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28 SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: ADMISSION/TRANSFER OF STROKE PATIENTS Page 1 of 2 No: STK-1 Prepared by: Stroke Management Committee Original Issue Date 1/03 Supersedes: 2/09 Committee: Stroke Management Committee Approval Medical Executive Committee Effective Date: 8/2010 The JC Standards:PC , PC , PC Approved by: Anny Yeung, RN, MPA Margaret Jackson, MA, RN Related Policies (Stk-2) Admission/Transfer of Ischemic Stroke Patients Receiving Intravenous Alteplase In The Ed David Conley, MBA Stanley Fisher, M.D. Michael Lucchesi, M.D. Debra D. Carey, MS Issued by: Regulatory Affairs I. PURPOSE To outline the process for admitting stroke patients. II. POLICY It is policy of University Hospital of Brooklyn that all patients presenting to the emergency room with a diagnosis of stroke or TIA should be admitted to the Stroke Unit unless their problems require care in the ICU. III. IV. DEFINITION(S) None RESPONSIBILITIES It is the responsibility of the Emergency, Admitting, Nursing, and Neurology Departments to ensure compliance with this policy. V. PROCEDURES/GUIDELINES: Emergency Room 1. All patients presenting to the emergency room with a diagnosis of stroke or TIA should be admitted to the Stroke Unit unless ICU level of care is deemed necessary.

29 2. All stroke patients without a Primary Care Provider (PCP) will be assigned a Neurologist as their primary physician and admitted to the Neurology Service. 3. All stroke patients with a PCP or managed by Family Practice or Medicine will be referred to the Neurology Service for consultation. 4. All stroke patients previously managed by a private neurologist within UHB have the option of having his or her patient admitted to the Stroke Unit under the specialized care of a Stroke Neurologist. 5. Patients who develop a stroke while an inpatient under another service will be referred to the Neurology Service for consultation and transferred to the Stroke Unit, unless their medical or surgical problems preclude transfer. Admitting 1. Admit all acute Stroke and TIA patients to the Stroke Unit. 2. Admit sub acute stroke patients to general Neuroscience Unit-NS 71, unless Stroke Unit beds are available. 3. Admitting to facilitate in-hospital transfers to the Stroke Unit as appropriate. 4. Receiving service (Neurosurgery or Neurology) will initiate call to admitting to advise them of transfer(s) from outside facility. 5. Admitting manages the transfer process and arranges for transportation. Nursing 1. Nursing is responsible for patient monitoring and triage and movement of the patient from the Stroke Unit to the general Neuroscience floor (NS 71/73). Guidance is provided by the Neurology service. VII. ATTACHMENTS: None VIII. REFERENCES: None Date Reviewed Revision Required (Circle One) Responsible Staff Name and Title 8/10 (Yes) No Sherene M. McIntyre, Associate Director of Nursing-Stroke Center Coordinator Stroke Center Coordinator Yes No Yes No Yes No 2

30 SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE No. STK-02 Subject: ADMISSION/TRANSFER OF ISCHEMIC STROKE PATIENTS Page 1 of 3 RECEIVING INTRAVENOUS ALTEPLASE Original Issue Date 1/23/09 Prepared by: Daniel Rosenbaum, M.D. Alison E. Baird, M.D. Supersedes: 2/09 Committee: Stroke Management Committee Effective Date: 8/10 Approval Medical Executive Committee Approved by: Anny Yeung, RN, MPA The JC Standards: PC , PC Margaret Jackson, MA, RN David Conley, MBA Stanley Fisher, M.D. Michael Lucchesi, M.D. Issued by: Regulatory Affairs Debra D. Carey, MS I. PURPOSE To outline the process for admission and transfer of Ischemic Stroke patients receiving Intravenous Alteplase in the Emergency Department and In-patient units. II. POLICY It is the policy of the University Hospital of Brooklyn that Ischemic Stroke patients, receiving IV Alteplase (Activase) in the Emergency Department, will be transferred to the stroke unit as soon as a bed is made available. Unstable Patients (i.e. patients requiring IV pressors, pre-existing multiple co morbidities warranting ICU standards of care) will be transferred to the Medical ICU service with Neurology as a consultant team. If the Medical ICU lacks bed availability, unstable patients will be admitted to the Stroke unit/ Neurosurgery Step-down unit under the care of the Neurology service with MICU as the consultant team. The MICU team will provide guidance regarding mechanical ventilator management, complex medical co morbidities and other critical care management as needed.

