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Modifiable
-Hypertension
-Atrial fibrillation
-Diabetes
-Dyslipidemia
-Sickle cell
-Oral contraceptive

Non-modifiable
-Age (advanced)
-Gender
-Race
-Family hx of stroke

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The penumbra is the zone of reversible ischemia around a core of irreversible infarction. This area of the brain is salvageable in the first few hours after onset of acute ischemic stroke symptoms.

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Stroke Certification with Joint Commission

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Stroke Certification with Joint Commission

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SMH has achieved Primary Stroke Center Certification by the Joint Commission in 2020

All hospital employees must be informed of the basic stroke process

The Emergency Department, Critical Care and Stroke Units must be able to verbalize their unit specific protocols, education requirements and stroke quality measures

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What are the approved Stroke Measures?  VTE administered by Hosp day #2, Discharged on Antithrombotic, Discharged on Anticoagulant Therapy for patient with AFib/Aflutter, Thrombolytic Therapy, Antithrombotic Therapy by end of Hosp #2 Day, Discharge on Statin Meds, Stroke Education, Rehab Evaluation.

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Code Rescue Stroke Alert, What’s my ROLE? 

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Code Rescue Stroke Alert, What’s my ROLE? 

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1. How do you call an in-patient Stroke Alert?  Call #7777, identify to the PBX operator that you are activating a Code Rescue Stroke Alert. The operator will page the Code Rescue Stroke Alert Team. Refer to the EBCC Neuro Emergent Stroke Response Orders (Inpatient Only)_B Power Plan

2. What are your Stroke Units?  ICU, CDU, 7 Pavillion, 4 Pavillion, 5 East Tower

3. Where is our Stroke Management Protocols & Procedures located and what does it include? It can be found in stroke resource binders or the BHSF intranet. It includes a copy of our stroke algorithm, EBCC Power Plans, Stroke/TIA Clinical Pathway and stroke assessment tools. This reflects our CPGs

4. What Competencies do you have? Stroke protocol, NIHSS, Nursing dysphagia screening, Tenecteplase administration. We are evaluated on our knowledge level and skills annually.

5. What Stroke Education have you received?  Orientation, hospital in-services, ED/ICU Skills Fairs, ED Stroke Competencies, BHU courses, Mock surveys/tracers.  Must be able to state stroke signs and symptoms, treatments and how to activate stroke alerts.

6. Describe your Hand off Communication between nursing units: When report is provided from the ED to the inpatient setting. Hand off communication is provided via EMR ED Patient Summary or SBAR Overview handoff. SBAR Overview is utilized for hand off communication between inpatient units.

7. How do we Measure our Stroke Care Performance? Daily surveillance of the 8(JC) performance measures, daily chart reviews, and patient surveys after discharge. A monthly report of the Joint Commission and AHA performance measures are provided to the unit Managers to share with the staff.

8. How do you follow up and evaluate your Stroke Program? Daily chart reviews are conducted by the Stroke Coordinator to measure our stroke care and performance. We utilize the Stroke Pathway as a visual tool to assist with our daily stroke care. Patients receive a survey 3-4 days after discharge.

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- Stroke alert assessed by MD? 5 minutes
-Target time to get your patient to CT scan? 5 min
-Target time for CT to complete? 10 min
-Target time to get your patient CT results? 15 minutes
-Target to initiate IV Tenecteplase from stroke alert? 30 minutes
-Target time to get your INR results? 45 minutes
-Target time transfer to BHM? 60 minutes

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1. What’s the goal to treat for IV Tenecteplase: 30 minutes from arrival to ED or LTKW or onset of signs and symptoms.

2. What if the patient isn’t a candidate for Tenecteplase? Focus is on optimizing cerebral perfusion, managing BP, and preventing stroke complications.  Use the Stroke protocols and order sets and if appropriate, transfer patients to CSC for endovascular/neurosurgical services if appropriate.

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Identification of Stroke Charts-WHITE BOARD 

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Identification of Stroke Charts-WHITE BOARD 

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1. STK 1: VTW prophylaxis or documentation by MD/ARNP
2. STK 2: Discharged on Antithrombotic, or documentation by MD/ARNP of contraindication
3. STK 3: Discharged on Anticoagulation for A-fib/Flutter
4.STK 4: Alteplase (ER ONLY)
5.STK 5: Antithrombotic administered by day 2
6.STK 6: Lipid drawn within 48 hrs. Of arrival to ED; discharge on statin LDL>70 or documentation by MD/ARNP of contraindication
7.STK 8: Pt/family provided stroke material and education documentation
8. STK 10: Pt assessed for rehabilitation (PT OT ST any or all of these) or documentation by MD/ARNP of contraindication

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1. What do you do if patients are showing new onset signs of Stroke? Remain calm with patient, perform a NIHSS, place the patient on a NPO status. If the NIHSS has an increase of 2 points from the prior assessment call the consulting Neurologist. If the NIHSS has an increase of 4 points from the prior assessment call a Code Rescue Stroke Alert. Anticipate an order for a STAT CT scan.

