01: EMS Pre-Notification Door-To-Needle Processes for Success:

Transcription

1 01: EMS Pre-Notification Door-To-Needle Processes for Success: Greenville Memorial Hospital Shannon Sternberg, RN, MSN, CNRN Stroke Program Coordinator Greenville Hospital System % 69 GMH ED - Stroke Alert Pages 44% 32% (Jan-Aug) After arrival SA page prior to arrival EMS notifies GMH ED Critical Care Nurse alerts ED physician & activates Stroke Alert Group Page 66% 01: EMS Pre-Notification 01: EMS Pre-Notification EMS Providers % Greenville 24 5% Laurens 22 5% MedTrans 22 5% Pelzer 50 11% Pickens GWTG-Stroke EMS from home/scene 2012 Jan-July 53% (285) Private transport 14% (77) Transfer from other hospital 33% (176) Monthly ETC & EMS Topic for 10 of 12 meetings Led by ED physician Martin Lutz, MD FACEP, Referral Development Officer EMS educational events Rachel Joseph Edwards, Director, Clinical Integration Transportation Greenville County EMS part of GHS Stroke Advisory Team ED physician & nurses responding to EMS prenotification by activating stroke alert 1

2 02: Stroke Tools 02: Stroke Tools Stroke Evaluation Orders Life or Death Status for CT & labs Nursing orders Standard BP management Online & printed packets Stroke Alert Process Prints with Stroke Eval Orders References SA criteria, time goals, dept/staff roles, IV t-pa contraindications NIHSS & Thrombolytic Communication Form Stroke Alert Progress Note New for neurologists ED Documentation IBEX Based on paper forms HPI CVA Includes prompts Includes NIHSS 03: Rapid Triage Protocol & Stroke Team Notification Stroke Acute Evaluation Orders & Stroke Alert Process define process Stroke Team Log is guiding document in organizing data for tracking & performance improvement... description of each item on the Stroke Alert Summary which will act as the stroke team log in addition to any additional medical record audits that may be deemed appropriate. The time data will be taken in the order of priority as numbered. Effort will be made to use automated times as priority when available from GHS computer systems. When automated times are unavailable, alternate recorded times will be used when appropriate... EMS calls with possible stroke patient Acute Stroke Decision Pathway Greenville Memorial Emergency Department Signs and Symptoms of Acute Stroke? Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Yes Onset less than 4.5 hr Triage in room Print Form M10357, M10108, M10682 Stroke Alert page to notify neurologist, CT & Lab MD assesses patient, NIHSS (full initially) TPA criteria reviewed (M10357) Stroke orders started (M10357) LOD labs (CBC, PT/PTT, INR, BMP) LOD Head CT STAT EKG, continuous cardiac & O2 monitoring, CXR, fingerstick glucose, urine pregnancy, NPO including meds Register patient in REACH cart (per neurologist request) Consult neurologist via REACH telemedicine TPA candidate? YES tpa Neurologist to initiated odiscuss risks/benefits w/ pt/family Goal: <60 omake recommendations for tpa in person or min via REACH & give order to ED RN RN to oadminister tpa, complete tpa orders M10682, transfer to GHS via Mobile Care or Med Trans ocomplete Dysphagia Screening ED Physician Goal: <10 min Stroke Alert Page Goal: <15 min Labs drawn & testing started - Goal: <15 min CT complete - Goal: <25 min CT & labs resulted Goal:< 45 min NOT TPA candidate ED MD to document reason in IBEX Doctor Notes, NIHSS Neurologist recommendations in person or per REACH consult ED MD calls PCP or neurologist for admission or transfer. (Follow normal admit procedure) Complete Dysphagia Screening No Onset greater than 4.5 hr Triage Patient presents to triage Stroke orders started Labs (CBC, PT/PTT, INR, BMP, fingerstick glucose, Head CT, EKG and continuous monitoring, NPO Assess using NIHSS (full initially, focused q 1 hr x 2 and then q2hr) Complete Dysphagia Screen ED MD calls PCP or Hospitalist for admission or transfer (Follow normal admit procedure) Nurse completes Dysphagia Screen before any PO Intake/Meds Stroke Alert Process GMH 2

