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Marylou Grant
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AR SAVES UPDATE JUNE 2011 HIGHLIGHTS FROM THE ALL SITES CALL UPCOMING EVENTS: July 1st marks the start of Year 4 for the AR SAVES program! We are time it would be very helpful.

Please do any *ED s PLACE The Top 10 ED Complaints Chris Melton, MD July 7th at 0710 *ED s PLACE OB Emergencies ners on the road to providing Arkansans with timely acute ischemic stroke care.

The 27th site to join AR SAVES is Magnolia Regional Hospital. Please help us to welcome them as they come on board in June.

Please continue to screen your potential AR SAVES patients utilizing the tpa checklist. This will help you determine if the patient is possibly eligible for tpa administration, or not.

1 AR SAVES UPDATE JUNE 2011 HIGHLIGHTS FROM THE ALL SITES CALL UPCOMING EVENTS: July 1st marks the start of Year 4 for the AR SAVES program! We are time it would be very helpful. Having the most accurate information Don t forget the APEX software is available for education on stroke so happy to have you all as part- allows us to pinpoint areas of and the NIHSS. Please do any *ED s PLACE The Top 10 ED Complaints Chris Melton, MD July 7th at 0710 *ED s PLACE OB Emergencies ners on the road to providing Arkansans with timely acute ischemic stroke care. As always, we love to hear any feedback, suggestions or questions regarding how this program can work more efficiently for you as the healthcare provider. We value your input! The 27th site to join AR SAVES is Magnolia Regional Hospital. Please help us to welcome them as they come on board in June. In the month of May, there were a improvement in trying to reach our goal of Door to Needle in 60 minutes. Please remember to turn in any invoices for reimbursement by June 30th! Please continue to screen your potential AR SAVES patients utilizing the tpa checklist. This will help you determine if the patient is possibly eligible for tpa administration, or not. If the patient falls outside of those checklist parameters, you can still obtain a certification updates with your NIHSS in the APEX software. When registering for the NIHSS check off, please use the facility key code provided to your Nurse Facilitator. This ensures that your completion is registered with your facility. William Greenfield, MD August 4th at 0710 total of 44 consults and tpa was given 8 times, for a 18% administration rate. In the May All-Sites call, a re- neurology consult by calling the PCC line at 866-UAMS-DOC. Also, keep in mind that the patient should be seen by your ED In the United States, every 40 seconds someone has a stroke. minder was issued to report accu- physician prior to calling SAVES. A rate times on the intake sheet. mini-neuro exam is appropriate For example, instead of guessing but a full NIHSS exam is not. what time the patient went to CT, if you could provide the actual THE AR SAVES CLOTBUSTER OF THE MONTH June s Clotbuster of the month comes from Ozark Health in Clinton, AR. Jill, RN and Dr. Pittman went above and beyond for a patient experiencing a very large stroke. Jill demonstrated how to be attentive while working quickly with a difficult patient. she kept calm while showing compassion, knowledge and care. Dr. Pittman was very kind to the daughter, as well as the patient. In addition to this patient, the ED was busy as well as being inspected at the same time, yet he still assisted with the NIH scale and with care of t he family. Dr William Pittman accepting Physician of the Year award

