Acute Stroke Management: an ED perspective. Tanya Frost Acute Stroke Nurse Eastern Health

Transcription

1 Acute Stroke Management: an ED perspective. Tanya Frost Acute Stroke Nurse Eastern Health

2 Overview Little about me Stroke Care aims Treatments Streamline of service regardless of access Treatment Times

3 Box Hill Hospital Primary Stroke Centre Situated in the Eastern Suburbs of Melbourne 621 Bed tertiary Hospital (Monash University) Catchment = 2800km, Population = 850,000

4 Maroondah Hospital A little further out Eastern Suburbs Even further out Eastern Suburbs Angliss Hospital

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6 Stroke is a medical emergency Second largest cause of death Leading cause of disability 1/5 th of all strokes occur in people under 55 years old 1/5 th die within 1 month 1/3 rd die within 12 months 88% of survivors live at home Most with persistent disability Cost burden of $2.14 billion/year

7 Stroke Care Recognition of Symptoms: Access help Diagnose stroke: where is the lesion? Focal neurological signs Treat as able: tpa ECR Fever, Sugar, Temperature, access to Stroke Unit Care: Secondary Prevention: Medications Education Risk Factor modification Mechanism Large Vessel Cardio embolic Small artery occlusion Stroke of other determined etiology Stroke of undertermined etiology Unknown Allied Health

8 Research

9 What is stroke. Acute loss of oxygen supply Therefore the aim is: Return of oxygen supply

10 tpa Thrombolytic given within 4.5hrs of Sx onset. Not appropriate for every patient Angioedema 1-2% Associated with ACEi use Antihistamine and steroid Bleeding Risk Symptomatic Haemorrhage 4-6% Other bleeding

11 ECR Endovascular clot retrieval

12 Slide used with permission of Dr Bruce Campbell ECR: Suitability

13 The golden hour T=0 10 min 15 min 25 min 45 min 60 min Suspected stroke patient Initial MD evaluation (including patient Stroke team Notified CT scan initiated CT & labs interpreted rt-pa given if patient arrives at history, lab work is eligible stroke unit initiation, & NIHSS) Slide courtesy of Boehringer Ingelheim

14 The golden hour T=0 10 min 15 min 25 min 45 min 60 min Suspected stroke patient Initial MD evaluation (including patient Stroke team Notified CT scan initiated CT & labs interpreted rt-pa given if patient arrives at history, lab work is eligible stroke unit initiation, & NIHSS) Slide courtesy of Skye Coote

15 The golden half-hour T= min 10 min 25 min 30 min Suspected stroke patient Patient arrives. Met at triage by Triage, direct-to-ct, CT scan completed & t-pa given if patient hospital stroke and ED team rapid (basic) interpreted is eligible pre-notification. stroke assessment, Stroke team IVB Notified Slide courtesy of Skye Coote

16 Pts who arrive within the golden hour are twice as likely to be treated. Improved patient outcomes and. Walk out of hospital

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18 Identification of Stroke An immediate life threatening emergency needing an ambulance may include:

19 Ambiguous stroke Sx Dizziness Drowsiness Visual disturbance Ataxia Numbness Tingling Can t understand surroundings

20 Ambulance Pre-notification Patients name & DOB Quick story Symptoms Time of onset Vitals signs & GCS 18G IVC (if able) ED: Code stroke paged CT freed Labels created Pt remains on AV monitor

21 Code Stroke Pt met at door by: Stroke Nurse Stroke Registrar HMO Assessed for suitability for direct to CT ABCD (Brief) Verify patient details- labels Triage is brief (Cat 2)

22 Direct to CT Walk and Talk: stroke assessments Senior clinician begins assessing Pt transferred onto CT table Off stretcher time Non Contrast CT Brain Rule out blood HMO IVC and pathology Red stream staff bring equipment Trolley, airway basket, monitoring CT Angiogram & Perfusion Routine investigation

23 CT interpretation Real time review NIHSS- stroke assessments continue Call to Consultant Swap monitors Contact family/gp tpa decision made Give tpa on CT table Must have all information LVO- ECR consideration

24 Victorian Stroke Telemedicine What every stroke patient needs Identification CT Onset time Bleeding Risk: past history and medications Process the same though the team is different. Time factors Read the CT scan

25 Thrombolysis CT- back to cubicle Undressed and checked Connected to monitor 12 Lead ECG +/- second IVC Explanation to pt and family Paperwork Considerations for transfer out

26 DIDO Door in Door Out Time How long does it take to get: Story CT scan Contraindications to treatment Decision to treat Pt out the door ECR: 37 for the year. Best 41 mins Longest 227 mins

27 Stroke Team Stroke Nurse/ ED Nurse Registrar 24/7 HMO / ED Dr Run an acute stroke presentation like a code Everyone has their roles CT notification Labels Equipment BHH Ed has similar (if not better) DTN times out of hours as in hours.

