Transcript Management of Stroke in the IN Patient Departments

Diane Kane RN
Program Coordinator
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Review/Update of Core Measures
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Stroke Education
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In Patient Code Purple
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Reason for no VTE Prophylaxis
Must be documented by Physician/APN/PA
 Documentation for NO VTE must be within first 24
hrs. of admission
 If NO VTE ordered or only Antiembs
Documentation must state why neither
pharmacological and mechanical were not ordered
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 Documentation can not say “No VTE pharmological
prophylaxis because of bleeding disorder”
 Documentation must say no VTE mechanical or
\pharmacological because of bleeding disorder.
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Additional Reason for NO VTE Prophylaxis
Physician/ANP/PA document adequate
anticoagulation or INR is therapeutic and
adequately anticoagulated at this time.
 Patient/Family refusal of VTE Prophylaxis can be
documented by nurse
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Medications that are approved for VTE
Prophylaxis for Stroke
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Heparin bolus
Lovenox
Coumadin
Xarolto
Arixta/Apixaban
Mechanical Devices that are approved for VTE
Prophylaxis
Pulse Boots
 SCD
ANTI EMBOLTIC STOCKINGS ALONE ARE NOT VTE
PROPHYLAXIS

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One Last Word
If the patient is on Heparin or post tPA they must
have SCD
 The measure meets the core measure standard when
the VTE prophylaxis was applied or given NOT
when ordered.
 If nurse does not apply SCD’s then we don’t meet
the standard.
 If nurse does not administer the drug till after the 24
hours the we don’t meet the standard.
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This measure applies to ischemic strokes only
This includes all antithrombotic or
anticoagulation drugs fro ASA, Plavix,
Aggrenox, Heparin, Lovenox, Xarolto, Pradaxa
If not placed on a medication the reason for not
doing so must be documented by the
Physician/APN/PA.
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Definition: Any documentation by a
Physician/ANP/PA that the patient has a
history of ANY atrial fibrillation/flutter (e.g.
remote, persistent, paroxysmal) OR any signed
ECG tracing of ANY atrial fibrillation/flutter.
All patients with any of the above must be on
anticoagulation during and on discharge.
If a Physician/ANP/PA document that no
anticoagulation secondary to either fall risk,
history of GI bleed, etc. then the patient is not
included in the measure.
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This is an Emergency Department core
measure that requires that the ED administer
tPA in a prescribed time frame from when the
patient was last know well.
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All Ischemic strokes must be on a statin at
discharge.
Exceptions;
If the LDL less than 100 without a history of being on a
statin at home
 If Physician/ANP/PA documents a reason for not
placing patient on statin therapy. Example Age, history of
liver disease, allergy. It must be documented “ Patient
not on statin therapy due to age”

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Intracerebral Bleeds or Subarachnoid bleeds are
not required to be on statin therapy.
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The measure calls for the patient is assessed for
reab not that they get rehab services.
If a physician/APN/PA documents that he has
assessed the patient for rehab services and
none are required that is sufficient to meet the
measure.
DOCUMENTATION TOOL
A dialog box
will open to
remind you
that all 5
educational
topics must be
completed
prior to
discharge.
If there are sections
not complete you
may complete
them. If all five
areas are
completed then
drop down to the
reinforced
education area.
SEE NEXT SLIDE
Utilize this
area to
demonstrate
education
that you are
reinforcing
on an
ongoing basis
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Stroke education is suppose to be individualized.
When risk factors, lifestyle, or medication section
opens click on only those areas that are specific to
your patient.
Watch where your clicking the end of that list is a
refusal of education and should only be used if
education is refused.
Optimally we would like to have some education
done daily but to ensure compliance please
complete all 5 topics within the first 24 hours and
the reinforce at least 2-3 times during admission.
NEW IN PATIENT
CODE PURPLE
PROCESS
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Try to include family on education especially
warning signs and calling 911. They are the
ones who are most likely going to recognize a
problem once the patient goes home.
TIA patients should be educated as well. The
are at high risk for a stroke and need to have
the information.
Keep up the great job we have gone from poor
compliance to 100% compliance and our
patients are better for it.
When to call a CODE PURPLE?
The Criteria has changed!!!
1.
a. Within 12 hours from Last Time
Known Well
b. Wake up stroke should be included
c. Unknown onset of symptoms
Other considerations include:
d. All patients in 1-3 hours of last time
known well or in specific situations 34.5 hours should be considered for tPA
Mildly or partially resolving stroke
deficit should be considered if the
deficit is disabling for the
patient/family. Is this a deficit the
patient can live with??
1.The patient will be a taken down to the CT Scanner
2. The Tele-Stroke Cart will be brought to the CT Scanner
by the ED. The Supervisor will input the initial data.
3. The patient and the cart will return to the inpatient unit.
4. The Hospitalist will indicated if Hershey consultant
should be contacted.
5. The Hershey Stroke Neurologist will complete their
exam.
6. Disposition will be made based on the findings of
Stroke Consultant with agreement of the Hospitalist
and/or PMD.
7. All orders will given by the Hospitalist or PMD.