Door to ct time for strokes

JDougRN, BSN, RN · Jan 31, 2011

Our Ed is in the hospital that is the "Stroke Hospital"- We have a really great MD who runs it- We have stroke guidelines- anyone suspected, we as nurses can call a stroke alert- Immediatly EKG, LAB, MD shows up to do what they need to do, and usually we hit CT scan within 10 minutes, unless the pt. isn't clinically stable enough to go- I believe stroke alerts are called a bit too often, but we have a specific set of guidelines to folllow- I've been in our ED for just a few months, but have given TPA to a 60 yo pt. who presented with total right sided loss, and was moving/feeling the right by the time I got her transfered to the ICU. It was amazing- we even have a seperate "sheet" on our computer charting- If a stroke alert is called, we have to document ime of arrival, time called, time RN was in, time MD was in, time to CT scan, ect. It's pretty impressive. Go DR. Brehaut, lol!

Editorial Team / Moderator · Jan 31, 2011

This is a great resource: http://stroke.ahajournals.org/

I did a project on the increasing windows of tPA administration during my BSN coursework, and there are a lot of free and interesting articles on stroke studies available through that site. There have been numerous trials and studies that constantly shape the way we treat strokes, and I imagine that the door-to-CT and other best practices originated from all the data.

USIJurgy · Feb 3, 2011

Our door to CT time is 20 minutes. There is no delay for IV or EKG (unless an unsafe rhythym is identified once the patient is placed on a portable monitor). It is OK for an RN to activate the stroke code and transport to CT with ACLS meds and equipment as long as the patient has no seizure history and has a stable blood glucose if the MD is not at the bedside within 10 minutes of presentation. CT results should be availble within 30 minutes and thrombolytic therapy should begin within one hour of presentation. I work in a 60,000 visit per year ER.

We activate a stroke code for any patient presenting with a positive Cincinnati scale (droop, drift, or slurred speech) within 8 hours of arrival (even though IV thrombolytic therapy can only be given within 3 [i think thats the new guideline] hours of onset of symptoms). Just because they arent eligible for IV tPA doesn't mean they aren't eligible for Merci Clot Retrieval or something similar. Patients who wake up with the symptoms are not considered stroke codes because you don't know the actual onset. A good question to ask family is "When was the last time you saw him normal?"

Hope this helps!

mwboswell · Feb 4, 2011

In answer to the original poster's question as to where these time guidelines come from: The American Stroke Association developed "best practice" guidelines called "Get with the guidelines" (GWTG) and they are recommended as the standard of care for acute CVA. The Joint Commission of Accreditation of Hospitals (Joint Comission) adopted these guidelines and uses them as the benchmark to evaluate for when a facility applies to be recognized as a certified stroke center. You can download the 10 Best Practice Guidelines from the American Stroke Association at :

http://www.bemetweb.com/docs/ASAGWTGCVA.pdf

mcknis · Feb 9, 2011

My facility acts as a spoke to one of the central ohio stroke centers and we currently are using the ASA guidelines for timing. Door - MD time of 10 minutes. Door - CT 25 minutes. Door - CT read 45 minutes. We only recently (less than 1 year) have been following these national guidelines, and prior to this, were simply acting upon sx and shipping the pt out. Now all RNs are certified in acute stroke presentation sx (4 hr physician clinical course) and are in direct communication to the stroke center via wireless video conferencing. Pretty cool stuff for being in 25 bed ER that must send out all Stroke sx pts!

ZooMommyRN, ADN, RN · Feb 19, 2011

if we think it's a stroke we can call a stroke alert, the pt then goes straight to CT, EMS can call it as well and the pt goes straight to CT on their stretcher then to ER for further eval.

miss81, BSN, RN · Mar 28, 2011

I wish we had this stoke alert! Sometimes our patients never get CT's (especially in the night) because our ER docs have to call the radiologist at home in the night time and the Neurologist at home and get the "ok"... then call in a Rad. tech in (from home) to do the CT scan. Even before that they are hesitant because "it might only be a palsy or something." We have come a long way with MI's but our stoke care needs an upgrade!

mwboswell · Mar 29, 2011

OH MY GOSH! That is CRAZY! To me it also screams of a potential liability! Unfortunately it sounds like your radiologists have been allowed to get LAZY as well as your ED MD's cause they don't push them to do the right thing. Up to 20-23% of all strokes can be HEMORRHAGIC and you NEED to know that when it happens before they herniate! YOU could become the champion for this and push for having CT done on every patient that meets "stroke criteria"....

All you have to do is paint the picture of how it is a serious liability waiting to happen.

You might also want to get in touch with your local ENA chapter or state council to see what resources you might have in your state to help support this endeavour.

Feel free to email me off list to discuss more if you like.

-MB

I wish we had this stoke alert! Sometimes our patients never get CT's (especially in the night) because our ER docs have to call the radiologist at home in the night time and the Neurologist at home and get the "ok"... then call in a Rad. tech in (from home) to do the CT scan. Even before that they are hesitant because "it might only be a palsy or something." We have come a long way with MI's but our stoke care needs an upgrade!

mwboswell · Mar 29, 2011

While I've heard of this being done - it's not highly advised, unless.... your ED MD can "briefly" do a quick primary survey (ABCD) and get a brief clinical on the patient. Takes a mere 60-90 seconds. There is a potential for bad outcomes for a patient the ED MD doesn't even know about if something "bad" happens in CT....

Also: it has been shown CONSISTENLY that the time-limiting step in achieving the stroke guidelines is getting the labs done. Almost no one has a problem getting a rapid CT done, but it's the blood draw, transport to lab and running it that consistently exceed the time guidelines.

if we think it's a stroke we can call a stroke alert, the pt then goes straight to CT, EMS can call it as well and the pt goes straight to CT on their stretcher then to ER for further eval.

gardengal1, ASN, RN · Mar 31, 2011

We follow the same guidelines as mwboswell has quoted

Natingale, EdD, RN · Apr 1, 2011

really nice poster ..short and to the point

http://www.activase.com/stroke/stroke_bestpractices.jsp