Stroke Training Module2 en

Best Practice Nursing Care Across the Acute Stroke Continuum
N S N C
Module 2
Hyperacute Stroke Management
1

Welcome!
This
session includes presentations and activities to enhance your learning

focus is on working with colleagues to discover best ways of using the tools in your clinical settings sit back (or stand up) and have fun!!!
The
So,
3/28/2014

Expectations?
So, what do you want to get out of this module?
3/28/2014

Objectives
Discuss the impact of hyperacute stroke management on patient outcomes

Identify your role in pre-hospital and ER stroke care Review the Best Practice Recommendations related to hyperacute stroke management Identify how you can help to implement these at your institution Identify your role in patient and caregiver education Create a stroke care action plan for hyperacute stroke management
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Agenda
Introduction
Stroke 101(optional) Pre-Hospital Stroke Care In the Emergency Room
15 min
15 min 45 min 30 min
Break
Patient and Family Education Putting It All Together
15 min
45 min 15 min 30 min
Hyperacute Stroke Management BPRs
3/28/2014

Continuum of Stroke Care
Prevention of stroke
Public awareness & patient education
Hyperacute stroke management
Acute inpatient stroke care
Stroke rehabilitation & community reintegration

Continuum of Stroke Care
Prevention of stroke
Public awareness & patient education
Early assessment for stroke rehabilitation should start here
Hyperacute stroke management
Acute inpatient stroke care
Stroke rehabilitation & community reintegration

Why Is This Important?
Acute stroke is a medical emergency and optimizing out-of-hospital care improves patient outcomes
EMS plays a critical role in assessment and management Acute interventions such as thrombolysis are time sensitive
Redirecting ambulances to stroke centres facilitates earlier assessment, diagnosis and treatment which may result in better outcomes.
3/28/2014
Synthesis of best practice recommendations for stroke care across the continuum Address critical topic areas Commitment to keep current and update every two years First edition released in 2006 Current update released in 2008

With four new recommendations Elaboration of existing ones
www.cmaj.ca December 2, 2008
Stroke 101
Intended only for audiences with no previous knowledge of stroke.

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Pre-Hospital Stroke Care

45 min
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11

Your Role in Pre-Hospital Stroke Care

1.
At your tables, discuss best practices for effective Pre-Hospital Stroke Care:
What information will you need EMS to gather about the patient? What you can do to help rapid assessment & triage in hospital?
2.
When done, we'll debrief the whole group to arrive at some best practices
TABLE ACTIVITY
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EMS Role in Hyperacute Stroke
Patient
should be transported without delay to the closest institution that provides emergency stroke care (BPR 3.1)

Patient or other members of public must make immediate contact with EMS EMS dispatchers must triage as priority Paramedics should use standardized screening tool Direct transport protocols should be in place Critical information/history should be obtained Receiving facility must be notified
DEBRIEF
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From Recognition to Pre-Admission
Detection
Dispatch Delivery
Door
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Care of Patient with Stroke
Why is the time of onset of the stroke a critical piece of information?

Stroke
patients who arrive to ER within three and one half hours of symptom onset may be candidates for thrombolytic therapy destination decisions may be based on time of onset of stroke symptoms
Hospital
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15

Last Seen Normal-1
A 53-year-old man with a history of hypertension was brought to the ED by paramedics after his employer noticed that he had difficulty with speech, ambulation, and vision.
The employer reported that the patient usually left his house at 3:40 am and arrived at work by 4:00 am; however, no one saw him arrive at work and no time clock is used. Paramedics were called at about 5:00 am. What was the time of onset of the stroke?
When he went to bed? 3:40 am? 4:00 am? 5:00 am?
CASE STUDY
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16

Last Seen Normal-2
What do we know:
Patient successfully drove to work; it is unlikely that the stroke began before he left the house.
Possible:
Symptoms MAY have been very mild at first, that he ignored them, and went to work anyway.
Decision:
Since we have no evidence for this yet, we TENTATIVELY assign an onset time of 3:40 am, subject to further history.
Needed:
Find someone at work who saw him and could testify that he was normal or obviously abnormal before the paramedics were called.
CASE STUDY
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Pre-Hospital Important Steps
Quick
identification and screening by prehospital providers in the field

