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

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100-250 Bed HospitalCertified JC PSC Hospitals

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Any Questions…..

•Thank You!

Contact Information:Sheila Barr or Kristin RandallTheda Clark Medical Center

130 Second Street Neenah, WI 54956(920)720-7328