Comprehensive Nursing Care For Stroke

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Comprehensive Nursing Care For Stroke
Tami Harris RN, CNRN
Stroke Program Coordinator
University of Missouri Hospital
 None
 Identify
what comprehensive means
 Review AHA/ASA guidelines for stroke care
 Review TCD guidelines for stroke care in
Missouri
 Image Trend: How to use this log to improve
stroke care
 Identify comprehensive ways to improve
stroke programs
 Complete;
including all or nearly all
elements or aspects of something
 Of
or relating to understanding
 Comprehensive
encompasses all levels and
phases of stroke care
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Community education
Pre-hospital
Emergency acute phase thrombolytic
OR and Interventional radiology
ICU stroke care
Standard ischemic and hemorrhagic stroke care
Rehabilitation Phase
Community support
Outreach education
Research to improve stroke care
Designated comprehensive stroke centers have
available to the patient, equipment and
personnel to provide the care required during all
phases of stroke care.
 Such as: Neurosurgery, Neurology, Emergency
medicine staff, Interventional endovascular
teams, OR and PACU staff, dedicated ICU staff,
Lab and radiology staff all available 24/7. ACLS
equipment in all areas of care, blood products
and medications needed for stroke care,
therapy, social work, research staff etc…
 How can a center provide comprehensive care if
it doesn’t have these resources or hasn’t been
designated as comprehensive?
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 STK
1 VTE prophylaxis
 STK 2 Discharge on antithrombotic therapy
 STK 3 Anticoagulation therapy for AFib/Flutter
 STK 4 Thrombolytic Therapy
 STK 5 Antithrombotic by end of day 2
 STK 6 Discharge on a Statin medication
 STK 8 Stroke education
 STK 10 Assess for rehabilitation
Smoking cessation tools, education and support
 Dysphagia screening performed before PO intake
 Thrombolytic at 3.5-4.5 hours from LKW
 Door to IV t-PA in 45 minutes
 NIHSS at time of presentation and discharge
 LDL documented
 Intensive Statin Therapy
 Depression screening
 Cognition screening
 Follow up on mRS post discharge
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 CSTK
1 NIHSS on arrival
 CSTK 2 90 day mRS
 CSTK 3 Severity assessment for ICH and SAH
 CSTK 4 Procoagulant reversal
 CSTK 5 Hemorrhagic complication review
 CSTK 6 Nimodipine treatment for SAH
 CSTK 7 Median time to revascularization
 CSTK 8 TICI Post treatment reperfusion grade
 The
Joint Commission designates stroke
centers based on clinical practice guidelines
and proof by documentation of compliance in
following these CPG’s
 The State designates levels of stroke centers
based on the type and availability of
treatment provided at the facility with an
extended focus on pre-hospital transport to
the appropriate facility, appropriate care in
the field, appropriate identification of stroke
patients and loop closure of care. Community
education and outreach are also a focus of
the State.
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Maintain a stroke log including :
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Response times
Patient diagnosis
Treatments/Actions
Outcomes
Benchmark indicators
Total number of patients
Appropriate and ongoing stroke education for providers,
nursing and ancillary staff
Documentation of appropriate skill set and volume of
patients to maintain these skills
PI/PS program
Morbidity and Mortality review
Review of pre-hospital care
Patient and public education on stroke prevention
Level I and II centers shall establish professional
education outreach
 Use
of the registry helps to follow patient
from time of onset through all aspects of
care
 Helps to identify ways to improve processes
throughout the region
 Can provide reports on internal audits as well
as complication review for individual stroke
programs
A patient has sudden onset of stroke symptoms
and calls 911
 EMS transports the patient to nearest Level II or
III center where patient is identified as eligible
and receives thrombolytic (t-PA) and is
transferred to nearest Level 1 center
 The patient then receives acute stroke
monitoring and care and then is transferred to
inpatient rehab
 When using the stroke registry a timeline is
created to show where patient received care,
how long it took at each stop and what the
outcome was
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 Onset
of symptoms
 Patient is transported by EMS staff that are
knowledgeable in identification and
transport of stroke patients
 Patient arrives to receiving facility with IV in
place and blood drawn along with a short
report on LKW, neuro status, vital signs etc..
 Patient is worked up for eligibility for
administration of t-PA or endovascular
procedure
Day 1 ICU care post intervention: Frequent
VS/Neuro checks & NIHSS. SCD’s are on. Strict BP
control. Stroke education provided to patient
and family. Dysphagia screen 12 hours after t-PA
administration. SW and Therapy is aware of
patient. Review of plan of care and anticipated
discharge disposition.
 Day 2 ICU: Repeat head CT at 24 hours if no
neuro changes. Start antithrombotic. PT/OT
evaluation if CT clear. SLP if patient has aphasia
or failed dysphagia screen. Transfer to floor if
patient is cleared. Education review with patient
and family. SW starts placement process
dependent on therapy recommendations.
 Day 3 Floor Care: Continued therapy,
assessments for need of placement. Depression
screening and cognition screening. Education
review. Continued SW follow up.
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Day 4 Floor: Continue to evaluate for placement
or safe to go home. Possible discharge over next
1-3 days. Continue education. Upon discharge,
document NIHSS and mRS scores
 Day 7 post discharge: Clinic visit with neurologist
or phone follow up
 Day 25-35 post discharge: Clinic visit with
neurologist. Obtain 30 day mRS, monitor
medication compliance, clinic and ED visits, and
30 day readmissions
 Day 85=95 Post discharge: Follow up phone call
to obtain 90 day mRS
 Post discharge follow up clinic visits as needed
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 Remember
the bottom line is “Patient first”
 Tailor your stroke care to fit the patient
 Numbers are very important, the information
from the data helps to drive change,
however…..
 Show compassion. Remember Stroke is the
5th cause of death and the leading cause of
disability in the US. These are patients not
statistics
 Educate
yourself and staff on how to
encompass comprehensive behaviors at your
facility
 Provide up to date and continuing education
for staff that care for stroke patients
 Perform internal audits . Auditing of
processes can lead to identifying
opportunities for improvement
 Internal audits also show processes that work
well
 Work
together as a community to provide the
right care at the right time for stroke
patients
 Participate in community efforts to educate
on stroke prevention
 Utilize available resources for professional
education (Thank you for attending our TCD
summit!)
 Provide information on improvement
opportunities to the Central Region EMS and
TCD coordinators committee, better yet
become a member!
 QUESTIONS?
 Webster’s
Dictionary
 www.merriamwebster.com/dictionary/comprehensive
 American Heart Association/Stroke
Association
 http://powertoendstroke.org/
 Department of Health and Senior Services for
Missouri
 http://health.mo.gov/living/healthcondiseas
es/chronic/tcdsystem/pdf/StrokeRegs6-3013.pdf
 The Joint Commission
 http://www.jointcommission.org/certificatio
n/primary_stroke_centers.aspx