Anne Anderson, RN BSNStroke Program Coordinator

Logan Regional Hospital

Best Practice TeleStroke-Door to Needle

TeleStroke Facility Request per Year

Door to Needle Time Logan Regional 2017

Intermountain Care Process Model: Emergency Management

of Acute Ischemic stroke

GOALS< 10 min from ED arrival to seen by MD

< 15 min from ED arrival to telestrokeactivation

< 25min from ED arrival to imaging

< 45 min from ED arrival to completion of labs and imaging evaluation

< 60 min from ED arrival to treatment

Goal: < 10 min ED Arrival to Seen by MD

• First Five

• BEFAST-Stroke Alert Activation Criteria

• Stroke Alert “time out”

First Five

Goals:

• Decrease door to seen & order time

• Decrease overall length of stay

• Have patient give one H&P

• Have MD get the FIRST H&P (more accurate)

• Increase confidence patients have in the healthcare team

• Consistency between all providers and RNs

Changed average door to doctor time to 4 minutes

Developed for Logan Regional Emergency Department by Matthew Harris, MD, Liz Pedersen RN-MSN, and Jacob Sanderson, RN-MSN, CCRN

t

Registration

1-2 min

Communication

Registration to TN/CN

that there is a new Pt

Tha

Pt taken to

room by

TN/CN/RN

Communication

TN/CN broadcast

“New Pt. Room ____”

Tha

Communication

TN/CN broadcast

“New Pt. Rapid Alert

Room ____”

Tha

MD

replies

Communication “Room____ Copy”

MD is in route to Room

Communication “Room ____ Go”

If delay in MD is expected

Allergies & Weight

saved in T1 by TN

Allergies & Weight

saved in T1 by TN

Communication

TN Calls and assigns

RN directly

Tha

Same pts we

would call

for MD Stat

to the room

Triage RN

leaves room

Triage RN

leaves room

Page 1

Primary RN Completes: *VS *T1 *T2

Pt placed in a gown UA obtained

*MD obtains H&P

*MD leaves room

*MD Places orders

RN completes Orders

RN Enters Room

*MD Enters Room

*MD obtains H&P

*MD may directs RN

to obtain VS

*MD leaves room

*MD Places orders

Primary RN enters

room

Pt placed in a gown UA obtained

Primary RN Completes *VS *T1 *T2

RN completes Orders

MD and PA enters

room

Page 2

Registration All rooms in the

back are full

Communication

Registration to TN/CN

that there is a new Pt

Tha

Pt taken to

Triage room 1

by TN

Triage RN Completes *VS *T1 *T2

Places Pt back into the waiting room

A Room in the ER opens. Triage nurse

takes the highest acuity pt to that room.

Communication

TN/CN broadcast

“New Pt. Room ____”

Tha

MD

replies

Communication “Room____ Copy”

MD is in route to Room

Communication

TN Calls and assigns

RN directly

Communication “Room ____ Go”

If delay in MD is expected

RED Status

BEFAST-STROKE ALERT CRITERIA BALANCE

Sudden loss of balance

Sudden ataxia in the arm or leg

EYES

Sudden double vision

Sudden visual field cut

FACE

Sudden facial droop

ARMS

Sudden weakness of the arm or leg

SPEECH

Sudden slurred or garbled speech

TIME

Last seen normal within 6 hours

*Call stroke alert for any ONE symptom PLUS last seen normal <6hours

*RN broadcast on vocera “stroke alert room ___”

*Physician leads a Stroke Alert “time out” confirming STROKE ALERT and LKW (in military time)

*RN orders Stroke/TIA PRG (order set) in iCentra once confirmed by physician

*RN call “CT tech” on vocera to facilitate CT head

BEFAST-Stroke Alert Activation Criteria

• Initiated by triage RN

• HUC calls operator to page Stroke Alert:

CT tech

Phlebotomy

Stroke Coordinator

• Confirmed by physician during “time out”

• Criteria posted in department:

Nursing Station

Critical care rooms 1-6

Triage room

Stroke Alert Binder

Stroke Alert “Time Out”

