STROKE
MANAGEMENT
PROCESS
Presented by:
Kelly Banasky, RN, BSN
GCH Emergency Services
Educator
Why are we doing this?
• Garden City Hospital is seeking certification as
a designated Stroke Center to better serve our
community and patients
• To accomplish this, education is necessary to
care for stroke patients
• Garden City Hospital Emergency and
Cardiology Departments have been successful
with management of AMI’s
• Garden City Hospital would like to have a
similar process for AIS (Acute Ischemic
Stroke)
U.S. Stats
• Every 40 seconds, someone will experience a
stroke.
• 795,000 thousand people suffer a stroke
annually within the US
• The annual stroke related medical and
disability cost is 73.7 billion dollars.
• Every 4 minutes someone dies from a stroke.
• By the end of this entire 2 ½ hour presentation:
• 225 people will have experienced a stroke
• At least 37 individuals will have died from
a stroke
Local Stats
• In 2008 there were 125 deaths total from
cerebrovascular disease in the following
communities:
• Dearborn Heights - 31
• Garden City - 16
• Inkster - 7
• Redford Twp. - 29
• Westland – 42
• Garden City Hospital regularly sees patients
from these communities
• Stroke impacts our surrounding community
personally
Critical Recognition
• Individuals with signs and symptoms of a
stroke may not always arrive from the
Emergency Department
• Sometimes patients wait to go to the ED.
• It could be an admitted patient that you are
caring for
• It could be a visitor anywhere in our facility
• It could be someone you know
• a family member
• A friend
• A neighbor
• It could be you.
Signs & Symptoms & Time
• Time is the single most important factor in
recognizing and treating a stroke.
• Time is Tissue…Time is Brain…Time is
function
• Knowing the symptoms and ACT FAST can
help prevent the further deterioration of a
stroke.
• Critical information needed:
• When was the last time the individual was
unaffected/normal
• Ask questions of family, friends, staff
• Knowing the last time the person was
unaffected determines treatment options
How do we recognize a
stroke?
•
•
•
•
•
•
•
•
•
•
Unilateral facial droop, arm droop
Weakness or numbness to one side of the body
Sudden confusion or dizziness
Right or Left visual field deficits
Dysarthria, dysphagia
Sensory loss in all 4 limbs
Decreased consciousness
Complaint of worst headache in life
Light intolerance
Nausea/vomiting
Continuity of Care Across our Spectrum
• The initial interventions in all areas are
universal.
• The ED and RRT are both expected to follow
the algorhythm to maintain consistent care at
all times.
• While the interventions are the same, there will
be some differences
• ED utilizes CPOE
• Hospital wide utilizes Invision order entry
• The same process of actual intervention is to
occur no matter where the individual is located.
Initial Actions by ED & RRT
• The goal is universally consistent care by ED
and RRT.
• Initial actions that occur in the ED will also be
expected to occur throughout the hospital.
• Once a stroke is recognized, it is critical that
the following occurs
• If outside the ED, call the Rapid Response
Team
• contact the CT scan room in radiology to
notify CT staff of “Stroke Protocol”
• Contact the Stroke Team
• Enter Orders for Stroke Algorhythm
• Answer return phone calls from the Stroke
Team
Points to consider specific to
RRT
• RRT is to be called for all in-house patients
and visitors suspected of having a stroke
• Always follow hospital guidelines for
response
• MOB – In addition to response, contact 911
• RRT will need to implement initial care
interventions and be mindful of the time.
• RRT will need to designate 1 individual to
answer phone calls and enter orders through
Invision
Points to consider specific to
ED
• ED will follow protocol of notifying CT STAT
of “Stroke Protocol”
• ED RN will transport patient to CT Scan with
monitoring
• Patients presenting with Stroke Like
Symptoms will receive prompt treatment
similar to the AMI patient
• Notification protocols are currently being
worked on similar to AMI
• Radiology has been on board and already in
practice with us regarding rapid CT scan
• Emergisoft order & intervention panels to
be developed soon.
Hyper-Acute Management
• Active Stroke requires intense rapid care
• The benefits for management outweigh the risk
• The benefits of reversal of stroke are improved
quality of life
• Without rapid intervention, victims of stroke
can sustain a varying degree of
deficit/disability ranging from hemi-paresis to
death.
• The hyper-acute management is really 2 phases
• Phase 1: initial recognition and intervention
• Phase 2: close monitoring during and after initial
intervention
Phase 1
The emergent/hyper-acute management focuses
on Identification of stroke symptoms:
•Identifications of infarct location through CT
•Assessing for long-term complications
•Determining treatment options and initial
interventions:
• To tPA or NOT tPA
• Neurosurgery?
• Rapidly admit for Intensive Care
management
Phase 1 Actions
.
