Stroke Training Module2 En

8/12/2019 Stroke Training Module2 En

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Module 2Hyperacute Stroke Management

Best Practice

Nursing CareAcross theAcute Stroke

Continuum

N SN C


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Hyperacute Stroke Management

This session includes presentations andactivities to enhance your learning

The focus is on working with colleagues todiscover best ways of using the tools in yourclinical settings

So, sit back (or stand up) and have fun!!!

Welcome!

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So, what do you want to get out of this module?

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Expectations?


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Discuss the impact of hyperacute stroke management on

patient outcomes

Identify your role in pre-hospital and ER stroke care

Review the Best Practice Recommendations related to

hyperacute stroke management

Identify how you can help to implement these at your institution

Identify your role in patient and caregiver education

Create a stroke care action plan for hyperacute stroke

management

Objectives

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Introduction 15 min

Stroke 101(optional) 15 min

Pre-Hospital Stroke Care 45 min

In the Emergency Room 30 min

Break 15 min

Hyperacute Stroke Management BPRs 45 min

Patient and Family Education 15 min

Putting It All Together 30 min

Agenda

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Prevention of strokePublic awareness & patient education

Hyperacute stroke

management

Acute inpatient stroke care

Stroke rehabilitation

& community reintegration

Continuum of Stroke Care


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Prevention of strokePublic awareness & patient education

Hyperacute stroke management

Acute inpatient stroke care

Stroke rehabilitation

& community reintegration

Early

assessment

for stroke

rehabilitation

should start

here

Continuum of Stroke Care


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Acute stroke is a medical emergency

and optimizing out-of-hospital care

improves patient outcomes

EMS plays a critical role in assessment

and management

Acute interventions such as

thrombolysis are time sensitive


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Redirecting

ambulances to

stroke centres

facilitates earlierassessment,

diagnosis and

treatment which

may result in

better outcomes.

Why Is This Important?


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Synthesis of best practice recommendations

for stroke care across the continuum

Address critical topic areas

Commitment to keep current and update

every two years First edition released in 2006

Current update released in 2008

With four new recommendations

Elaboration of existing ones

www.cmaj.caDecember 2, 2008
http://www.cmaj.ca/http://www.cmaj.ca/


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Intended onlyfor audiences

with no previous

knowledge of

stroke.

Stroke 101Hyperacute Stroke Management


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Hyperacute Stroke ManagementPre-Hospital Stroke Care45 min


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Your Role in Pre-Hospital Stroke Care

1. At your tables, discuss best practices for effective

Pre-Hospital Stroke Care:

What information will you need EMS to gather about

the patient?

What you can do to help rapid assessment & triage

in hospital?

2. When done, we'll debrief the whole group to

arrive at some best practices

Pre-Hospital Stroke Care

3/28/2014 12TABLE ACTIVITY


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Patient should be transported without delay to the

closest institution that provides emergency stroke

care (BPR 3.1)

Patient or other members of public must make

immediate contact with EMS

EMS dispatchers must triage as priority

Paramedics should use standardized screening tool

Direct transport protocols should be in place

Critical information/history should be obtained

Receiving facility must be notified

EMS Role in Hyperacute Stroke

3/28/2014 13DEBRIEF


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From Recognition to Pre-Admission


Detection Dispatch

Delivery

Door

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Why is the time of onset of the stroke a

critical piece of information?

Stroke patients who arrive to ER within three andone half hours of symptom onset may be

candidates for thrombolytic therapy

Hospital destination decisions may be based on

time of onset of stroke symptoms

Care of Patient with Stroke

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A 53-year-old man with a history of hypertension was broughtto the ED by paramedics after his employer noticed that he haddifficulty with speech, ambulation, and vision.

The employer reported that the patient usually left his house at

3:40 am and arrived at work by 4:00 am; however, no one sawhim arrive at work and no time clock is used.

Paramedics were called at about 5:00 am.

What was the time of onset of the stroke?

When he went to bed? 3:40 am?

4:00 am?

5:00 am?

Last Seen Normal-1

3/28/2014CASE STUDY


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What do we know:

Patient successfully drove to work; it is unlikely that the stroke beganbefore he left the house.

Possible:

Symptoms MAY have been very mild at first, that he ignored them,and went to work anyway.

Decision:

Since we have no evidence for this yet, we TENTATIVELY assign anonset time of 3:40 am, subject to further history.

Needed:

Find someone at work who saw him and could testify that he wasnormal or obviously abnormal before the paramedics were called.

