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Stroke in the Rural Setting: How You Can Make A Difference. Susie Fisher, RN, BSN Program Manager Providence Stroke Center Portland, OR

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Stroke in the Rural Setting: How You Can Make A Difference. Susie Fisher, RN, BSNProgram ManagerProvidence Stroke CenterPortland, OR

Presenter
Presentation Notes
It’s hard for me to understand who wouldn’t want to live here, I’m a native Oregonian and I love how unique every corner of our state is. So how can we love living in every corner of our state and provide the best stroke care we possibly can?
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State StatisticsThe Oregon ProblemTime & TreatmentsSteps to Making a DifferenceThe FutureResources

Outline

Presenter
Presentation Notes
Today, I’ll be covering…
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•Third leading cause of death•Leading cause of adult disability•Leading diagnosis from hospital to LTC•$181 million…total cost of stroke hospitalizations in 2006 (OR)•OR 5th highest stroke death rate

Presenter
Presentation Notes
First, let’s go through some of the national and state stroke statistics… most of us may know: In addition, OR is ranked 5th in the nation for stroke mortality, no clear reason why at this time. Research is underway. In
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Presenter
Presentation Notes
This is a great mapping project done in 07 by the AHA/ASA. You can see the population density along with self reported hospital designations. Joint Commission Primary Stroke Centers in OR include: PSV, PPMC, Legacy Good Samaritan, Legacy Meridian Park, Sacred Heart Eugene, Rogue Valley Medford. Those in yellow report they are acute stroke capable (have protocols). So if you look at this map all PSC’s are on the I-5 corridor which adds to some of the barriers for rural stroke care.
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Presenter
Presentation Notes
From this slide we can see that the Highest stroke death rates are clustered in North Central Oregon and along lower Columbia River
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Presenter
Presentation Notes
A project done in 2008 by the NW Regional Stroke Network does a nice job of visualizing the service areas within a 90 min R/T air radius and PSC’s in OR.. Again showing a vast area of OR with more challenges for expert stroke care
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Presenter
Presentation Notes
So, herein lies one of the biggest problems for stroke care in OR… the vast beauty and land, a quality so many of us love, and the challenge that places on stroke care.
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Problem……

Small rural hospital Oregon (Oct. 2008) :Want to give most up to date stroke careLimited resources:

Not a Primary Stroke CenterNo Neurology coverage Limited N. Surgery, pharmacy, radiology, Hospitalist coverageLimited knowledge of tPA / specialty care

“How can we better serve our patients?”

Presenter
Presentation Notes
This was a call to me last year, and seems to reflect the concerns of so many rural providers I talk to… wanting to do the right thing but not knowing a) what exactly is the right thing? b) how to go about it?
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Stroke Treatment in Rural Oregon

Local treatment is necessary due to Time dependent therapy and long distances between people and tertiary facilities capable and experienced with treatmentMinimum requirements for administering thrombolytic therapy are:

CT scanner 24/7

EMS Protocol for expediting transport & pre-notification

Acute care/t-PA protocol

Presenter
Presentation Notes
We need to start with our local site, our own resources and move out from there… to ensure we are doing the Right thing, at the right place at the right time. As we move through this, rest assured I will leave you with links to resources that there is not time to put into this presentation, including protocols for hospitals with and without CT scanners.
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In the US only 4% stroke patients receive the only FDA approved treatment for acute stroke

Patients don’t often recognize their symptoms as stroke and don’t understand the need to seek emergent care via 911Primary providers have very little training or experience in treating stroke patients let alone use of t-PANeurologists are in short supply and clustered in urban areasUntil recently there was no economic incentive to treat acute stroke

Presenter
Presentation Notes
There is so much that can be done to treat or lessen the effects of a stroke if patients can recognize the symptoms, get in early to the right place where protocols will provide the most optimal outcome.
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Stroke Treatment..(Ischemic)

t-PA approved in 1996… ONLY APPROVED MEDICATIONMust be given w/in 3 hrs of onset (last normal)

Requires neurological expertise, urgent CT scanningPROTOCOL necessaryPrimary Stroke Centers

Protocols, experts, guidelines, registries, data, quality improvement, outcomes

Presenter
Presentation Notes
So, much of what we’re talking about today is treatment for ISCHEMIC stroke… the “clot” kinds of stroke vs. the hemorrhage kinds of strokes to put it simply. tPA is Tissue Plasminogen Activator. Neuro expertise b/c must be given correctly to the right patient, high risk for bleeding. PSC’s are your resources,,approved by TJC they have….
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Oregon, 2009TJC certified Primary Stroke Centers

Providence St. Vincent’s, 2004Legacy Good Samaritan, 2004Legacy Meridian Park, 2004Providence Portland, 2005Rogue Valley (Medford), 2006OHSU, 2007Sacred Heart (Eugene), 2008

*24/7 Comprehensive Capability

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Treatment Options / ComprehensiveStroke Centers

IV t-PAIntra-arterial t-PAIntra-arterial devices

(up to 8 hr window)Clinical Trials

Drugs and devicesHypothermia

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Rural Oregon… the beauty and the challenge.