2 THE HOOKUP By Phillip Martin A few reminders from IT: PLEASE always use your remote control to move your camera! The camera is the most expensive, and important, piece of equipment on the telemedicine cart so treat it with care. PLEASE check your batteries in your remote. They may be getting old or corroding and need to be replaced! PLEASE remember to send your test CT images weekly. If your radiology department wants to use the same scan for each week, make sure they change the date or name on that image. If not, the repository sees it as the same image and will not re-post it THE RX PAD Sami Harik, MD Early publications from the National Institute of Neurological Disorders and Stroke concerning intravenous t-pa treatment of acute ischemic stroke listed several exclusion criteria. Chief amongst those was history of intracranial hemorrhage. However, experience over the past two decades caused many stroke experts to rethink the wisdom of these rigid contraindications to t- PA in patients who desperately need it. The age of patients is no longer restricted and most other exclusions were relaxed depending on the clinical circumstances. Exclusions were recently revisited when a patient presented with acute stroke symptoms and was being evaluated for intravenous t- PA therapy. Head CT scan revealed craniotomy, encephalomalacia from an old contusion, and intraventricular shunt. This raised the question whether the patient should be even considered for intravenous t-pa therapy. patient with intravenous t-pa. Further history revealed major Thus, not all intracranial hemorrhages are created equal. This is head trauma with probable subdural and brain hemorrhages where the clinical expertise of the many years ago. We continued neurologist is needed for a judgment call. The eventual question the evaluation process and the patient was not given t-pa because of low Stroke Scale score. nous t-pa administration exceed is: Do the advantages of intrave- the disadvantages? Also, the I agree with relaxation of previously imposed rigid exclusion presence of a ventricular shunt, in my opinion, is not a contraindication to t-pa in a patient with an criteria, particularly those affecting patients with intracranial hemorrhage. The subject is not clear acute ischemic stroke. cut; brain hemorrhages have Having said all of the above, I numerous causes and a wide wish to remind the reader that a spectrum of sequelae. For example, if a patient had brain hemor- intracranial bleed may have resid- patient with shunt or history of rhage from AV malformation or ual neurological deficits that increase the NIH Stroke Scale intracranial aneurysm, I would not treat with intravenous t-pa for score. For this reason, it is important for physicians and nurses to fear of causing a fatal intracranial bleed. However, if a patient had determine whether the neurological deficits in a patient who pre- traumatic subdural hematoma or intracerebral hematoma more sents with an alleged ischemic than a decade ago and now presents with acute cerebral ische- those that the patient had at stroke are definitely worse than mia, then I will probably treat the baseline. This makes the evaluation of the patient more difficult because the NIH Stroke Scale score may have been greater than zero before the recent deterioration which is now being blamed on an acute ischemic stroke. Quantitating the neurological impairment that is caused by acute ischemic stroke in any patient becomes more difficult in the presence of long-standing neurologic impairment. The moral of the story is that the clinical sense of physicians and nurses that evaluate patients is paramount in deciding whether intravenous t-pa should be given or withheld.

3 AR SAVES UPDATE Page 3 LOOKING AHEAD Julie Hall-Barrow, EdD What an exciting three years. Since November 1, 2008 to May 31, 2011, AR SAVES has consulted on 575 patients with 127 meeting criteria to receive t-pa. To date we have 27 spoke sites that are connected to the AR SAVES tele-stroke network. We have been able to increase access to sub-specialty consults for rural and urban Arkansans alike. According to the American Heart and Stroke Association only 38.4% of the state population was within a 60-minute drive in an ambulance drive that was equipped to provide acute stroke care. Today, more than 90% of the population is within a 60-minute drive of acute stroke care. Although this is a tremendous improvement, there is still much work to be done. The goal of AR SAVES is to be within a 30-minute ambulance ride to acute stroke care. Currently we are reaching approximately 60% of the population and leaves 40% for us to focus on this next year. The AR SAVES Second Annual conference was a huge success. We received many great comments and regret that as we grow we will have to move the conference from scenic Mt. Magazine to Little Rock. With growth however comes success, and we hope to attract many more physicians and staff to next year s conference. Please help me congratulate the AR SAVES award winners. Washington Regional Medical Center ~ Exceptional Facility of the Year Saline Memorial ~ Most Improved Facility of the Year Dr. William Pittman ~ Physician of the Year Rick Washam ~ AR SAVES Team Member of the Year Please continue to spread the word of stroke awareness and how your hospital is the BEST place for patients to get to FAST. DON T FORGET... Physician Call Center For emergency transfers, press 9 For all other referring physician calls, press 1

Page 4 Interesting Facts OUT AND ABOUT www.twitter.com/arsaves June's flower is the rose or honeysuckle June's birthstone is the pearl, Alexandrite, or moonstone.