31 ADMISSION/TRANSFER OF ISCHEMIC STROKE PATIENTS RECEIVING INTRAVENOUS ALTEPLASE IN THE ED III. DEFINITION(s) None IV. RESPONSIBILITIES: It is the responsibility of the Emergency, Admitting, Nursing, and Neurology Departments to ensure compliance with this policy. V. PROCEDURES/GUIDELINES: A. Emergency Department 1. All patients presenting to the Emergency Department with a diagnosis of Ischemic Stroke who are eligible to receive IV Alteplase will be admitted to the Stroke Unit/ Neurosurgery Step-down Unit under the care of the Neurology service. Patients deemed unstable (i.e. patients requiring IV pressors, preexisting multiple co morbidities warranting ICU standards of care) will be transferred to the MICU service with Neurology as a consultant team. If MICU lacks bed availability, unstable patients will be admitted to the stroke unit, under the care of the Neurology service with MICU as the consultant team. The MICU team will provide guidance regarding mechanical ventilator management, complex medical co morbidities and other critical care management as needed. 2. All Ischemic stroke patients receiving IV Alteplase without an existing Primary care provider will be assigned a Neurologist as their Primary Physician under the Neurology service. 3. All Ischemic stroke patients receiving IV Alteplase with a Primary care provider will be referred to the Neurology service for consultation. B. Admitting 1. Existing adult in-patients whom develop a stroke while under the care of another service and receive IV Alteplase for acute stroke will be referred to the Neurology service for consultation. Patients will be transferred to the Stroke Unit/ Neurosurgery Step-down Unit for specialized care if stable. Patients deemed unstable (i.e. patients requiring IV pressors, pre-existing multiple co morbidities warranting ICU standards of care) will be transferred to the MICU service with Neurology as a consultant team. If MICU lacks bed availability, unstable patients will be admitted to the Stroke unit/ Neurosurgery Step-down Unit under the care of the Neurology service with MICU as the consultant team. The MICU team will provide guidance regarding mechanical ventilator management, complex medical co morbidities and other critical care management as needed. 2. Admit Ischemic stroke patients receiving IV Alteplase to the Stroke unit as soon as a bed can be made available, unless patient is unstable requiring ICU level of care. 2

32 ADMISSION/TRANSFER OF ISCHEMIC STROKE PATIENTS RECEIVING INTRAVENOUS ALTEPLASE IN THE ED 3. Facilitate in-hospital stroke transfers to the Stroke unit Neurosurgery Step-down Unit as appropriate. 4. Receiving service (Neurology) will initiate the call to admitting to apprise them of impending patient transfers from outside facility. 5. All efforts will be employed to have a stroke bed available for Ischemic stroke patients who have received IV Alteplase. 6. The transfer process including transportation will be managed by Admitting/ Bed Management. C. Nursing 1. A Registered Professional Nurse is responsible for patient assessment, continuous monitoring, medication administration, documenting patient response, communicating with MD, and reporting any deterioration in patient status immediately to MD. In the event that a monitored bed is not available for the patient post Alteplase infusion, a qualified Registered Nurse will be allocated by Nursing Administration to provide the appropriate level of care for the patient wherever the patient is. D. Neurology 1. The admitting service will be available to address patient management concerns as they arise. VI. ATTACHMENTS None VII. REFERENCE Joint Commission Standards Date Reviewed Revision Required (Circle One) Responsible Staff Name and Title 8/10 Yes No Sherene M. McIntyre, Associate Director of Nursing-Stroke Center Coordinator Yes No 3

