developing a neuroscience systems of care

Stroke Teams, Transfers and Primary Stroke Centers

NEURONS4U: Promoting Patient Advocacy

Susan Freeman, MSN, FNP-BC

Program Manager, Neurosciences

Pitt County Memorial Hospital, University Health Systems

Eastern North Carolina Stroke Network

April 14, 2010

Team: A group of animals or people linked in a common purpose

Who are we together?

What are we here to do?Who am I ?

Who are you?

How are we going to do it?How are we doing?How did we do?

Patient

HealthcareProviders

Common Purpose

1.Rapid patient

recognition of and reaction to stroke

warning signs

Key Steps for Maximizing Clinical Outcomes “The Stroke Chain of Survival”

Effective EMS systems can minimize delays in prehospital dispatch, assessment, transport and –ultimately- the number of patients reaching the

hospital with the 3-hour treatment window for fibrinolytic therapy

AHA. Circulation. 2005;112:111-120; Wojner-Alexandrov et al. Stroke. 2005;36:1512-1518; Deng et al. Neurology. 2006;66:306-312.

2.Rapid emergency medical services (EMS) dispatch

3.Rapid EMS system

transport and hospital pre-notification

4.Rapid in-hospital

diagnosis and treatment

NIH-Recommended Emergency Department Response Times

The “golden hour” for evaluating and treating acute stroke

Door-to-needle time ≤60 minutes

0

Suspected stroke patient arrives at ED

CT scan initiated

CT & labs interpreted

tPA given if patient is

eligible

Minutes: 10 15 25 45 60

Initial MD evaluation

Stroke team notified

NINDS Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke, December 12-13, 1996. http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/recs-emerg.htm. Accessed November 8, 2007.

BAC: Primary Stroke Center Criteria

• Acute stroke teams that are available 24/7 • Written care protocols that include appropriate

use of Activase (Alteplase) • Emergency medical services coordinating with

ED • ED personnel trained in diagnosis and treatment

of all strokes• Stroke unit (not necessarily a formal unit)• Neurosurgical services available within 2 hours

when needed

What and Why?

• Identify dedicated Stroke Responders• Make sure they are stroke trained• Mold these responders into a team• Hold them accountable for Best Practice• Stroke Center Capable versus Certification• Prepare team : Acute Stroke Treatment• Increases access to care for acute stroke• Promotes best practice• Bottom line: It’s the right thing to do !

OPPORTUNITY:Develop a Stroke Response Team

Create a process that incorporates skilled and highly trained nurses to respond emergently to Code Stroke

Define a Team: Which Nurses?

• What works best for your hospital?

• Emergency response team?

• Emergency Room Nurses?

• Dedicated team?

-Nurses engaged with the population

-Accepting the challenge

• Who else?

Training the Team

• 8 hour RNCH approved class• NIHSS certification required• Alteplase competency• Critical Focus -Ongoing feedback -Special emphasis on ownership -Emergency medication access -Documentation -Action plans for Continuous Quality

Improvement

Stroke Response Team• Take Pride

• Celebrate successes

Acute Stroke Priorities

• Initiation of Code Stroke Protocol• Emergency Response• Rapid Assessment• Promotion of Goal Times to positively impact

patient outcomes– Neurologist Response Time– Head CT– Labs – EKG– Chest X-Ray– Ongoing Assessment– Door to lytic Therapy

• Stroke Response Nurses to identify variability of recording

• Discuss potential solutions at monthly meetings (stroke log, NIHSS, etc.)

• Review and discuss ALL documentation• Brainstorm- How do we enforce consistent

documentation? • Plan collaborative discussions with physician groups

PLAN: Code Stroke Documentation and Data Collection

PLAN: Medication Access, labs, CT and supplies

• Collaborate with Pharmacy • Medication safety-process for accessing t-PA• Alteplase 100mg/100ml vial secure • Labetolol 50mg/50ml vial secure or other anti-

hypertensive drugs• Policy and quality check for response equipment

and supplies• Collaborate with Lab - readily identify Stroke labs• Coordinate with CT Radiology

DO: Code Stroke Documentation-Log & Recording Sheet

• Code Stroke Log to reflect a collaborative approach to plan

• Code Stroke Log to include reason why lytics not given

• Develop Code Stroke Recording sheet that fits your facility needs

• Input from all members

Code Stroke Log

Log: Quality Process Assessment

DO: Medication Access, labs, CT and supplies

Monitor Bag & Secure Medication Tag

Continuous Feedback

Because the TEAM owns the process- Continuous Quality Improvement is a part of

EVERY case and feedback

CHECK: Medication, documentation, feedback

• Medication process is successful ?• Location of documentation is centralized • TEAM agrees with approach• SRT nurses and others provide ongoing

feedback, especially with medication quality • Process changes made based on Quality

Improvement assessment• TEAM approves all changes

ACT: Review and Implement Opportunities for Improvment

• Transition phases

• Evaluate effectiveness of documentation via chart reviews (Stroke Coordinator, others)

• Encourage ongoing feedback from SRT group

• Discuss opportunities for Improvement at monthly meetings (include ED/EMS, Nurses, physicians, lab and CT personnel

ACT:Implement ED/EMS and Inpatient Action Plans

• Share ED/EMS action plans with SRT Nurse group and strategize- Why are we not meeting the Golden Hour?

• Provide immediate feedback for ALL Code Stroke cases identified with opportunities for improvement

• Continue to encourage collaboration between SRT nurses and physicians

• Highlight and recognize SRT nurses for accomplishments

Track Outliers

TEAM owns the process.

An outlier commonly impacting delay in lytic administration is BP control.

Another outlier- Obtaining consent

Pushing the envelope: Preventing outliers

EMS

PCMH Community

Hospitals

Patient

Access to Care

Best Practice

Regional Partnerships

TIME

IS BRAIN

Accepting the Challenge + Owning the Process= Success

While you consider the best approach for your hospital, your patients, your community- remember that neurons wait for no one.

Questions?