Last Seen Normal-2

3/28/2014CASE STUDY


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Quick identification and screening by pre-

hospital providers in the field

Blood glucose measurement to excludehypoglycaemia as a cause of neurological

deficit

Notification of receiving hospital

Transport

Treatment to stabilize the patient

Pre-Hospital Important Steps

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Consistently identifies patients with stroke

Evaluate three major findings:

Facial droop

Arm weakness

Speech abnormalities

Based on the Cincinnati Stroke Scale or Los Angeles Stroke Scale

Key Components of Paramedic Prompt Cards

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Patients with 1 of these 3 findings

72% probability of an acute stroke if the symptomsare new

Patients with all 3 findings..

85% probability of an acute stroke if the symptomsare new

If the patient has a positive CPSS or one ormore of the findings, immediately activate localacute stroke protocol

Cincinnati Pre-Hospital Stroke Scale

3/28/2014REVIEW


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Symptom Onset

Time

Trauma (history)

Seizure

Neurological Exam

LOC

Pre-Hospital Stroke

Scale

Basic DataAge and gender

Chief complaint

Other tPA exclusionsAs per tPA protocol

inclusion/exclusioncriteria

Information obtained and relayedby EMS provider is vital

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Hyperacute Stroke ManagementNIH Stroke Scale

Standard assessment tool formeasuring neurologic deficit

Measures level ofconsciousness, best gaze,visual, facial palsy, motorfunction, language, dysarthria,extinction and inattention

Can be used to quantifyneurologic function inspecified categories at varioustime points

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3/28/2014 23Source: www.ninds.nih.govEXAMPLE


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3/28/2014 24Source: www.ninds.nih.govEXAMPLE


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Canadian Neurological Scale

was designed as a simple

clinical tool to evaluate theneurological status of acute-

stroke patients

Measures level of

consciousness, orientation,speech and motor functions

CNS Stroke Scale

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Check Up Quiz

EXAMPLE


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Hyperacute Stroke ManagementCheck Up

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In hyperacute stroke

management, EMS should

transport a patient withoutdelay to what type of

institution?

To the nearest institution thatprovides emergency stroke care


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What are the four steps in

pre-hospital stroke care fromrecognition to pre-

admission?

Detection, Dispatch,Delivery, Door


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What are the four steps in

pre-hospital stroke care fromrecognition to pre-

admission?

Detection, Dispatch,Delivery, Door


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Why is blood glucosemeasurement so important?To exclude hypoglycaemia as acause of neurological deficit


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What is the probability of acute

stroke if a patient is abnormal on allthree of the Cincinnati measures

and symptoms are new?

85% probability


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What does the CanadianNeurological Scale measure?

Level of consciousness, orientation,speech and motor functions


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In the Emergency Room30 min


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Hyperacute Stroke Management7-Step Stroke Chain of Survival

Detection

Dispatch Delivery

Door

DataDecision

Intervention


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Time is Brain


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1. Treatment in the ER is only the start

2. Patients will have varying outcomes:

Lazarus effect (complete or almost recovery) Light to moderate disability

Moderate to severe disability

Where You Can Make a Difference!

HERE`S WHERE YOU CAN REALLY MAKE A DIFFERENCE!


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Diminishing Returns over TimeFavorable Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90 Adjusted odds ratio with

95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776)

Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I,

~4h 40min

Courtesy Brott T et al


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Your Role in the Emergency Room

1.At your tables, discuss and flip chart key points about your

role in the ER:

What can you do to assess patients & triage rapidly?

What are the key activities of the stroke team?

What is your role in facilitating a smooth transfer from ER

to an inpatient unit?

2.When done, well debrief the whole group to arrive at some

best practices

In the Emergency Room

TABLE ACTIVITY


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What is the single most important key to stroke care

success?


Interprofessional

Communication!

so that everyone knowswhat to do and things can

be activated simultaneously!


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What needs to get done?


TABLE ACTIVITY


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Include:

Maintaining or improving breathing,

CV function, nutrition, hydration and electrolyte balance

Evidenced based neurological assessment Limiting further neurological damage

Preventing complications

Treating or modifying reversible risk factors

Patient and family education

Treatment Objectives


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Check airway, breathing, vitals (including

temperature)

Ensure adequate respiration, monitor BP and cardiac

rhythm Establish time of stroke symptom onset

Alert stroke team

Establish IV access-possibly 2 lines

Draw blood for CBC, blood glucose and other tests(INR)

Early ManagementInitial Steps


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Perform neuro assessment

NIH Stroke Scale

Canadian Neurological Scale

Use of preprinted standard orders or protocols

Order a CT scan

Keep NPO until swallowing screen completed

Educate patient and family

Early ManagementInitial Steps


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Candidates for t-PA


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Bypass and repatriation protocols to closest Regional Stroke

Centre

Established thrombolysis protocol

Triage: Rapid assessment using Acute Stroke protocol eligibilitycriteria / NIH Stroke Scale

t-PA target times: ensure you can meet the < 4.5 hr window

(ECASS III)