Presenter
Presentation Notes
All of those wonderful treatments are great… but look where we are! Thus, the challenge.
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Making a difference in your hospital & community…YOU CAN:

Find a clinical championRecruit administrative supportAssess resources (Pharmacy, Radiology, Lab, etc)

Develop protocols (ED & in-patient)Work closely with first respondersRelationship with experts for advice / transferEDUCATE staffEducate communityQuality review processes

Presenter
Presentation Notes
The challenge is not without hope and options a lot of what will lead to the best outcome for your patient is solid, guideline driven in-patient protocols.
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Pre-Hospital Stroke Care

Scoop and go! Pre-notify Hospital

Presenter
Presentation Notes
We really encourage pre-hospital EMS to have stroke protocols that are quick and easy, to scoop and go, the process needs to be aligned as much as possible with acute MI processes.
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Presenter
Presentation Notes
The Montana Stroke Network is a great resource for all rural hospitals, their website is included in the resources as the end. This is an example of a quick stroke scale EMS can use utilizing the Cin. Stroke Scale
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Neurological Assessment Patient With Stroke-Like Symptoms

Exam elements:Level of consciousnessPupils and gazeArm and leg motor exam

strength and overall coordinationFacial symmetry and smile effortSpeech and understanding

Slurred speechClear but nonsensical speechProblems understanding simple commands

Must be quick and simple

Presenter
Presentation Notes
This slide contains animations that can be advanced by clicking your mouse.
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The Emergency Room

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Presenter
Presentation Notes
Along with a standardized order set, a nursing care plan is helpful to maintain the timelines and processes
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Presenter
Presentation Notes
The NIH SS is the neuro specific exam for stroke patients that is a proven indicatin of stroke severity. It often drives decision making by stroke experts. Scored from lower to higher (worse) this version is the modified NIHSS. We are conducting research on a NIHSS in PE to simplify the neuro specific wording to increase accuracy for those who don’t use the tool frequently. Stay tuned
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Beware!Common errors to avoid….

Blood PressureDo not treat elevated blood pressure unless > 220 systolic or, diastolic > 115Treating with t-PA must be below 185/110 The brain needs the perfusion, can worsen stroke if lower blood pressure too low

IV FluidsAvoid glucose containing solutionsCorrect hypotension and volume deficits from dehydration otherwise run fluids TKO

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STAT Non-Contrast Head CT

Two pts both present w/ L sided weakness:A. Ischemic stroke R. hemisphere – not yet visibleB. R. hemispheric intracerebral hemorrrhage

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tPA Administration Considerations

Must be started before 3 hours from onset (last normal)No blood on head CTReview patient’s history for other risk factorsAccurate inclusion / exclusionRecord weightBP less than 185/110 to treat

http://www2.massgeneral.org/stopstroke/protocolThromIVAdmin.aspx

Presenter
Presentation Notes
BP treatment labatolol 10-20 mg IV over 1-2 min., may repeat x1 or nirtropaste 1-2 in. Patient should not receive tPA if treatment fails
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Hemorrhage SuspectedSTOP TPA INFUSION, call MD immediatelyStat head CT without contrastDraw blood for PT, PTT, plt ct, fibrinogen, and type and holdPrepare for administration of cryo and or platelets

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Drip and Ship?

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Remote Expert Options:

503-494-9000 Future?

< OR >

Phone Consultation

Bring the expert to you viaTelestroke

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Other Treatment Options for Ischemic Strokes

If symptom onset is greater than 3 hrs ~consider up to 8 hrs:

Interventions (IA, Merci, stenting) Clinical Trials

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Treatment Cont…If not a tPA candidate, ASA in ED. Rectal ASA if fails swallow eval. or if swallow eval. not complete. Keep NPO, until a formal swallow eval. is done.Admit as Inpatient and perform diagnostic testing: Carotid US, Echo, TEE, ECG monitoring for a-fib, MRI, fasting Lipid, Clotting disorder blood work (Antiphospholipid, Factor V, Antithrombin III)Rehabilitation

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Presenter
Presentation Notes
Hopefully pts npo up until this point… you can’t tell by NIHSS or looking if someone has compromised swallow. One of the best ways to prevent complicatons, asp. Pneumonia, is to do a BSS. Not time consuming and can save a life
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In-patient ConsiderationsNursing Issues

