CODE STROKE

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CODE STROKE
Putnam Hospital Center

• Putnam Hospital Center
• Education and Training Department

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STROKE CENTER MISSION

• The mission of the Stroke Program at Putnam
  Hospital Center is to provide state of the art,
  high quality medical and diagnostic care to our
  patients who are identified as possible stroke
  victims. All patients presenting with signs and
  symptoms of Acute CVA, will be evaluated upon
  arrival. They will be evaluated using established
  criteria for administration of t-PA or other
  appropriate therapies. Each patient will receive
  assessment, stabilization, diagnostic treatment
  and interventions within the timeframe and
  guidelines set by the AHA/American Stroke
  Association.
• Key Elements in place to provide this care are
• Evidence based medical and nursing care
• Interdepartmental approach for quality care
• Education for patients and families
• Safe and appropriate discharge planning
• Continuing medical and nursing education
• Community Education

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Our Commitment is to

• education, including hospital staff,
  pre-hospital care providers, patients and the
  community at large
• quality and a continuing drive to improve the
  care given to our patients
• offer support services that are available 24
  hours a day, 7 days a week
• provide timely and efficient transfers when
  needed. We have documented transfer agreements
  with Vassar Brothers Medical Center and
  Westchester Medical Center for neurosurgical
  services should they be needed

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Designated Stroke Center

• These services are provided by utilizing
• Multidisciplinary Approach
• Designated beds
• Performance Improvement Initiatives Get With the
  Guidelines (GWTG)
• Highly trained, dedicated staff which includes
• Physicians Board Certified in Emergency
  Medicine, Neurology and Interventional Radiology
• Dedicated critical care, step-down and medical
  staff
• The latest monitoring and treatment technology
  for the care of stroke patients

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PROCEDURE

• Coordinated Care between the ED and EMS
• Patient assessed by EMS utilizing Cincinnati
  Stroke Scale
• Emergency Department contacted via radio or ALS
  phone regarding acute stroke patient en-route to
  facility.
• Medical control physician alerts secretary and
  nursing staff of incoming acute stroke patient
• Ancillary services (radiology/lab) notified of
  incoming code stroke patient.

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Cincinnati Pre-Hospital Stroke Scale

• Assess for facial droop have the patient show
  their teeth or ask the patient to smile.
• Assess for arm drift have the patient close
  their eyes and hold both arms straight out for 10
  seconds.
• Assess for abnormal speech have the patient say,
  you cant teach an old dog new tricks.

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Suspected CVA

• R/o other causes of symptoms
• Hypoxia
• Hypoglycemia
• Hypoperfusion
• Post Ictal (Todd's Paralysis)
• Determine Time of onset of symptoms
• Less than 2 hours transport to Stroke Center.

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ASSESSMENT and TREATMENT TIMEFRAMES

• Assessment and treatment times frames are less
  than or equal to
• Door to MD assessment 10 minutes
• Door to Stroke Team contact 10 minutes
• Door to CT Scan 25 minutes
• Door to CT read time 45 minutes
• Door to Lab results 45 minutes
• Door to t-PA administration 1 hour
• ( from door to med FDA is 3
  hours from
• 
  onset of witnessed symptoms)
  

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Code Stroke Inpatient Protocol

• Utilized for emergent treatment of patients,
  staff or visitors currently in the hospital
  building presenting with symptoms of stroke.
• Anytime a person exhibits signs or symptoms of
  stroke, and onset is less than three hours, Code
  Stroke may be activated by a staff member of the
  hospital.
• Code Stroke team is activated by dialing 2222
  and telling the operator to page Code Stroke
  overhead, adding the unit where the event
• is occurring.

