Process to Improve Stroke Care. Reduce time to brain imaging Partner with EMS to improve skills & early identification Enhanced ED response & evaluation through training & competency assessments Develop Stroke Alert Decrease door to needle time
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Reduce time to brain imaging
Partner with EMS to improve skills & early
Enhanced ED response & evaluation through
training & competency assessments
Develop Stroke Alert
Decrease door to needle time
Critical access/rural hospital transfer
1. Ongoing review of data
2. Look at process & flow
3. Encourage staff input
4. Celebrate improvements & thank
direct care staff
Provide EMS with stroke education
Stroke alert Train-the-Trainer Program offered in MI
Stroke info cards developed for EMS services
4. Stroke criteria developed for hospital
notification at time of transport
5. ED supervisor, CT scan & lab staff notified
if criteria met
last known well, age, gender, s/s & ETA
Educate and reeducate ED staff
Every stroke considered for tPA
3. Educate triage nurses
Mock stroke codes
Developed pocket cards with emergent guidelines for staff to carry
Reinforced appropriate use of Stroke Alert beeper
Ongoing ED resident education
7. Optional stroke rotation for ED residents
Triage immediately to ED based CT scanner
Draw blood & NIHSS
Notify Stroke Team
Bring clot box & infusion pump to CT
5. Interpret images & treat immediately
6. Nurses provides tPA bolus & resident injects
7. Nurse programs IV pump & initiates infusion
8. Electronic access to tPA protocols anywhere in hospital
Stroke Team challenged to decrease door to needle time to 45 minute target
Individual patient treatment times are reviewed monthly
Follow up on failures or extended times
Verify triage time, time CT completed and administration of drug
1. Educate all ED staff on stroke
3. Everyone is a thrombolytic therapy candidate until excluded
4. Assess & treat emergently
Partner with a stroke center for support
6. Set up transfer protocol
7. Notify center with NIHSS, last known well time, pertinent health history, pertinent labs, & CT results
8. Review exclusion/inclusion criteria with referral physician
9. Start tPA if appropriate criteria met
Transfer with appropriate staff while tPA
11. Send copy of imaging & labs
12. Accepting hospital re-evaluates patient &
Telemedicine is an effective method to provide expert care to stroke patients in rural areas.
Robotic evaluation is another option in rural areas.
Stroke. 2007; 38: 1655-711.
Seminars in Neurology. 2005; 25:337-44
The “drip and ship” method of delivering tPA has been safe and efficacious.
“Drip and ship: protocols use telemedicine consultation or robotic evaluation to determine eligibility before tPA is started and the patient is transferred.
Neurology Today. 2009; 9: 2,13-14
Neurology. 2005; 64: 154-6.
“First, do no harm”
To do nothing is doing harm.