ENCSN Hospitals' Plans of Care Workgroup
Workgroup Goal: "Primary stroke centers and acute stroke capable hospitals establish and
consistently use clinical plans of care that are based on national guidelines and standards of care."
Workgroup chairs: Norman Taylor, Norman.Taylor@onslowmemorial.org
Next Meeting
March 16, 2010 (2PM-3PM)
Call-in # (866) 903-1314 Passcode: 20520096#
Hospitals' Plans of Care Meeting Minutes, 1/13/10
Hospitals' Plans of Care Meeting Minutes, 11/17/09
Hospitals' Plans of Care Meeting Minutes, 10/14/09
Hosptials' Plans of Care Meeting Minutes, 8/24/09
Hospitals' Plans of Care Meeting Minutes, 6/3/09
Hospitals' Plans of Care Meeting Minutes, 3/31/09
Hospitals' Plans of Care Meeting Minutes, 2/3/09
Hospitals' Plans of Care Meeting Minutes, 12/09/08
Plan of Care Development Resources
AHA/ASA Stroke Algorithm, based on the Get With The Guidelines Toolbox
American College of Emergency Physicians Article on tPA Litigation
- Emergency Physicians More Likely To Be Sued by Stroke Patients Who Do Not Receive tPA (February 2008)
Activase Stroke Team and Center Support
Guidelines and advice on coordination of care, NIH studies, and resources.
- Genentech Pocket Cards for Acute Ischemic Stroke
- Brain Attack Coalition List of Clinical Pathway Examples
- Brain Attack Coalition List of Stroke Scales (Hospital and Pre-Hospital)
- April 2007 Guidelines for the Early Management of Adults With Ischemic Stroke (AHA)
- Elements of a Primary Stroke Center (Brain Attack Coalition)
- July 2005 Recommended Elements of a Primary Stroke Center (Brain Attack Coalition)
- Activase Clinical Library
A Clinical Library of stroke-related articles that discuss the safety and efficacy of Activase, as well as the importance of stroke centers and early treatment.
- Stroke Assessment Tools
Tools to aid in the assessment, diagnosis, and treatment of stroke for you and your patients.
- Guidelines and consensus statements on the use of Activase (t-PA) in acute ischemic stroke
Stroke policy statements and guidelines from the American Academy of Neurology (AAN), the American College of Emergency Physicians (ACEP), the American Heart Association/American Stroke Association (AHA/ASA), and the Brain Attack Coalition (BAC).
- tPA Patient Fact Sheet from Activase (also available in Spanish on request)
- Telestroke networks throughout the United States (Network information current as of August 2009)
Go to the above link on the Activase website to find out more information about individual telestroke systems in the United States. New telestroke networks can further expand the reach of specialized stroke care to rural and underserved areas of the United States.
In North Carolina, stroke telemedicine systems exist at Wake Forest University Baptist Medical Center in Winston-Salem (contact Jonathan Bailey, Neuroscience Director, for more information or download brochure here), and at Forsyth Stroke and Neurovascular Center in Winston-Salem (a hub-and-spoke type system, Novant Neuro Science Solution Network).
Click here to see video clips of actual telestroke consultations on the NIH Stroke Scale from Partners TeleStroke Center in Boston, MA.
Regional Genentech (Activase) Contact
Pat McCormick
Clinical Specialist
Genentech USA
919-802-5214
mccormick.patricia@gene.com
Existing Collected Stroke Plans of Care:
DISCLAIMER: These listed Plans of Care are to be used as guides. These documents were shared with ENCSN before April 2009 and may not represent the most recent national guidelines or most recent protocols at each of these hospitals. A future goal of the HPC workgroup is to create a unified summary Plan of Care, however this project is still in development. We have posted these Plans so that Network members may have a starting point for the creation of their own Plans, and to see the formats of existing NC hospital Plans of Care. The information contained in each Plan of Care does not constitute medical or legal advice. Neither ENCSN nor the authors of the Plans of Care provided make any claim, promise or guarantee about the accuracy, completeness, or adequacy of the information contained therein, or that any Plan is appropriate for your particular use. Neither ENCSN nor any other party involved in the preparation of these Plans shall be liable for any damages, of any kind, resulting in whole or in part, from any user's use of or reliance upon this material. To receive the most up-to-date guidance on stroke protocol development, please participate in the monthly workgroup conference calls and request to be added to the HPC workgroup email list!
