Acute Stroke Management

an ED perspective

Tanya Frost

Acute Stroke Nurse

Eastern Health

Overview

bull Little about me

bull Stroke Care aims

bull Treatments

bull Streamline of service regardless of access

bull Treatment Times

Box Hill Hospital

bull Primary Stroke Centre

bull Situated in the Eastern Suburbs of Melbourne

bull 621 Bed tertiary Hospital (Monash University)

bull Catchment = 2800km Population = 850000

Maroondah Hospital

bull A little further outhellip Eastern Suburbs

bull Even further outhellip Eastern Suburbs

Angliss Hospital

Stroke is a medical emergency

bull Second largest cause of death

bull Leading cause of disability

bull 15th of all strokes occur in people under 55 years old

bull 15th die within 1 month

bull 13rd die within 12 months

bull 88 of survivors live at homendash Most with persistent disability

bull Cost burden of asymp $214 billionyear

Stroke Care

bull Recognition of Symptoms

ndash Access help

bull Diagnose stroke

ndash where is the lesion

ndash Focal neurological signs

bull Treat as able

ndash tPA

ndash ECR

ndash Fever Sugar Temperature

access tohellip

bull Stroke Unit Care

bull Secondary Prevention

ndash Medications

ndash Education

ndash Risk Factor modification

bull Mechanism

ndash Large Vessel

ndash Cardio embolic

ndash Small artery occlusion

ndash Stroke of other determined

etiology

ndash Stroke of undertermined

etiology

ndash Unknown

bull Allied Health

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Overview

bull Little about me

bull Stroke Care aims

bull Treatments

bull Streamline of service regardless of access

bull Treatment Times

Box Hill Hospital

bull Primary Stroke Centre

bull Situated in the Eastern Suburbs of Melbourne

bull 621 Bed tertiary Hospital (Monash University)

bull Catchment = 2800km Population = 850000

Maroondah Hospital

bull A little further outhellip Eastern Suburbs

bull Even further outhellip Eastern Suburbs

Angliss Hospital

Stroke is a medical emergency

bull Second largest cause of death

bull Leading cause of disability

bull 15th of all strokes occur in people under 55 years old

bull 15th die within 1 month

bull 13rd die within 12 months

bull 88 of survivors live at homendash Most with persistent disability

bull Cost burden of asymp $214 billionyear

Stroke Care

bull Recognition of Symptoms

ndash Access help

bull Diagnose stroke

ndash where is the lesion

ndash Focal neurological signs

bull Treat as able

ndash tPA

ndash ECR

ndash Fever Sugar Temperature

access tohellip

bull Stroke Unit Care

bull Secondary Prevention

ndash Medications

ndash Education

ndash Risk Factor modification

bull Mechanism

ndash Large Vessel

ndash Cardio embolic

ndash Small artery occlusion

ndash Stroke of other determined

etiology

ndash Stroke of undertermined

etiology

ndash Unknown

bull Allied Health

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Box Hill Hospital

bull Primary Stroke Centre

bull Situated in the Eastern Suburbs of Melbourne

bull 621 Bed tertiary Hospital (Monash University)

