The Importance of Stroke Programs in an Acute Care Setting by Debbie Estes, RN, BSN Stroke Program Coordinator, Medical City of Dallas

Transcription

1 The Importance of Stroke Programs in an Acute Care Setting by Debbie Estes, RN, BSN Stroke Program Coordinator, Medical City of Dallas

2 Objectives Describe the road to the gold Discuss the importance of the Journey to PSC Discuss the impact Primary Stroke Centers have on patient outcomes. Discuss the impact stroke data analysis has on acute stroke care. Describe the role Primary Stroke Centers have on preventing secondary strokes. Identify the difference between Primary Stroke Centers and Comprehensive Stroke Centers

3 Stroke Statements We already give IV tpa for acute ischemic strokes! We treat all strokes urgently! We don t have enough stroke patients to be a stroke center! Patients get here too late to give IV tpa! In our ER, we tend to look for reasons not to administer IV tpa.

4 Puzzle Pieces Emergency Medical Services Emergency Department Nurses Physicians Rehabilitation Stroke Data Community

5 TJC Stroke Centers Connect the Puzzle Pieces Stroke Data Nurses Emergency Administration Case Management Social Workers EMS Stroke Support Group Joint Commission GETAC Physicians Community Rehab

6 Stroke Centers Reach For The Gold

7 Stroke Centers That s not How We Do things!!

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9 Why are Stroke Centers Important??? More patients are treated with IV tpa Hospitals can now get double the reimbursement for treating with TPA Strokes are prevented Patients have less disabilities

10 Case Study 36 y/o male walked into rural hospital with a facial droop and problems with his speech. He arrived at 6:15pm, his wife told the ER nurse, I think my husband is having a stroke ; The symptoms started at 5:08 pm. Negative medical history and not on any medications.

11 Case Study - FACTS Rural hospital was not a Primary Stroke Center ER Physician and nurse informed wife No, your husband is too young to have a stroke

12 Case Study Continued Patient s father arrived at the ER requesting, My son is having a stroke and I want him to get that new clot buster medication

13 Case Study Outcome The neurologist went to the rural hospital per family request and the patient was eventually transferred to HMFW TOO LATE FOR TPA Scott was diagnosed to have a PFO which was closed. Scott Cowan is disabled due to inability to speak.

14 Acute Stroke is a TRUE EMERGENCY Acute Ischemic Stroke is CPR Acute Ischemic Stroke is Trauma

15 Acute Stroke How do you define AIS? What are the signs of AIS? What are the treatment options for AIS? What are TJC s Expectations?

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17 TJC Acute Stroke Recommendations Door to MD Order to CT completed CT Completed to Read Order to CXR completed Order to EKG completed Order to Lab completed Door to TPA 10 minutes 25 minutes 20 minutes 45 minutes 45 minutes 45 minutes 60 minutes

18 TJC Primary Stroke Centers DVT Prophylaxis TPA Administration Antithrombotics 48 hrs Antithrombotics at Discharge Anticoag with Afib Dysphagia Stroke Education Rehabilitation Lipids

19 Get Rid of the Bugs

20 Events of Case #2 Call to EMS from wife Chief complaint: slurred speech and weakness on right side. EMS Treatment: BS by EMS = 105 V/S 148/84, 94 (NSR), 20, O2 sat 94% (1) IV LAC 18g KVO O2 N/C at 4 liters Bag of medications brought to ED

21 ED Events #2 Arrived at ED at 0905 Onset of symptoms 0815 per EMS

22 Acute Stroke Reponse Goals Door to MD Phone to Neurology expertise CT completed CT read Lab, CXR & EKG completed Door to tpa Neurosurgeon availability 10 minutes 15 minutes 25 minutes 20 minutes 45 minutes 60 minutes 2 hours

23 ED Events - continued Determine exact onset of symptoms If acute notify stroke team - Acute Stroke Place on O2, heart monitor, dynamap, full set of V/S, Draw lab (PT, PTT, CBC, BMP), wt in KG Transport to CT of Head without contrast P/CXR and EKG NIHSS Screen for tpa candidacy Consult Neurology

24 CT Results Negative CT Scan of Head Without Contrast Results were faxed at 0952

25 IV tpa Inclusion Criteria Stroke onset < 3 hours > 18 years of age No hemorrhage visible on CT scan or MRI Measurable deficit on the NIHSS (4-22)

26 IV tpa Clinical Contraindications Stroke onset > 3 hours Rapidly improving symptoms Mild stroke signs/symptoms (NIHSS < 4) Seizure within 3 hours of symptom onset Clinical presentation suggestion of SAH regardless of CT result Hypertension > 185/110

27 Case Continued IV tpa was given at 1030 NIHSS 24 hrs = 4 NIHSS discharge (5 days) = 0 No intracranial bleeding was noted on post tpa MRI Patient was discharged home on Lipitor, ASA and Beta blockers.

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30 Comprehensive Stroke Centers JC Primary Stroke Center Certification 24/7 Stroke Team Personnel with expertise Interventional Neuroradiology Vascular neurology, advanced practice nurses, rehabilitation specialists, critical care specialists Advanced diagnostic imaging techniques (mri, CTA, TEE, TCD) Capability to perform surgical and interventional therapie such as stenting and angioplasty of intracranial vessels, carotid endarterectomy, aneurysm clipping and coiling, endovasculary ablation of AVM s and intra-arterial reperfusion. Educational and research programs

31 Thrombectomy Devices

32 Stroke Centers Begin With YOU