3 EMS calls ED Report meets Stroke Alert criteria Team is paged Text message with pt name or ETA, location, call back number ED Doctor & Nurses start evaluation NIHSS Blood draw Onset, brief history Weight 03: Rapid Triage Protocol & Stroke Team Notification Neurologist responds Phone initially and/or bedside for IV t-pa Stroke Alert Page <15 bedside tpa start <45 <60 Rec d Labs CT Median ED MD Lab Result CT Head Report Admit time <10 <15 <45 <25 <45 <180 GMH :05 0:03 0:20 0:46 0:15 0:29 1:08 GMH :00 0:00 0:15 0:36 0:12 0:26 0:28 1:02 3:02 GMH :00 0:07 0:14 0:35 0:13 0:25 0:24 1:00 2:53 GMH Q1 Y12 0:00 0:08 0:16 0:35 0:15 0:24 0:22 1:00 3:12 All stroke alerts (no exclusions) Percent less than goal time Average time to goal Median time to goal 3

4 04: Single Call Activation System GHS Call Center Stroke Account 04: Single Call Activation System Type Of Code: Stroke Alert Facility: GMH 3 Type Of Call: ER GMH 1 Caller's Name: SARA Caller's Number: Patient's Name: UNKNOWN Location Of Patient: ETA 15 MIN Message History Account: Taken: Fri 21-Sep :27a 1SG Given: Fri 21-Sep :26a pgr Stroke Alert Call Center Group Page Text message Neurologists ED responders CT tech Lab Pharmacy Bed Office 05: Transfer Directly to CT Scanner Current process does not include transfer directly to CT Arrival to Critical Care ED next to ambulance bay CT across hall Initial NIHSS assessment (will be used in future implementation of CTA/CTP imaging) Lab draws required prior to CT Weight often taken to/from CT on stroke stretcher 05: Transfer Directly to CT Scanner Stroke Team Log CT Head Completed (goal < 25 min) Time on CT head film Time of CT tech documentation of CT head complete Time of radiologist documentation of CT head complete Time of ED documentation of CT head complete CT complete Average Time Median Time % < Goal GMH :20 0:15 75% GMH :16 0:12 85% GMH :17 0:13 85% GMH Q1 Y12 0:20 0:15 78% 4

5 06: Rapid Acquisition and Interpretation of Brain Imaging CT techs perform head imaging and notify radiologist to review Pager notification of Stroke Alert LOD priority puts SA pt in front of all others Room held for SA pt Hand carry requisition to radiologist for rapid read Radiologist calls preliminary report to ED physician/np Neurologist also reviews 06: Rapid Acquisition and Interpretation of Brain Imaging Stroke Team Log CT Head Reported (goal <45 min) Time of report as dictated by radiologist Time of comments related to reporting in PACS Time of radiologist dictation (when retrievable by radiology department) Time of ED documentation of report Time of neurologist documentation of CT interpretation CT Reported Average Time Median Time % < Goal GMH :35 0:29 78% GMH :31 0:26 89% GMH :29 0:25 86% GMH Q1 Y12 0:28 0:24 86% 06: Rapid Acquisition and Interpretation of Brain Imaging 46.4% 13/28 > 45 min 06: Rapid Acquisition and Interpretation of Brain Imaging Dec 08- Feb 09 Arrival to CT complete (goal < 25 min) Stroke Alert 87% ** No Stroke Alert 25% Arrival to CT reported (goal <45 min) Stroke Alert 70% No Stroke Alert 20% Arrival to Labs complete (goal <45 min) Stroke Alert 33% No Stroke Alert 9% 5

6 07: Rapid Laboratory Testing (Including POC Testing) 3 pager notification Track time to delivery & time to resulted 07: Rapid Laboratory Testing (Including POC Testing) No POC platform that will test PT/PTT using one cartridge/test/sample FDA approvals for current POC testing for monitoring current medications, not for emergent i.e. stroke situations. Would require additional training and competency for ETC staff (>200) funding to also interface these instruments. funding for new equipment Success in Coumadin Clinics due to strong leadership and a VERY limited number of staff who perform testing. Coagulation is sensitive in that one change to the test system can cause huge deviations in results. Staff turnover rates can present QC challenge Device approved for monitoring of patients on Warfarin & using as a screen is similar but would open system up to classification as a highly complex test 07: Rapid Laboratory Testing (Including POC Testing) Stroke Team Log Blood in lab (goal <15 min) Labs resulted (goal <45 min) Lab tests include a complete blood cell count with platelet count, coagulation studies, (PT, INR), and blood chemistries. Labs rec'd < 15m Labs result < 45m Average Time Median Time % < Goal Average Time Median Time % < Goal GMH :29 0:20 30% 0:55 0:46 48% GMH :20 0:15 50% 0:42 0:36 70% GMH :18 0:14 59% 0:41 0:35 73% GMH Q1 Y12 0:19 0:16 49% 0:43 0:35 67% CBC average = 24 min BMP average = 39 min PT/PTT average = 36 min ED tech included on SA page No holding of decision on labs unless exposed to anticoagulants Explore EMS drawn labs 08: Mix tpa Ahead of Time Not routinely mixed ahead of time Call made to mix when administration anticipated No contraindication identified based on history & CT Before neurologist risk/benefit discussion 6