Blood
glucose measurement to exclude hypoglycaemia as a cause of neurological deficit Notification of receiving hospital Transport Treatment to stabilize the patient
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Key Components of Paramedic Prompt Cards
Consistently
Evaluate
Facial
identifies patients with stroke
three major findings:
droop Arm weakness Speech abnormalities
Based on the Cincinnati Stroke Scale or Los Angeles Stroke Scale
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19

Cincinnati Pre-Hospital Stroke Scale
Patients
72%
with 1 of these 3 findings
probability of an acute stroke if the symptoms are new
Patients
85%
with all 3 findings..
probability of an acute stroke if the symptoms are new
If
the patient has a positive CPSS or one or more of the findings, immediately activate local acute stroke protocol
REVIEW
20
3/28/2014

Symptom
Time Trauma Seizure
Onset
Basic
Age
Data
(history)
and gender Chief complaint

Other
As
tPA exclusions
Neurological
LOC Pre-Hospital
Exam
per tPA protocol inclusion/exclusion criteria
Stroke
Scale
Information obtained and relayed by EMS provider is vital
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NIH Stroke Scale
Standard assessment tool for measuring neurologic deficit
Measures level of consciousness, best gaze, visual, facial palsy, motor function, language, dysarthria, extinction and inattention
Can be used to quantify neurologic function in specified categories at various time points
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NIH Stroke Scale
EXAMPLE
Source: www.ninds.nih.gov
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NIH Stroke Scale
EXAMPLE
Source: www.ninds.nih.gov
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CNS Stroke Scale
Canadian Neurological Scale was designed as a simple clinical tool to evaluate the neurological status of acutestroke patients Measures level of consciousness, orientation, speech and motor functions
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CNS Stroke Scale
EXAMPLE
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Check Up Quiz
EXAMPLE

Check Up
In hyperacute stroke management, EMS should To the nearest institution that transport a patient without provides emergency stroke care delay to what type of institution?
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Check Up
What are the four steps in pre-hospital stroke care from Detection, Dispatch, Delivery, Door recognition to preadmission?
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29

Check Up
What are the four steps in pre-hospital stroke care from Detection, Dispatch, Delivery, Door recognition to preadmission?
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30

Check Up
Stroke can be Why ispatients the timewho of onset of diagnosed with a CT within three the stroke a critical piece of hours of symptom onset may be information? candidates for thrombolytic therapy
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Check Up
Why ishypoglycaemia blood glucose as a To exclude measurement so important? cause of neurological deficit
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Check Up
1. does Facial droop What the Pre-Hospital 2. Arm weakness Stroke Scale measure? 3. Speech abnormalities
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Check Up
What is the probability of acute stroke if a85% patient is abnormal on all probability three of the Cincinnati measures and symptoms are new?
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Check Up
Level of consciousness, best gaze, visual, facial palsy, What does the NIH motor Strokefunction, Scale language,measure? dysarthria, extinction and inattention
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35

Check Up
What does the Canadian Level of consciousness, orientation, Neurological Scale measure? speech and motor functions
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36
In the Emergency Room

30 min

7-Step Stroke Chain of Survival
Dispatch
Delivery Door
Detection
Intervention
Decision
Data
Time is Brain

Where You Can Make a Difference!
1.
2.
Treatment in the ER is only the start

Patients will have varying outcomes:

Lazarus effect (complete or almost recovery) Light to moderate disability Moderate to severe disability
HERE`S WHERE YOU CAN REALLY MAKE A DIFFERENCE!
Diminishing Returns over Time

Favorable Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90 Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776)
Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I,
~4h 40min
Courtesy Brott T et al

Your Role in the Emergency Room
1.At
your tables, discuss and flip chart key points about your role in the ER:

What can you do to assess patients & triage rapidly? What are the key activities of the stroke team? What is your role in facilitating a smooth transfer from ER to an inpatient unit?
2.When
done, well debrief the whole group to arrive at some best practices
TABLE ACTIVITY

What is the single most important key to stroke care success?
Interprofessional Communication!
so that everyone knows what to do and things can be activated simultaneously!

