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Description : Check out this medical titled "Stroke Program Orientation for Medical Staff" by Stony Brook Medicine.

This medical talks about stroke (also known as a cerebrovascular accident). Stroke occurs when there is an interruption of blood flow to the brain. This can happen due to a blockage of a blood vessel in the brain (ischemic stroke) or the rupture of a blood vessel in the brain (hemorrhagic stroke).

Ischemic stroke is more common, accounting for about 85% of all strokes, and is typically caused by a blood clot that forms in an artery supplying blood to the brain. Hemorrhagic stroke, on the other hand, occurs when a weakened blood vessel in the brain ruptures and causes bleeding into the surrounding brain tissue.

The symptoms of a stroke can vary depending on which part of the brain is affected, but may include sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, sudden vision problems, severe headache, and loss of balance or coordination.

Stroke is a medical emergency and requires immediate treatment to prevent brain damage and potentially fatal complications. Treatment options may include medication to dissolve blood clots, surgery to repair ruptured blood vessels, and rehabilitation to help regain lost function and prevent future strokes.

Tags : Stroke, ischemic stroke, hemorrhagic stroke, medical emergency, Emergency Medicine, Emergency Medicine

Published on : Apr 14, 2023 | Views : 1485 | Downloads : 0

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Slide 1-

Stony Brook Medicine Comprehensive Stroke Program Stroke Program Orientation for Medical Staff
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Objectives: Familiarize with acute stroke response time targets Familiarize with the available acute stroke codes and call criteria - CODE BAT (Brain Attack Team) CODE CSI (Complex Stroke Intervention) Understand responsibilities of the primary team during an Inpatient CODE BAT Verbalize where to locate stroke-related clinical practice guidelines and protocols Familiarize with Joint Commission, New York State Department of Health and Stroke:Get-With-The-Guidelines core measures and quality requirements STROKE PROGRAM ORIENTATION – MEDICAL STAFF
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STROKE FACTS Each year, about 795,000 people experience a new or recurrent stroke Approximately 610,000 of these are first attacks 185,000 are recurrent attacks On average, every 40 seconds, someone in the United States has a stroke Stroke is a leading cause of serious long-term disability in the United States Stroke is the No. 5 cause of death in United States; 1 of every 19 deaths 87% of the stroke risk could be attributed to modifiable risk factors such as HTN, obesity, DM, HLD, and renal dysfunction; 47% could be attributed to behavioral risk factors such as smoking, sedentary lifestyle, and an unhealthy diet. Centers for Disease Control and Prevention website: Stroke Facts American Heart Association Heart Disease and Stroke Statistics—2021 Update
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Lacunar infarct - are small (<20 mm) infarcts in the distal distribution of deep penetrating vessels result from occlusion of one of the small penetrating end arteries result primarily from in situ microatheroma formation or lipohyalinosis (Ex: hypercoagulable state from cancer, antiphospholipid syndrome, Factor V Leiden, arterial dissection, vasculitis, fibromuscular dysplasia, Illicit Drug use, etc) Kleindorfer DO, et al 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: AHA/ASA. Stroke. 2021 Jul;52(7) Watershed infarct – are ischemic lesions which are situated along the border zones between the territories of two major arteries usually caused by hypoperfusion or decreased blood flow. STROKE FACTS
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The direct and indirect cost of stroke in the United States was $49.8 billion Common complications after stroke include both short-term complications such as seizures, DVT, PE, urinary infection, aspiration pneumonia, decubitus ulcers, and constipation and long-term sequelae, including pain syndromes, pseudobulbar affect, depression and anxiety, cognitive impairment and dementia, epilepsy, gait instability, and falls and fractures American Heart Association Heart Disease and Stroke Statistics—2021 Update STROKE FACTS
