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  • We work with The Neuroscience Group of Northeast Wisconsin, NeuroSpine, and Fox Valley Radiology
  • Neurology and Neurosurgery are on-call 24 hours a day/7days a week
    Stroke Unit includes: ICU, INU, and floor
    Nursing staff trained on how to perform the NIH Stroke Scale
    Pathways have been established to help direct the patient’s care.
  • AMC specializes in heart and cancer care
    TC specializes in neuro and trauma
  • Our neurologist have an agreement with the ED physicians that if the ED receives a call about accepting a stroke patient, they are able to accept the patient for the neurologist who will talk over the care once they get here.
  • These is a map of our referring hospitals. The ER physicians will contact the on-call neurologist to see if they will accept the transfer. Theda Star may be sent to pick up some of the patients depending on the time frame if further intervention is needed.
  • EMS uses the Cinnicinati Scale
  • CT is done in the Emergency department
  • The lesser dose is if there is the possibility that Intra-arterial tPA is going to be needed. In the past we have had a patient given the whole dose by IV which did not allow for any to be given Intra-arterially.
  • Our hospital had 14 patients that received tPA. That is out of 274 patients. #1 reason that people did not get tPA is that they were out of the 3 hour window. Some patients were candidates for intra-arterial tPA.
  • Some RNs may have to mix the tPA themselves. There is a specific way that it needs to be mixed, so education for the staff is necessary if the pharmacy is not available to prepare it.
  • If patient chooses to stay at AMC, the hospitalist will be the admitting MD
    ED nurse will call dispatch for the ambulance to arrange for emergent transfer
    Some of the other hospitals may choose Theda Star as the mode of transportation to get the patient to TC.
    At our emergent hospitals the mode of transportation may be Theda Star
  • Our ER is notified of the incoming patient but will not see patient unless there is complications while enroute.
    ALL stroke are admitted to the INU or ICU post tPA for at least the first 24 hours
  • We give feedback to our ED about patient process and let them know about areas of concern and how we can improve and also things that went right!
  • The smaller hospitals have just as good of chance of giving tPA than then the Primary Stroke Centers.
  • Presentation

    1. 1. Dripping and Shipping Theda Clark Medical Center Appleton Medical Center Sheila Barr, RN Kristin Randall, RN Stroke Program Coordinators
    2. 2. 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
    3. 3. Theda Care System • 4 - Hospitals • 17 - Family and Internal Medicine Clinics • 1 - Fast Care location open 7 days a week
    4. 4. Theda Clark Medical Center Neenah, 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
    5. 5. 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
    6. 6. Appleton Medical Center Appleton, WI • 160 Beds • Specialty oncology and cardiac • Sister hospital with Theda Clark Medical Center • Together they provide coordinated specialty care
    7. 7. New London Medical Center & Riverside Medical Center - Waupaca, WI • Small rural community hospitals • Both provide general acute care
    8. 8. 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
    9. 9. Rhinelander Manitowoc Green Bay Marinette Oshkosh Fond du LacWaupun New London Shawano Waupaca Wild Rose Chilton Antigo Langlade Appleton Berlin
    10. 10. 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.
    11. 11. Acute CVA worksheet • Code Stroke ERCode Stroke Worksheet.doc
    12. 12. 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
    13. 13. tPA is a go……. • STAT Labs: BMET, CBC, PT, PTT • EKG • Vital Signs every 15 minutes until infusion completed • 2 IV sites established
    14. 14. 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.
    15. 15. 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
    16. 16. 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
    17. 17. 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
    18. 18. Stroke Center here we come!!! • Other treatment options for Ischemic Strokes – Intra-arterial tPA – MERCI Retrieval Device
    19. 19. Modes of transfer • Theda Star Air medical staffed by RNs • Ambulance
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. 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
    25. 25. January February March April May June July August September October November December 100-250 Bed Hospital Certified JC PSC Hospitals 0% 10% 20% 30% 40% 50% 60% 70% IV tPA withing 2 Hours 100-250 Bed Hospital Certified JC PSC Hospitals
    26. 26. Any Questions….. •Thank You! Contact Information: Sheila Barr or Kristin Randall Theda Clark Medical Center 130 Second Street Neenah, WI 54956 (920)720-7328