• Physician ABC exam/NIH stroke screen

• Nails down the LAST KNOWN WELL time

• Physician states clearly to the team:

“This is a Stroke Alert”

“Last known well time is 18:15” (military time)

• Nurse on computer enters iCentraNeuro/Stroke TIA PRG

• White board information in every room

Goal: <15 min From ED Arrival to TeleStroke Activation• TeleStroke activated BY PHYSICIAN BEFORE patient goes to CT

Goal < 25 min ED Arrival to Imaging

• RN calls CT tech directly on Vocera

• RN accompanies patient to CT scan

• 1:1 nursing care

• RN returns patient to ED and finishes orders and prepares for telestrokecamera exam

Goal <60 min ED Arrival to Treatment Time

• Telestroke/Reference guide for RN

• Stroke Alert Binder

• tPA ordered with iCentra Stoke AlteplasePRG

• Alteplase dosing based on Intermountain charts included with stroke box

• MIX the tPA!

• ED RNs mix and administer tPA

• Confirm dosing on Vocera with pharmacist

Challenges in Reaching DTN Goals

• Telestroke equipment problems

• Staff communication

• Education/skill retention

• ED physician culture

Equipment Problems &Communication

• Technical problems get reported in real time.

• HUC and RN documentation (*disclaimer on form: not a part of medical record)

• Gather physician “time out” tracking information

Stroke Alert Documentation HEALTH UNIT COORDINATOR

Prehospital notification? YES/NO Mode of Arrival: _____________________

Arrival date and time: _____________________

Patient’s Last Known Well (LKW) date and time: ___________________

Time Stroke Alert called: ____________________

Time TELESTROKE activated by ED physician: ________________ (use N/A if not activated)

LKW stated to clerk by ED physician with TELESTROKE activation? YES/NO

Telestroke neurologist camera exam? YES/NO

Any Telestroke equipment problems? YES/NO IF YES, please report problem to IT at 6-3456 and state problem below:

Problem: __________________________________________________________________________________

IT ticket Number: ___________________

Stroke Alert Physician Name Time Paged Time Responded

Telestroke physician

Neurologist

Neurosurgeon

Radiologist

Other physician

Other physician *please also document ALL of this table of information in iCentra using STOKE ALERT form in Ad Hoc forms.

Transfer to NON-Intermountain facility? YES/NO IF YES, state why: __________________________________________

Triage RN________________________________

Charge RN _______________________________

Primary RN_______________________________

HUC____________________________________

PRIMARY NURSE/CHARGE NURSE

Did the physician lead a “time out” stating “this is a STROKE ALERT”? YES/NO and

clearly state the LAST KNOWN WELL TIME in military time? YES/NO

Notes to Stroke Coordinator from ED team members (what went well, areas noted for improvement):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Please email sensitive concerns to anne.anderson@imail.org.

“Time Out” Feed Back

STROKE ALERT

“TIME OUT”

“This is a Stroke

Alert”

Stated LKW

(military time)

LKW given to HUC

with telestroke

activation

June (starting 22nd) 3/3 1/3 1/2

July 6/8 4/8

August 7/11 8/11 2/8

September 4/5 5/5 3/4

October to 10th 4/4 4/4 3/4

TOTAL 77% (UP from 76%) 70% (UP from 64%) 50%(UP from 41%)

Education/Skill Retention

• New ED RN orientation “boot camp”• Annual Skills tPA mixing and

administration • Annual TeleStroke skills/NIH pass off.

TEAM LEADS TEAMS• Individual feedback to physicians prn• Staff meeting for trends• Zero Harm Reporting-horizontal level• Label rooms for organization• EMS outreach education

ED Physician Culture

• Provide feed back, both positive and areas for improvement.

• Reports on individual physicians

• Stroke lead physician reinforce/ approach/educate (peer peer)

• Provide the latest research

Reducing YOUR Door to Needle Times

Making a Process Change

• Think small (processes and groups)

• Use LEAN process concepts

• Measure and track data

• Post data for staff viewing

• Celebrate successes