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Acute stroke
total solution service
From thrombolysis to
post-acute care
Show Chwan health
system
Attaining rapid stroke
thrombolysis within 30 min
Thrombolysis bundle
initiative in Show Chwan
health system
急性中風後期
照護提升計畫
PAC-CVD
Acute stroke
Reputation
establishment
Few Nudge
High risk
A possible niche
(3~4.5 hours)
1st TPA locked in syndrome
Recent challenge
Pass the high standard of the
critical care evaluation process
EBM guidance
Neurology guideline
Conform the current NHI regulation
Refer to the stroke bundle
implemented in Helsinki and
Melbourne
Bundle care coverage
From door to ward
1 . ER TPA or aspirin (door to needle)
2 . ICU care (needle to ward)
Resources reconstruction
Triage
ER Doctors
ER Nurses
Neurologists
Lab technician
CT room alert
ICU doctors
ICU nurses
Stroke nurse specialist
Endovascular specialists
Neurosurgeons
Audit, Award, Penalty
Bundle care coverage
From door to ward
1 . ER TPA or aspirin (door to needle)
2 . ICU care (needle to ward)
Possible advantage
Form the 1st comprehensive stroke
care bundle in Taiwan
Helsinki model
Meretoja 2013
Helsinski District
Sea faced, capital of Finland
Parallel processing
N o n -t r an sf er r abl e?
Meretoja 2013
I moved to Melbourne in Nov 2011
Meretoja 2013
20 km radius
Meretoja 2013
Other approach
• Admitting
– Patient identification
– Registration
– Room assign
• EMS
– Delivers patient to room
– Reports to nursing
• Nursing
– IV placement
– Monitor hook-up
– Vital sign monitoring
– Blood glucose
– Lab draw
– Weight estimate of patient
• Clinical Assessment
– History
– Medications/allergies
– Identification of witness
– Time of onset/last normal
– Witnesses difficult to locate
• Clinical Assessment (cont.)
– NIHSS
– Neurological Exam
• Labs
– PT/PTT, CBC, Creatinine
– Emergent transport of bloods to
lab
• Imaging
– Disconnect from monitor
– Transport patient to CT
– CT scan
– Transport from CT to room
– Reconnect to monitoring
• Drug Preparation
– Order tPA
– Calculate tPA dose
– Prepare tPA
• Bolus and infuse tPA
ISC 2012 New Orleans
Problem #1: Overwhelming # of tasks to complete in 60 min
1
2 3 4 5
6
Emergent Unit 1
Nursing Station
Trauma Critical Care
CT
CT
Ambulance Bay
Problem #2: Inefficient choreography
ISC 2012 New Orleans
Problem #3: Labs take too long
• Labs needed for tPA
– Platelets
– INR (PT/PTT)
– Blood glucose
• On average, in
2010, it took 33 min
to get results after
ordering labs
ISC 2012 New Orleans
Show Chwan
model
A possible niche
market
Show Chwan model
Stroke TPA Action Treatment group (STAT)
Within the guidance of NHI:
<3 hours, many outdated exclusion
Rearrange the workflow
STAT team member training
Suggestion
Triage dispatching
Inform neurologist (get the mobile phone number of
the ambulance)
Arrange admission and registration
ICU booking
Check CT room
Inform Point of care lab staff (INR, glucose, platelet)
Suggestion
ER doctor
Check list and pre-ordered order
Verify duration
Check vital signs
Basic NE: MP, Babinski
POC video demo if needed (out of hour
neurologist)
Video source and permit signing
Signature from 2 patient’s family or friends
Telephone if needed (and document on the permit)
Sign permit if no one is available after consult social
worker to document the condition and start TPA
Neurologist
In hours:
Immediate evaluation including signing document
and explanation
Out of hours:
Evaluate the patient with ambulance staff via
mobile phone
Point of care video neurological examination
ER nurse
Check vital signs and body weight
Set big IV line and 3tubes (vein)
Prepare IV pump for TPA
0.9*BW (1cc=1mg, max 90mg)
1st min: rate: x cc *60, volume: x cc
1 hour: rate: y cc, volume: y cc
ER logistics
Direct from ambulance stretch to CT
bed
IV, blood sampling, vital signs
Body weight, quick (video) NE
Question
Point of care INR and STAT CBC/PLT
When to initiate IA thrombolytics?
If <6 hours (Do MRI with MRA)
If personnel available
If basilar artery occlusion
Show Chwan
model
Beyond the NHI guidance
A possible niche market
Attaining rapid stroke
thrombolysis within 30 min
Thrombolysis bundle
initiative in Show Chwan
health system
急性中風後期
照護提升計畫
PAC-CVD
10 月 7 日
白話
急性中風後期
照護提升計畫
PAC-CVD
這次不一樣 ????
又來了
首波
沒有品質
沒有核刪
特點
高給付額
團隊報名
時間
急性後期
下轉開始
6 到 12 週
分級
起始狀況
積極復健潛能
潛能
意願
體力
主動
家庭
結案
好了
沒進步
沒潛能
>12 週
AAD
Expire
條件
跨院際
整合團隊模式
提出申請
復健人力物力
每 4 床至少需
1 位 物理 or
職能 or
語言治療人員
( 治療師 or 治療生 )
急性後期照護團隊
專責醫師
神經科、神經外科、復
健科
內科、家醫科
至少各 1 名
專任 護理人員
物理治療師
職能治療師
語言治療師
藥師
營養師
社工人員
,
專屬床位
急性後期
照護單位
個人專屬
急性後期照護計畫
急性後期照護單位
床位數
床位編號
照護人力
( 專業別、人數、專任或兼任、各類人員醫病比 )
照護設備
FRG1
FRG2
評估費用
高強度
可能策略
自轉 PAC
評估收入
體系之內
彰化彰濱互轉
下轉田中仁和
員林何醫院
竹山秀傳
無專責語
言治療師
另外結盟
台中榮總
台中中國
台中中山
彰化漢銘
員林員榮
署立彰化
體系之外
彰基轉彰化彰濱
( 彰化市、鹿港、芳苑、福興 )
彰濱轉鹿基、二基
( 二林、鹿港、芳苑、福興 )
建議
彰基合作
中風急性中期後期
復健網
資源
請行政組依規定要求擬定計畫
書初稿
定日程安排院際會議
增聘一位後急性中風專員
績效組定立適當收案獎金
時程
10 月兩次
參與醫院院際討論會議
10 月底
完成計畫書
最後期限
11 月 8 日 完成版本
11 月 15 日 最後修
定
急性中風後期
照護提升計畫
PAC-CVD
Independence
Acute stroke
total solution service
From thrombolysis to
post-acute care
Show Chwan health
system

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