7 09 : Rapid Access and Administration of IV t-pa 09 : Rapid Access and Administration of IV t-pa Pharmacy AIS Response SA page notification 455-PILL Prep in Main Pharmacy 24/7 Label with dosing info Bedside goal <10 min Transition in 2011 Pulling of excess dose from vial adds steps in high stress setting Pharmacy offered to mix deliver 24/7 <10 min 1. Receive stroke alert page Alert of a stroke evaluation 2. Pharmacy notified (5-PILL) Special ringtone Direct Pharmacist line 24/7 IV tech places alteplase under hood Waits for pharmacist signal to admix Always stocked in IV clean room Alaris Infusion Pump 1.Bolus & infusion program combined Call to Delivery min min 10: Team-Based Approach Stroke Alert Summary Stroke Advisory Team Neurology ED nursing & physician 2C Neuro/Stroke 4B Cardiology Medicine Neuro Trauma ICU CCU/RRT leadership Lab, CT, Pharmacy Rehab therapies (ST, OT, PT) Quality Management Greer & Hillcrest Hospitals Other depts prn EMS, neurosurgery, hospitalist, case management, patient referral center, patient placement office Meet every other month Review & development of procedures/processes Quality review of data Stroke Alert Summary Min from Time ED arrival Comments Sx onset/last known well 16:30 83 yo male w/ confusion, unable to follow commands, R facial droop, slurred speech EMERGENCY DEPARTMENT First record of ED arrival (i.e. TOG): 17:25 0:55 Brown & Bridwell Stroke Alert Page: Goal <15 min 17:15 PTA no name, ETA 5 min, called by Britt ED Physician: Goal <10 min 17:25 0:00 Knott, seen on arrival ED NP/PA response to Stroke Alert: 17:35 0:10 Mitchem, NIH 13 RADIOLOGY CT Head Ordered: LOD 17:29 0:04 Stroke protocol CT Head Completed: Goal <25 min 17:33 0:08 CT Head Reported: Goal <45 min 17:50 0:25 Farnsworth called report to Knott: no evidence of acute stroke CT Head Ordered to CT Reported: Goal <45 min 0:21 7

8 Stroke Alert Summary Stroke Alert Summary Min from Time ED arrival Comments LABORATORY Labs Drawn: LOD 17:25 0:00 Labs Ordered: 17:29 0:04 Received in Lab: Goal <15 min 17:38 0:13 Labs Drawn to Received: 0:13 CBC 1743, PT/PTT 1754 BMP 1753 Labs Resulted: Goal <45 min 17:54 0:29 Labs Ordered to Labs Resulted: Goal <45 min 0:25 NEUROLOGY Neuro phone contact: Neuro at bedside Goal <45 min 17:45 0:20 Jain, seen w/i 20 min of arrival per H&P: impression acute stroke likely related to new onset a-fib Stroke Alert to Neuro consult: 0:30 Min from Time ED arrival Comments THROMBOLYTICS TPA order/decision 17:55 time of written order tpa initiated: Goal <60 min 18:04 0:39 90 mg, Bridwell, NIH 14, TPA complete 18:55 ADMISSION Admission Goal <180 min 22:53 5:28 Admit NTICU w/ NIH 10 Outcome MRI 3/30 w/ acute embolic infarcts in L MCA distribution. DC home w/ NIH 0 on 4/6/12 Dysphagia screen 18:27 Yes NP: Score=2 Red= Exceeds time goals Green= Within time goals Yellow = Missing data 11: Prompt Data Feedback 11: Prompt Data Feedback Mean time Mean Door to IV rt-pa times for Stroke Review by neurologist of door to treatment times Poster with 40 pts receiving treatment < 60 min at GMH in 2011 EMS provider ED RN ED MD ED NP/PA CT tech/radiologist Pharmacist Neurologist min Greenville County Windsor Janse Rettew Scott/Cowley Chapman Hughes 8