bull Catchment = 2800km Population = 850000

Maroondah Hospital

bull A little further outhellip Eastern Suburbs

bull Even further outhellip Eastern Suburbs

Angliss Hospital

Stroke is a medical emergency

bull Second largest cause of death

bull Leading cause of disability

bull 15th of all strokes occur in people under 55 years old

bull 15th die within 1 month

bull 13rd die within 12 months

bull 88 of survivors live at homendash Most with persistent disability

bull Cost burden of asymp $214 billionyear

Stroke Care

bull Recognition of Symptoms

ndash Access help

bull Diagnose stroke

ndash where is the lesion

ndash Focal neurological signs

bull Treat as able

ndash tPA

ndash ECR

ndash Fever Sugar Temperature

access tohellip

bull Stroke Unit Care

bull Secondary Prevention

ndash Medications

ndash Education

ndash Risk Factor modification

bull Mechanism

ndash Large Vessel

ndash Cardio embolic

ndash Small artery occlusion

ndash Stroke of other determined

etiology

ndash Stroke of undertermined

etiology

ndash Unknown

bull Allied Health

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Maroondah Hospital

bull A little further outhellip Eastern Suburbs

bull Even further outhellip Eastern Suburbs

Angliss Hospital

Stroke is a medical emergency

bull Second largest cause of death

bull Leading cause of disability

bull 15th of all strokes occur in people under 55 years old

bull 15th die within 1 month

bull 13rd die within 12 months

bull 88 of survivors live at homendash Most with persistent disability

bull Cost burden of asymp $214 billionyear

Stroke Care

bull Recognition of Symptoms

ndash Access help

bull Diagnose stroke

ndash where is the lesion

ndash Focal neurological signs

bull Treat as able

ndash tPA

ndash ECR

ndash Fever Sugar Temperature

access tohellip

bull Stroke Unit Care

bull Secondary Prevention

ndash Medications

ndash Education

ndash Risk Factor modification

bull Mechanism

ndash Large Vessel

ndash Cardio embolic

ndash Small artery occlusion

ndash Stroke of other determined

etiology

ndash Stroke of undertermined

etiology

ndash Unknown

bull Allied Health

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Stroke is a medical emergency

bull Second largest cause of death

bull Leading cause of disability

bull 15th of all strokes occur in people under 55 years old

bull 15th die within 1 month

bull 13rd die within 12 months

bull 88 of survivors live at homendash Most with persistent disability

bull Cost burden of asymp $214 billionyear

Stroke Care

bull Recognition of Symptoms

ndash Access help

bull Diagnose stroke

ndash where is the lesion

ndash Focal neurological signs

bull Treat as able

ndash tPA

ndash ECR

ndash Fever Sugar Temperature

access tohellip

bull Stroke Unit Care

bull Secondary Prevention

ndash Medications

ndash Education

ndash Risk Factor modification

bull Mechanism

ndash Large Vessel

ndash Cardio embolic

ndash Small artery occlusion

ndash Stroke of other determined

etiology

ndash Stroke of undertermined

etiology

ndash Unknown

bull Allied Health

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Stroke Care

bull Recognition of Symptoms

ndash Access help

bull Diagnose stroke

ndash where is the lesion

ndash Focal neurological signs

bull Treat as able

ndash tPA

ndash ECR

ndash Fever Sugar Temperature

access tohellip

bull Stroke Unit Care

bull Secondary Prevention

ndash Medications

ndash Education

ndash Risk Factor modification

bull Mechanism

ndash Large Vessel

ndash Cardio embolic

ndash Small artery occlusion

ndash Stroke of other determined

etiology

ndash Stroke of undertermined

etiology

ndash Unknown

bull Allied Health

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Research

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

What is strokehellip

Acute loss of oxygen supply

Therefore the aim is

Return of oxygen supply

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

tPA

bull Thrombolytic given within 45hrs of Sx onset

bull Not appropriate for every patient

bull Angioedema 1-2

ndash Associated with ACEi use

ndash Antihistamine and steroid

bull Bleeding Risk

ndash Symptomatic Haemorrhage 4-6

ndash Other bleeding

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

ECR

bull Endovascular clot retrieval

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

ECR Suitability

Slid

e u

se

d w

ith

pe

rmis

sio

n o

f D

r B

ruce

Cam

pb

ell

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Boehringer Ingelheim

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

The ldquogolden hourrdquo

T=0

Suspected

stroke patient

arrives at

stroke unit

le10 min

Initial MD evaluation

(including patient

history lab work

initiation amp NIHSS)

le 15 min

Stroke team

Notified

le 25 min

CT scan

initiated

le 45 min

CT amp labs

interpreted

le 60 min

rt-PA

given if patient

is eligible

Slide courtesy of Skye Coote

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

The ldquogolden half-hourrdquo

T= -10

Suspected

stroke patient

hospital

pre-notification

Stroke team

Notified

0 min

Patient arrives

Met at triage by

stroke and ED team

le 10 min

Triage

direct-to-CT

rapid (basic)

