You are in: eMedicine Specialties > Neurology > Neuro-vascular Diseases Stroke Team Creation and ManagementArticle Last Updated: Jan 11, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 8
  Author: Helmi L Lutsep, MD, Associate Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center Helmi L Lutsep is a member of the following medical societies: American Academy of Neurology and American Stroke Association Coauthor(s): Wayne M Clark, MD, Director of Oregon Stroke Center, Department of Neurology, Professor, Oregon Health Sciences University Editors: Richard M Zweifler, MD, Professor, Director of Stroke Center, Director of Neurosonology Lab, Director of Vascular Neurology Fellowship, Director of Medical Student Education, Department of Neurology, University of South Alabama; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center; Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital; Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants Author and Editor Disclosure Synonyms and related keywords: tissue plasminogen activator, tPA, emergency medical services, EMS, emergency department, ED, computed tomography scanning, CT scanning, pharmacy, stroke treatment, stroke warning signs, treatment of acute stroke, stroke management INTRODUCTIONSection 2 of 8
  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. 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), computed tomography (CT) scanning, and pharmacy. 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 its role. For excellent patient education resources, visit eMedicine's Stroke Center. Also, see eMedicine's patient education article Stroke. THE STROKE TEAMSection 3 of 8
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, radiology, and physical medicine and rehabilitation. Development of the team often requires early inputs from the hospital's administration to enhance problem solving and integration between services. PREHOSPITAL NEEDSSection 4 of 8
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. Primary care providers should encourage patients' use of the EMS system. Since they 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. EMS providers can assist the treatment process further by establishing the time of onset of stroke symptoms. 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 NEEDSSection 5 of 8
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 the development of a stroke pathway ("critical" or "collaborative" pathway or caremap), a multidisciplinary care plan tailored to the specific hospital's needs. The pathway outlines the role of each ED member and the protocol to be followed. In any pathway, 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. 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. 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. 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 rapidly available. 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. MONITORINGSection 6 of 8
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 pathway 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 MOBILE STROKE TEAM AND HOSPITAL NETWORKSection 7 of 8
In some cities, coordinating stroke treatment efforts among multiple hospitals has been helpful. 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. REFERENCESSection 8 of 8
Stroke Team Creation and Management excerpt Article Last Updated: Jan 11, 2007 |