Onslow Memorial Hospital Stroke Plans of Care Documents (updated October 2009)
- ED Stroke Order Set
- Inpatient Stroke Order Set
- ED MEND Exam
- ED Alteplase Administration Protocol
- Nursing Dysphagia Screening Tool
- NIH Stroke Scale Assessment
Pitt County Memorial Hospital Plans of Care
Moses Cone Plans of Care
- Moses Cone Stroke-TIA Admission Orders
- Moses Cone tPA Administration Orders
- Moses Cone tPA Dose Administration
WakeMed Plans of Care
- WakeMed Non-Hemorrhagic Stroke-TIA Admission Orders
- WakeMed Possile Acute Stroke Inpatient Orders
- WakeMed IntraVenous t-PA (Alteplase) Thrombolytic Therapy
Acute Non-Hemorrhagic Stroke
Duplin General Hospital Plans of Care
Forsyth Stroke and Neurovascular Center
Carteret General Hospital
Carolinas Medical Center-Northeast
- Stroke Patient Information
- Anticipated Recovery Plan for Ischemic Stroke
- Consent for Administration of Intravenous tPA
- Thrombolytic Checklist for IVr-tPA
- Ischemic Stroke Interdisciplinary Form Page 1 of 2
- Ischemic Stroke Interdisciplinary Form Page 2 of 2
- Modified Rankin Scale
- New ECC Stroke Protocol
- Acute Ischemic Stroke non-tPA Protocol Page 1
- Acute Ischemic Stroke non-tPA Protocol Page 2
- Acute Ischemic Stroke tPA Protocol Page 1
- Acute Ischemic Stroke tPA Protocol Page 2
Iredell Memorial Hospital
- Dysphagia Screening Protocol
Note on this tool: Last Quarter (before August 2009), Iredell was at 100% compliance with dysphagia screening, up from 20% in years past. A Speech Therapist developed the tool that the ED actually uses.
Wilson Medical Center
- Wilson Medical Center Stroke Protocol (reviewed October 2009)
Also see the ENCSN Quality Improvement webpage for resources on Quality Measures!
Expanding the Window for Administration of tPA in Ischemic Stroke. Pharmacists Letter/Prescriber's Letter. July 2009~Volume 25~Number 250717.
AHA/ASA science advisory recommends use of tPA between three and 4.5 hours after stroke, from the ECASS III Trial (Stroke. 2009;40:2262.).
Patients who are eligible for treatment with rtPA within 3 hours of onset of stroke should be treated as recommended in the 2007 guidelines.1 Although a longer time window for treatment with rtPA has been tested formally, delays in evaluation and initiation of therapy should be avoided, because the opportunity for improvement is greater with earlier treatment.
rtPA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B). The eligibility criteria for treatment in this time period are similar to those for persons treated at earlier time periods, with any one of the following additional exclusion criteria: Patients older than 80 years, those taking oral anticoagulants with an international normalized ratio 1.7, those with a baseline National Institutes of Health Stroke Scale score >25, or those with both a history of stroke and diabetes. Therefore, for the 3-to-4.5–hour window, all patients receiving an oral anticoagulant are excluded regardless of their international normalized ratio. The relative utility of rtPA in this time window compared with other methods of thrombus dissolution or removal has not been established. The efficacy of intravenous treatment with rtPA within 3 to 4.5 hours after stroke in patients with these exclusion criteria is not well established (Class IIb Recommendation, Level of Evidence C) and requires further study.
Ancillary care for patients receiving rtPA at 3 to 4.5 hours after ischemic stroke should be similar to that included in the 2007 American Heart Association Stroke Council Guidelines.1
These recommendations, which are based on peer-reviewed publications, should be reevaluated after the results of regulatory agency review of detailed, nonpublicly available data are known. The recommendations use the American Heart Association’s classification of recommendations and levels of evidence shown in the Table.
Workgroup chairs: Norman Taylor, Norman.Taylor@onslowmemorial.org
Next Meeting
March 16, 2010 (2PM-3PM)
Call-in # (866) 903-1314 Passcode: 20520096#
- Emergency Physicians More Likely To Be Sued by Stroke Patients Who Do Not Receive tPA (February 2008)
- Genentech Pocket Cards for Acute Ischemic Stroke
- Brain Attack Coalition List of Clinical Pathway Examples
- Brain Attack Coalition List of Stroke Scales (Hospital and Pre-Hospital)
- April 2007 Guidelines for the Early Management of Adults With Ischemic Stroke (AHA)
- Elements of a Primary Stroke Center (Brain Attack Coalition)
- July 2005 Recommended Elements of a Primary Stroke Center (Brain Attack Coalition)
- Activase Clinical Library
- A Clinical Library of stroke-related articles that discuss the safety and efficacy of Activase, as well as the importance of stroke centers and early treatment.
- Stroke Assessment Tools
- Tools to aid in the assessment, diagnosis, and treatment of stroke for you and your patients.
- Guidelines and consensus statements on the use of Activase (t-PA) in acute ischemic stroke
- Stroke policy statements and guidelines from the American Academy of Neurology (AAN), the American College of Emergency Physicians (ACEP), the American Heart Association/American Stroke Association (AHA/ASA), and the Brain Attack Coalition (BAC).
- tPA Patient Fact Sheet from Activase (also available in Spanish on request)
- Telestroke networks throughout the United States (Network information current as of August 2009)
- Go to the above link on the Activase website to find out more information about individual telestroke systems in the United States. New telestroke networks can further expand the reach of specialized stroke care to rural and underserved areas of the United States.