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ACUTE STROKE IS A MEDICAL EMERGENCY J.L.Saver, Time is Brain-Quantified, Stroke. 2006;37:263-266. TIME IS BRAIN
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Target Response Times: EMS recognition of stroke in the field → hospital pre-notification that a stroke patient is en route MD Evaluation: <10 minutes Stroke Team: < 15 minutes CT Initiation Time : <15 minutes Lab result : <45 minutes ; only the assessment of blood glucose level must precede the administration of IV alteplase or IV tenecteplase unless there is a suspicion of abnormal hematologic or coagulation test. IV thrombolytic administration : <45 minutes Mechanical Thrombectomy: First Pass : < 60 minutes for Transfers and Mobile Stroke Unit; < 90 minutes for patients presenting directly to Stony Brook ED ACUTE STROKE MANAGEMENT
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Rationale for rapid evaluation and treatment At the onset of stroke symptoms, the stroke is evolving Rapid clot lysis reperfuses ischemic tissue limiting the eventual size of the infarct Timely restoration of blood flow in ischemic stroke patients is effective in reducing long-term morbidity. ACUTE STROKE MANAGEMENT Ischemic Penumbra brain tissue at risk of progressing to infarction but is still salvageable if re-perfused. generally located around an infarct core which represents the tissue which has already infarcted or is going to infarct regardless of reperfusion.
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Acute ischemic stroke treatment: IV thrombolytic for eligible acute ischemic stroke patients with last known well time up to 4.5 hours Alteplase (Activase) Tenecteplase (TNKase) for patients with who are also eligible for mechanical thrombectomy Mechanical thrombectomy for eligible patients with large vessel occlusion STROKE PROGRAM
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STROKE PROGRAM
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Stony Brook Em,ergency Departm,ent Acute Strok,e Teaim Activations ,. 'I ... ... Pathway#l Patient arrives to ED via EMS or walk In with AC71VE signs and or symproms of a stroke {Parioots wM remlvea symptoms wW fol/aw the T.IA parl1WfIJ1} . Triage stuff member performs and dowment5 LAMS +Speech 5co{:e ,. ""I ,. ,. ' Score<4 AND >6hours fmmlast known well at Srore<4AND 6hours from last known wefl at presentlltion presentation Score 4 AND 0-24 hours from last known well at presentation ... -' ... ... ' • --,, ""I ' Triage Nurse actNates CODE SAT Triage Nurse octJwttes CODECS/ ... ' NOCOOE .Notlfy MD '"pom,tia1stroke" MD may .aalvofe CODE SAT or .,- II IF APPROPRIATE \. r ""I , ,. --, Neurology responds :- f-----,"" 1/ ICH or LVO ls d/so:Jvered the dlrddtm will ac:tJvote I,,._ ... Iii,.. r to rapidly evaluate the patient forTPA and intervention ... Pathw:ay# 2 Patient Is transferred from another hospital With an lschemlc:stroke or spontaneou.s; non troumatk /m:t:fJCronJQI ge EMS natifies Stroke Neurolorn Resident and NeumS11rgei:,y PA/NP of the es.timam:t time of arrival. 11ie ptlng PbyslcJan or wlR notify EMS lf a CODE BAT orCODE est fs tobemHed,. ff QITf ls . on amvol and lf thepatient ·l'lfH bypm:, theED/w sulte \._ ' ,. "I EMS actlYates CODESAT TRANSFER" at1.0 minute ETA "' ... , II 1 .., .,) r Neurology, Neurosurgery and Cerebrovascular Team respond to rapidly evaluate the patient for intervention Pathway#3 An)IEDpatlent NCIT'pnvlousl,J asseSstM as part of a stroke ..C. ODE"" found to hove anew sponw non-traumatfc m tnxtanioJ heroormage \. Revi ewed: August .25, .20 .21
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Code BAT Activat ion or Code CSI Activation N@1ir o lo gy l!n rJ/m N@uros urgery resporKI Stm k@ Att @nd ing no1tl fi @d , g oal 5 15 mlnut:E:s To CCED if pati@nt n@eds to b@ stabil lize d' prlor 10C1H Labs, Drawn Mearnrnd w lght obtai ne d' for IV thromboliljtlc patl1mrs Et::G i f or d er ed, goal 5 45 minute s a, !!'St X- r ay If ordered, goal c5 45 m 1nut es CTIH/CTA/C11P l n iti atieel CTIHln l a,t lon, goa l 15 minutes CTM read , geal 5 3, 5 m i nut e I I / .., ,, ICH or SAi-i " LVO and' Ell gjbl @ for I V tllro m bol\ftlc i n, 0 4.Sh rs Call Code CSI if not Cod@ CSI pn! vlou sly No LVO and Eliglbl@ for IV throm bo lyt lc In 0-4.Shr:s Call Code C51 if not C.ode CSI previous.Iv \. --' 1 + \ I' -.,, LVO ;md Not Elfglbl