Target: STROKE The Team-Based Approached November 19, 2013 Tuesday 1300 1400 Thank you for joining today s webinar, the presentation will begin shortly. A special thank you to Cornerstone Therapeutics Inc., for sponsoring this educational event 11/19/2013 2010, American Heart Association 2
Speakers for Today s Program: Kathleen Burger, DO Mary Cres Rodrigazo, BSN, RN, SCRN Barbara Neiswander, MSN, RN, CEN Stroke Program Director Stroke Program Coordinator Clinical Supervisor The George Washington The George Washington Emergency Department University Hospital University Hospital The George Washington Washington, DC Washington, DC University Hospital Washington, DC 11/19/2013 2010, American Heart Association 3
Objectives: Describe the process involved in a team-based approach to stroke care. Review protocols that lead to efficient and rapid treatment of acute stroke patients Discuss the importance of a multidisciplinary approach to stroke care and performance improvement 11/19/2013 2010, American Heart Association 4
Affects 795,000 persons a year STROKE STATISTICS On average, stroke occurs every 40 seconds Every 4 minutes, someone dies of stroke 4 th Leading cause of death Leading cause of Disability Cost $73 billion per year Global Statistics 15 millions strokes yearly 5 millions deaths 5 million with disability 11/19/2013 5
DEMOGRAPHICS 11/19/2013 6
371 beds 18,372 Inpatient Admissions 108,710 Outpatient Visits Emergency Department (Level I Trauma Center) 74,056 Patient Visits.
National Capital Area The George Washington University Medical Center Department of Neurology Acute Stroke Unit E M S Emergency Radiology Laboratory Interventional Nursing Stroke Coordinator American Heart Association The George Washington University Hospital
Stroke Team CORE Stroke Neurologist Stroke Coordinator Neurology Residents Stroke Nurses COMPREHENSIVE To be determined MULTIDISCIPINARY Stroke and general Neurologists Attending and Residents Stroke Coordinator Stroke Nurses ICU Emergency Department Neurosurgery Neuroradiology Interventional Neuroradiology Rehabilitation Team (PT OT ST) Quality team and Data Analysts Administration Educators
Brain Attack Policy Neurological Examination ER order set oiv-monitor-vitalsglucose onihss olabs obrain imaging ER Stroke Protocol Initiate Brain Attack system
Brain Attack Protocol
Stroke tpa protocol
Multidisciplinary Stroke Meeting Attendees: Stroke Neurologist Stroke Coordinator Emergency Department - Neuroradiology Neurosurgery Rehabilitation team Quality (Data abstractors) Review data Define refine and maintain the system - Checks and Balances Opportunities for improvement Maximize strengths Improve weaknesses
IV-tPA Outcome Patients Symptomatic ICH 40 35 30 25 20 15 10 5 0 2009 2010 2011 2012 2013 YTD 11/19/2013 2010, American Heart Association 14
Achievements: Advanced Primary Stroke Center with Joint Commission Certification 2007- Present Gold Plus Achievement Award by The American Heart Association 2010, 2011, 2012, 2013 Target Stroke Honor Award by The American Heart Association 2011-2012 and 2012-2013 11/19/2013 2010, American Heart Association 15
GOALS Maintain effective protocols Improve treatment times Stroke Unit Expansion GW Transfer -One Call Comprehensive Stroke Center
The Road To Target Stroke 11/19/2013 2010, American Heart Association 17
Process: Lean Six Sigma Brain Attack Responders Comprehensive Stroke Education Stroke Data Measures Stroke Collaborative Group Target Stroke 11/19/2013 2010, American Heart Association 18
LEAN Six Sigma Neurology Emergency Department Laboratory Radiology Identify our goal Review and understand the process Remove steps by creating Flow Chart Develop strategies Implementation though process change Quality
Brain Attack Responders: Neurology Residents Stroke Coordinator Charge Nurses ASU Clinical Supervisor Scope of Practice Respond to all BA in house and the ED Arrived within 10 minutes Support neurologist and nurses mixing tpa 11/19/2013 2010, American Heart Association 20
Comprehensive Stroke Education: NIH Stroke Scale Certification Mandatory Stroke Class Stroke Healthstream Modules Emergency Room Nurses Intensive Care Unit Acute Stroke Unit Radiology Technicians 11/19/2013 2010, American Heart Association 21
Minutes 90 Average Door to tpa (tpa Pts) 80 70 60 50 40 30 20 10 0 11/19/2013 2010, American Heart Association 22
Minutes 40 Average Door to CT (tpa Pts) 35 30 25 20 15 10 5 0 11/19/2013 2010, American Heart Association 23
Minutes 42 Average Door to Lab Result (tpa Pts) 41 40 39 38 37 36 35 34 33 32 11/19/2013 2010, American Heart Association 24
Stroke Census 371 PTS 405 PTS 400 467 PTS 439 PTS 365 PTS PTS 467 PTS 439 PTS 405 PTS The George Washington University Hospital
Joining Collaborative Group Share resources and best practices Stroke improvement process Stoke education and training Community City wide stroke outreach o Stroke Screening o Blood pressure Screening o Stroke Education 11/19/2013 2010, American Heart Association 26
Target: Stroke Best Practices EMS Pre Notification Stroke Tools Rapid Triage Protocol & Stroke Team Single Call Activation System Transfer Directly to CT Rapid Acquisition & Interpretation of Brain Imaging Rapid Lab Testing Mix tpa ahead of time Rapid access of IV tpa Team-based approach Prompt data Feedback 11/19/2013 2010, American Heart Association 27
Target Stroke: Best Practices 11/19/2013 2010, American Heart Association 28
Stroke Arrival to the Emergency Department: EMS Arrival Brain Attack Page Direct bedding Quick Registration Immediate stroke protocol initiated 11/19/2013 2010, American Heart Association 29
Rapid Triage of Ambulatory Patients 11/19/2013 30
Single Call Activation System: Brain Attack Announcement overhead or pager The following are being notified: Neurology Attending Neurology Residents Stroke Coordinator House Operation Supervisor Brain Attack Responder 11/19/2013 2010, American Heart Association 31
Stroke Tools GW Home Page Recognition Stroke algorithm developed Stroke protocols Brain Attack order set 11/19/2013 2010, American Heart Association 32
STROKE Care in the ED Designated Stroke Area in the ED ED specific Critical Care room for Stroke patients Reference Stroke Board t-pa Tackle Box Pump for medication administration
Rapid Laboratory Testing: Laboratory technician Direct Hand off Blue Card Call back to the ED with lab results I -STAT for Point of Care Testing
Radiology CT radiology technician Priority Patient Radiologist for immediate reading Post scan weight 24/7 Availability CT Next Door Door to Results 45 minutes
Medication
Stroke Documentation 11/19/2013 37
Immediate feedback to all individuals involved in stroke care of the patient including EMS Address delays based of results of each case to devise strategies Set targets and monitor progress closely on a case to case basis. Feedback Form: 11/19/2013 2010, American Heart Association 38
Questions? 11/19/2013 2010, American Heart Association 39
REFERENCES American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics 2012 Update: A Report From the Americal Heart Association. Circulation. 2012;125:e2-e220; originally published online December 15, 2011; doi: 10.1161/CIR.0b013e31823ac046 American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947; originally published online January 31, 2013; doi: 10.1161/STR.0b013e318284056a 11/19/2013 2010, American Heart Association 40