Dripping and Shipping

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Dripping and Shipping

• Theda Clark Medical Center
• Appleton Medical Center
• Sheila Barr, RN
• Kristin Randall, RN
• Stroke Program Coordinators

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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

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Theda Care System

• 4 - Hospitals
• 17 - Family and Internal Medicine Clinics
• 1 - Fast Care location open 7 days a week

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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

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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

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Appleton Medical CenterAppleton, WI

• 160 Beds
• Specialty oncology and cardiac
• Sister hospital with Theda Clark Medical Center
• Together they provide coordinated specialty care

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New London Medical CenterRiverside Medical
Center - Waupaca, WI

• Small rural community hospitals
• Both provide general acute care

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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

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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.

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Acute CVA worksheet

• Code Stroke ER\Code Stroke Worksheet.doc

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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

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tPA is a go.

• STAT Labs BMET, CBC, PT, PTT
• EKG
• Vital Signs every 15 minutes until infusion
  completed
• 2 IV sites established

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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.

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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

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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 patients
  bed

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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

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Stroke Center here we come!!!

• Other treatment options for Ischemic Strokes
• Intra-arterial tPA
• MERCI Retrieval Device

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Modes of transfer

• Theda Star Air medical staffed by RNs
• Ambulance

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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

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Transfer process continue

• The stroke center is notified of admission of a
  stroke patient.
• Placement is determined by patients status ICU
  vs Intermediate Neuro Unit
• Report is called over to the admitting RN
• Direct Admit to their room

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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

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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

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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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Any Questions..

• Thank You!
• Contact Information
• Sheila Barr or Kristin Randall
• Theda Clark Medical Center
• 130 Second Street Neenah, WI 54956
• [phone]