e for IV th rom bol vt lc Call Code C5!1 i i not Code CS.1 pr@viou:sly . --' , I, /" " / RN mi)!l!s IV i enectep lase l!S ordered / ' Adinlnls[@r IV Tenoctepl.i!Se, go al ..,; 45. m lnu.tM Go fo r Interv enti on or admit to approprlat@ servlce ,md leve l of care \. Nor@: I V Alt@plai;e will b@ :m opt i o n for adm tnistr ,atl on ii' Ten@ct epl a,se Is not ava ll aibl e or aiS per St roll:@ Ammding d@ci slon bi!iSed on the d ln ica l si tuati on _,I RN mlx@s I V Al'l!e,p ase a:s ordernd Administer IV Alt@pl;;tse, goa l 5 45 ml nut!M .... J '- . eve Team tr ansf@r:s patl@nt to eve Suit @ for M E.R go al d oor&t o • dev l c@: ..,; 90 mfaut8 for dErecr ED arri v1ni ii at len ts o r ..,; 60 m,inu te,s. fo r MSU or transfers "- , , i Adm it to .appropriate service and level of care ,1 il StonyB1 k Medicine E1m ergency Depa rtmenit Code, BAT and Code CSI Process Flow Updated/Reviewed - Augu t 25, 2021 Wlilen mo t e th an onl!! p,at:iu t arr ive:s at the same time and fulflll th, e to d e BAT or Code CSI t:ri teria: file S!Tokl!-Att@ndIng tor ll ls/h 1M de l gM @J, I n co ll abor.i ti on wit h tll@ E.D Att ena ing Pll vslclan or N'@ur o.sur g @ry Attending are responsib!@ for o vers@e fng the d eclsi o,n m akl ng process for p rior i ti zing BJnd exp-editing BJ r .apld p rfm ary surv,!!'V; evaluaitlon ., st.i!bll Bi tl on, managem@nt, and treatm, t forsuspected acuU! stml::@/TIA p.rtri.nK u s[on r IBAT• BraIn Attack T@aim CSI - Cornpl@X Stroke lnt@rv @n ti on MER - Mechanl cal End 011a seu!ar R@perf LVO- Largl! Ve:ss@I Ord u l on Door-to -D ev c@ - ar rllv al to fi rst pass wit h th romh ea omy ae ce MSU - M obrle Stroke Unit ' U{WT - U!St known W@I I t Eme
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CTH Init i at ed goal :5a 25 rn imut es str etch goaI ::, 1 5 m inu t es CTH read goa l :Jo fo do11a oular lnte,rventi on l'ES E11dovasc111 l ar Interv ention l If going for ndo11am.1lar Interv enti on j Transfe r t o St ro ke Unit or IOU for fu rt her mc1n agem ent M an ageme nt per Pr im ary Tea m or t ransfer t o app ropriate l evel of ,ca re CVC Team ev<1I u <1t e s p ati en t P at ient t ra nsfer re dl to CVCS uite When the,ire is m or e t h an one Co de BAT callied sim ult an e0. 111s l y : T h e Stro ke Att en ding (or desi gneel in coll abor at ion w ith t h e Pr im ary Team are r esp on sib le for ove rse eing t he d eci.s.i on-m c1k i n g p ro ce ss. fo r p ri or iti zing and e x:p edit ing a rap id primary surve,y eva lu.i t i on, st abili z.itio n, ..,m_ anagem en, t and tr eatm en t for su sp ect ed acut e stroke pat ient s. BAT- Bra in At ta dk Team LKWT - Last Kno w n W e iI Time or last kn o w n t ime t o b e at b asel in e LVO - large Vessel Occlu 1sio n CVC - Cerebrov ascular Cen te r
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INPATIENT CODE BAT To help expedite inpatient Code BAT process: Primary Team Physician/NP/PA and/or Primary RN to stay at bedside to give SBAR to Stroke Team Ex: Pertinent PMH/hospital course, stroke symptoms, last known well time, symptoms discovery time, if patient is on anticoagulation, if recent surgery, pertinent lab result Obtain blood sugar level to rule-out hypoglycemia Make sure a working IV is in place, 2 IVs preferable Primary Team to order “CODE BAT CT Head w/o Contrast” STAT to rule-out ICH. If indicated, a STAT “CODE BAT CT Angio Head/ Neck with IV CON with Perfusion” will be ordered to evaluate vessels and perfusion. Connect patient to a portable cardiac monitor for transport, have oxygen available if needed Patient is transported to CT Scan by Primary Team Physician/NP/PA, ICU competent RN or Stroke ICR competent RN Notify CT staff if patient is en route to CT, if Code BAT is being cancelled or if there is delay in transporting patient For IV thrombolytic: Call the 13N charge nurse if IV thrombolytic is needed for an inpatient Code BAT in the original hospital building Call the NCCU/NICR charge nurse if IV thrombolytic is needed for an inpatient Code BAT in the new hospital pavilion The RNs in 13N and NCCU/NICR are competent in IV thrombolytic administration and monitoring during and after administration Collaborate with ADN if patient needs transfer to another service or higher level of care The ED may be contacted if additional assistance is needed for IV thrombolytic administration Note: Measured weight is needed for IV thrombolytic dosing
Slide 15-

