Guidelines for Resident Rotation in the Stroke Service
A. General Information:
- Rounds every morning @ 10:30am with Dr. Kase, Dr. Romero; times for Dr. Babikian and Dr. Nguyen TBA daily.
- All patients need to be assessed by both the PGY2 and PGY 3 (unless PGY 3 is doing consults) prior to rounds with attending.
- Stroke pathways are started on all patients diagnosed with ICH, SAH, TIAs & ischemic stroke in the ER. Day One on the medical floor is the first day of admission.
- Contact PCP on admission and discharge (by phone or email) & document this contact or attempted contact in the chart in discharge summary.
- Use the sunrise stroke template orders for all patients admitted to the stroke unit.
- All stroke pt should have PT/OT, MRI/A, TTE w/bubble, INR, Random glucose, creatinine, Fasting lipid panel, HbA1C, and Homocysteine orders. Consider speech therapy evaluation for patients with swallowing issues, dysarthria, or language impairment.
- Young (< 50yo) pt should have hypercoag w/u (Lupus Anticoagulant, Cardiolipin Abs, Protein C and Protein S activity, AT III activity, Factor V Leiden and Prothrombin gene mutation, activated protein C resistance,- consider HB electropheresis, beta-2 Glycoprotein 1 Abs, MTHFR mutation and HIT antibodies in specific situations) and serum + urine tox screen.
- If there is a contraindication for any of the above please document.
- PLEASE USE THE DISCHARGE ORDER IN THE STROKE PATHWAY! (This is important for our data registry and tracked by SCM)
- Use the admission worksheet to help organize patient care (optional but helpful)
- All Stroke patients are to be NPO until a Dysphagia screening is performed. If patient is to remain NPO, please assure patient has a Dobhoff or NG tube to be able to administer meds. If this is not possible, please assure meds are ordered IV or PR . ie: antithrombotics, antihypertensives. If patient is on tube feeds and needs to lie flat for CT or anything else, please remind nursing staff to turn off tube feeds.
- If patients are NPO for a procedure or another reason, please assure IV fluids are ordered overnight.
- BP parameters written for all Stroke/ICH/SAH patients.
- All stroke patients who are deemed eligible for either in-patient or out-patient rehab will need Rehab consult in addition to PT/OT.
- All diabetic patients should have a diabetes team consultation.
- Daily multidisciplinary rounds at 10 AM to communicate with nurses, case managers and social services; Required to ensure all disciplines are in agreement and know the patient issues and plan of care and evaluation of treatment.
- Email Stroke, ENC and ICU signouts to Judy every Sat, Sun and holiday-Needed for Stroke log to track patients
- Use templated Stroke H & P for admission note. Do not skip requested items.
- Discharge summaries must include the following:
- Stroke f/u clinic date, time, and location
- Contacted PCP (by phone or email). PCP appointment
- Name and address of PCP (massmedboard.org)
- Summary of stroke syndrome, evaluation, and mechanism of stroke to explain rationale for treatments used, and what secondary prevention measures were used. If one not used (for instance statins or Coumadin for afib) must document why.
- Discharge mRS and NIHSS, d/c PE and BP
- Outstanding issues (labs to follow, repeat imaging, etc)
- CHECK on every patient: that they are discharged on:
- Intensive statin treatment if documentation of large vessel artherosclerosis (If not discharged on one of these med categories, state reason, N/A is not an acceptable reason)
- If patient has a history of Afib or has afib in hospital document if d/c on Coumadin or document why not.
- Attending @ time of d/c is the one who the d/c summaries are forwarded to for signature
- Name of facility d/c to (home, SNF, acute rehab)
- Use Discharge from Stroke Pathway order to d/c
- Progress notes are required to be written on day of discharge.
C. Acute Stroke Cases: DPH and GWTG requirements for Primary Stroke Center Certification.
- The goal is to achieve fast door to needle times in appropriately selected patients. Current guidelines are < 60 minutes, other stroke centers are achieving this in as fast as 20 or 30 minutes (i.e. Germany).
- Resident will go immediately to the acute cases
- Resident will contact fellow or an attending ASAP of possibility of acute case
- Resident will be expected to present pt’s brief HPI, NIHSS score, imaging and indications/contraindications for t-PA. t-PA should be initiated w/the OK from fellow/attending as they are on route. Stroke attending or fellow will contact ED attending regarding resident starting t-PA.
- Note that for inclusion of the patient for acute treatment, accurate knowledge of Last Known Well and Discovery of Symptom date/time is essential, please use all resources to clarify this information (i.e. talk to ER staff, nurse, EMS technician, relatives as needed).
- If intervention is anticipated (i.e. IV t-PA or IA) resident must recruit stroke fellow for help early on.
- If the patient time of arrival to BMC is < 4.5 hours, answer “Yes” in SCM and accurately fill out all pertinent times. (Essential for tracking acute cases)
- Contraindications and warnings/cautions can be found on this site http://bmc.org/stroke.
