Stroke Alert at Lutheran Stroke Alert at Lutheran General Hospital, General Hospital,

Park Ridge, ILPark Ridge, IL

Lynn Michel, RN, MSN, APN / CNSLynn Michel, RN, MSN, APN / CNS

Stroke AlertStroke Alert Stroke Alert started on 01/01/07Stroke Alert started on 01/01/07 700 bed suburban teaching hospital700 bed suburban teaching hospital Level I Trauma CenterLevel I Trauma Center

Pre-Stroke AlertPre-Stroke Alert

Emergency roomEmergency room

Patient triaged as Patient triaged as priority 3 or 4 / 5priority 3 or 4 / 5

CT ordered along with CT ordered along with other “stat” ER ordersother “stat” ER orders

In-House patientsIn-House patients

Physician notified of Physician notified of patients change in patients change in conditioncondition

CT if ordered was CT if ordered was ordered “stat”ordered “stat”

Neurology consult if Neurology consult if orderedordered

Why do a Stroke Alert?Why do a Stroke Alert?

As a Primary Stroke Center we wanted to As a Primary Stroke Center we wanted to have a process in place to:have a process in place to:

Expedite the assessment and treatment of Expedite the assessment and treatment of patients experiencing stroke symptoms.patients experiencing stroke symptoms.

To decrease the “Door to CT time” to 25 To decrease the “Door to CT time” to 25 minutes or less for minutes or less for ERER and and inpatients inpatients experiencing stroke symptoms less than 3 experiencing stroke symptoms less than 3 hours in durationhours in duration

Why is a Stroke Alert important?Why is a Stroke Alert important?

tPA can reverse an Acute tPA can reverse an Acute IschemicIschemic Stroke Stroke but must be given within 3 hours of but must be given within 3 hours of symptom onsetsymptom onset Interventional procedures now availableInterventional procedures now available

Hemorrhagic strokeHemorrhagic stroke is also an emergency is also an emergency and may require surgical intervention.and may require surgical intervention.

Hemorrhagic Stroke Hemorrhagic Stroke

10-15% of all strokes… 37,000 to 52,400 new 10-15% of all strokes… 37,000 to 52,400 new cases / yearcases / year

Incidence: 15 per 100,000 individuals / yearIncidence: 15 per 100,000 individuals / year Rate expected to double by 2050Rate expected to double by 2050 African-American and Japanese: incidence is African-American and Japanese: incidence is

twofold than in Caucasianstwofold than in Caucasians 35 to 52% 1 month mortality35 to 52% 1 month mortality Only 20% were living independently by 6 monthsOnly 20% were living independently by 6 months

The beginning….6 months prior The beginning….6 months prior to startingto starting

Stroke CoordinatorStroke CoordinatorStroke Team NeurologistStroke Team NeurologistED Medical DirectorED Medical DirectorCritical care directorCritical care directorHospital OperatorHospital Operator

Stroke AlertStroke Alert Based on the “Code Yellow” and “Cath Based on the “Code Yellow” and “Cath

Lab Alert”Lab Alert”

We chose to call it “Stroke Alert” and We chose to call it “Stroke Alert” and not another “coded name”not another “coded name”

This increases awareness to staff and This increases awareness to staff and lay people that stroke is an emergencylay people that stroke is an emergency

What we needed:What we needed:•Provide rapid diagnosis and treatment of stroke. (RRT for inpatients)

•Written protocols (time frame) for assessment and treatment. (RRT)

•CT to get a scanner prepared•tPA if appropriate (tPA on call list)•Neuro-Surgery if appropriate

Nursing ConsiderationsNursing Considerations Call x 213333 and report that you have Call x 213333 and report that you have

a “Stroke Alert”a “Stroke Alert”

The operator will pageThe operator will page “ “Stroke Alert…and unit name”Stroke Alert…and unit name” or “Stroke Alert…ER” or “Stroke Alert…ER”

RRT will be paged and respond to in-RRT will be paged and respond to in-house strokeshouse strokes

Nursing considerationsNursing considerations CT department will get a CT scanner CT department will get a CT scanner

ready for the patient.ready for the patient.

Nurse can call RRT first who then will Nurse can call RRT first who then will assess and call the “Stroke Alert”assess and call the “Stroke Alert”

Stroke Alert 1 year laterStroke Alert 1 year later

How many?How many?

196 stroke alerts in 196 stroke alerts in 20072007

11stst quarter of 2007 quarter of 2007 5757

11stst quarter of 2008 quarter of 2008 5353

Where do the Stroke Alerts Where do the Stroke Alerts Happen at LGH?Happen at LGH?

Stroke Alerts by Location

Inpatient, 23%

ER 77%

What inpatient units?

0

5

10

15

20

25

30

1

Inpatient Units

Nu

mb

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of

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ok

e A

lert

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Telemetry

Medical

Orthopedics

Surgical

Stepdown ICU

Rehab

Behavior health

Inpatients CT timesInpatients CT times

Inpatients CT times

0

10

20

30

40

Time frame

Series1 34 28

1 2

2007 2008

Door to CT times for ER patientsDoor to CT times for ER patients

2006

2007

0

5

10

15

20

25

30

35

40

45

50

1 2

Min

ute

s

The use of tPA increased by 64% The use of tPA increased by 64% in the ERin the ER

tPA given

2006

2007

0

5

10

15

20

1

Nu

mb

er

of

pa

tie

nts

Lessons learnedLessons learned

Pharmacy became involved to start the tPA Pharmacy became involved to start the tPA checklistchecklist

There was “over calling” in the beginningThere was “over calling” in the beginning

Need to orient new personnelNeed to orient new personnel

Need to change time criteria to reflect IA tPA Need to change time criteria to reflect IA tPA and research study time framesand research study time frames

Barriers 1 year outBarriers 1 year out

MYTHS:MYTHS:

Physicians and nurses Physicians and nurses believe that Stroke Alert believe that Stroke Alert is only for those patients is only for those patients who qualify for tPAwho qualify for tPA

TRUTHTRUTH

10-15% of all strokes are 10-15% of all strokes are hemorrhagic which also hemorrhagic which also need emergency need emergency treatment treatment

LGH has a stroke LGH has a stroke research project for research project for ischemic stroke patients ischemic stroke patients who don’t qualify for tPAwho don’t qualify for tPA

Questions?Questions?