JOINT COMMISSION: PRIMARY STROKE CORE MEASURES STK-1 VTE prophylaxis on the day of or the day after hospital admission. STK-2 Antithrombotic therapy at hospital discharge. STK-3 Anticoagulation for Atrial fibrillation/flutter at hospital discharge. STK-4 IV t-PA initiated at this hospital within 3 hours of time last known well. STK-5 Antithrombotic therapy by the end of hospital day 2. STK-6 Statin medication at hospital discharge. STK-8 Patient and/or caregiver stroke education: EMS Activation/calling 911, need for follow-up after discharge, medications prescribed at discharge, personal risk factors for stroke and warning signs and symptoms of stroke. STK-10 Rehabilitation services assessment LIPs must be mindful of the specific time period of the core measures for compliance. Reason(s) must be documented in the medical record why elements of the core measures were not implemented for the patient Example: No antithrombotic by hospital day 2 secondary to concern for bleeding. No statin on discharge due to patient refusal of statin recommendation.
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JOINT COMMISSION: COMPREHENSIVE STROKE CORE MEASURES CSTK 01 – Initial NIH Stroke Scale score CSTK 02 - Modified Rankin Score at 90 Days CSTK 03a - Severity Measurement Performed : Hunt and Hess Scale performed for SAH patients CSTK 03b – Severity Measurement Performed: ICH Score performed for ICH patients CSTK 04 - Procoagulant Reversal Agent Initiation for ICH patients CSTK 05a - Hemorrhagic Transformation for IV t-PA patients CSTK 05b - Hemorrhagic Transformation for IA t-PA and/or Endovascular Reperfusion Therapy patients CSTK 06 - Nimodipine Treatment Administered CSTK 07 - Median Time to Revascularization CSTK 08 - Thrombolysis in Cerebral Infarction (TICI) post-treatment reperfusion grade CSTK 09 - Arrival Time to Skin Puncture CSTK 10 - Modified Rankin Score at 90 Days CSTK 11 - Timeliness of Reperfusion: Arrival Time to TICI 2B or Higher CSTK 12 - Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher
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Additional Requirements for New York State and Stroke: Get-With-The- Guidelines: EMS pre-notification of a potential stroke patient with Last Known Well time and Stroke Scale Findings. Dysphagia Screen before being given any food, fluids, or medication by mouth RN or LIP completes bedside swallow evaluation using the Yale Swallow Protocol If indicated, formal swallow evaluation by Speech and Language Pathologist For patients who failed swallow evaluation and need to be on an antithrombotic: Consider ordering Aspirin Per Rectum or place NGT for patients who need Plavix (Clopidogrel), Brilinta (Ticagrelor) or oral anticoagulant Lipid profile HgbA1C NIH Stroke Scale at discharge modified Rankin Score at discharge Intensive statin therapy use: Lipitor (Atorvastatin) ≥ 40mg, Crestor (Rosuvastatin) ≥ 20mg Need documentation of reason if intensive statin dose is not considered/ordered at discharge Stroke-Diabetes measures: Diabetes Treatment (diet or medication, follow-up for diabetes management at discharge), Therapeutic lifestyle recommendation (diet, target BMI ≤ 25, increasing physical activity), antihyperglycemic medication with proven CVD benefit (GLP-1 receptor agonist or SGLT-2 inhibitor) Annual 8 hours of cerebrovascular-related continuing education for Physicians, NP, PAs and RNs taking care of stroke patients
