Developing a Neuroscience Systems of Care
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Transcript of Developing a Neuroscience Systems of Care
Stroke Teams, Transfers and Primary Stroke Centers
NEURONS4U: Promoting Patient Advocacy
Susan Freeman, MSN, FNP-BC
Program Manager, Neurosciences
Pitt County Memorial Hospital, University Health Systems
Eastern North Carolina Stroke Network
April 14, 2010
Team: A group of animals or people linked in a common purpose
Who are we together?
What are we here to do?Who am I ?
Who are you?
How are we going to do it?How are we doing?How did we do?
Patient
HealthcareProviders
Common Purpose
1.Rapid patient
recognition of and reaction to stroke
warning signs
Key Steps for Maximizing Clinical Outcomes “The Stroke Chain of Survival”
Effective EMS systems can minimize delays in prehospital dispatch, assessment, transport and –ultimately- the number of patients reaching the
hospital with the 3-hour treatment window for fibrinolytic therapy
AHA. Circulation. 2005;112:111-120; Wojner-Alexandrov et al. Stroke. 2005;36:1512-1518; Deng et al. Neurology. 2006;66:306-312.
2.Rapid emergency medical services (EMS) dispatch
3.Rapid EMS system
transport and hospital pre-notification
4.Rapid in-hospital
diagnosis and treatment
NIH-Recommended Emergency Department Response Times
The “golden hour” for evaluating and treating acute stroke
Door-to-needle time ≤60 minutes
0
Suspected stroke patient arrives at ED
CT scan initiated
CT & labs interpreted
tPA given if patient is
eligible
Minutes: 10 15 25 45 60
Initial MD evaluation
Stroke team notified
NINDS Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke, December 12-13, 1996. http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/recs-emerg.htm. Accessed November 8, 2007.
BAC: Primary Stroke Center Criteria
• Acute stroke teams that are available 24/7 • Written care protocols that include appropriate
use of Activase (Alteplase) • Emergency medical services coordinating with
ED • ED personnel trained in diagnosis and treatment
of all strokes• Stroke unit (not necessarily a formal unit)• Neurosurgical services available within 2 hours
when needed
What and Why?
• Identify dedicated Stroke Responders• Make sure they are stroke trained• Mold these responders into a team• Hold them accountable for Best Practice• Stroke Center Capable versus Certification• Prepare team : Acute Stroke Treatment• Increases access to care for acute stroke• Promotes best practice• Bottom line: It’s the right thing to do !
OPPORTUNITY:Develop a Stroke Response Team
Create a process that incorporates skilled and highly trained nurses to respond emergently to Code Stroke
Define a Team: Which Nurses?
• What works best for your hospital?
• Emergency response team?
• Emergency Room Nurses?
• Dedicated team?
-Nurses engaged with the population
-Accepting the challenge
• Who else?
Training the Team
• 8 hour RNCH approved class• NIHSS certification required• Alteplase competency• Critical Focus -Ongoing feedback -Special emphasis on ownership -Emergency medication access -Documentation -Action plans for Continuous Quality
Improvement
Stroke Response Team• Take Pride
• Celebrate successes
Acute Stroke Priorities
• Initiation of Code Stroke Protocol• Emergency Response• Rapid Assessment• Promotion of Goal Times to positively impact
patient outcomes– Neurologist Response Time– Head CT– Labs – EKG– Chest X-Ray– Ongoing Assessment– Door to lytic Therapy
• Stroke Response Nurses to identify variability of recording
• Discuss potential solutions at monthly meetings (stroke log, NIHSS, etc.)
• Review and discuss ALL documentation• Brainstorm- How do we enforce consistent
documentation? • Plan collaborative discussions with physician groups
PLAN: Code Stroke Documentation and Data Collection
PLAN: Medication Access, labs, CT and supplies
• Collaborate with Pharmacy • Medication safety-process for accessing t-PA• Alteplase 100mg/100ml vial secure • Labetolol 50mg/50ml vial secure or other anti-
hypertensive drugs• Policy and quality check for response equipment
and supplies• Collaborate with Lab - readily identify Stroke labs• Coordinate with CT Radiology
DO: Code Stroke Documentation-Log & Recording Sheet
• Code Stroke Log to reflect a collaborative approach to plan
• Code Stroke Log to include reason why lytics not given
• Develop Code Stroke Recording sheet that fits your facility needs
• Input from all members
Code Stroke Log
Log: Quality Process Assessment
DO: Medication Access, labs, CT and supplies
Monitor Bag & Secure Medication Tag
Continuous Feedback
Because the TEAM owns the process- Continuous Quality Improvement is a part of
EVERY case and feedback
CHECK: Medication, documentation, feedback
• Medication process is successful ?• Location of documentation is centralized • TEAM agrees with approach• SRT nurses and others provide ongoing
feedback, especially with medication quality • Process changes made based on Quality
Improvement assessment• TEAM approves all changes
ACT: Review and Implement Opportunities for Improvment
• Transition phases
• Evaluate effectiveness of documentation via chart reviews (Stroke Coordinator, others)
• Encourage ongoing feedback from SRT group
• Discuss opportunities for Improvement at monthly meetings (include ED/EMS, Nurses, physicians, lab and CT personnel
ACT:Implement ED/EMS and Inpatient Action Plans
• Share ED/EMS action plans with SRT Nurse group and strategize- Why are we not meeting the Golden Hour?
• Provide immediate feedback for ALL Code Stroke cases identified with opportunities for improvement
• Continue to encourage collaboration between SRT nurses and physicians
• Highlight and recognize SRT nurses for accomplishments
Track Outliers
TEAM owns the process.
An outlier commonly impacting delay in lytic administration is BP control.
Another outlier- Obtaining consent
Pushing the envelope: Preventing outliers
EMS
PCMH Community
Hospitals
Patient
Access to Care
Best Practice
Regional Partnerships
TIME
IS BRAIN
Accepting the Challenge + Owning the Process= Success
While you consider the best approach for your hospital, your patients, your community- remember that neurons wait for no one.
Questions?