What needs to get done?
TABLE ACTIVITY

Treatment Objectives
Include:
Maintaining or improving breathing, CV function, nutrition, hydration and electrolyte balance Evidenced based neurological assessment
Limiting further neurological damage

Preventing complications Treating or modifying reversible risk factors Patient and family education

Early Management Initial Steps
Check airway, breathing, vitals (including temperature)

Ensure adequate respiration, monitor BP and cardiac rhythm Establish time of stroke symptom onset Alert stroke team Establish IV access-possibly 2 lines Draw blood for CBC, blood glucose and other tests (INR)

Early Management Initial Steps
Perform neuro assessment

NIH Stroke Scale Canadian Neurological Scale
Use of preprinted standard orders or protocols
Order a CT scan
Keep NPO until swallowing screen completed Educate patient and family

Candidates for t-PA

Optimal Stroke Management with rt-PA
Bypass and repatriation protocols to closest Regional Stroke Centre

Established thrombolysis protocol Triage: Rapid assessment using Acute Stroke protocol eligibility criteria / NIH Stroke Scale t-PA target times: ensure you can meet the < 4.5 hr window (ECASS III) Access to CT scanning
Stroke team: (Stroke expert, emergency or family physician, nursing staff, allied healthcare professionals, stroke survivor, family, support network central to team)

Exclusions for t-PA

Optimal Stroke Mgmt with t-PA: Triage
Exclusion criteria for intravenous t-PA
CT evidence of cerebral hemorrhage or an infarction that involves >1/3 of the middle cerebral artery territory Blood pressure >185/110 mmHg that cannot be reduced with appropriate intravenous bolus dose of labetalol (alpha blocker) A prolonged PTT (Partial Thromboplastin Time), or an INR (International Normalized Ratio) >1.7 (1.4), or platelet count <100,000/mm Stroke or head injury within past 3 months
Major surgery within past 14 days

Optimal Stroke Mgmt with t-PA: Triage
Exclusion criteria for intravenous t-PA, cont

Seizures at onset of stroke Other major bleeding (e.g., gastrointestinal) within past 21 days MI within past 14 days
Rapidly improving neurological signs or minimal deficit

Other illness that, in the physicians judgment, could limit effectiveness of t-PA or increase risk of bleeding

EMonitoring needs during t-PA treatment
Canadian Guidelines for Intravenous Thrombolytic Treatment in Acute Stroke: (1998)
Vital signs should be taken every 15 minutes during the drug infusion, then 30 minutes for the next 2 hours, then hourly for 5 hours Neurovital signs should be performed hourly for 6 hours, and then according to the patient's condition
Source: Can. J. Neurol. Sci. 1998; 25: 257
Check Up Quiz
QUIZ

Check Up
Interprofessional Communication! What is the single most so that everyone knows what important key to stroke care to do and things can be activated success simultaneously
3/28/2014
55

Check Up
Ensure you can meet the < 4.5 hr What is the t-PA target time? window (ECASS III)
3/28/2014
56

Check Up
Stroke expert, emergency or family physician, allied Who shouldnursing be partstaff, of the Stroke healthcare professionals, stroke team? survivor, family, support network central to team
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57

Check Up
According to the Canadian Every 15 minutes the drug Guidelines for during Intravenous infusion, then Treatment 30 minutes the Thrombolytic infor Acute next 2 hours, then hourly for 5 hours Stroke, when should vital signs be taken?
3/28/2014
58

Check Up
A stroke or head injury within what period of time is an Stroke or head injury within past 3 exclusion months for intravenous tPA treatment?
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59
Lets take a break

15 min
Best Practice Recommendations

45 min

Best Practices Recommendations
3.1 EMS management of acute stroke patients
Patients who show signs and symptoms of hyperacute stroke, usually defined as symptom onset within the previous 4.5 hours, must be treated as time-sensitive emergency cases and should be transported without delay to the closest institution that provides emergency stroke care
Patient or other members of public must make immediate contact with EMS EMS dispatchers must triage as priority Paramedics should use diagnostic screening tool Direct transport protocols should be in place Critical information/history should be obtained Receiving facility must be notified
OVERVIEW