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29 Barriers to treatment Public awareness of stroke symptoms delayed presentation Ambulance calls go through central base and ED not direct to stroke team/neurologist Lack of response to ambulance pre-notification team not present on patient arrival May have implications for future notifications Lack of stroke recognition by ED staff Delays in calling Code Stroke Stroke trials with extended time frames: keeping ED informed Going via resus for monitoring and assessment ED resources Awaiting results of multi-modal images to make a decision

30 Barriers to treatment ED medical review before notification to stroke doctor Despite ambulance notification of a stroke patient Impact on calling in after-hours radiography staff Time delay in calling stroke doctor Time taken for stroke doctor to come in to hospital Radiographer offsite after 7pm limited cover Lack of in-house CT interpretation off site service slow Reduced staff to assist with drawing up delayed CT N times Delays in CT images being loaded for external viewing

31 Enablers to treatment Being a stroke thrombolysis receiving hospital Ambulance preference Increased frequency of stroke increases ED awareness notifications More than one CT scanner Relationship with CT staff Team work across multiple disciplines Role definition Champions Executive buy in Medical support

32 Take Home message Think FAST Nothing can be decided without a CT Stroke team are the people around you Get expert help VST Transfer protocols Efficiency and safety. Despite your size you can have massive impact..

33 References Bhatia, R., Hill, M. D., Shobha, N., Menon, B., Bal, S., Kochar, P.,... Demchuk, A. M. (2010). Low Rates of Acute Recanalization With Intravenous Recombinant Tissue Plasminogen Activator in Ischemic Stroke: Real-World Experience and a Call for Action. Stroke, 41(10), doi: /strokeaha Berkhemer, O. A., Fransen, P. S. S., Beumer, D., van den Berg, L. A., Lingsma, H. F., Yoo, A. J.,... Dippel, D. W. J. (2015). A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. New England Journal of Medicine, 372(1), doi: doi: /nejmoa Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N.,... Davis, S. M. (2015). Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. New England Journal of Medicine, 372(11), doi: doi: /nejmoa Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J.,... Hill, M. D. (2015). Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. New England Journal of Medicine, 372(11), doi: doi: /nejmoa Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M.,... Hacke, W. (2015). Stent-retriever thrombectomy after intravenous t-pa vs. t-pa alone in stroke. New England Journal of Medicine. Jovin, T. G., Chamorro, A., Cobo, E., de Miquel, M. A., Molina, C. A., Rovira, A.,... Dávalos, A. (2015). Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. New England Journal of Medicine, 372(24), doi: doi: /nejmoa Goyal, M., Menon, B. K., van Zwam, W. H., Dippel, D. W. J., Mitchell, P. J., Demchuk, A. M.,... Jovin, T. G. Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet. doi: /S (16)00163 Collateral flow predicts response to endovascular therapy for acute ischaemic stroke A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke Antithrombotic therapy for acute Ischaemic stroke Mr clean and memery lapses Mr rescue: emerging therapy critiques Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke Endovascular treatment for acute ischaemic stroke: Stroke: Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic Stroke:2011;42: ) Lippencotts Illustrated reviews: Neuroscience Mr Clean Polishes Stroke Outcome with endovascular therapy Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes Stroke: The Impact of Recanalization on Ischemic Stroke Outcome: A Meta-Analysis Joung-Ho Rha and Jeffrey L. Saver Stroke. 2007;38: ; originally published online February 1, 2007 Clinical guidelines for acute stroke management 2010 Lees et al. Lancet 2010;375:

34 More References.. Nursing Critical Care: Issue: Volume 11(3), May 2016, p Lackland DT, Roccella EJ, Deutsch AF, et al. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke. 2014;45(1): Bhatia, R., Hill, M. D., Shobha, N., Menon, B., Bal, S., Kochar, P.,... Demchuk, A. M. (2010). Low Rates of Acute Recanalization With Intravenous Recombinant Tissue Plasminogen Activator in Ischemic Stroke: Real-World Experience and a Call for Action. Stroke, 41(10), doi: /strokeaha Berkhemer, O. A., Fransen, P. S. S., Beumer, D., van den Berg, L. A., Lingsma, H. F., Yoo, A. J.,... Dippel, D. W. J. (2015). A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. New England Journal of Medicine, 372(1), doi: doi: /nejmoa Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N.,... Davis, S. M. (2015). Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. New England Journal of Medicine, 372(11), doi: doi: /nejmoa Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J.,... Hill, M. D. (2015). Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. New England Journal of Medicine, 372(11), doi: doi: /nejmoa Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M.,... Hacke, W. (2015). Stent-retriever thrombectomy after intravenous t-pa vs. t-pa alone in stroke. New England Journal of Medicine. Jovin, T. G., Chamorro, A., Cobo, E., de Miquel, M. A., Molina, C. A., Rovira, A.,... Dávalos, A. (2015). Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. New England Journal of Medicine, 372(24), doi: doi: /nejmoa Goyal, M., Menon, B. K., van Zwam, W. H., Dippel, D. W. J., Mitchell, P. J., Demchuk, A. M.,... Jovin, T. G. Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet. doi: /S (16)00163-X

35 Thank you Tanya Frost Acute Stroke Nurse