June 1, 1938 Superman comics are launched June 2, 1935 Babe Ruth s last baseball game June 3, 1965 Edward White became the 1st American to walk in space June 6 Dalai Lama Tibetan spiritual leader was

4 Page 4 Interesting Facts OUT AND ABOUT June's flower is the rose or honeysuckle June's birthstone is the pearl, Alexandrite, or moonstone. No other month begins on the same day of the week as June. June 1, 1938 Superman comics are launched June 2, 1935 Babe Ruth s last baseball game June 3, 1965 Edward White became the 1st American to walk in space June 6 Dalai Lama Tibetan spiritual leader was born June 8 Frank Lloyd Wright- Architect was born June 10 Judy Garland actress, singer was born Community education specifically aimed at stroke appears critical to reducing the time for stroke patient s arrival at AR SAVES Tele-stroke site. Many factors contribute to delays in seeking treatment for stroke, but the principal factor is lack of public knowledge regarding stroke signs and symptoms and the need for rapid response to those indicators. At the 2 nd Annual AR SAVES Stroke Conference participants in the Community Education Workshop were given digital tool-kits with resources for community stroke education. Each person was able to Outreach Plan for the next seven months. These individual plans included at least two community outreach events per month. The education events could be either passive (ex. bathroom posters, materials at barber and beauty shops) or active (presentations, health fairs, etc.). Physician office stroke education kits were also distributed with order forms for additional kits. AR SAVES facilitators and their teams are accepting the challenge of initiating specifically targeted education regarding stroke risk factors, stroke symptoms, and the appropriate re- of stroke by calling 911. As you plan your community education campaign remember one of the major goals of stroke education is to decrease the time from stroke symptom onset to emergency department. The challenge for your AR SAVES Team is to give hope to your communities that Stroke is an emergency and stroke is treatable! June 11, 1979 John Wayne died develop a 2011 Community sponse to signs and symptoms June 11 Jeannette Rankin 1st woman elected to Congress June 12 Anne Frank Holocaust survivor, author was born June 14, 1775 The US Army was founded June 15, 1836 AR entered the Union June 16, 1876 Mark Twain s Tom Sawyer published June 18 Paul McCartney singer was born June 18, Sally K Ride became America s 1st woman in space June 22, 1868 AR was readmitted to the Union June 23, 1955 Disney s Lady and the Tramp opened in Los Angeles, CA June 26 Pearl S Buck-novelist was born June 27 Helen Keller was born June 30, 1936 Gone With the Wind was first published Contact Stacy Pitsch for comments and/or suggestions at sapitsch@uams.edu

5 Page 5 THE FRESHMEN CLASS Five Rivers Medical Center in Pocahontas is the 25th site to join AR SAVES! RN, CNO and Danna Guntharp, RN-CEN, serve together as Nurse ticed as an RN for 14 years with 10 years experience as an ED Su- Medical-Surgical Supervisor and staff nurse, and as a Nursing In- Five Rivers Medical Facilitators for this or- pervisor, flight nurse, structor. Center is a 50 bed hos- ganization. Pamela patient care co- pital with 3 ICU beds Smith serves as the IT coordinator and ED available. The ED has a Facilitator. Dr. William staff nurse. total of 7 beds and sees 7600 patients annually. The ED staff has been treating Acute Ischemic Strokes with tpa since Mandy Dollins, Lewis serves as Medical Director. Mandy Dollins, RN has been the Chief Nursing Officer at FRMC for 4 years. She has prac- Danna Guntharp, RN is the Nursing Supervisor of the ED and has been an RN for 12 years with experience in Cardiac Catheterization, OR,

6 2011 AR SAVES Conference at Mt Magazine

7 2011 Strike Out Stroke night with the Travelers

SARASOTA MEMORIAL HOSPITAL POLICY

smh0076850ps1070 SARASOTA MEMORIAL HOSPITAL POLICY TITLE EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: Job Title of Responsible Owner: Director, Patient Care 12/09/13 08/19/16 Clinical Non-Clinical