TELENEUROLOGY: STREAMLINING CARE OF STROKE PATIENTS IN EMERGENCY ROOMS
Benjamin McPherson, BSN, RN; Carri Carson, BSN, RN, CEN; Debra Littlefield, BSN, RN; Kelly Bernatene, BSN, RN; Jessica Dyson, RN, CEN; Leighann Wells, BSN, RN; Joseph Zink, BSN, RN, CEN
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Session A presented Thursday, September 14, 2017
Purpose: Patients in Emergency Departments(EDs) that are having strokes now have an opportunity to receive endovascular therapy(EVT) for improved outcomes.1,2,3 Unfortunately, most hospitals cannot provide this care. There is variability and inconsistency in practice among providers creating a need to use tele-medicine to help streamline care of patients in EDs so that the treatment can be consistently faster to appropriate facilities.
Design: This project was developed by a focus group that breated the tele-neurology team and disseminated the project to 21 hospitals to implement individually before a predetermined go live date. Stakeholder departments had small work groups that developed their plan of action with the implementation of tele-neurology.
Setting: The hospital is an urban level II trauma center that is a primary stroke center with 46 beds and treats approximately 400 people per day. We have about 30 stroke alerts each month and approximately 70-80 patients receive alteplase(t-PA) per year. This was the beta site after a much smaller rural alpha site.
Participants/Subjects: All patients were included that presented to the ED via ambulance that were experiencing stroke-like symptoms with a last known well time(LKWT) of less than 6 hours. Prior to arrival the RN taking the radio report from the paramedic would receive a phone call to acquire patient identifiers. The patient’s electronic medical record would be available in the system prior to arrival for physician auditing. This same RN would call the tele-neurologist and operator directly to activate a stroke alert. The RN would assist the tele-neurologist and ED physician examining the patient, checking blood glucose, starting intravenous catheters(IVs), and vitals including a weight which he or she would then begin calculating the dose of the t-PA before the drug was even ordered. The calculated dose would then be entered into the IV pump which would be put on standby until the t-PA arrived from pharmacy. If (t-PA) was given the primary RN would begin post t-PA monitor and help coordinate transport to a comprehensive stroke center if necessary.
Methods: Approximately 60 stroke simulations were completed in under a month to teach a department of 200 nurses leading up to the go live date. Also a small group of nurses helped to determine how best to implement this new process via several meetings. Interventions included a special t-PA checklist, a box that contains all necessary equipment, devoted portable monitoring and computers, and hyperlinks on the charting software that allow faster calculations and tracking.
Results/Outcomes: The goal was to decrease the door-to-needle(DTN) times thus improving patient outcomes and decreasing length of stay. DTN times prior to the project was a median of 43 minutes(min) on average on 58 patients in 11 months. After the go live date there was an 8 min shorter median DNT compared to patients before (p < 0.0001) on 88 patients in 13 months.
Implications: This program when implemented by ER managers and performed by ER nurses can make significant decreases in DTN times which have been linked to better outcomes for patients and decreased length of stay.
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