33 SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: ACUTE STROKE ALERT CODE S (Neurology/ Stroke Program-Code S) Page 1 of 4 No: STK-3 Original Issue Date 6/10 Prepared by: Sherene M. McIntyre NP-C, RN Supersedes: New Committee: Stroke Performance Improvement Approval Committee Effective Date: 6/10 Pharmacy & Therapeutics Committee Medical Executive Committee The JC Standards MM ,PC : Related Policies Approved by Nicholas Galeota, MS, RPh (Stk-2) Admission/Transfer of Ischemic Stroke Patients Receiving Intravenous Alteplase In The ED : Anny Yeung, RN, MPA Margaret Jackson, MA, RN David Conley, MBA Stanley Fisher, M.D. Michael Lucchesi, M.D. Debra D. Carey, MS Issued by: Regulatory Affairs I. PURPOSE To outline the rapid clinical response process to facilitate urgent assessment, evaluation and treatment of patients experiencing acute stroke symptoms, presenting to the Emergency Department (ED) and on adult in-patient units. II. POLICY It is the policy of University Hospital of Brooklyn (UHB) that the American Stroke Association and New York State Department of Health (NYSDOH) guidelines for responses to Acute Stroke are met. Code S is activated for patients with acute neurological symptoms, who were last seen well within 6 hours before ED arrival. It is also activated upon recognition of acute neurological changes in adult in-patients. Although patients (and family, as appropriate), must be advised about treatment, informed consent is not necessary for IV Alteplase administration for patients if symptom

34 ACUTE STROKE ALERT CODE S onset is less than 3 hours. For the extended window of hrs, informed consent is required. III. DEFINITION(S) A. Code S Code S is the single call activation mechanism for acute stroke. This ensures that appropriate staff and departments are alerted to assess, diagnose, and treat acute stroke patients in the ED and Adult in-patient units experiencing stroke symptoms. B. Adult in-patient units All acute patient care areas of UHB from the second 2 nd through eighth 8th floors. IV. RESPONSIBILITIES: It is the responsibility of the Stroke Team, Radiology, Laboratory Services, Nursing Administration, Bed Management, University Police, Environmental Services, Pharmacy and Telecommunications to ensure compliance with this policy. V. PROCEDURES/GUIDELINES: 1. The healthcare provider that notices acute neurological changes consistent with signs/symptoms of an acute stroke activates Code S by dialing x 2323 stat. Nursing staff will assess the patient s blood glucose via point of care testing and measure vital signs. 2. Telecommunications places an Overhead page announcement. Operator states Code S, Patient s Location. Alpha numeric page alerts are sent to the Stroke Team, Radiology, Laboratory Services, Nursing Supervisor, Bed Management Coordinator, University Police and Pharmacy, that reads Code S, Patient s Location, unit phone extension. 3. *The Stroke Team will arrive to assess patient within ten (10) minutes of receiving notification. The stroke team is the treatment decision maker for the administration of Thrombolytics or Interventional treatment if indicated. The stroke team and a nursing staff member will transport patient in their current bed to Radiology suite (on the 1 st floor) for stat brain imaging. 4. University Police: For Code S in-patients: Securing elevator # 8 or # 9, the University Police member will proceed to the floor and remain at the elevator site awaiting patient and Stroke team. The Stroke team and patient will be transported to 1 st floor or sub-basement of UHB for stat brain imaging. Upon completion, the Stroke team will contact University Police at x Securing elevator # 8 or # 9 the University Police member will proceed to the floor and remain at the elevator site awaiting patient and Stroke team. Stroke team and patient will be transported to the floor of designated unit. Note: Code S in the ED: University Police services are not warranted. 5. The Radiology Technician prioritizes access to the CT scanner (on the 1 st floor) in the following manner. Scanner will be kept vacant for ten (10) minutes to 2