3.2 Acute management of TIA and minor stroke
Patients who present with symptoms suggestive of minor stroke or transient ischemic attack must:

Undergo a comprehensive evaluation to confirm the diagnosis Begin treatment to reduce the risk of major stroke as soon as is appropriate to the clinical situation
OVERVIEW

3.3 Neurovascular imaging
All patients with suspected acute stroke or transient ischemic attack should undergo brain imaging immediately

In most cases, initial modality in a non-contrast CT scan Vascular imaging should be done as soon as possible If MRI is performed, it should include diffusion-weighted sequences
OVERVIEW

3.4 Blood glucose abnormalities
All patients with suspected acute stroke should have their blood glucose concentration checked immediately.
Blood glucose measurement should be repeated if the first value is abnormal or if the patient is known to have diabetes. Hypoglycemia should be corrected immediately Elevated blood glucose concentrations should be treated with glucose-lowering agents
OVERVIEW

3.5 Acute thrombolytic therapy
All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with intravenous tissue plasminogen activator (alteplase)
All eligible patients should receive intravenous alteplase within 1 hour of arrival (door-to-needle time < 60 min) Administration of alteplase should follow the ASA guidelines
OVERVIEW

3.6 Acute ASA therapy
All acute stroke patients should be given at least 160 mg of ASA immediately as a one-time loading dose after brain imaging has excluded intracranial hemorrhage
In patients treated with recombinant tissue plasminogen activator, ASA should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage ASA (80325 mg daily) should then be continued indefinitely or until an alternative antithrombotic regime is started
OVERVIEW

3.7 Management of subarachnoid and intracerebral hemorrhage
Patients with suspected subarachnoid hemorrhage should have an urgent neurosurgical consultation for diagnosis and treatment
Patients with cerebellar hemorrhage should have an urgent neurosurgical consultation for consideration of craniotomy and evacuation of the hemorrhage
Patients with supratentorial intracerebral hemorrhage should be cared for on a stroke unit
OVERVIEW

Recommendations Briefing
1.
2.
3.
Form two groups at your table and have each select and prepare a briefing on one of the sections in Hyperacute stroke management Use the worksheet in your PW to help structure your briefing Focus on the following topics:

Rationale for recommendation System implications of it
Performance measures
4.
When done, each group will present its briefing to the other and discuss
TABLE ACTIVITY
Imagine you have been asked to brief your colleagues back home on one of the key sections in Hyperacute stroke management.

Recommendations Briefing
1.
Now switch sections with the other group at your table and prepare to answer the following:
How will this recommendation improve stroke care at your institution?
What role can you play in implementing it?

What barriers or enablers do you see?
2. 3.
When done, brief the other group on these issues and discuss Then, well debrief the whole group to arrive at some best practices
Imagine you have been asked to brief your colleagues back home on one of the key sections in Hyperacute stroke management.
TABLE ACTIVITY
Patient and Family Education

15 min
From the Patient and Familys Perspective:

Where You Can Make a Difference!
1.
At your tables, discuss

What would be your role in educating and supporting patients and caregivers about hyperacute stroke management? Did you know that skills training of caregivers makes a huge difference in patient outcomes in areas of functionality and depression!
2. 3.
When done, brief the other group on these issues and discuss When done, we'll debrief the whole group to identify some best practices

Content should be specific to;

The phase of care Patient/caregiver readiness Patient/caregiver needs
Education should be timely, interactive, up to date and provided in a variety of formats, languages including aphasia friendly Processes should be established by clinical teams for education including designating team members for provision and documentation of education
REVIEW

Education content should include:

The nature of the stroke and its manifestations Signs and symptoms of stroke Impairments and their impact on the person Caregiver training to manage Risk factors Post-stroke depression Cognitive impairment Discharge planning and decision making Community resources Home adaptations
REVIEW
Putting It All Together

30 min

Case Study
1.
2.
Review the case study in your PW

With your team, answer the questions on the worksheet at the end of the study Well review when done to share some best practices and get ready to create a Stroke Care Action Plan
3.
TABLE ACTIVITY

