CODE STROKE

1. Putnam Hospital Center CODE STROKE Putnam Hospital Center Education and Training Department

2. 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

3. 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

4. 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

6. 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 en-route 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.

7. 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.”

8. 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.

9. ASSESSMENT and TREATMENT TIMEFRAMES • Assessment and treatment times frames are less than or equal to: • Door to MD assessment 10 minutes • Door to Stroke Team contact 10 minutes • Door to CT Scan 25 minutes • Door to CT read time 45 minutes • Door to Lab results45 minutes • Door to t-PA administration 1 hour * (* from door to med – FDA is 3 hours from onset of witnessed symptoms)

10. “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.

11. PROCEDURE ~ TEAM ACTIVATION • 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

12. 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

13. CODE STROKE DOCUMENTATION • Code Stroke Flow Sheets ensure documentation compliance • Timeline • Diagnostics • NIHSS • Eligibility/Exclusion Criteria • Medications/Interventions

14. CODE STROKE~ STROKE LOG • Stroke Log is the evaluation tool used measure compliance with the evidence based timeframes

15. PUTNAM HOSPITAL CENTER PATIENT CARE SERVICES UNIT: DATE OF CODE: PERFORMANCE IMPROVEMENTCODE STROKE EVALUATION RECORD TIME OF CODE: PATIENT NAME/DRILL: PRIMARY DIAGNOSIS: 1. Was Critical EMS assessment completed, if applicable, and appropriate actions taken? YES NO • Support ABC’s: oxygen given if needed YES NO • Perform pre-hospital stroke assessment YES NO • Establish time when patient last known normal YES NO • Transport: consider bringing a witness, family member or caregiver YES NO • Alert hospital YES NO • Check glucose if possible YES NO 2. Support ABC’s: oxygen given if needed YES NO • Perform pre-hospital stroke assessment YES NO • Establish time when patient last known normal YES NO • Transport: consider bringing a witness, family member or caregiver YES NO • Alert hospital YES NO • Check glucose if possible YES NO 3. Was there an immediate neurologic assessment by stroke team or designee YES NO • completed within 25 minutes of arrival in the ED?YES NO • Review of patient historyYES NO • Establish symptom onsetYES NO • Perform neurologic examination using NIH Stroke Scale YES NO 4. Was CT report received within 45 minutes of arrival in ED? YES NO 5. Was CT consistent with no hemorrhage?YES NO • If yes Check for fibrinolytic exclusions YES NO • Repeat the neurologic exam: are deficits rapidly improving to normal?YES NO 6. Was CT consistent with hemorrhage? YES NO • If yes Consult neurologist or neurosurgeon YES NO • Consider transfer to another facility YES NO 7. Is patient a candidate for fibrinolytic therapy? YES NO 8. If not a candidate for fibrinolytic therapy was ASA given?YES NO 9. If an appropriate candidate were risks and benefits explained and tPA administered within 60 minutes of arrival in ED? YES NO SIGNATURE AND COMMENTS OF EVALUATOR:

16. 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!

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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 CODE STROKE ~CRITICAL CARE SERVICES

23. PUTNAM HOSPITAL CENTERPARTIAL FORMNEURO STROJKE ASSESSMENT FLOW SHEETCircle 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

24. CODE STROKE ~MEDICAL SERVICES • Identified Unit: Reed 2 • Close to Nursing Station to facilitate safety • Easy access to equipment • Modifications to the environment • All Stroke Patients on • Yellow Dot/Falls Prevention Program • Aspiration Precautions • Patient and Family Education Ongoing • Begins in the Emergency Department • Follows through discharge and outpatient

25. 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

26. CODE STROKE ~ Documentation • Cerner • Interactive View • Complete Neurological Assessment • Include appropriate NIHSS • Include education provided to patient and family

27. 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

28. 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 Therapy • ADL’s, Safety Awareness & Cognition • Speech and Language Pathology • Speech, Language & Swallowing difficulties

29. CODE STROKE ~CASE MANAGEMENT • Psychosocial/Continuing Care Assessment • 24-48 hrs. after admission • Social Work Referral if indicated • 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

30. 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

31. 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

32. 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

33. 2011 PHC Code Stroke