35 ACUTE STROKE ALERT CODE S ensure rapid access for the acute stroke patient. Particular studies already in progress will not be interrupted, i.e. Cardiac CTA, Virtual Colonoscopies and other studies being performed on patients deemed clinically unstable. *NY State Department of Health guideline: Brain imaging is to be performed within 25 minutes of ED arrival. For existing in-patients: Imaging is to be performed within 25 minutes of symptom discovery. 6. The Brain Image reading will be performed by the Stroke Team. *NY State Department of Health guideline: Brain imaging is to be read within 45 minutes of ED arrival. For existing in-patients: Imaging is to be read within 45 minutes of symptom discovery. 7. Laboratory services processes Code S specimens stat. Specimens to be collected are CBC, Chemistry Panel, INR, and Platelets. The turnaround time for results is 45 minutes. 8. The stroke team communicates the patient treatment plan and necessary level of care to the Nursing Supervisor/ Assistant Director of Nursing. In collaboration with the Bed Management Coordinator, the Nursing Supervisor facilitates patient transfer to the Stroke Unit/Neurosurgery step-down or other available monitored bed. The Nursing Supervisor communicates the patient bed assignment to the Stroke Team. 9. The Bed Management Coordinator communicates with Environmental Services to have the identified monitored bed sanitized (if necessary). Environmental Services will sanitize identified beds in an expedient fashion to accommodate patient transfer as directed by the Bed Management Coordinator. 10. If the patient meets criteria to receive IV Alteplase (a.k.a. t-pa) and a monitored bed can not be established, the patient will return to their original bed. The Nursing Supervisor ensures the appropriate level of care is brought to the patient, including but not limited to an RN trained in the administration of IV Alteplase, and cardiac monitoring equipment. The Nursing Supervisor prioritizes patient transfer to a monitored setting as soon as possible. 11. Acute stroke patients in the Emergency Department will receive IV Alteplase in the ED admixed by an ED nurse in the manner described below in #14 (Alteplase Admixture and Administration Procedures for Stroke). Patients are transferred to the Stroke/ Neurosurgery Step-down unit expeditiously upon completion of the Alteplase infusion. 12. Upon determination that Alteplase is warranted, the Stroke Team contacts Pharmacy via text page message that states: Mix t-pa, Patient location. Stroke Team completes Ischemic Stroke IV Alteplase Administration Order and faxes to Pharmacy s STAT fax machine (x 2855). Order includes patient location. 13. Pharmacy begins reconstitution of Alteplase once text page from Stroke Team is received. Once Alteplase written order is received, Pharmacy withdraws excess Alteplase to provide exact dose per order and connects solution to IV tubing set and prime IV line with alteplase. RN signature on Ischemic Stroke IV Alteplase 3

36 ACUTE STROKE ALERT CODE S Administration Order is waived for dispensing. Pharmacy technician hand delivers solution to the designated patient unit. (See Stroke Alert Pharmacy Pathway- Attachment B) 14. Alteplase (Activase ) Admixture and Administration Procedures for STROKE *NY State Department of Health guideline: IV Alteplase administration should commence within 60 minutes of ED arrival. For existing in-patients: IV Alteplase administration should commence within 60 minutes of symptom discovery. Admixing and Reconstitution of 100 mg vial a) Use aseptic technique throughout. b) Remove the protective flip-caps from one vial of Alteplase and one vial of Sterile Water for Injection, USP (SWFI). c) Open the package containing the transfer device by peeling the paper label off the package. d) Remove the protective cap from one end of the transfer device and keeping the vial of SWFI upright, insert the piercing pin vertically into the center of the stopper of the vial of SWFI. e) Remove the protective cap from the other end of the transfer device. DO NOT INVERT THE VIAL OF SWFI. f) Holding the vial of Alteplase upside-down, position it so that the center of the stopper is directly over the exposed piercing pin of the transfer device. g) Push the vial of Alteplase down so that the piercing pin is inserted through the center of the Alteplase vial stopper. h) Invert the two vials so that the vial of Alteplase is on the bottom (upright) and the vial of SWFI is upside-down, allowing the SWFI to flow down through the transfer device. Allow the entire contents of the vial of SWFI to flow into the Alteplase vial (approximately 0.5 ml of SWFI will remain in the diluent vial). Approximately 2 minutes are required for this procedure. i) Remove the transfer device and the empty SWFI vial from the Alteplase vial. Safely discard both the transfer device and the empty diluent vial according to institutional procedures. j) Swirl gently to dissolve the Alteplase powder. DO NOT SHAKE. k) Remove from the vial any quantity of drug in excess of that specified for patient treatment. Administration 1) RN assigned to patient must sign t-pa order prior to administration 2) Program smart pump to deliver Alteplase bolus and maintenance dose per Ischemic Stroke IV Alteplase Administration Order 3) Once infusion of Alteplase is completed, un-spike the empty Alteplase vial and re-spike infusion set with 50 ml bag of NS. 4

37 ACUTE STROKE ALERT CODE S 4) Program smart pump using Basic Infusion with the following: a. Enter same rate for Alteplase maintenance dose b. Set VTBI as 30 ml to infuse remaining Alteplase in IV tubing c. Attach infusion set to IV access d. Start infusion to provide total dose of Alteplase VII. ATTACHMENTS A - Code S Algorithm B - Stroke Alert Pharmacy Pathway C - Ischemic Stroke IV Alteplase Administration Order VIII. REFERENCES Joint Commission Standards Date Reviewed Revision Required (Circle One) Yes No Yes No Yes No Responsible Staff Name and Title 5