This must occur within 15 minutes from recognition of symptoms
• Ensure ABC are stabilized •
• Call CT IMMEDIATELY •
• 2046 or 2690
•
• 3412 or 2682
•
• Accucheck
•
• Labs
• Basic Metabolic panel – •
yellow tube
• CBC – Lavender tube
• PT, PTT – blue tube
• Troponin – Green Tube
EKG
Oxygen
2 IV lines
Cardiac Monitor
Order entry of CT
Scan
Physician to fill out
Invision NIH Stroke
Scale Packet
CT Scan
• CT Scan of the head must be completed
within
• 25 minutes of arrival to ED
• 25 minutes from recognition on the
floor/unit/etc.
• Patient must be transported to and from CT
by RN with cardiac monitor applied
• Neurology is to be notified upon completion
of CT
CT Result
• If the patients CT scan of head is Positive
for bleed, Notify Neurosurgery STAT
• If the patient’s CT scan of head is Negative
for Bleed:
• Consider if patient is candidate for tPA
administration
• Follow guidelines in GCH Stroke Packet
Phase 1 Ongoing
• 3 hours to 24 hours after initial recognition
with interventions and ongoing interventions
• The patient will be admitted to the ICU for
close monitoring after interventions have
occurred
• Frequent VS & NIHSS assessment
• Repeat CT scans
• Critical care is required
• Elevate HOB 30°
• Observing for further deterioration
• Attaining and Maintaining Stabilization of
patient
Phase 2
•
•
•
•
•
•
•
•
This stage is 24 to 72 hours after stroke
Maintain HOB 30°
The focus is on:
Clarification of the cause
Preventing medical complications
Discharge planning with patient and family
Instituting long term secondary prevention
Ancillary service involvement will be based on
complications and prevention of stroke
How are we going to do this?
• This is a newer process for many of you, but it
has been a practiced process for departments
such as the ER and Cardiology.
• Having a streamlined consistent process allows
for all of us to work together for the best of the
patient.
• Keeping the algorhythm readily available is
one basic step to remind us.
• Order sets are being finalized
• Documentation forms are being evaluated
Fear
• When the ED first started the AMI process, it
was a bit scary for many of us.
• How many minutes?
• Who were they kidding?
• How on earth are we expected to get this
done so quickly when we have so many
other responsibilities?
• Who is going to take care of our other
patients?
How to overcome that fear
•
•
•
•
•
•
•
•
Accept the challenge
Practice the algorhythm
Be supportive of each other
Ask a lot of questions
Read regularly about Stroke.
Know the symptoms
Do NOT ever be afraid to ask for help
And Most of all…TEAMWORK
Time makes all things better
• Over time, we learned that we could fix our
practice and make things better
• The fear is no longer there.
• Instead, the challenge is now who can have the
quickest door to balloon time.
• The process keeps improving as time passes
• Our care has improved as time passes
Pitfalls
•
•
•
•
•
Believing that this can NOT be done
Not supporting each other
Fear
Ineffective communication
Not including all key players
• Talk to your secretaries
• Talk to your nurse assistants
• Include your entire team. It’s a team effort
to get this done
Tips from Experience
• Review the chart after your are finished and
have time to calm down
• Be mindful of various methods to track time;
What one watch says will be different than
what a wall clock reads or what the PC’s clock
reads
• Data tracking is an absolute MUST! It is how
deterrents to the timeliness get discovered.
• When issues come up, take time to listen to all
sides.
• Be proud of yourselves for making this effort
to save lives.
References
•
•
•
•
•
•
•
•
•
•
American Heart Association/American Stroke Association 2010
http://www.strokeassociation.org
Dr. Brian Kim
Dr. Anna Pawlak
Thomas, Jennifer (2010) Patients Do Better at Hospitals That Follow Stroke
Guidelines Chances of survival were higher study shows retrieved
electronically from Circulation: Cardiovascular Quality and Outcomes
Michigan Department of Community Health (2010) Number of Deaths by
Underlying Cause of Death Statistics retrieved electronically from
http://www.mdch.state.mi/us
Dr. Greg Holzman, CME MDCH for the State of Michigan (2010) State of
Stroke in Michigan Michigan Stroke Conference 2010: Bridging the Gaps
Summers et. Al. (2009) Comprehensive Overview of Nursing and
Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific
Statement from the American Heart Association retrieved electronically from
http://stroke.ahajournals.org
Latchaw et. Al. (2009) Recommendations for Imaging of Acute Ischemic
Stroke: A Scientific Statement from the American Heart Association retrieved
electronically from http://stroke.aha.journals.org
Michigan Stroke Network (2010) Supportive Care for all Stroke Patients
Miller et. Al. (2010) Comprehensive Overview of Nursing and Interdisciplinary
Rehabilitation Care of the Stroke Patient: A Scientific Statement from the
American Heart Association http://stroke.aha.journals.org