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Target: STROKE
The Team-Based Approached
November 19, 2013 Tuesday
1300 – 1400
Thank you for joining today’s webinar, the presentation will begin shortly.
11/19/2013 ©2010, American Heart Association 2
A special thank you to Cornerstone Therapeutics Inc., for
sponsoring this educational event
Kathleen Burger, DO Mary Cres Rodrigazo, BSN, RN, SCRN Barbara Neiswander, MSN, RN, CEN
Stroke Program Director Stroke Program Coordinator Clinical Supervisor
The George Washington The George Washington Emergency Department
University Hospital University Hospital The George Washington
Washington, DC Washington, DC University Hospital
Washington, DC
Speakers for Today’s Program:
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• Describe the process involved in a team-based approach to
stroke care.
• Review protocols that lead to efficient and rapid treatment of
acute stroke patients
• Discuss the importance of a multidisciplinary approach to
stroke care and performance improvement
Objectives:
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STROKE STATISTICS
Affects 795,000 persons a year
On average, stroke occurs
every 40 seconds
Every 4 minutes, someone dies
of stroke
4th Leading cause of death
Leading cause of Disability
Cost $73 billion per year
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Global Statistics
15 millions strokes yearly
• 5 millions deaths
• 5 million with disability
371 beds
18,372 Inpatient Admissions
108,710 Outpatient Visits
Emergency Department
(Level I Trauma Center)
74,056 Patient Visits.
The George Washington University Hospital
National Capital Area
The George Washington University Medical Center
Acute Stroke Unit
Emergency
Radiology
Laboratory
Nursing
Stroke Coordinator
Department of Neurology
American Heart Association
Interventional
E
M
S
Stroke Team
CORE
Stroke Neurologist
Stroke Coordinator
Neurology Residents
Stroke Nurses
MULTIDISCIPINARY
• Stroke and general Neurologists • Attending and Residents
• Stroke Coordinator
• Stroke Nurses
• ICU
• Emergency Department
• Neurosurgery
• Neuroradiology
• Interventional Neuroradiology
• Rehabilitation Team (PT OT ST)
• Quality team and Data Analysts
• Administration
• Educators
COMPREHENSIVE To be determined
ER Stroke Protocol
Brain Attack Policy
Neurological
Examination
ER order set
oIV-monitor-vitals-
glucose
oNIHSS
oLabs
oBrain imaging
Initiate Brain Attack system
Multidisciplinary Stroke Meeting
• Attendees: Stroke Neurologist – Stroke Coordinator –
Emergency Department - Neuroradiology – Neurosurgery –
Rehabilitation team – Quality (Data abstractors)
• Review data
• Define refine and maintain the system - Checks and Balances
• Opportunities for improvement
• Maximize strengths
• Improve weaknesses
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0
5
10
15
20
25
30
35
40
2009 2010 2011 2012 2013 YTD
IV-tPA Outcome
Patients Symptomatic ICH
Achievements:
• Advanced Primary Stroke Center
with Joint Commission Certification
2007- Present
• Gold Plus Achievement Award by
The American Heart Association
2010, 2011, 2012, 2013
• Target Stroke Honor Award by The
American Heart Association 2011-
2012 and 2012-2013
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GOALS
• Maintain effective protocols
• Improve treatment times
• Stroke Unit Expansion
• GW Transfer -One Call
• Comprehensive Stroke Center
• Lean Six Sigma
• Brain Attack Responders
• Comprehensive Stroke Education
• Stroke Data Measures
• Stroke Collaborative Group
• Target Stroke
Process:
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LEAN Six Sigma
• Neurology
• Emergency
Department
• Laboratory
• Radiology
• Quality
• Identify our goal
• Review and understand the
process
• Remove steps by creating
Flow Chart
• Develop strategies
• Implementation though
process change
Brain Attack Responders: • Neurology Residents
• Stroke Coordinator
• Charge Nurses ASU
• Clinical Supervisor
Scope of Practice
– Respond to all BA in house and
the ED
– Arrived within 10 minutes
– Support neurologist and nurses
mixing tPA
•
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NIH Stroke Scale Certification
Mandatory Stroke Class
Stroke Healthstream Modules
• Emergency Room Nurses
• Intensive Care Unit
• Acute Stroke Unit
• Radiology Technicians
Comprehensive Stroke Education:
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0
10
20
30
40
50
60
70
80
90
Min
ute
s
Average Door to tPA (tPA Pts)
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0
5
10
15
20
25
30
35
40
Min
ute
s
Average Door to CT (tPA Pts)
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32
33
34
35
36
37
38
39
40
41
42
Min
ute
s
Average Door to Lab Result (tPA Pts)
Stroke Census
The George Washington University Hospital
371
PTS
405
PTS
400
PTS
467 PTS 439 PTS 365 PTS 371
PTS
405
PTS
400
PTS 467 PTS 439 PTS 405 PTS
• Share resources and best practices
• Stroke improvement process
• Stoke education and training
• Community City wide stroke
outreach
o Stroke Screening
o Blood pressure Screening
o Stroke Education
Joining Collaborative Group
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Target: Stroke Best Practices EMS Pre – Notification
Stroke Tools
Rapid Triage Protocol &
Stroke Team
Single Call Activation
System
Transfer Directly to CT
Rapid Acquisition &
Interpretation of Brain
Imaging
Rapid Lab Testing
Mix tPA ahead of time
Rapid access of IV tPA
Team-based approach
Prompt data Feedback 11/19/2013 ©2010, American Heart Association 27
• EMS Arrival
• Brain Attack Page
• Direct bedding
• Quick Registration
• Immediate stroke
protocol initiated
Stroke Arrival to the Emergency Department:
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Brain Attack Announcement
overhead or pager
The following are being notified:
• Neurology Attending
• Neurology Residents
• Stroke Coordinator
• House Operation Supervisor
• Brain Attack Responder
Single Call Activation System:
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Stroke Tools
• GW Home Page
Recognition
• Stroke algorithm
developed
• Stroke protocols
• Brain Attack order set
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STROKE Care in the ED
• Designated Stroke Area in
the ED
• ED specific Critical Care
room for Stroke patients
• Reference Stroke Board
• t-PA Tackle Box
• Pump for medication
administration
Rapid Laboratory Testing:
• Laboratory technician
– Direct Hand off
– Blue Card
– Call back to the ED with
lab results
– I -STAT for Point of Care
Testing
Radiology • CT radiology technician
• Priority Patient
• Radiologist for immediate reading
• Post scan weight
• 24/7 Availability
• CT Next Door
• Door to Results 45 minutes
• Immediate feedback to all
individuals involved in stroke
care of the patient including
EMS
• Address delays based of results of
each case to devise strategies
• Set targets and monitor progress
closely on a case to case basis.
Feedback Form:
11/19/2013 ©2010, American Heart Association 38
American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease
and Stroke Statistics – 2012 Update: A Report From the Americal Heart Association. Circulation.
2012;125:e2-e220; originally published online December 15, 2011; doi:
10.1161/CIR.0b013e31823ac046
American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral
Vascular Disease, and Council on Clinical Cardiology. Guidelines for the Early Management of
Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2013;44:870-947; originally published
online January 31, 2013; doi: 10.1161/STR.0b013e318284056a
REFERENCES
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