Here’s a sample stroke protocol
Here’s a sample stroke protocol
Assume that paramedics call and report they have a 54-year-old male who collapsed at his desk 15 minutes ago and will arrive at the ED in less than three minutes. At St. Elizabeth Medical Center in Edgewood, KY, the Possible Stroke ED Care Map covers the patient’s first two hours of care. (See protocol, p. 99.) Here are the steps taken in this hypothetical scenario, according to Rebeca Tacy, RN, BSN, CEN, assistant ED nurse manager:
1. Paramedics alert the ED. The paramedics have been trained in the acute ischemic protocol and have already prepared for the patient to receive tissue plasminogen activator (t-PA), the only clot-busting medication approved by the Food and Drug Administration.
"The paramedics have begun the history-taking process to determine that the patient has no contra-indications to thrombolytic therapy," says Tacy.
2. The ED physician on duty prepares the critical care ED room, and the stroke team is called. "The patient has not even arrived, and life-saving measures have already been implemented," Tacy notes.
3. When the patient arrives, the ED team is wait-ing. The patient’s vitals are reassessed, a second IV saline lock is inserted, an electrocardiogram, portable chest X-ray, and standard lab tests are performed.
4. While the ED physician evaluates the patient, a modified National Institutes of Health Stroke Scale assessment is performed, which serves as a quick screen of the patient’s deficits.
5. Upon arrival, the patient and family receive a quick orientation of the process. "They are informed that speed is of the essence, because the quicker that the stroke is treated, the greater the benefit to the patient," Tacy explains. "The family is extremely valuable in giving medical information for the stroke patient."
6. CT is ready within five minutes of the patient’s arrival. "The registration process is not complete; however, registration must never delay the diagnosis and treatment of the patient," notes Tacy.
An immediate report is received from the radiologist. Copies of the CT films are made for the stroke team neurologist, who consults over the phone to save time. "Twenty minutes have elapsed since the patient arrived in the ED, and 40 minutes have passed since his stroke began," says Tacy.
No delay in giving drug
7. Because the CT is negative, the decision to treat with Activase (altephase, recombinant, manufactured by Genentech in San Francisco) is made by the ED and stroke team physicians. "Because the Activase is available in the ED, there is no delay in getting the drug to the patient," Tacy explains.
8. While the drug is being mixed, the family and patient are informed of the risks and benefits of the medication. The family gives verbal consent. "Since the FDA has approved the treatment of AIS [acute ischemic stroke] with Activase, no formal consent is required," Tacy says. "A written consent would further delay the treatment to the patient."
9. The Activase is hung within 45 minutes of the symptom onset for this patient. The Stroke Team physician arrives as the medication is begun.
10. Admission into a critical care bed is arranged, and the patient’s progress is monitored while he is in the ED. Twenty minutes after initiating the Activase, the patient begins to show improvement under the modified stroke scale assessment, says Tacy.
"Twenty-four hours later, in the ICU, the patient is able to move all extremities and shows minor dysarthria," she says. "Three months later, the patient is back to work."
A National Institute of Neurologic Disorders and Stroke study showed that patients treated with Activase during an acute ischemic stroke were 30% more likely to have minimal or no disability at three months.1
Reference
1. National Institute of Neurologic Disorders and Stroke rt-PA Stroke Study Group. Tissue Plasminogen Activator for Acute Ischemic Stroke. N Eng J Med 1995; 333:1,581-1,587.
For more information about the ED’s stroke protocol, contact:
• Rebeca Tacy, RN, BSN, CEN, St. Elizabeth Medical Center, South Emergency Department, 1 Medical Village Drive, Edgewood, KY 41017. Telephone: (859) 344-2644. Fax: (859) 344-2022.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.