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Dripping and Shipping
Theda Clark Medical Center
Appleton Medical Center
Sheila Barr, RN
Kristin Randall, RN
Stroke Program Coordinators
Objectives
• To understand the coordination of care between referring hospitals and primary stroke centers.
• To develop relationships with referral hospitals in administering tPA
• To develop teamwork philosophy with referral hospitals
Theda Care System
• 4 - Hospitals
• 17 - Family and Internal Medicine Clinics
• 1 - Fast Care location open 7 days a week
Theda Clark Medical CenterNeenah, WI
• Primary Stroke Center since 2004
• 250 licensed beds• One of the largest
acute care facilities in the area
• Level 2 Trauma Center
• Theda Star
The Stroke Team
• Emergency Room • EMS• Neurology• Neurosurgery• Radiology• Neuroradiology• Stroke Unit
• Physiatry• Physical, Occupational
and Speech Therapy• Rehabilitation Unit• Transitional Rehab• Outpatient Rehab• Stroke Coordinators
Appleton Medical CenterAppleton, WI
• 160 Beds• Specialty oncology
and cardiac • Sister hospital with
Theda Clark Medical Center
• Together they provide coordinated specialty care
New London Medical Center&
Riverside Medical Center - Waupaca, WI
• Small rural community hospitals
• Both provide general acute care
Referrals to the Stroke Center
• Appleton Medical Center
– Sent 56 patients from their ED to the Stroke Center
– tPA cases - 3
• New London Medical Center
– Sent 24 patients from their ED to the Stroke Center
– tPA cases - 1
• Riverside Medical Center
– Sent 12 stroke patients from their ED to the Stroke Center
– tPA cases - 2
Rhinelander
Manitowoc
Green Bay
Marinette
Oshkosh
Fond du Lac Waupun
New London
Shawano
Waupaca
Wild Rose
Chilton
Antigo Langlade
AppletonBerlin
The referral process….AMC to Theda Clark
• Patient presents to the hospital
• ED triage nurse/EMS documents stroke symptoms and determines the time of onset.
• Acute CVA worksheet initiated for those presenting within 8 hours of onset of symptoms.
Acute CVA worksheet
• Code Stroke ER\Code Stroke Worksheet.doc
tPA Candidate
• ED physician consults with neurologist.
• Standard tPA Orders• Neurologist will order
tPA dosage – Dosages:
• 0.9 mg/kg
• 0.6 mg/kg
• Max dose is 90 mg
tPA is a go…….
• STAT Labs: BMET, CBC, PT, PTT
• EKG• Vital Signs every 15
minutes until infusion completed
• 2 IV sites established
tPA Candidates
• Nationally only 1-6 % of stroke patients arrive to the hospital in time to be considered for tPA!
• Theda Clark has a 5% rate of patients that received tPA.
tPA started…
• Order is sent to the pharmacy where is it dosed and mixed.
• RN administers the tPA– 10% as a bolus over 1
minute
– Remaining infused over an hour
Thrombolytic Precautions
• Strict bedrest for 24 hours
• Draw labs from capped IV – waste 8 mL blood first
• Keep all dressings on for 24 hours
• No heparin, aspirin, Coumadin, or other antiplatelets or anticoagulants for the first 24 hours after tPA
• Guiac all stool for occult blood
• Place Thrombolytic Precaution Sign over patient’s bed
The Decision to transfer
• The ED Physician and Neurologist talk…..– Neurologist recommends that the patient be
transferred to the Stroke Center– Patient/family must agree to transfer– Transfer process is initiated by ED RN
Stroke Center here we come!!!
• Other treatment options for Ischemic Strokes– Intra-arterial tPA– MERCI Retrieval Device
Modes of transfer
• Theda Star Air medical staffed by RNs
• Ambulance
Transfer Process
• RN contacts EMS for a STAT transfer.
• Our Theda Star dispatch can help assist with making arrangements if the helicopter is needed.
• If tPA is completed, patient sent in ambulance with EMS personnel
• If tPA still infusing, an RN will ride along
Transfer process continue
• The stroke center is notified of admission of a stroke patient.
• Placement is determined by patient’s status: ICU vs Intermediate Neuro Unit
• Report is called over to the admitting RN
• Direct Admit to their room
Where do we go from here?
• In the process of developing a feedback letter to our referring hospitals to acknowledge accomplishments.
• We involve quality improvement when necessary.
• Moving towards a system wide electronic medical record
Billing
• Emergency Department Bill + MD Charges– If tPA started – ED bills for the charge
• Transfer Bill (EMS or Theda Star)
• Theda Clark Hospital Bill + MD Charges
Admission to the Stroke Center
• Established standing orders
• Mild, moderate, severe stroke pathways
• Testing: MRI/MRA, labs, TEE, ECHO
Carotid Ultrasound
• Therapies: OT, PT, Speech
January
Febru
ary
Marc
h
April
May
June
July
August
Septe
mber
Octo
ber
Novem
ber
Decem
ber
100-250 Bed HospitalCertified JC PSC Hospitals
0%
10%
20%
30%
40%
50%
60%
70%
IV tPA withing 2 Hours
100-250 Bed Hospital Certified JC PSC Hospitals
Any Questions…..
•Thank You!
Contact Information:Sheila Barr or Kristin RandallTheda Clark Medical Center
130 Second Street Neenah, WI 54956(920)720-7328
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