ACVLSStroke Team Protocols

• Kim Szymczak MSN, APRN-GCNS

• Stroke Coordinator

• Thrombectomy Capable Stroke Certified – Aug.

• SHMG Neuro Intervention – 24/7

• SHMG Neurosurgery

oDr. Borsellino

oDr. Donich

oClipping capability

• Comprehensive Stroke Center Gap Analysis in Progress

oSAH volumes

What’s New for 2019?

ED Stroke Team Policy Changes – Oct 1st

• SummaryoReplace tPA with “alteplase” – for medication safety

oDecrease AR2 resident role during day

• Neuro resident continues to respond

oAdd CC APP role for days to facilitate intervention patients to ICU

o Increase role of ED Provider

oClarify telemed expectations

oOverall simplification

STROKE TEAM POLICY

Class A:Acute stroke team patients who have the potential for receiving acute stroke interventionswhich include IV tPA and endovascular interventions

• Age removed

STROKE TEAM POLICY

Class A Criteria: acute focal neuro symptoms, excludes DNR-CCO

•Last seen well < 4.5 hours before ED arrival, NIHSS > 1•Last seen well < 24 hours, NIHSS > 5

• Emergent transfers from another facility who received IV tPA or are endovascular candidate

Also consider for Stroke Team Activation:

• Thunderclap headache

•Dysarthria with no other clear etiology

•Diplopia

•Vertigo

•Ataxia

•Unexplained coma

•Vision less

Modified Rankin Score

• Disability Index used in Research and outcome measurement

oAnd now qualification for procedure

oEmbedded in neuro note

oModified Rankin <2: walks independently, able to care for self

CT Perfusion Mismatch

RAPID

STROKE TEAM POLICY

Class B: Patients with acute focal neuro deficits that do not meet Class A criteria, and are NOT eligible for acute stroke interventions

Neuro Teams

ED Trauma Flow RN’s

•Document using EPIC Stroke Narrator

oED RN enters Class A order set

oDocumenting for the “Team”

• Includes NIH

• RN Cell phone – contact for Stroke Neurologist

• Consistent responder

Acute Stroke Team Evaluation Targets

To maintain current level award – Gold Plus Target Stroke Elite Plus

• Door to tPA within 60 minutes 85% of time (85%)

• Door to tPA within 45 minutes 75% of time (72%)

• Door to tPA within 30 minutes 50% of time (45%)

AHA Target Stroke Phase III – Award Criteria

•New – Stroke Honor Roll Advanced Therapy

•Door to device times (arrival to first pass)

o 90 minutes for direct ED patients 50% of time

o 60 minutes for transfer patients 50% of time

•Adding First Pass tracking to Stroke Team log to track monthly

19

25

25

10

4

5

28

40

11

10

39

30

0 20 40 60 80 100 120 140

Patient example

Goal

imaging complete Imaging read IR activation Pt arrival in IR Groin puncture First pass Reperfusion

Arrival to First Pass

• Confirms Class A Stroke and activates “Stroke Team”

• Patient is seen immediately by ED attending to verify stable to go straight to CT

• Receives handoff from EMS, maintains care of patient

• RN Initiates Summa ED Neuro Deficit – Class A Stroke orders via Stroke Narrator

• Patient goes straight to CT if stable

• NIHSS after noncontrast CT done

• Pharmacy – alteplase order and phone call

• Family (re-establish onset, plan)

• Informed Consent

ED Attending Response to Stroke Teams

• Responds to Stroke Teams

• Accompany patient to CT

• Collect data via EPIC, PLATO, 3M

• History, medications, inclusion/exclusion criteria

• Assist neurologist with NIH after CT scan

• Assists with coordination of Intervention

• Communicate with ICU

If Neuro Resident 7A-5P

Critical Care APP – 7A - 5PAR2 – 5P - 7A

• Responds to stroke team, accompany pt to CT

• Assists ED physician/neurologist with data collection, history, meds for inclusion/exclusion

• Assists with coordination if intervention – alteplase or endovascular

• Communicates with ICU attending and prepares for admit to T2 ICU

• If Thrombectomy

oEnters XA Special Procedure -“bilateral cerebral angiogram order

oFoley order

• Enters appropriate Stroke order set for patients admitted to ICU

• Documents “brief” note

• On Call Stroke Neurologist – via RCC

• Call back if no response in 5 min.

