Transcript You Can Do It Faster_Nickel

YOU CAN DO IT FASTER
11 WAYS TO DECREASE DOOR TO NEEDLE TIME
Jeff Nickel, MD FACEP
ED Medical Director
Parkview Regional Medical Center
TARGET STROKE
• A national quality improvement initiative of the
American Heart Association/American Stroke
Association to improve the care of stroke patients
• Phase 1 - Door to IV TPA goal was median time of
<60 minutes
• Phase 2 – 75% <60 minutes. Median time 45 minutes
• Every 15 minute reduction in time has been shown
to improve favorable outcomes by 4%
• With best practices we could get this down to 30-45
minutes
1) EMS PRE-NOTIFICATION
EMS outreach and education
Be aware of local hospitals capabilities
Gather all significant history
Notify ED as early as possible
Relay patient name and information
Bring witness/family member to ED with patient
Initiate antecubital IV, collect blood, check sugar,
bring medications if available.
• Register into EMR before arrival if possible
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2) STROKE TOOLKIT
• Rapid triage protocol
• Stroke team member assignments
• Clinical decision support tool –TPA screening
Checklist
• Specific order sets
• Critical pathways
• NIH Stroke Scale
3) RAPID TRIAGE PROTOCOL AND
STROKE TEAM NOTIFICATION
• Triage Protocols facilitate timely recognition of
Stroke.
• Stroke team should be activated as soon as patient
is identified pre-hospital or at triage
• Rapid neurologic evaluation should be performed
ASAP in ED or on CT table
• NIH scale done ASAP
Bleed
Sx Resolved
Non-Contrast Head CT
See TIA
Protocol
(Patient REMAINS IN CT for CTA/CTP if criteria below met)
See ICH/SAH
Protocol
Negative
• Radiologist confirms:
No bleed or early signs of stroke
• SCNN called: Have tPA inclusion/exclusion info ready for neurologist
NOW
(IV Alteplase)
for any significant deficit
up to 4.5 hrs* (physician order required) AND
*Between 3-4.5 hrs,
EXCLUDE from IV tPA if:
• > 80 yrs old
• History of DM and Stroke
• On oral anticoagulant
regardless of INR
• NIHSS > 25
Version 05-2015
• NIHSS
mRS < 2**
• No known renal insufficiency
• Will not delay IV tPA!!!
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Neurointervention
(if indicated per Interventionalist)
Version 05-2015
> 5 (estimate acceptable)
**mRS < 2 = No
Disability to Slight
Disability prior to
this stroke
Sx Resolved
Bleed
Non-Contrast Head CT
See TIA
Protocol
(Patient REMAINS IN CT for CTA/CTP if criteria below met )
See ICH/SAH
Protocol
Negative
• Radiologist confirms:
No bleed or early signs of stroke
• SCNN called: IF pt. meets initial neurointervention criteria below
If pt. does not meet
this screening
criteria for
neurointervention,
neurologist paged by
ED physician for
consult as
appropriate
CTA/CTP
• NIHSS > 5 (estimate acceptable)
• mRS < 2*
• No known renal insufficiency
Neurointervention
Version 05-2015
(if indicated per Interventionalist)
*mRS < 2 = No
Disability to Slight
Disability prior to
this stroke
» CT/CTA/CTP & Call SCNN
If pt. does not meet
this screening
criteria for
neurointervention,
neurologist paged by
ED physician for
consult as
appropriate
• NIHSS > 5 (estimate acceptable)
• mRS < 2**
• No known renal insufficiency
Neurointervention
(if indicated per Interventionalist)
Version 05-2015
*Drip and Ship patients are
NOT to be direct admits:
To be re-assessed upon
arrival to PRMC ED to
determine if meet criteria
for CT/CTA/CTP & neurointervention.