Access to CT scanning

Stroke team: (Stroke expert, emergency or family physician,

nursing staff, allied healthcare professionals, stroke survivor,

family, support network central to team)

Optimal Stroke Management with rt-PA


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Exclusions for t-PA


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Exclusion criteria for intravenous t-PA

CT evidence of cerebral hemorrhage or an infarction that involves

>1/3 of the middle cerebral artery territory

Blood pressure >185/110 mmHg that cannot be reduced withappropriate intravenous bolus dose of labetalol (alpha blocker)

A prolonged PTT (Partial Thromboplastin Time), or an INR

(International Normalized Ratio) >1.7 (1.4), or platelet count


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Exclusion criteria for intravenous t-PA, cont

Seizures at onset of stroke

Other major bleeding (e.g., gastrointestinal) within past 21 days

MI within past 14 days

Rapidly improving neurological signs or minimal deficit

Other illness that, in the physicians judgment, could limit

effectiveness of t-PA or increase risk of bleeding

Optimal Stroke Mgmt with t-PA: Triage


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EMonitoring needs during t-PA treatment

Canadian Guidelines for Intravenous Thrombolytic Treatment in

Acute Stroke: (1998)

Vital signs should be taken every 15 minutes during the druginfusion, then 30 minutes for the next 2 hours, then hourly for 5

hours

Neurovital signs should be performed hourly for 6 hours, and then

according to the patient's condition


Source: Can. J. Neurol. Sci. 1998; 25: 257


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Check Up Quiz

QUIZ


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What is the single most

important key to stroke caresuccess

Interprofessional Communication!

so that everyone knows what

to do and things can be activated

simultaneously


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What is the t-PA target time?

Ensure you can meet the < 4.5 hr

window(ECASS III)


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Who should be part of the Stroke

team?

Stroke expert, emergency or familyphysician, nursing staff, allied

healthcare professionals, strokesurvivor, family, support network

central to team


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According to the CanadianGuidelines for Intravenous

Thrombolytic Treatment in AcuteStroke, when should vital signs be

taken?

Every 15 minutes during the drug

infusion, then 30 minutes for thenext 2 hours, then hourly for 5 hours


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Lets take a break15 min



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Best Practice

Recommendations45 min



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3.1 EMS management of acute stroke patients

Patients who show signs and symptoms of hyperacute stroke,

usually defined as symptom onset within the previous 4.5

hours, must be treated as time-sensitive emergency cases and

should be transported without delay to the closest institution

that provides emergency stroke care

Patient or other members of public must make immediate contact

with EMS

EMS dispatchers must triage as priority

Paramedics should use diagnostic screening tool

Direct transport protocols should be in place

Critical information/history should be obtained

Receiving facility must be notified

Best Practices Recommendations

OVERVIEW


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3.2 Acute management of TIA and minor stroke

Patients who present with symptoms suggestive of minor

stroke or transient ischemic attack must:

Undergo a comprehensive evaluation to confirm the diagnosis

Begin treatment to reduce the risk of major stroke as soon as is

appropriate to the clinical situation


OVERVIEW


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3.3 Neurovascular imaging

All patients with suspected acute stroke or transient ischemic

attack should undergo brain imaging immediately

In most cases, initial modality in a non-contrast CT scan

Vascular imaging should be done as soon as possible

If MRI is performed, it should include diffusion-weighted sequences


OVERVIEW


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3.4 Blood glucose abnormalities

All patients with suspected acute stroke should have their blood

glucose concentration checked immediately.

Blood glucose measurement should be repeated if the first value is

abnormal or if the patient is known to have diabetes. Hypoglycemia

should be corrected immediately

Elevated blood glucose concentrations should be treated with

glucose-lowering agents


OVERVIEW


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3.5 Acute thrombolytic therapy

All patients with disabling acute ischemic stroke who can be

treated within 4.5 hours after symptom onset should be

evaluated without delay to determine their eligibility for

treatment with intravenous tissue plasminogen activator

(alteplase)

All eligible patients should receive intravenous alteplase within 1

hour of arrival (door-to-needle time < 60 min)