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Check-out the Stroke Intranet Site in ThePulse. It contains the Stroke- related Clinical Practice Guidelines (CPGs), protocols, staff and patient resources. Click to review STROKE CLINICAL PRACTICE GUIDELINES
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STROKE CLINICAL PRACTICE GUIDELINES Guidelines for the early management of patients with acute ischemic stroke 2019 update (AHA/ASA 2019) Guidelines for the management of spontaneous ICH (AHA/ASA, 2015) Guideline for reversal of antithrombotic in intracranial hemorrhage (NCS,2015) Guidelines for prevention of stroke in patients with stroke and TIA (AHA/ASA 2021) Guidelines for adult stroke rehabilitation and recovery (AHA/ASA 2016) Guidelines for the management of patients with unruptured intracranial aneurysms (AHA/ASA, 2015) Guidelines for the management of aneurysmal SAH (AHA/ASA, 2012) Guidelines for the acute treatment of cerebral edema in neurocritical care patients (NCS 2020) Guidelines on the management of patients with extracranial carotid and vertebral artery disease (AHA/ASA, 2011) Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease (Society for Vascular Surgery, 2011) The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures (Society for Vascular Surgery, 2018)
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Dispatched by Suffolk County EMS/911 Assessment on scene CC ED RN, Paramedic, Neurologist-telemedicine Imaging on scene immediately sent to PACS CT Head to see bleeding/stroke CTA Head to see vessel occlusion Treatment provided en route IV thrombolytic for eligible patients KCentra for bleeding due to anticoagulant Critical Care medicines and equipment for blood pressure and airway emergencies Disposition to the appropriate hospital coordinated by Stony Brook EMS Stony Brook or nearest Comprehensive Stroke Center for complex stroke: ICH/SAH Large Vessel Occlusion requiring mechanical thrombectomy Nearest Primary Stroke Center for non- interventional stroke care MOBILE STROKE UNIT (MSU) LIE Exit 57 MSU #1 LIE Exit 68 MSU #2
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Stroke Support Group Receive encouragement, feedback and inspiration. Gain knowledge. Learn about helpful programs and resources. Open to all stroke survivors, family members and caregivers. Stroke Caregiver Support Group - Meets the second Tuesday of every month, 7pm-8pm Stroke Survivor Support Group - Meets the last Tuesday of every Month, 7pm-8pm For more information, contact: Tel: (631) 638-2638 Email: marret.anderson@stonybrookmedicine.edu, anne.froehlich@stonybrookmedicine.edu Brain Aneurysm/ Arteriovenous Malformations (AVM) Support Group This support group is co-sponsored by Stony Brook Medicine and the Brain Aneurysm Foundation. Meets: Third Monday of each month (no meetings in July and August) Time: 6PM to 7:30 PM For more information, contact: Tel: (631) 444-8121 Email: dawn.madigan@stonybrookmedicine.edu SUPPORT GROUPS
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Thank you for all you do everyday for our stroke patients. For questions, contact: Dr. Michael Guido Stroke Program Medical Director michael.guido@stonybrookmedicine.edu Antonieta Rosenberg Nurse Practitioner - Stroke Service Antonieta.Rosenberg@stonybrookmedicine.edu Anne Froehlich Stroke Program Coordinator anne.froehlich@stonybrookmedicine.edu