Putnam Hospital
Center
CODE STROKE
Putnam Hospital Center
Education and Training Department
STROKE CENTER
MISSION
The mission of the Stroke Program at Putnam Hospital Center is to
provide state of the art, high quality medical and diagnostic care to
our patients who are identified as possible stroke victims. All
patients presenting with signs and symptoms of Acute CVA, will be
evaluated upon arrival. They will be evaluated using established
criteria for administration of t-PA or other appropriate therapies.
Each patient will receive assessment, stabilization, diagnostic
treatment and interventions within the timeframe and guidelines
set by the AHA/American Stroke Association.
Key Elements in place to provide this care are:
 Evidence based medical and nursing care
 Interdepartmental approach for quality care
 Education for patients and families
 Safe and appropriate discharge planning
 Continuing medical and nursing education
 Community Education
Our Commitment is to…




…education, including hospital staff, pre-hospital
care providers, patients and the community at large
…quality and a continuing drive to improve the care
given to our patients
…offer support services that are available 24 hours
a day, 7 days a week
…provide timely and efficient transfers when
needed. We have documented transfer agreements
with Vassar Brothers Medical Center and
Westchester Medical Center for neurosurgical
services should they be needed
Designated Stroke Center

These services are provided by utilizing
Multidisciplinary Approach
 Designated beds
 Performance Improvement Initiatives: Get
With the Guidelines (GWTG)
 Highly trained, dedicated staff which includes:
 Physicians ~ Board Certified in
Emergency Medicine, Neurology and
Interventional Radiology
 Dedicated critical care, step-down and
medical staff
 The latest monitoring and treatment
technology for the care of stroke
patients

PUTNAM HOSPITAL CENTER STROKE TEAM MEMBERS
Stroke Center
Program Director
Emergency
Department
Registered Nurse
Dietician
Registered Nurse
on the Inpatient
Care Unit
Attending Primary
Care Physician
Emergency
Department
Physician
Attending
Neurologist
EMS Paramedic
Physical
Therapist
Occupational
Therapist
Speech Therapist
PROCEDURE

Coordinated Care between the ED
and EMS
Patient assessed by EMS utilizing Cincinnati
Stroke Scale
 Emergency Department contacted via radio or
ALS phone regarding acute stroke patient enroute to facility.
 Medical control physician alerts secretary and
nursing staff of incoming acute stroke patient
 Ancillary services (radiology/lab) notified of
incoming code stroke patient.

Cincinnati Pre-Hospital Stroke
Scale



Assess for facial droop: have the patient
show their teeth or ask the patient to
smile.
Assess for arm drift: have the patient
close their eyes and hold both arms
straight out for 10 seconds.
Assess for abnormal speech: have the
patient say, “you can’t teach an old dog
new tricks.”
Suspected CVA

R/o other causes of symptoms
– Hypoxia
– Hypoglycemia
– Hypoperfusion
– Post Ictal (Todd's Paralysis)

Determine Time of onset of symptoms
– Less than 2 hours transport to Stroke
Center.
ASSESSMENT and
TREATMENT TIMEFRAMES

Assessment and treatment times frames are less
than or equal to:






Door
Door
Door
Door
Door
Door
to
to
to
to
to
to
MD assessment
Stroke Team contact
CT Scan
CT read time
Lab results
t-PA administration
10 minutes
10 minutes
25 minutes
45 minutes
45 minutes
1 hour *
(* from door to med – FDA is 3 hours from
onset of witnessed symptoms)
“Code Stroke”
Inpatient Protocol



Utilized for emergent treatment of patients, staff or
visitors currently in the hospital building presenting
with symptoms of stroke.
Anytime a person exhibits signs or symptoms of
stroke, and onset is less than three hours, “Code
Stroke” may be activated by a staff member of the
hospital.
Code Stroke team is activated by dialing “2222” and
telling the operator to page “Code Stroke”
overhead, adding the unit where the event
is occurring.
~
TEAM ACTIVATION
PROCEDURE



Rapid Response Team responds to the call
for all inpatient units
Emergency Dept. Code Response Team
responds to all other hospital locations
(outpatient, staff, or visitors)
“Code Stroke” alerts the Radiology dept.:


if CT scan is in use, to remove the patient from CT and
prepare for STAT CT scan of stroke patient
“Code Stroke” alerts lab:

to perform STAT lab work and turn around results in 45
minutes or less
CODE STROKE
~ POLICY, PROCEDURE AND
DOCUMENTATION







