????? stroke
corner 1.??.??????????? ?.??????? ?.??????? 2.
??.???????????????? ?.?????????? 3.
??.????????????? ?.???????? 4. ??.???????????
?.???????? 5.??.??????? ?.??????? 6.??.?????? 7.??
.????
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Telemedicine
Allows for remote presence Being there
anytime anywhere

• System is comprised of a laptop linked via the
  Internet and a wireless network

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Telemedicine stroke Network
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Thank you for your attension