Started on stroke prevention medications (antithrombotic within 48 hr)?Clinical pathway followed?Blood pressure within appropriate parameters (Mean 100) Know signs of suspected Intracranial Hemorrhage and actions to take (change in LOC?)DVT prophylaxis addressed by day 2? Compression Devices/Lovenox/heparin SQ per ordersTherapies seeing patient? Review PT/OT/ST recommendations

Presenter
Presentation Notes
BP unless heart is at risk, no acute treatment is needed. If BP is normal can increase blockage and worsen stroke, maximize blood flow and minimize damage. Turn q 2, elevate paralytic extrem, avoid IV in paralytic arm
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Inpatient Cont…

IV fluids (Normal Saline or LR)?Nutrition? Dietary evaluation. Assistive devices for feeding. SWALLOW SCREEN DONE? Fever? Treat if greater than 99 F with TylenolBlood glucose within appropriate parameters? Obtain sliding scale if necessary.Positioning? Pillows under affected limbs. Turn Q2hours. Accommodate limitationsRehab consults as soon as possible, if needed

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Hemorrhagic Stroke Treatment

Do not give antithrombotics or anticoagulantsMonitor and treat blood pressure greater than 150/105 (Table 6, 2005 Guidelines update)NPO, until swallow eval is completedAnticipate Neurosurgical consultPossible administration of blood products

Presenter
Presentation Notes
BP treatment - nipride
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Stroke‐ready Dispatch and EMS personnel Clear routing to stroke‐ready hospitalsStroke‐ready ED’s/hospitals/transfer systemsResponsive ED/stroke care teamInterdisciplinary, regional or state‐wide team to develop all of the above

The ideal stroke system interface

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Small rural hospital SE Oregon..Scenario #2… future

Providers will be educated on diagnosis and stroke optionsWill call experts for advise ASAPMay treat with tPA at rural hospitalPatient will be rapidly transferred to appropriate Primary / Comprehensive Stroke Center for treatment and/or further care.Inpatient protocols to guide best care

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Building the Oregon Stroke System of Care: Connecting Rural and Urban Populations to Improve Outcomes

Third Annual Meeting of the Oregon Stroke Network In Collaboration with Oregon EMS & Trauma Systems ProgramOctober 23, 2009Riverhouse Resort, Bend, OR

Information will be posted on the Office ofRural Health website

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Resources

Providence Stroke Center, www.providence.org/[email protected] 503-216-1011

Montana Stroke Network, www.montanastroke.org (rural protocols/templates)

2008 Hospital Survey conducted by Heart Disease and Stroke Prevention Program with the Hospital association: http://www.oregon.gov/DHS/ph/hdsp/docs/hospcapacityrpt0929.pdf2008

Northwest Regional Stroke Network Burden Report http://www.doh.wa.gov/cfh/NWR-Stroke-Network/publications/NWRSN-Burden-Doc.pdf

2007 EMS survey conducted by the Heart Disease and Stroke Prevention Program and the AHA/ASA

http://www.oregon.gov/DHS/ph/hdsp/docs/emssurvey07.pdf

Heart Disease and Stroke Prevention Program data and data related reports are at: http://www.oregon.gov/DHS/ph/hdsp/pubs.shtml

http://www.providence.org/stroke
mailto:[email protected]
http://www.montanastroke.org/
http://www.oregon.gov/DHS/ph/hdsp/docs/hospcapacityrpt0929.pdf
http://www.doh.wa.gov/cfh/NWR-Stroke-Network/publications/NWRSN-Burden-Doc.pdf
http://www.doh.wa.gov/cfh/NWR-Stroke-Network/publications/NWRSN-Burden-Doc.pdf
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Oregon State Stroke System of Care(Recommendations for the American Stroke Association’s Establishment of Stroke Systems of Care can be found at http://stroke.ahajournals.org/cgi/content/full/36/3/690)opportunities for your hospitals to get involved with1. Oregon Stroke Network:

• Steering Committee, • Symposium Planning Committee• Delivery of Care- EMS Subcommittee• Data/Quality Improvement/ Surveillance Subcommittee: TBD

2. NWRSN:http://www.doh.wa.gov/cfh/NWR-Stroke-Network/default.htm3. Annual OR Stroke Symposium in October, Bend 20094. Get With The Guidelines: Stroke5. Stroke Camp for Families living with Aphasia6. Telemedicine/ Telehealth: Oregon Health Network (in development)

http://stroke.ahajournals.org/cgi/content/full/36/3/690
http://www.doh.wa.gov/cfh/NWR-Stroke-Network/default.htm

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