- Fill out MRI screening form in ED
- Be aware of each patient’s HCP/Guardianship status on admission. Social Worker will obtain HCP’s on all possible patients. If the patient is not able to make their own decisions, guardianship paperwork will be started. Please fill out MD portion ASAP to prevent delays.
D. Helpful Tidbits:
- Please feel free to direct all questions to Judy Clark. She is one of your important resources during your Stroke Rotation. Judy will:
- Help to facilitate discharge planning with the case managers
- Problem solve difficulties w/ other services, nursing, case management, rehab, etc
- Assure compliance with GWTG
- Schedule Stroke f/u
- Assist with Stroke Education
- Logistical Help
- Call MRI and speak with the Radiologist to facilitate emergent need for Stroke MRIs; speak to MRI technologists once authorized by radiologist to expedite the test.
- When ordering TEE refer to handouts
- When ordering ultrasound “CAROTID/VERTEBRAL DUPLEX”
- MassHealth prior Authorization forms http://www.internal.bmc.org/pharmacy/outpatient/welcome.htm
- Computer Desktops have Core Collection of Stroke Papers from the International stroke conference
- Things to keep in mind for any patient with stroke
- Dysphagia and swallow screen must always be done (even if it seems like the patient can swallow and is 100% normal) to ensure no risk of aspiration. You have to document that the patient was NPO if he fails the screen.
- EKG on admission, cardiac enzymes at least x2, and telemetry on all stroke patients (they often time will have cardiac arrhythmias due to CNS dysfunction leading to abnormal activation of the parasympathetic and sympathetic nervous systems, sometimes evolving to subendocardial damage and real MIs).
- CBC, and general chem panel to ensure electrolyte abnormalities are corrected.
- Labs that are necessary for the stroke work-up: CBC, chem 10, fasting lipid panel, HBA1c, TSH/ FT4, serum and urine tox screens. Would consider ESR, CRP, homocysteine, hypercoagulable panel (see # 16 below) on an as needed basis depending on the case. Not everyone needs B12, folate, RPR etc, unless there is clinical suspicion that these will be helpful somehow.
- DVT prophylaxis on all patients c/ ischemic stroke. For hemorrhagic strokes, DVT ppx can be started after 48h of stroke if bleeding is stable (i.e., no progression).
- Smoking cessation should be ordered on all the smokers and consider nicotine patch/ gum/ electric cigarette. Always counsel the patient on smoking cessation with each clinical encounter (data shows that patients that are counseled while in house have a 40% higher likelihood of quitting smoking).
- Antiplatelets when appropriate, statins, and diabetes teaching/ consult if a new diagnosis. High dose statins (e.g. atorvastatin 80 mg, crestor 20 mg) should be given for patients with significant large vessel atherosclerosis.
- Early mobilization is key!! We are trying to get the nurses to help us more with this, so continue to insist as much as you can! It is the nurses's responsibility to get the patients OOB to chair (they do NOT have to wait for PT/ OT to do so). Patients should be out of the bed as soon as possible and as soon as you feel safe. Please ensure the mobility orders state OOB to chair.
- Hydration… never forget to hydrate your stroke patient. They will often tank as they don’t get food in the first 24h, are stuck in the ED etc!
- Early feeding is important, so if you feel your patient will not pass the swallow screen at all please place a Dobhoff sooner rather than later and start enteral meds and tube feeds. Such a simple measure can avoid clinical decompensation in the first 12-124h of a stroke.
- Make sure to complete ALL the mandatory checkboxes for the H&Ps before the Attendings can sign off.
- Dr. Kase asked that we ensure that PCPs are always contacted upon admission, and arrange follow up with them.
- Discharge summaries should be sent to all PCPs.
- Consult and H/P notes should all include meds, PMH, SH, FH, and the stroke pathway.
- It is recommended you do the NIHSS CD video or watch the explanation on the AHA website (http://learn.heart.org/ihtml/application/student/interface.heart2/nihss.html) at least once so you can know all of the stuff for rt-PA and to understand how to triage appropriately in the ER.
- The hypercoagulable panel, when needed, should include the following: Protein C and Protein S activities (different than the antigens), Antithrombin III activity, homocysteine, activated protein C resistance, Factor V Leiden, prothrombin gene mutation (G20201A mutation), lupus anticoagulant, anticardiolipin antibodies (and if the last two are neg, then check beta 2 glycoprotein 1 antibodies), hemoglobin electrophoresis, ESR, CRP, ANA. Consider MTHFR gene mutation, HIT antibodies and cancer work-up if clinical suspicion.
- Please don’t forget to do a sign-off note on all of the stroke consult patients with our final recommendations.
- Please call patient’s family within 36 hours of admission and before discharge.
Stroke resident rotation guideline available on: http://bmc.org/stroke-cerebrovascular/services/stroke-resident-rotation-guide.htm