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PROCEDURE TEAM ACTIVATION

• Rapid Response Team responds to the call for all
  inpatient units
• Emergency Dept. Code Response Team responds to
  all other hospital locations (outpatient, staff,
  or visitors)
• Code Stroke alerts the Radiology dept.
• if CT scan is in use, to remove the patient from
  CT and prepare for STAT CT scan of stroke patient
• Code Stroke alerts lab
• to perform STAT lab work and turn around results
  in 45 minutes or less

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CODE STROKE
POLICY, PROCEDURE AND
DOCUMENTATION

• Code Stroke Packet
• Policy Procedure
• Code Stroke Order Sheet
• NIH Stroke Scale Assessment Sheet
• Consent Form for t-PA
• Admission or Transfer protocols
• Admission Order Sets

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CODE STROKE DOCUMENTATION

• Code Stroke Flow Sheets ensure documentation
  compliance
• Timeline
• Diagnostics
• NIHSS
• Eligibility/Exclusion Criteria
• Medications/Interventions

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CODE STROKE STROKE LOG

• Stroke Log is the evaluation
• tool used measure
• compliance with
• the evidence based
• timeframes

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• PUTNAM HOSPITAL CENTER PATIENT CARE SERVICES
  UNIT
  DATE OF CODE
• PERFORMANCE IMPROVEMENTCODE STROKE EVALUATION
  RECORD
  TIME OF CODE
• PATIENT NAME/DRILL
• PRIMARY DIAGNOSIS
• 
  
• 1. Was Critical EMS assessment completed, if
  applicable, and appropriate actions taken?
  YES NO
• Support ABCs oxygen given if needed
  
  YES NO
• Perform pre-hospital stroke assessment
  
  YES NO
• Establish time when patient last known normal
  
  YES NO
• Transport consider bringing a witness, family
  member or caregiver
  YES NO
• Alert hospital
  
  YES NO
• Check glucose if possible
  
  YES NO
• 2. Support ABCs oxygen given if needed
  
  YES NO
• Perform pre-hospital stroke assessment
  
  YES NO
• Establish time when patient last known normal
  
  YES NO
• Transport consider bringing a witness, family
  member or caregiver
  YES NO
• Alert hospital YES NO
• Check glucose if possible YES NO
• 3. Was there an immediate neurologic assessment
  by stroke team or designee YES NO

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DEPARTMENTAL RESPONSIBILITIES

• Each department has established responsibilities
• Each department involved in the
• CODE STROKE
• Coordinates with each other
• to ensure the highest quality care
• in the most efficient amount of time
• Time is of the essence!

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CODE STROKEEMERGENCY DEPARTMENT

• Identification/Notification of a potential Code
  Stroke patient
• Preliminary notification of Radiology and
  Laboratory
• Patient Room
• placement
• 1 to 1 Nursing Care

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CODE STROKE Radiology

• All Radiologists are experienced in the
  interpretation of
• acute stroke CT and
• MR Neuro-images
• Fellowship-trained
• neuro-radiologists are
• on call 24/7

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CODE STROKE RADIOLOGY

• Goal Perform Rapid CT Assessment of BRAIN
  ATTACK
• Patient with a timely, expert
  interpretation
• Emergency Dept. informs CT Technologist of
• Code Stroke
• CT Table is held open until patient arrives
• Radiologist is informed of
• pending scan
• Scan performed
• Results
• communicated
• to ED physician
• within designated
• timeframe

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CODE STROKE LABORATORY

• Emergency Department
• Calls to notify Lab of impending Code Stroke
  specimen
• Complete patient information is given to the Lab
  office staff who takes the call
• Lab office staff notifies the Lab technical staff
  of impending Code Stroke so they can prepare
  workstations
• Lab office staff member who took the call has
  ownership of the specimen to log it in and
  deliver it to the lab technical staff for
  analysis.
• There are no handoffs! Chain of
• custody must be maintained by
• the staff member who took the call.
• Lab technical staff calls the result to the ER

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CODE STROKE CRITICAL CARE SERVICES
ADMISSION CRITERIA

• Acute neurologic events requiring frequent
  neurological or respiratory checks to evaluate
  progression including
• Post IV t-PA
• Large hemispheric stroke, in whom impending
  mental status decline and loss of protective
  airway reflexes is of a concern
• Basilar thrombosis or top of the basilar syndrome
• Crescendo TIAs
• Patients requiring blood pressure augmentation
  for a documented area of hypoperfusion
• IV blood pressure or heart rate control
• Every1-2 h neurological evaluation depending on
  symptom fluctuation or if ongoing ischemia is
  suspected
• Worsening neurological status

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CODE STROKE CRITICAL CARE SERVICES