• Neurologist discusses case with NeuroIntervention

• Neurointerventionalist Activates Interventional Stroke Team (*757 via Stat line) – if endovascular procedure indicated

• Endovascular Intervention – Specials

1. Order “XA Special Procedure”

“Bilateral Cerebral Angiogram”

2. Foley order - tell RN to insert

Process

Cancelled or Downgraded to Class B

• Please be clear to entire team if neurologist cancels or downgrades stroke team – clarify with neurologist if uncertain

• No alteplase or intervention does not mean cancelled

• If imaging series complete and all resources utilized, cannot cancel stroke team

“Stroke Team Brief Note”

• Will be template with drop down/fill ins

• Arrival NIH

• CT results

• Post CT NIH

• Neurologist

• Intervention

oAlteplase/ reason no alteplase

oThrombectomy/ reason no thrombectomy

oDisposition

• Staff nurse Rapid Response Stroke Team

• AR2 Continues to respond day and night - unchanged

o You are the ED physician

o Initiate Summa Stroke Team Class A Order Set

o Labs only IF NEEDED, can uncheck if repeat

o Accompany pt to CT CDU holding bed

o Communicates with neurologist

o Coordinates transfer, additional orders etc.

o Updates attending physician

oMake sure the robot is with the patient

In-House Stroke Teams

• Please continue to use the correct order sets when admitting patients

• Summa Stroke tPA Orders – if In-House ST

• XA Special Procedures – Bilateral Cerebral Angiogram

• Summa Stroke/TIA Admission order set

• Summa Stroke Post tPA Admit to ICU Orders

• Summa ICH Admission ICU

• Post Neuroendovascular Order Set (thrombectomy)

Stroke Order Sets in EPICSumma Customized - Dr. Bowling Version

• Clarify in order set entry

• Medication orders should match parameters in orders

• Duplicate orders????

• AIS No Intervention BP < 220/120 > 100/60

• AIS s/p alteplase BP < 180/105 > 100/60

• AIS s/p successful thrombectomy BP < 140/90 > 100/60

• ICH BP < 140/90 > 90/50

• SAH BP < 140/90 > 90/50

What is the Blood Pressure Target?

Thrombolytic Therapy

•Door to Drug goal = 60 min. 45 min. 30 min.•Rapid communication•DO NOT need to wait for CTA results for tPA eligibility•May NOT need to wait for lab results

•Labs drawn after CT•Only need glucose to give tPA per guidelines

•Early BP management• BP<185/110 pre• BP<180/105 post

Door to Drug Times 2018

24

Door to Drug Times through June 2019

65

57 59

48 47 49 47

37

0

10

20

30

40

50

60

70

2012 2013 2014 2015 2016 2017 2018 2019 YTD

Summa Akron City Hospital

•Primary Stroke Center since 2007

•Stroke Gold Plus Target Stroke Elite Plus

•Only area hospital to receive Gold Plus for 9th year in a row

2/2018

Minutes in ED After tPA Started

2017 Average 70 minutes – Goal < 30 minutes2018 Average 52 minutes2019 Average 53 minutes

9/23/2019 Meeting

71

2723

13

48

82

39

83

68

13

39

91

29

85

45

97

7676

32

60

50

116

67

41

22

48

37

52

87

52

78

14

70

52

37

120

69

40

31

42

7879

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Evaluation of patients from transferred facilities with acute neuro symptoms• All transfers via RCC

• Appropriate consulting service

• Transfer to Summa Akron City Campus

• Stroke Team activated upon arrival to ACH

o Class A Stroke Team upon arrival if:

Received IV tPA at transferring facility

Potential endovascular candidate

Emergency Neuro Transfers – “Stroke Team”

Transfers

If transfer from other facility

Do not need to repeat labs if have results

May not need to repeat CT head (per neuro direction) but may need CTA/P

Do not slow the process by repeating

• Patient/Family Education Information

• For alteplase or thrombectomy risk/benefit education

• Consent

• Alteplase – verbal, informed consent

• Thrombectomy – written consent

o Responsibility of interventionalist

Stroke Team Packet

NEW

• Coiling

• option for ruptured aneurysm and unrupturedaneurysm treatment

• Coiling intervention in Special Procedures

• Surgical clipping by SHMG Neurosurgery at ACH

• Goal – Aneurysms secured within 24-48 hours

• Admitted from ED to T2 ICU, with intervention scheduled for next day

• All SAH cases are discussed with Summa Neurointerventionalist via REGIONAL CALL CENTER