Administration of alteplase should follow the ASA guidelines


OVERVIEW


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3.6 Acute ASA therapy

All acute stroke patients should be given at least 160 mg of

ASA immediately as a one-time loading dose after brain

imaging has excluded intracranial hemorrhage

In patients treated with recombinant tissue plasminogen activator,

ASA should be delayed until after the 24-hour post-thrombolysis

scan has excluded intracranial hemorrhage

ASA (80325 mg daily) should then be continued indefinitely or until

an alternative antithrombotic regime is started


OVERVIEW


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3.7 Management of subarachnoid and intracerebral

hemorrhage

Patients with suspected subarachnoid hemorrhage should have

an urgent neurosurgical consultation for diagnosis and

treatment

Patients with cerebellar hemorrhage should have an urgent

neurosurgical consultation for consideration of craniotomy and

evacuation of the hemorrhage

Patients with supratentorial intracerebral hemorrhage should be

cared for on a stroke unit


OVERVIEW


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1. Form two groups at your table and have

each select and prepare a briefing on

one of the sections in Hyperacute stroke

management

2. Use the worksheet in your PW to help

structure your briefing

3. Focus on the following topics:

Rationale for recommendation

System implications of it Performance measures

4. When done, each group will present its

briefing to the other and discuss

Recommendations Briefing

TABLE ACTIVITY

Imagine you have

been asked tobrief your

colleagues back

home on one of

the key sections

in Hyperacute

stroke

management.


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1. Now switch sections with the other

group at your table and prepare to

answer the following:

How will this recommendation improve

stroke care at your institution?

What role can you play in implementing

it?

What barriers or enablers do you see?

2. When done, brief the other group on

these issues and discuss

3. Then, well debrief the whole group toarrive at some best practices

Recommendations Briefing

TABLE ACTIVITY

Imagine you have

been asked tobrief your

colleagues back

home on one of

the key sections

in Hyperacute

stroke

management.


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Patient and

Family Education15 min



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From the Patient and Familys

Perspective:


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1. At your tables, discuss

What would be your role in educating

and supporting patients and caregivers

about hyperacute stroke management?

2. When done, brief the other group onthese issues and discuss

3. When done, we'll debrief the wholegroup to identify some bestpractices

Where You Can Make a Difference!

Did you know that

skills training of

caregivers makesa huge difference

in patient

outcomes in areas

of functionality

and depression!


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Content should be specific to;

The phase of care

Patient/caregiver readiness

Patient/caregiver needs

Education should be timely, interactive, up to date and provided

in a variety of formats, languages including aphasia friendly

Processes should be established by clinical teams for

education including designating team members for provisionand documentation of education

Patient and Family Education

REVIEW


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Education content should include:

The nature of the stroke and its manifestations

Signs and symptoms of stroke

Impairments and their impact on the person Caregiver training to manage

Risk factors

Post-stroke depression

Cognitive impairment

Discharge planning and decision making

Community resources

Home adaptations

Patient and Family Education

REVIEW


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Putting It All Together30 min


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1. Review the case study in your PW

2. With your team, answer the questions on the worksheet at

the end of the study

3. Well review when done to share some best practices and get

ready to create a Stroke Care Action Plan

Case Study

TABLE ACTIVITY

H S k M


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Mrs. R is a 76 year old right handed woman who was shopping at

Canadian Tire at 1030am when she suddenly started to feel unwell.

She went to the clerk to ask for assistance but was unable to talk

and had a right sided weakness.

The clerk called 911 and she was taken to the local stroke centrewhere she was assessed at 1115am

Her past medical history includes: hypertension,

hypercholesteremia, osteoporosis and gastroesophageal reflux

Her current medications include: hydrochlorothiazide, coversyl,

simvastatin, didrocal and ranitidine She has no known allergies and does not smoke or drink alcohol

Case Study

H t St k M t


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On admission to ER:

BP 162/72

Pulse 100 and irregular

Respirations 26

Temperature 37.0C

Heart sounds irregular but no murmurs heard

Lungs clear. No peripheral edema. Abdomen soft and non tender and

non-distended

Neurologically:

Mental status limited due to expressive aphasia but able to follow

simple commands Right visual field defect

Right facial weakness

Dense right flaccid hemiparesis

Blood work: Glucose: 6.8, WBC: 5.0, Platelets: 221, Hemoglobin: 122,

Sodium: 137, Potassium: 3.7, Troponin < 0.04, INR: 0.9

Case Study

H t St k M t


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Did Mrs. C meet the criteria to activate the Code Stroke

Team?

Is Mrs. C a candidate for tPA? Why?

Case Study Questions

TABLE ACTIVITY

H t St k M t


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If Mrs. C met the criteria for tPA, what possible complications

would you monitor for?

If Mrs. C receives tPA, when is the recommended time to

administer ASA 160mg?

What teaching would you give the patient/family in this phaseof care?

Case Study Questions

TABLE ACTIVITY

H t St k M t


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1. With the case study we just reviewed in mind, create a stroke

care action plan

Identify 1-2 key learnings from today that you could take back to

help kick start your change initiatives

2. Use the Stroke Care Action Plan worksheet in your PW to

record your plan

Creating a Stroke Care Action Plan

INDIVIDUAL ACTIVITY


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Best Practice Nursing CareAcross the Acute Stroke

ContinuumThank you for your participation!

Stroke Training Module2 En

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