eMedicine Specialties > Neurology > Neuro-vascular Diseases

Stroke Team Creation and Primary Stroke Center Certification

Author: Karen Ellmers, RN, MS, CCNS, Adjunct Faculty, Oregon Health & Science University School of Nursing; Clinical Nurse Specialist, Emergency Department, Trauma, Neurology, Orthopedic, Poison Division, Oregon Health & Science University Hospital
Coauthor(s): Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center; Wayne M Clark, MD, Director of Oregon Stroke Center, Professor, Department of Neurology, Oregon Health & Science University
Contributor Information and Disclosures

Updated: Apr 2, 2009

Introduction

In June 1996, tissue plasminogen activator (tPA) was the first drug to be approved by the US Food and Drug Administration (FDA) for the acute treatment of stroke. This drug has been shown to work only within the first 3 hours of onset of symptoms, making stroke treatment a true emergency.¹ The short treatment window requires rapid evaluation of patients who may have had a stroke. Stroke teams have been created for this purpose. The members of a stroke team vary depending on the needs of the individual hospital, although code team personnel often include one or more neurologists and nurses.

To achieve maximal efficiency, the team must integrate itself with all services involved in the care of patients with acute stroke, which include the local community, emergency medical services (EMS), the emergency department (ED), interventional radiology (IR), neurosurgery, nursing, computed tomography (CT) scanning, laboratory, pharmacy, rehabilitation, and inpatient units. The team educates the public and care providers about stroke warning signs and availability of stroke treatments, evaluates and streamlines services, provides stroke treatment rapidly, and continuously monitors the efficacy of its work. This article examines the creation of the stroke team and the role of the Primary Stroke Center in improving the delivery and coordination of care in acute stroke.

For related information, see eMedicine articles Acute Stroke Management and Mechanical Thrombolysis in Acute Stroke.

The Stroke Team

The Brain Attack Coalition published a set of recommendations for the establishment of Primary Stroke Centers in 2000.² These are comprised of 11 major elements that help an organization achieve the level of collaboration among services required to rapidly identify and treat acute stroke patients. The Joint Commission also adopted these elements for their Disease-Specific Primary Stroke Center Certification.³  These elements will be discussed in greater detail and include the following:

• Hospital and administrative support
• Acute stroke team
• Written care protocols
• Emergency medical systems
• Emergency department
• Stroke units
• Neurosurgical services
• Neuroimaging
• Laboratory services
• Outcomes/Quality improvement
• Educational programs

The first major element is the creation of an acute stroke team. Members of the stroke team have a strong common interest in treatment of acute stroke. The team comprises 2 parts: (1) the code team members, who respond to a code pager and deliver urgent treatment, and (2) a task force that works daily to facilitate patient access to treatment.

Usually, the code team consists of a neurologist or, in some cases, an ED physician, and a nurse. The task force, which is frequently larger, may include members from many disciplines—neurology, emergency medicine, neurosurgery, nursing, radiology, pharmacy, laboratory, physical medicine, and rehabilitation.

Hospital and Administrative Support

Development of the team often requires early inputs from the hospital's administration to enhance problem solving and integration between services. Designation of resources in the form of a specific individual, often an advanced practice nurse, to lead the initiative is beneficial for keeping the process organized and consistently moving forward.

Written Care Protocols

Creating a written care protocol is helpful (see Media file 1). This outlines what each member of the team is responsible for and helps to set timeframes for what is to be accomplished. Separate sections for actions based on duration of a patient's stroke symptoms is a useful organizational strategy (ie, <3 hours, >3 but <8 hours, >24 hours). Representatives from each discipline should take part in determining the content of the protocol. These discussions may seem time consuming on the front end, but can be extremely helpful on the back end as all parties have come to a consensus on how the acute stroke patient is to be managed. Protocols should be reviewed and revised annually and can be used as part of quality improvement initiatives.