Code Stroke Packet
Policy & Procedure
Code Stroke Order Sheet
NIH Stroke Scale Assessment Sheet
Consent Form for t-PA
Admission or Transfer protocols
Admission Order Sets
CODE STROKE
DOCUMENTATION

Code Stroke Flow Sheets ensure
documentation compliance
Timeline
 Diagnostics
 NIHSS
 Eligibility/Exclusion Criteria
 Medications/Interventions

CODE STROKE
~ STROKE LOG

Stroke Log is the evaluation
tool used measure
compliance with
the evidence based
timeframes
PUTNAM HOSPITAL CENTER PATIENT CARE SERVICES
PERFORMANCE IMPROVEMENTCODE STROKE EVALUATION RECORD
UNIT:
DATE OF CODE:
TIME OF CODE:
PATIENT NAME/DRILL:
PRIMARY DIAGNOSIS:
1. Was Critical EMS assessment completed, if applicable, and appropriate actions taken?

Support ABC’s: oxygen given if needed

Perform pre-hospital stroke assessment

Establish time when patient last known normal

Transport: consider bringing a witness, family member or caregiver

Alert hospital

Check glucose if possible
2. Support ABC’s: oxygen given if needed

Perform pre-hospital stroke assessment

Establish time when patient last known normal

Transport: consider bringing a witness, family member or caregiver

Alert hospital

Check glucose if possible
3. Was there an immediate neurologic assessment by stroke team or designee

completed within 25 minutes of arrival in the ED?

Review of patient history

Establish symptom onset

Perform neurologic examination using NIH Stroke Scale
4. Was CT report received within 45 minutes of arrival in ED?
5. Was CT consistent with no hemorrhage?

If yes Check for fibrinolytic exclusions

Repeat the neurologic exam: are deficits rapidly improving to normal?
6. Was CT consistent with hemorrhage?

If yes Consult neurologist or neurosurgeon

Consider transfer to another facility
7. Is patient a candidate for fibrinolytic therapy?
8. If not a candidate for fibrinolytic therapy was ASA given?
9. If an appropriate candidate were risks and benefits explained and tPA
administered within 60 minutes of arrival in ED?
SIGNATURE AND COMMENTS OF EVALUATOR:
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
NO
DEPARTMENTAL
RESPONSIBILITIES


Each department has established
responsibilities
Each department involved in the
CODE STROKE
– Coordinates with each other
– to ensure the highest quality care
– in the most efficient amount of time ~
Time is of the essence!
CODE STROKE
~EMERGENCY DEPARTMENT




Identification/Notification of a
potential “Code Stroke” patient
Preliminary notification of Radiology
and Laboratory
Patient Room
placement
1 to 1 Nursing Care
CODE STROKE
~Radiology


All Radiologists are experienced in the
interpretation of
acute stroke CT and
MR Neuro-images
Fellowship-trained
neuro-radiologists are
on call 24/7
CODE STROKE
~RADIOLOGY
Goal: Perform Rapid CT Assessment of “BRAIN ATTACK”
Patient with a timely, expert interpretation
 Emergency Dept. informs CT Technologist of
Code Stroke




CT Table is held open until patient arrives
Radiologist is informed of
pending scan
Scan performed
Results
communicated
to ED physician
within designated
timeframe
CODE STROKE
~LABORATORY

Emergency Department
– Calls to notify Lab of impending Code Stroke specimen
– Complete patient information is given to the Lab office staff who
takes the call
– Lab office staff notifies the Lab technical staff of impending Code
Stroke so they can prepare workstations
– Lab office staff member who took the call has ownership of the
specimen to log it in and deliver it to the lab technical staff for
analysis.


There are no handoffs! Chain of
custody must be maintained by
the staff member who took the call.
Lab technical staff calls the result to the ER
CODE STROKE
~CRITICAL CARE SERVICES
* ADMISSION CRITERIA *

Acute neurologic events requiring frequent
neurological or respiratory checks to evaluate
progression including:








Post IV t-PA
Large hemispheric stroke, in whom impending mental status
decline and loss of protective airway reflexes is of a concern
Basilar thrombosis or top of the basilar syndrome
Crescendo TIA’s
Patients requiring blood pressure augmentation for a
documented area of hypoperfusion
IV blood pressure or heart rate control
Every1-2 h neurological evaluation depending on symptom
fluctuation or if ongoing ischemia is suspected
Worsening neurological status
CODE STROKE
~CRITICAL CARE SERVICES