• The Neuro Stroke Scale Assessment Flow Sheet
  will be used to monitor
• All post t-PA patients with assessments done q1h
  x 24 hours
• All non t-PA patients with assessments done q2h
  x 24 hours
• Stroke patients will have special attention paid
  to
• Eye care
• Potential for seizure
• Airway
• Tissue perfusion
• Safety needs
• Altered body image
• Mobility DVT skin breakdown
• Nutritional concerns
• Glucose management
• Signs and symptoms of meningeal irritation

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PUTNAM HOSPITAL CENTER

PARTIAL FORM


NEURO STROJKE ASSESSMENT FLOW SHEET

Circle times when
patient care was rendered
7 - 8 - 9 - 10 - 11 - 12 - 13 - 14 - 15 -
16 - 17 - 18 - 19 - 20 - 21 - 22 - 23 - 24 - 1 -
2 - 3 - 4 - 5 - 6 CATEGORY
DESCRIPTION SCORE

1a. Level of Consciousness (Alert Drowsy etc.) Alert Drowsy Stuporous Coma 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
1b. LOC Questions (Month Age) Answers both correctly Answers one correctly Both incorrect0 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2
1c. LOC Commands (Open, close eyes make fist, let go) Obeys both correctly Obeys one correctly Both incorrect 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2
2. Best Gaze (Eyes open- patient follows finger or face) Normal Partial gaze palsy Forced deviation 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2
3. Visual (Introduce visual stimulus to patients visual field quadrants No visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
4. Facial Palsy (Show teeth, raise eyebrows and squeeze eyes shut) Normal Minor Partial Complete 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
5a. Motor Arm Left (Elevate extremity to 90 degrees and score drift/movement) No drift Drift Cant resist gravity No effort against gravity 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3






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CODE STROKE MEDICAL SERVICES

• Identified Unit Reed 2
• Close to Nursing Station to facilitate safety
• Easy access to equipment
• Modifications to the environment
• All Stroke Patients on
• Yellow Dot/Falls Prevention Program
• Aspiration Precautions
• Patient and Family Education Ongoing
• Begins in the Emergency Department
• Follows through discharge and outpatient

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CODE STROKE Documentation

• NIHSS needs to be completed at
• 15 minutes
• 30 minutes
• 60 minutes
• 90 minutes
• Per order for 24 hours or 48 hours
• Discharge

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CODE STROKE Documentation

• Cerner
• Interactive View
• Complete Neurological Assessment
• Include appropriate NIHSS
• Include education provided to patient and family

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CODE STROKE Documentation

• Discharge
• NIHSS must be done at discharge
• Documentation of where patient is going after
  discharge
• Documentation of discharge medications
• BOX MUST BE CHECKED FOR THE EDUCATION PORTION
  (page 2) OF THE DISCHARGE FORM
• Time out must be completed by two nurses
  signifying that the form is complete and that all
  information has been relayed to the patient

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CODE STROKE REHABILITATION DEPARTMENT

• PHC offers comprehensive Rehabilitative Services
  for Inpatients and Outpatients
• These services include
• Physical Therapy
• Range of Motion Strength
• Functional Mobility, Gait Balance
• Occupational Therapy
• ADLs, Safety Awareness Cognition
• Speech and Language Pathology
• Speech, Language Swallowing difficulties

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CODE STROKE CASE MANAGEMENT

• Psychosocial/Continuing Care Assessment
• 24-48 hrs. after admission
• Social Work Referral if indicated
• to assist with supportive counseling regarding
  adjustment to deficits
• Utilization Management Advocacy
• to assist patient in discharging to the most
  appropriate post hospital care setting

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Education and Training

• Annual Staff Education
• All nursing staff involved in Acute Stroke
  patient care
• Attend 4 hours of stroke education annually
• Stroke specific educational opportunities
  provided by PHC throughout the year

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Educational Support of EMS by the Stroke Center

• EMS receives lectures bi-monthly from the
  Assistant Director of the Department of Emergency
  Medicine
• Bi-annual education regarding acute stroke
  provided to EMS via didactic lectures, case
  presentations, and call audits

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CODE STROKE PERFORMANCE
IMPROVEMENT

• Chart reviews
• Data is aggregated
• Monthly P. I. meetings
• Results forwarded to the Performance Improvement
  Committee
• Findings reported to Patient Care Services,
  Hospital QA Committee and to department staff
  members

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2011 PHC Code Stroke