**mRS < 2 = No
Disability to Slight
Disability prior to
this stroke
Acute
Stroke Protocol
• Transfer pt. with known ICH/SAH or
• ICH/SAH diagnosed upon arrival
ICH
STAT Neurosurgery consult if:
• > 3 cm or…
• Posterior fossa location or…
• Hydrocephalus or…
• Shift or…
• GCS < 10
Version 05-2015
SAH
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STAT CTA head and neck
NeuroInterventionalist paged
Intensivist consult
STAT Neurosurgery consult for EVD if:
 Hydrocephalus or
 Intraventricular hemorrhage or
 Poor mental status
Protocol
Assess Patient using
Scale
A = Age
1 point given if patient is ≥ 60 yrs old
B = Blood Pressure
1 point given if Systolic BP > 140 mmHg OR Diastolic BP > 90 mmHg
C = Clinical features of TIA
0 points given if neither speech impairment nor unilateral weakness
1 point given if speech impairment without weakness
2 points given if unilateral weakness
D= Diabetes
0 points given if no history of diabetes diagnosis
1 point given if current or past diabetes diagnosis
D= Duration
0 points given if TIA Duration < 10 min
1 point given if TIA Duration 10-59 min
2 points given if TIA Duration > 60 min
Hospitalize patient if presents within 72 hrs of the event
ABCD2 score is:
 Greater than or equal to 3
 0-2 but outpatient workup cannot be completed within 2 days
 0-2 with other evidence for focal ischemia causing event
Version 05-2015
Use TIA Admission Order Set
4) SINGLE CALL ACTIVATION SYSTEM
• One call should activate the entire stroke team
• Includes ED staff, CT, Lab, Pharmacy, Neurologist,
Radiologist, Chaplain, Stroke Team Nurses,
Research Nurse, Stat Nurse, ICU Nurse, etc.
5) TRANSFER DIRECTLY TO CT
• Eligible stroke patients, if appropriate should go
directly to CT from ambulance or triage
• Protocols to ensure patients requiring emergency
medical assessment or stabilization are not directly
triaged to CT
• Get patient weight on gurney or CT table if possible
• Physician evaluation and NIH scale can be
obtained in CT
6) RAPID INTERPRETATION OF CT
• Initial plain CT only. Delay advanced imaging until
it is determined patient is not a TPA candidate
• Consider Radiologist or Neurologist in CT scanner for
real time interpretation
• Acquisition time should be within 20 minutes of
arrival and complete interpretation within 35
minutes of arrival
7) RAPID LABORATORY TESTING
Draw blood pre-hospital or upon arrival
Glucose, Glucose, Glucose
Point of care testing
Lab turn around time should be less than 30 minutes,
prioritize INR and platelets
• If patient is not are risk for coagulation defect and
not on anticoagulants, consider not delaying tpa
while waiting on results
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8) MIX TPA AHEAD OF TIME
• TPA stored in ED has been shown to reduce
administration time
• If stored in pharmacy, pharmacist must be notified
immediately on patient arrival and given patients
weight.
• Mix the TPA when a potential patient is identified
• Manufacturer will replace unused thrombolytic free
of charge
9) RAPID ACCESS AND
ADMINISTRATION OF TPA
• Only one IV necessary initially, start second when
possible
• Bolus should be given ASAP even on CT table if
possible. Drip should be started immediately. One
nurse can give bolus while second is preparing and
priming drip.
• Have your TPA administration protocol in your stroke
tool kit
10) TEAM-BASED APPROACH
• Team approach based on standardized stroke
pathways and protocols has proven to be effective
in enhancing the number of eligible patients treated
and reducing time to treatment
• Essential for successful stroke performance
improvement
• Huddle after every TPA eligible patient to discuss
what went right and wrong, opportunities for
improvement
11) PROMPT DATA FEEDBACK
• Accurately measure and track your door to needle
times, IV TPA treatment rates and time intervals
• Disseminate data and outcomes on every patient
on a real time basis
• Meet frequently to devise strategies to identify and
overcome barriers, set targets and monitor
progress.
FEEDBACK TOOL
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