Case Study
Mrs. R is a 76 year old right handed woman who was shopping at Canadian Tire at 1030am when she suddenly started to feel unwell. She went to the clerk to ask for assistance but was unable to talk and had a right sided weakness.
The clerk called 911 and she was taken to the local stroke centre where she was assessed at 1115am Her past medical history includes: hypertension, hypercholesteremia, osteoporosis and gastroesophageal reflux Her current medications include: hydrochlorothiazide, coversyl, simvastatin, didrocal and ranitidine
She has no known allergies and does not smoke or drink alcohol

Case Study
On admission to ER:

BP 162/72
Pulse 100 and irregular Respirations 26 Temperature 37.0C Heart sounds irregular but no murmurs heard
Lungs clear. No peripheral edema. Abdomen soft and non tender and non-distended
Neurologically:
Mental status limited due to expressive aphasia but able to follow simple commands
Right visual field defect

Right facial weakness Dense right flaccid hemiparesis Blood work: Glucose: 6.8, WBC: 5.0, Platelets: 221, Hemoglobin: 122, Sodium: 137, Potassium: 3.7, Troponin < 0.04, INR: 0.9

Case Study Questions
Did Mrs. C meet the criteria to activate the Code Stroke Team?
Is Mrs. C a candidate for tPA? Why?
TABLE ACTIVITY

Case Study Questions
If Mrs. C met the criteria for tPA, what possible complications would you monitor for?
If Mrs. C receives tPA, when is the recommended time to administer ASA 160mg?
What teaching would you give the patient/family in this phase of care?
TABLE ACTIVITY

Creating a Stroke Care Action Plan
1.
With the case study we just reviewed in mind, create a stroke care action plan
Identify 1-2 key learnings from today that you could take back to help kick start your change initiatives
2.
Use the Stroke Care Action Plan worksheet in your PW to record your plan
INDIVIDUAL ACTIVITY
Best Practice Nursing Care Across the Acute Stroke Continuum

Thank you for your participation!

Stroke Training Module2 en

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Best Practice Nursing Care Across the Acute Stroke Continuum

Hyperacute Stroke Management

session includes presentations and activities to enhance your learning

Hyperacute Stroke Management

So, what do you want to get out of this module?

Hyperacute Stroke Management

Discuss the impact of hyperacute stroke management on patient outcomes

Hyperacute Stroke Management

Hyperacute Stroke Management BPRs

Hyperacute Stroke Management

Hyperacute stroke management

Acute inpatient stroke care

Stroke rehabilitation & community reintegration

Hyperacute Stroke Management

Early assessment for stroke rehabilitation should start here

Hyperacute stroke management

Acute inpatient stroke care

Stroke rehabilitation & community reintegration

Hyperacute Stroke Management

With four new recommendations Elaboration of existing ones

www.cmaj.ca December 2, 2008

Intended only for audiences with no previous knowledge of stroke.

Hyperacute Stroke Management

Pre-Hospital Stroke Care

Hyperacute Stroke Management

Your Role in Pre-Hospital Stroke Care

Hyperacute Stroke Management

Hyperacute Stroke Management

From Recognition to Pre-Admission

Hyperacute Stroke Management

Why is the time of onset of the stroke a critical piece of information?

Hyperacute Stroke Management

When he went to bed? 3:40 am? 4:00 am? 5:00 am?

Hyperacute Stroke Management

Hyperacute Stroke Management

identification and screening by prehospital providers in the field

Hyperacute Stroke Management

identifies patients with stroke

three major findings:

droop Arm weakness Speech abnormalities

Based on the Cincinnati Stroke Scale or Los Angeles Stroke Scale

Hyperacute Stroke Management

with 1 of these 3 findings

probability of an acute stroke if the symptoms are new

with all 3 findings..

probability of an acute stroke if the symptoms are new

Hyperacute Stroke Management

and gender Chief complaint

per tPA protocol inclusion/exclusion criteria

Information obtained and relayed by EMS provider is vital

Hyperacute Stroke Management

Standard assessment tool for measuring neurologic deficit

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management

Hyperacute Stroke Management