Brain attack: Treatment moves from wait and see’ to code blue
Brain attack: Treatment moves from wait and see’ to code blue
Tele-BAT goes into hypermode to start stroke pathway
Every minute counts now that tissue plasminogen activator (TPA) is available for stroke patients. In fact, some now refer to that condition as "brain attack," connoting its very urgent nature under the latest care guidelines.
Marian LaMonte, MD, MSN, the head of the Brain Attack Team (BAT) at the University of Maryland Medical Center in Baltimore told participants at the American Heart Association’s (AHA) 23rd International Joint Conference on Stroke and Cerebral Circulation in February in Orlando, FL, that BAT’s goal is to reduce the amount of time spent evaluating stroke. Tele-BAT, a combination of video, cellular telephone, and computer technology, comes close to accomplishing that. With Tele-BAT on board the facility’s ambulance the BAT mobile all systems are go for incoming stroke patients.
It typically takes 15 minutes to evaluate patients once they are in the hospital. With Tele-BAT, valuable information on whether a stoke is in progress and when symptoms may have begun is conveyed while the patient is in the ambulance. That enables the emergency department (ED) to be ready to send appropriate patients for a CT scan as soon as they arrive. Only ischemic strokes can be treated with TPA, and it takes a CT to determine whether the attack was caused by a clot (ischemic) or hemorrhage.
While connected to Tele-BAT via the Internet, LaMonte can watch pictures at 10- to 15-second intervals as the patient is examined by paramedics in the ambulance. She can receive information on vital signs via computer, evaluate the situation, and give directions. "We go through the National Institutes of Health Stroke Scale together to determine the patient’s condition," she explains.
The perspective on stroke has changed. "In the past, we didn’t triage stroke patients with any immediacy," explains Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of neurology at the University of Cincinnati Medical Center. Their care was largely supportive to prevent another incident and to prevent or deal with complications due to the current stroke.
Laura R. Sauerbeck, RN, BSN, CEN, clinical research coordinator for the Greater Cincinnati/Northern Kentucky Stroke Team in Cincinnati, agrees: "For years, these were the patients we put in a corner to deal with when everything else was taken care of. We knew there was nothing we could do."
But now, with new stroke protocols and TPA, that attitude is obsolete. "There’s a lot we can do for patients if they qualify for treatment," explains Teri McClean, RN, CEN, an emergency nurse at the University of California-San Diego. And whether they qualify for treatment depends on how fast an evaluation is made. That makes the situation a lot more critical than it once was. Now these patients are treated with the same severity rating as those with heart attack or multiple trauma. "We expedite the labs," Sauerbeck says, "and bump routine CT patients. The pharmacy runs the thrombolytics up to the ED immediately, just as they do with an myocardial infarction."
Karen Rapp, RN, BSN, CCRN, clinical coordinator at the University of California-San Diego Stroke Center, puts it this way: The perception of a patient who comes into the ED not speaking or moving has changed from stable to code blue.
Researchers examined the cost-effectiveness of acute stroke teams at 47 medical centers and presented their findings at the AHA conference in February. Just over half of the teams cost $5,000 per year or less, and only 24% cost more than $10,000 a year.
"They do not seem to create a large financial burden," Mark Alberts, MD, from Duke University in Durham, NC, told the gathering. A fairly recent phenomenon, most teams have been assembled since 1994.
When a stroke code is called at Rapp’s facility, the team neurologist, stroke nurse, and in-house neurology resident often arrives in the ED before the patient does. Radiology is alerted STAT to prepare for a patient coming in for a CT scan.
The pathway at the University of Texas Stroke Program in Houston also ensures not a minute is wasted. "We designed the pathway to point out the importance of time, since whenever we’re not moving as fast as we can, the patient is actually losing brain cells," explains Patti Bratina, RN, BSN, clinical research coordinator there.
Stroke pathways begin in the ED. Upon the patient’s arrival, the following occur:
• monitor vital signs including pulse oximetry, consider supplemental oxygen;
• assess rapid blood glucose level;
• monitor neurology;
• monitor cardiac;
• establish intravenous access;
• obtain laboratory samples and order studies including clotting, type, and screen;
• order head CT scan;
• order EKG and chest X-ray.
Quick, accurate determination of the onset time of symptoms is crucial. "We ask if the patient was awake when symptoms started. If not, we find out when they went to bed and try to ferret out the onset time," says Spilker. If the onset time is within three hours, the patient is considered for treatment with thrombolytics.
When the patient arrives, you must try to pinpoint a time when symptoms began, which involves some detective work. "You have to try and figure out when the patients started feeling numb on the left side of the body or when he or she couldn’t move the left arm," says Spilker.
Pinpointing the onset of the stroke requires top-notch assessment skills. "It is one of the hardest things to find out," says McClean. "Nine times out of ten, the person woke up with the symptom, or he or she doesn’t remember when it started."
In one case, when it was determined that a stroke patient had collapsed at the bus station, McClean quickly made numerous phone calls to track down a security guard who witnessed the incident to confirm the time the fall occurred.
How quickly the patient presents to the ED after noticing symptoms can make or break eligibility for treatment. Some patients present within 30 minutes of symptom onset, and others present with only 30 minutes remaining before the time window runs out. "If the patient sits at home for the first two hours, you only have one hour left," Rapp says. "That’s why it’s important that health care providers use that one hour very wisely."
[Editor’s note: The National Stroke Association (NSA) offers a stroke protocol, "The first few hours Emergency evaluation and treatment," that can be accessed on the Internet at http://www.stroke.org/ First_Few_Hours.html. For an excellent document on stroke center recommendations, contact:http://www. stroke.org/SCN_Recommendations .html.]
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