Prehospital Needs

Public and care provider education

Although many patients know the symptoms of a heart attack, few are aware of the signs and symptoms of stroke. Those most at risk for stroke, the elderly, are least likely to know the risk factors and warning signs of stroke. In addition, while a heart attack frequently causes discomfort that invites the patient to seek rapid medical attention, a stroke does not. These factors impede the early arrival of patients in the ED, preventing them from receiving treatment. Patient education regarding stroke symptoms and the need to call 911 for these symptoms is imperative.

Primary care providers also must be educated on the availability of therapy for acute stroke and the critical 3-hour time frame for treatment with intravenous tPA and up to an 8-hour window for intra-arterial tPA or clot extraction maneuvers. Primary care providers should encourage patients' use of the EMS system. Since primary care physicians see patients before they present with ischemic events, care providers in the community can identify patients at high risk for stroke and initiate preventive therapies.

Emergency medical services

EMS providers must be trained in the recognition of stroke and in prioritizing the patient with stroke for rapid transport to the hospital. The prehospital stroke scale used in Cincinnati defines 3 major physical findings to identify patients with stroke: facial droop, arm weakness, and speech abnormalities.⁴ EMS providers can assist the treatment process further by establishing the time of onset of stroke symptoms. They need to be aware of the timeframes for intravenous and intra-arterial tPA, as well as clot extraction maneuvers, and know which facilities in their region are set up to provide these therapies. While a variety of regional policies currently exist for the regulation of patient transportation, the recommendation is for processes to enable rapid access to appropriate therapies.⁵

EMS staff members should be reminded not to overtreat high blood pressure in the stroke patient, in whom maintaining perfusion pressure to the brain is vital. Once a brief assessment has been performed, the time spent in the field must be minimized. Stroke patients should be transported to the hospital with the same level of urgency as those with myocardial infarction (sometimes referred to as "load and go"). Early notification of ED personnel can shorten the time to evaluation so that treatment can start as soon as the patient arrives in the ED.

Hospital Needs

Emergency department

Once the patient arrives in the ED, ED personnel should perform a brief assessment of the patient and immediately contact the stroke code team. To make this as easy as possible, the code team is best reached through a single pager number. The efficiency of the ED evaluation and treatment can be enhanced by following the multidisciplinary written care protocol that outlines the role of each ED member and the steps to be followed.

The first step is to contact the stroke code team before the evaluation is complete. Full history, examination, CT scan, and other laboratory results may still be pending when the code team is called. The respective roles of the code team nurse and the ED nurse in performing such tasks as starting a second intravenous line, taking blood pressure, or mixing the tPA, if it is to be administered, need to be defined (see Multimedia files 2-4). Standard orders may save valuable time and prevent omissions in the care of the patient with acute stroke. ED personnel can be helpful in locating family members who might have additional information about the time of onset of stroke and other issues concerning the patient.

Radiology, laboratory, and pharmacy

The stroke pathway or protocol in the ED should provide for diagnostic studies in every patient with stroke.⁶ Of these, the most critical is the CT scan. The procedure for obtaining the CT scan should be streamlined to ensure that the scan is obtained urgently (within 25 minutes of arrival). Both the CT scanner and someone to read the scan need to be readily available at all hours or arrangements must be made for transfer of the patient to another hospital with these facilities.

Code team members may need to transport the patient to the CT scanner if waiting for someone else to perform this service might delay the scan. Laboratory tests should be ordered and performed promptly so that the results are available within 45 minutes. A chest radiograph and 12-lead ECG within 45 minutes is also helpful. If the drugs required for treatment, including tPA, are not located in the ED, the procedure for obtaining them from the pharmacy after regular hours needs to be outlined and administration instructions should be easily accessible.

The protocol should include criteria for which patients will be admitted or transferred to another facility with more comprehensive stroke services available.⁷

Stroke Units

Inpatient units receiving patients after the initial ED workup should have staff trained in the care of the acute stroke population. Multidisciplinary care protocols should be written outlining inpatient management in the critical care and acute care phase, as well as monitoring of the patient post-tPA (see Media files 5-7). Preprinted order sets can help ensure predefined care elements are considered (see Media files 8-12).