The “Neuro Stroke Scale Assessment Flow Sheet” will be
used to monitor



All post t-PA patients with assessments done q1h x 24 hours
All non t-PA patients with assessments done q2h x 24 hours
Stroke patients will have special attention paid to:










Eye care
Potential for seizure
Airway
Tissue perfusion
Safety needs
Altered body image
Mobility – DVT – skin breakdown
Nutritional concerns
Glucose management
Signs and symptoms of meningeal irritation
PARTIAL FORM
PUTNAM HOSPITAL CENTER
NEURO STROJKE ASSESSMENT FLOW SHEET
Circle times when patient care was rendered
7 - 8 - 9 - 10 - 11 - 12 - 13 - 14 - 15 - 16 - 17 - 18 - 19 - 20 - 21 - 22 - 23 - 24 - 1 - 2 - 3 - 4 - 5 - 6
CATEGORY
DESCRIPTION
SCORE
Alert
Drowsy
Stuporous
Coma
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
1b. LOC Questions:
(Month Age)
Answers both correctly
Answers one correctly
Both incorrect0
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
1c. LOC Commands:
(Open, close eyes ;make fist, let go)
Obeys both correctly
Obeys one correctly
Both incorrect
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
2. Best Gaze:
(Eyes open- patient follows finger or face)
Normal
Partial gaze palsy
Forced deviation
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
3. Visual:
(Introduce visual stimulus to patient’s visual field
quadrants
No visual loss
Partial hemianopia
Complete hemianopia
Bilateral hemianopia
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
4. Facial Palsy:
(Show teeth, raise eyebrows and squeeze eyes
shut)
Normal
Minor
Partial
Complete
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
5a. Motor Arm Left:
(Elevate extremity to 90 degrees and score
drift/movement)
No drift
Drift
Can’t resist gravity
No effort against gravity
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
1a. Level of Consciousness:
(Alert Drowsy etc.)
CODE STROKE
~MEDICAL SERVICES

Identified Unit: Reed 2




All Stroke Patients on



Close to Nursing Station to facilitate safety
Easy access to equipment
Modifications to the environment
Yellow Dot/Falls Prevention Program
Aspiration Precautions
Patient and Family Education Ongoing


Begins in the Emergency Department
Follows through discharge and outpatient
CODE STROKE ~
Documentation

NIHSS needs to be completed at:
15 minutes
 30 minutes
 60 minutes
 90 minutes
 Per order for 24 hours or 48 hours
 Discharge

CODE STROKE ~
Documentation


Cerner
Interactive View
Complete Neurological Assessment
 Include appropriate NIHSS
 Include education provided to patient and
family

CODE STROKE ~
Documentation

Discharge
NIHSS must be done at discharge
 Documentation of where patient is going after
discharge
 Documentation of discharge medications
 BOX MUST BE CHECKED FOR THE
EDUCATION PORTION (page 2) OF THE
DISCHARGE FORM
 Time out must be completed by two nurses
signifying that the form is complete and that
all information has been relayed to the
patient

CODE STROKE
~REHABILITATION
DEPARTMENT

PHC offers comprehensive Rehabilitative
Services for Inpatients and Outpatients
These services include:
 Physical Therapy


Range of Motion & Strength
Functional Mobility, Gait & Balance
 Occupational

ADL’s, Safety Awareness & Cognition
 Speech

Therapy
and Language Pathology
Speech, Language & Swallowing
difficulties
CODE STROKE
~CASE MANAGEMENT

Psychosocial/Continuing Care
Assessment


Social Work Referral if indicated


24-48 hrs. after admission
to assist with supportive counseling regarding
adjustment to deficits
Utilization Management Advocacy

to assist patient in discharging to the most
appropriate post hospital care setting
Education and Training
Annual Staff Education
 All nursing staff involved in Acute
Stroke patient care
Attend 4 hours of stroke education annually
 Stroke specific educational opportunities
provided by PHC throughout the year

Educational Support of
EMS by the Stroke Center


EMS receives lectures bi-monthly from
the Assistant Director of the
Department of Emergency Medicine
Bi-annual education regarding acute
stroke provided to EMS via didactic
lectures, case presentations, and call
audits
CODE STROKE
~PERFORMANCE
IMPROVEMENT





Chart reviews
Data is aggregated
Monthly P. I. meetings
Results forwarded to the Performance
Improvement Committee
Findings reported to: Patient Care
Services, Hospital QA Committee and to
department staff members
PROPERTIES
On passing, 'Finish' button:
On failing, 'Finish' button:
Allow user to leave quiz:
User may view slides after quiz:
Close Window
Goes to Slide
At any time
At any time