stroke assessment

IVB

le 25 min

CT scan

completed amp

interpreted

le 30 min

t-PA

given if patient

is eligible

Slide courtesy of Skye Coote

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

bull Pts who arrive within

the golden hour are

twice as likely to be

treated

bull Improved patient

outcomes

andhellip

bull Walk out of hospital

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Identification of Stroke

bull An immediate life threatening emergency

needing an ambulance may include

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Ambiguous stroke Sx

bull Dizziness

bull Drowsiness

bull Visual disturbance

bull Ataxia

bull Numbness

bull Tingling

bull Canrsquot understand surroundings

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Ambulance Pre-notification

bull Patients name amp DOB

bull Quick story

ndash Symptoms

ndash Time of onset

ndash Vitals signs amp GCS

bull 18G IVC (if able)

bull ED ldquoCode strokerdquo paged

bull CT freed

bull Labels created

bull Pt remains on AV monitor

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Code Stroke

bull Pt met at door by

ndash Stroke Nurse

ndash Stroke Registrar

ndash HMO

bull Assessed for suitability for

direct to CT

ndash ABCD (Brief)

ndash Verify patient details- labels

ndash Triage is brief (Cat 2)

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Direct to CT

bull Walk and Talk stroke assessments

bull Senior clinician begins assessing

bull Pt transferred onto CT table

ndash Off stretcher time

bull Non Contrast CT Brain

ndash Rule out blood

ndash HMO ndash IVC and pathology

bull Red stream staff bring equipment

ndash Trolley airway basket monitoring

bull CT Angiogram amp Perfusion

ndash Routine investigation

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

CT interpretation

bull Real time review

bull NIHSS- stroke

assessments continue

bull Call to Consultant

bull Swap monitors

bull Contact familyGP

bull tPA decision made

ndash Give tPA on CT table

ndash Must have all informationhellip

bull LVO- ECR consideration

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Victorian Stroke Telemedicine

bull What every stroke patient needs

ndash Identification

ndash CT

ndash Onset time

ndash Bleeding Risk past history and

medications

bull Process the same though the

team is different

ndash Time factors

bull Read the CT scanhellip

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Thrombolysis

bull CT- back to cubicle

bull Undressed and checked

bull Connected to monitor

bull 12 Lead ECG

bull +- second IVC

bull Explanation to pt and family

bull Paperwork

bull Considerations for transfer out

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

DIDO

bull Door in Door Out Time

bull How long does it take to get

ndash Story

ndash CT scan

ndash Contraindications to treatment

ndash Decision to treat

ndash Pt out the doorhellip ECR 37 for the year

Best 41 mins

Longest 227 mins

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Stroke Team

bull Stroke Nurse ED Nurse

bull Registrar 247

bull HMO ED Dr

bull CT notification

bull Labels

bull Equipment

bull Run an acute stroke

presentation like a

codehellip

bull Everyone has their

roles

bull BHH Ed has similar

(if not better) DTN

times out of hours

as in hours

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Barriers to treatment

bull Public awareness of stroke symptoms ndash delayed presentation

bull Ambulance calls go through central base and ED

ndash not direct to stroke teamneurologist

bull Lack of response to ambulance pre-notification

ndash team not present on patient arrival

ndash May have implications for future notifications

bull Lack of stroke recognition by ED staff

ndash Delays in calling Code Stroke

bull Stroke trials with extended time frames keeping ED informed

bull Going via resus for monitoring and assessment

bull ED resources

bull Awaiting results of multi-modal images to make a decision

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Barriers to treatment

bull ED medical review before notification to stroke doctor

ndash Despite ambulance notification of a stroke patient

ndash Impact on calling in after-hours radiography staff

bull Time delay in calling stroke doctor

ndash Time taken for stroke doctor to come in to hospital

bull Radiographer offsite after 7pm ndash limited cover

ndash Lack of in-house CT interpretation

ndash off site service ndash slow

bull Reduced staff to assist with drawing up

ndash delayed CTndashN times

bull Delays in CT images being loaded for external viewing

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Enablers to treatment

bull Being a stroke thrombolysis receiving hospital

bull Ambulance preference

bull Increased frequency of stroke increases ED awareness

ndash notifications

bull More than one CT scanner

ndash Relationship with CT staff

bull Team work across multiple disciplines

bull Role definition

bull Champions

bull Executive buy in

bull Medical support

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Take Home message

bull Think FAST

bull Nothing can be decided without a CT

bull Stroke team are the people around you

bull Get expert helphellip VST

bull Transfer protocols

bull Efficiency and safety

bull Despite your size you can have massive

impacthellip

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

Referencesbull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163

bull Collateral flow predicts response to endovascular therapy for acute ischaemic stroke