Neurosurgical Services

Patients who are identified as having a hemorrhagic stroke, and certain patients with ischemic stroke, will need neurosurgical evaluation. Facilities keeping these patients will need to develop a plan to have fully functional operating room facilities and neurosurgical staff available within 2 hours of the clinical need being recognized. If that is not possible, a transfer plan should be developed for those patients who are identified as needing neurosurgical services the facility is not able to provide (see Media file 13). Remote consults from a regional comprehensive stroke center can be very helpful in making these decisions.

Monitoring

Continuous review of the entire stroke care system can help to improve its function. In particular, the cause of delays in evaluation and treatment should be investigated and corrected. The stroke protocol can be used to assess outcome measures such as the timeliness of interventions, patient recovery, and costs. Feedback given to the people involved in the patient's care, including EMS personnel and those in the ED, provides an educational opportunity and maintains interest in providing care to patients with acute stroke.

The Get With the Guidelines-Stroke database can be very helpful in driving quality improvement activities.⁸ Demographic and clinical data are entered for each patient admitted with acute stroke (ischemic stroke, transient ischemic attack, intracerebral hemorrhage, or subarachnoid hemorrhage). Reports can be run to track performance on a variety of indicators, including 10 predetermined stroke performance measures. These 10 measures focus on early identification and treatment with tPA, prevention of in-hospital complications, and secondary stroke prevention. The performance measures are as follows:

• DVT prophylaxis
• Discharged on antithrombotics
• Patients with atrial fibrillation receiving anticoagulation therapy
• tPA considered
• Antithrombotic medication within 48 hours of hospitalization
• Lipid profile
• Screen for dysphagia
• Stroke education for patient/family
• Tobacco cessation counseling for patient/family
• Plan for rehabilitation considered

The Mobile Stroke Team and Hospital Network

In some cities, coordinating stroke treatment efforts among multiple hospitals has been helpful.^9,10 In these cases, a single stroke code team is mobile and travels between the hospitals. The mobile stroke team allows specialized stroke care to be provided to hospitals that by themselves may not have such resources, while avoiding time delays and costs incurred through transfer of a patient to a single site.

Conclusion

Rapid recognition and treatment for the patient with acute stroke can improve clinical outcomes. A coordinated multidisciplinary effort is necessary to accomplish this goal. The establishment of a stroke team and adherence to the recommendations for a Primary Stroke Center can provide a clear framework for development of a successful program.

Multimedia

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Media file 1: Interdisciplinary practice standard for the emergency department (includes ischemic stroke, transient ischemic attack, intracerebral hemorrhage, and subarachnoid hemorrhage).

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Media file 2: Interdisciplinary practice standard for the intravenous administration of tPA in acute ischemic stroke.

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Media file 3: tPA dosing chart.

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Media file 4: tPA administration instructions.

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Media file 5: Interdisciplinary practice standard for the inpatient management of ischemic stroke and transient ischemic attack (TIA).

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Media file 6: Interdisciplinary practice standard for the inpatient management of intracerebral hemorrhage.

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Media file 7: Interdisciplinary practice standard for the inpatient management of subarachnoid hemorrhage.

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Media file 8: Admission order set for stroke/rule out stroke/transient ischemic attack.

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Media file 9: Post-tPA order set.

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Media file 10: Aneurysmal subarachnoid hemorrhage order set.

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Media file 11: Craniotomy for aneurysm: ICU postoperative orders

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Media file 12: Ruptured aneurysm: Postembolization orders.

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Media file 13: Transfer protocol.

Keywords

stroke team, tissue plasminogen activator, tPA, stroke, acute stroke, stroke code team, stroke treatment, stroke warning signs, treatment of acute stroke, stroke management, emergency medical services, EMS, emergency department, CT scanning

The authors would like to acknowledge the contributions of the interdisciplinary team at Oregon Health & Science University for their dedication and caring for stroke patients.

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