SAH Aneurysm Program

• CT confirms SAH, STAT CTA must be performed

• Stroke neurologist (if stroke team patient) or ED physician calls Regional Call Center for Neurointervention consult

• Intubate if GCS < 8

• Admit to T2 using SAH order set

• Will also need to enter XA Special Procedure order Bilateral Cerebral Angiogram: coiling

Subarrachnoid Aneurysm

• Follow ED SAH Protocol (Algorithm and protocol pocket cards)

• SBP control < 140, titratable agent preferred

• Prophylactic antiepileptic medication or control of active seizure

• Steroids for headache control if needed

• Zofran for nausea

• Anticoagulation reversal if indicated

• O2 to keep sats > 94%

• Bedrest, HOB 30 degrees

• 12 lead EKG if not already done

• Communication with ED physician and nurse regarding plan is critical

Patient Care in the ED as Directed by Neurologist

Aneurysm Coiling

08.08.2017

Stroke EPICOrder Sets

Patient Status

• ED Stroke orders

• Summa Stroke Team Class A

• Summa Stroke Class B

• IV Thrombolytic – Summa Stroke tPA

• Intervention orders – “Special Procedure”

• Summa Stroke/TIA admission orders

• ICH/SAH admission orders

• Other neuro order sets

EPIC Order Sets – See handout

Summa Stroke Order Sets

ED – Summa Stroke Team Class A

All Prechecked

Summa Stroke tPA Order Set

Summa Stroke/TIA Admission Orders

LABS ARE PRECHECKED

IMAGING NEEDS TO BE SELECTED Based on what has been done in last 24 months.

Imaging Series

•MRI complete series

oMRI brain with & without

oMRA head without

oMRA neck with & without

•If already had CTA done in ED, MRA would be duplication

•Angiography is preferred over Carotid Dopplers

Admission Orders

•Activity

oLimit bedrest, only if absolutely necessary

oBedrest for 24 hours is NOT “protocol”

•NPO

oMust have swallow screen prior to any po, including meds

oED nurses, stroke unit nurses & rapid response all trained (ICU nurses coming soon . . .)

oASA can be given PR

Hemorrhage Order Sets

© 2017 Epic Systems Corporation. Confidential

•Stroke Quality

Performance Measures

VTE Prophylaxis

• By Day 2, next day after admission (not full 48 hours)

•What is acceptable??

oPneumatic cuffs

oHeparin 5,000 units subQ, lovenox subQ

oAlready therapeutically anticoagulated

•Heparin gtt, coumadin, full dose lovenox

•New non-warfarin oral anticoagulants

•Who needs it??

oAll patients that are not HALLWAY AMBULATORY

Discharged on Antithrombotic Therapy

•Antithrombotics

oAntiplatelets and anticoagulants

•ASA, Plavix, Aggrenox,

•Coumadin, Pradaxa, Xarelto, Eliquis, Fragmin/Lovenox

•Appropriate Secondary prevention if stroke/TIA

Afib receiving Anticoagulation

•Anticoagulation is standard of care

• Coumadin, Pradaxa, Xarelto, Eliquis

•Document clearly why contraindicated

oIncluded in Stroke Notes

• Includes if current afib or history of afib

• Includes paroxysmal and permanent afib

•Heparin 5,000 units not acceptable

•ASA and/or Plavix does NOT = anticoagulation

Acute Stroke Interventions

•All patients are assessed for alteplase/Intervention

•Document why patient did not receive alteplase as discussed with neurologist

•Document why patient did not receive thrombectomy

oNo LVO

Antithrombotic by Day 2

•Antiplatelet or Anticoagulant

•Sooner ASA given, better outcome

•ASA can be given PR/suppository

•Day 2 is day after admission (not full 48 hours)

Discharged on Statin

•Lipid panel in first 48 hours

• Included in Stroke/TIA Admission Order Set (prechecked)

•LDL > 70

•Document contraindication

•Statin specific

•Discharge omission order

Assessed for Rehabilitation

•All Stroke/TIA patients

oIschemic and Hemorrhagic

oResolved TIA pts may have small infarct on MRI

•Barthel Index

•Speech (for dysphagia), PT, OT

•Speech for language/cognition additional order if aphasic

•Does not mean “Rehab consult”

Thank you!

Questions?