bull A randomised trial for tenecteplase versus alteplase for acute ischaemic stroke

bull Antithrombotic therapy for acute Ischaemic stroke

bull Mr clean and memery lapses

bull Mr rescue emerging therapy critiques

bull Developing practice reccomendations for endovascular revascularisation for acute ischaemic stroke

bull Endovascular treatment for acute ischaemic stroke Stroke Collateral flow Predicts Response to Endovascular Therapy for Acute Ischaemic

Stroke201142693-699)

bull httpmusommarshalledugraphicdesignibooksNervous20NormalhtmlprettyPhoto[pp_gal]9

bull Lippencotts Illustrated reviews Neuroscience

bull Mr Clean Polishes Stroke Outcome with endovascular therapy

bull Endovascular Mechanical Thrombectomy of an occluded superior division branch of the L) MCA for acute cardioembolic stroke

bull Predictors of functional dependance despite successful revascularisation in large vessel occlusion strokes

bull Stroke The Impact of Recanalization on Ischemic Stroke Outcome A Meta-Analysis Joung-Ho Rha and Jeffrey L Saver Stroke 200738967-973

originally published online February 1 2007

bull Clinical guidelines for acute stroke management 2010

bull Lees et al Lancet 20103751695-1703

More References

bull Nursing Critical Care Issue Volume 11(3) May 2016 p 28ndash36

bull Lackland DT Roccella EJ Deutsch AF et al Factors influencing the decline in stroke mortality a statement from the American Heart

AssociationAmerican Stroke Association Stroke 201445(1)315ndash353

bull Bhatia R Hill M D Shobha N Menon B Bal S Kochar P Demchuk A M (2010) Low Rates of Acute Recanalization With Intravenous

Recombinant Tissue Plasminogen Activator in Ischemic Stroke Real-World Experience and a Call for Action Stroke 41(10) 2254-2258 doi

101161strokeaha110592535

bull Berkhemer O A Fransen P S S Beumer D van den Berg L A Lingsma H F Yoo A J Dippel D W J (2015) A Randomized Trial of

Intraarterial Treatment for Acute Ischemic Stroke New England Journal of Medicine 372(1) 11-20 doi doi101056NEJMoa1411587

bull Campbell B C V Mitchell P J Kleinig T J Dewey H M Churilov L Yassi N Davis S M (2015) Endovascular Therapy for Ischemic

Stroke with Perfusion-Imaging Selection New England Journal of Medicine 372(11) 1009-1018 doi doi101056NEJMoa1414792

bull Goyal M Demchuk A M Menon B K Eesa M Rempel J L Thornton J Hill M D (2015) Randomized Assessment of Rapid Endovascular

Treatment of Ischemic Stroke New England Journal of Medicine 372(11) 1019-1030 doi doi101056NEJMoa1414905

bull Saver J L Goyal M Bonafe A Diener H-C Levy E I Pereira V M Hacke W (2015) Stent-retriever thrombectomy after intravenous t-PA

vs t-PA alone in stroke New England Journal of Medicine

bull Jovin T G Chamorro A Cobo E de Miquel M A Molina C A Rovira A Daacutevalos A (2015) Thrombectomy within 8 Hours after Symptom

Onset in Ischemic Stroke New England Journal of Medicine 372(24) 2296-2306 doi doi101056NEJMoa1503780

bull Goyal M Menon B K van Zwam W H Dippel D W J Mitchell P J Demchuk A M Jovin T G Endovascular thrombectomy after large-

vessel ischaemic stroke a meta-analysis of individual patient data from five randomised trials The Lancet doi 101016S0140-6736(16)00163-X

Thank you

bull Tanya Frost

Acute Stroke Nurse

TanyaFrosteasternhealthorgau

Thank you

bull Tanya Frost

Acute Stroke Nurse

TanyaFrosteasternhealthorgau