38 SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: DOCUMENTATION GUIDELINES- ACUTE STROKE CARE Page 1 of 3 No: STK-4 Prepared by: Lisa Schumann, RN Original Issue Date 5/03 Supersedes: 1/05 Committee: Stroke Performance Improvement Approval Committee Effective Date: 8/10 Approved by Anny Yeung, RN, MPA Margaret Jackson, MA, RN David Conley, MBA Stanley Fisher, M.D. The JC Standards RC , PI PC Related Policies (Stk-2) Admission/Transfer of Ischemic Stroke Patients Receiving Intravenous Alteplase In The ED Michael Lucchesi, M.D. Debra D. Carey, MS Issued by: Regulatory Affairs I. PURPOSE To delineate the need for accurate documentation in the treatment of the acute stroke and TIA patient, with emphasis on the importance of Time Intervals that will have direct implications for ensuring compliance with the Brain Attack Coalition (BAC) and New York State Department of Health (NYSDOH) guidelines for NY State Designated Stroke Centers. II. POLICY It is policy of University Hospital of Brooklyn that all practitioners will adhere to strict guidelines for documentation of the Time and Time Frames with regard to assessment and intervention and request for tests/procedures to ensure that Brain Attack Coalition and NYS DOH time targets are met. III. DEFINITION(S) Acute stroke patient: Patient experiencing sudden continuous neurological impairment for up to six hours.

39 IV. RESPONSIBILITIES (All departments/services involved in development/ implementation and/ or monitoring): All Patient Care disciplines V. PROCEDURES/GUIDELINES: The date and time of the following must be clearly recorded in the medical record. A. EMS Pre-notification received B. Patient was last seen in their usual state of health C. Symptom discovery D. Emergency Department MD assessment E. Stroke Team Assessment F. CT Completed (actual time stamp on the radiology image) G. CT Reading by Stroke Team H. Type of Stroke I. National Institute of Health Stroke Scale Score (NIHSS on admission, discharge and q shift during stay in stroke unit) J. Relevant Contraindications/Warnings for Alteplase (Activase, t-pa) Administration as delineated on the Ischemic Stroke IV Alteplase Administration Record K. Time of Alteplase Administration/Discontinuation L. Vital Signs, neuro checks, blood glucose as delineated in the Ischemic Stroke IV Alteplase Administration Record M. Any incidence of symptomatic or non-symptomatic Intracerebral hemorrhage secondary to Alteplase N. Perform and document results of Swallow screen as: Patient able/not able to swallow water. Note: To be performed on ALL Acute Stroke patients prior to any oral intake, including food, fluid or medication. O. Stroke Team members must clarify their signatures and titles with Stroke Team. P. All orders and notes must be clearly dated and timed, notes must state plan of care daily. Q. Anti-coagulants, DVT prophylaxis, and reasons for discontinuation or contraindications when applicable must be documented on DVT Prophylaxis Order Form. R. Neurosurgery notification and response (when applicable) S. Patient/Family Education Record (Cardiac and Stroke) T. UHB Stroke Brochure- given to all acute stroke patients U. Rehabilitation consultation request (when applicable) V. Fasting Lipid Panel Results- If LDL > 100, cholesterol lowering agent must be ordered; Contraindications to treatment must be documented. W. HgbA1C for all Diabetics; if > 7.0, treatment must be employed. Contraindications to treatment must be documented. VI. STAFF EDUCATION All patient care disciplines will have written instruction of medical record documentation VII. PERFORMANCE IMPROVEMENT The PI department will audit all criteria delineated in item V. with input/guidance from the Neurology department. VIII. ATTACHMENTS None 2

40 IX. REFERENCES a) New York State Department of Health Pilot Stroke Center Initiative b) Brain Attack Coalition (BAC) Practices/Protocols/Procedures/Guidelines c) New York State Department of Health Department of Health d) Joint Commission Standards Date Reviewed Revision Required (Circle One) Responsible Staff Name and Title 8/2010 (Yes) No Sherene M. McIntyre, Associate Director of Nursing-Stroke Center Coordinator Yes No Yes No Yes No 3

41 You have now completed reviewing the Stroke Material. Please click here to proceed to the Stroke Post Test.