2. What if a pt had a stroke and then fell? Isn’t that trauma? Yes, but this time the trauma occurs after the Stroke, It takes a detailed exploration of the initial events to determine what happened first, but most cases are clear cut. If a patient tripped and then fell and now they sustained a bleed, they are considered trauma correlated with the CT scan reports.

3. How do we measure the level of severity of Stroke? By using the NIHSS on presentation, changes in neuro status, transfers, handoff during shift report, and discharge.

4. What are some common problems encountered by Stroke Patients?Dysphagia (trouble Swallowing), Dysphasia (trouble speaking) DVTs, Skin Breakdown, Loss of Bowel and Bladder control, Depression. FALL & BLEEDING precautions.

5. When do you start patient on Rehabilitation? Ask for eval upon Day #1.Remember that they aren’t less smart, hard of hearing etc, but may need more time to process information. Speak slower, clearer and allow time for response. Avoid sensory overload.

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Document ONCE A SHIFT

& Update Care Plan to mirror patient’s condition with care plan such as:

Impaired Communication

Risk for Aspiration

Impaired Mobility

Impaired Swallowing

Cerebral Tissue Perfusion

Altered Neurological Status

Moreover...DC Planning, Bleeding, Infection, Safety, Coping, Depression, Mobility, Pain etc

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What do you look for in a patient with dysphagia while eating/drinking? Tears can be a sign of silent aspiration, pocketing of food, wet voice, lengthy swallowing process, and cough.

What Protocol do we follow to prevent Aspiration Pneumonia? A nursing dysphagia screening is administered on all stroke patients. If a patient fails the screening, SLP is consulted within 24 hours.  Remember! When there’s a change in patient’s condition; re-evaluate!

Why do we focus on making a patient NPO? Studies have shown that up to 52% of Stroke patients suffer some form of dysphagia which can easily lead to aspiration. Aspiration leads to pneumonia and pneumonia is the #1 killer in Stroke patients. Water and medications are very easy to aspirate on so for stroke pts NPO means nothing by mouth. Only competent personnel may perform a swallow eval.(simple water swallow test

Who can perform the simple swallow evaluation?Trained nurses should administer the Simple swallow screening on all Stroke patients in any unit.  If a patient fails the screen, SLP is consulted for dysphagia evaluation within 24 hours. The patient will remain NPO until the SLP evaluates the patient and makes their recommendations

What do you look for in a patient with dysphagia while eating/drinking? Tears can be a sign of silent aspiration, pocketing of food, wet voice, lengthy swallowing process, and cough.

Discuss how the swallow screen performed? First assess (visual) if the patient meets criteria for the screen. If no, stop and refer to SLP for an evaluation. Where is the simple swallow screening documented? The nursing dysphagia screening is located in Ad Hoc.

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• Complete all sections of the Stroke Education Tab, including personalized risk factors (Ex: Hypertension)

• Complete the Stroke Patient/Family Education contract SMH 4881

What is Includes in the Patients Education upon Discharge? We provide education that is culturally and linguistically sensitive. 1) How to Activate EMS 911, 2) Specific Risk  Factors for the patient,  3) Warning Signs & Symptoms of Stroke,  4) Instructions regarding medications that the patient is being discharge with,  5) The importance of following up with primary care and consulting physicians after their hospital admission.

How are Patients & Family members involved in their stroke Care?Encourage pt to take on an active role in their care, encourage family members & caregiver to take active role, involve them in planning, teaching, and evaluation.

EDUCATION! FALL & BLEEDING precautions!!!

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Detail VTE Prophylaxis, what counts? Most occur by day 2 of Admission: Pharmacological: Lovenox, SQ Heparin, Aggrenox, Arixtra, Coumadin, Xarelto, Pradaxa. Non-Pharmacological: SCDs.AMBULATION and TED HOSE alone doesn’t meet the VTE requirement!!Patients without any restrictions should be ambulating by Hosp day #2. Ambulation requirement: In the hallway w/w/o assistance and treatment with PT.

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Describe Pre-Hospital Notification: The FAST-ED Scale is the assessment tool that is administered by EMS to triage the patient to identify the severity of the stroke and determination of patient destination. The FAST-ED Scale is also used to detect a large vessel occlusion (LVO) that may require neuroendovascular surgery. EMS will call the ED via Communication Radio to present the last time known well, onset of symptoms, blood sugar, clinical findings, medical history, and a current list of medications. Acute Stroke Workflow on the stroke clip board must be used. All stroke alert activations by EMS will include a FAST-ED score. For a score equal to or equal or greater than 6, s/s of aphasia, hemiparesis, neglect, or eye deviation, the Stroke Transfer Center must be notified immediately.

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A NATIONAL INSTITUTE STROKE SCALE (NIHSS) ASSESSMENT IS PERFORMED BY TRAINED AND CERTIFIED STAFF.

ALL STROKE PATIENTS MUST HAVE AN NIHSS ASSESSMENT COMPLETED ON INITIAL ASSESSMENT, EVERY SHIFT & WITH ANY CHANGE IN CONDITION.

NEURO CHECKS ARE COMPLETED EVERY 4 HRS. ON TELE UNITS

Q1HR IN CRITICAL UNITS, & Q2 HRS. IN ER