In North Carolina, stroke telemedicine systems exist at Wake Forest University Baptist Medical Center in Winston-Salem (contact Jonathan Bailey, Neuroscience Director, for more information or download brochure here), and at Forsyth Stroke and Neurovascular Center in Winston-Salem (a hub-and-spoke type system, Novant Neuro Science Solution Network).
Click here to see video clips of actual telestroke consultations on the NIH Stroke Scale from Partners TeleStroke Center in Boston, MA.
AHA/ASA Stroke Algorithm, based on the Get With The Guidelines Toolbox
American College of Emergency Physicians Article on tPA Litigation
Activase Stroke Team and Center Support
Guidelines and advice on coordination of care, NIH studies, and resources.
Guidelines and advice on coordination of care, NIH studies, and resources.
Regional Genentech (Activase) Contact
Pat McCormick
Clinical Specialist
Genentech USA
919-802-5214
mccormick.patricia@gene.com
Existing Collected Stroke Plans of Care:
DISCLAIMER: These listed Plans of Care are to be used as guides. These documents were shared with ENCSN before April 2009 and may not represent the most recent national guidelines or most recent protocols at each of these hospitals. A future goal of the HPC workgroup is to create a unified summary Plan of Care, however this project is still in development. We have posted these Plans so that Network members may have a starting point for the creation of their own Plans, and to see the formats of existing NC hospital Plans of Care. The information contained in each Plan of Care does not constitute medical or legal advice. Neither ENCSN nor the authors of the Plans of Care provided make any claim, promise or guarantee about the accuracy, completeness, or adequacy of the information contained therein, or that any Plan is appropriate for your particular use. Neither ENCSN nor any other party involved in the preparation of these Plans shall be liable for any damages, of any kind, resulting in whole or in part, from any user's use of or reliance upon this material. To receive the most up-to-date guidance on stroke protocol development, please participate in the monthly workgroup conference calls and request to be added to the HPC workgroup email list!
- ED Stroke Order Set
- Inpatient Stroke Order Set
- ED MEND Exam
- ED Alteplase Administration Protocol
- Nursing Dysphagia Screening Tool
- NIH Stroke Scale Assessment
- Moses Cone Stroke-TIA Admission Orders
- Moses Cone tPA Administration Orders
- Moses Cone tPA Dose Administration
- WakeMed Non-Hemorrhagic Stroke-TIA Admission Orders
- WakeMed Possile Acute Stroke Inpatient Orders
- WakeMed IntraVenous t-PA (Alteplase) Thrombolytic Therapy Acute Non-Hemorrhagic Stroke
- Stroke Patient Information
- Anticipated Recovery Plan for Ischemic Stroke
- Consent for Administration of Intravenous tPA
- Thrombolytic Checklist for IVr-tPA
- Ischemic Stroke Interdisciplinary Form Page 1 of 2
- Ischemic Stroke Interdisciplinary Form Page 2 of 2
- Modified Rankin Scale
- New ECC Stroke Protocol
- Acute Ischemic Stroke non-tPA Protocol Page 1
- Acute Ischemic Stroke non-tPA Protocol Page 2
- Acute Ischemic Stroke tPA Protocol Page 1
- Acute Ischemic Stroke tPA Protocol Page 2
- Dysphagia Screening Protocol
- Note on this tool: Last Quarter (before August 2009), Iredell was at 100% compliance with dysphagia screening, up from 20% in years past. A Speech Therapist developed the tool that the ED actually uses.
- Wilson Medical Center Stroke Protocol (reviewed October 2009)
Onslow Memorial Hospital Stroke Plans of Care Documents (updated October 2009)
Pitt County Memorial Hospital Plans of Care
Moses Cone Plans of Care
WakeMed Plans of Care
Duplin General Hospital Plans of Care
Forsyth Stroke and Neurovascular Center
Carteret General Hospital
Carolinas Medical Center-Northeast
Iredell Memorial Hospital
Wilson Medical Center
Also see the ENCSN Quality Improvement webpage for resources on Quality Measures!
Expanding the Window for Administration of tPA in Ischemic Stroke. Pharmacists Letter/Prescriber's Letter. July 2009~Volume 25~Number 250717.
AHA/ASA science advisory recommends use of tPA between three and 4.5 hours after stroke, from the ECASS III Trial (Stroke. 2009;40:2262.).
Patients who are eligible for treatment with rtPA within 3 hours of onset of stroke should be treated as recommended in the 2007 guidelines.1 Although a longer time window for treatment with rtPA has been tested formally, delays in evaluation and initiation of therapy should be avoided, because the opportunity for improvement is greater with earlier treatment.
rtPA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B). The eligibility criteria for treatment in this time period are similar to those for persons treated at earlier time periods, with any one of the following additional exclusion criteria: Patients older than 80 years, those taking oral anticoagulants with an international normalized ratio 1.7, those with a baseline National Institutes of Health Stroke Scale score >25, or those with both a history of stroke and diabetes. Therefore, for the 3-to-4.5–hour window, all patients receiving an oral anticoagulant are excluded regardless of their international normalized ratio. The relative utility of rtPA in this time window compared with other methods of thrombus dissolution or removal has not been established. The efficacy of intravenous treatment with rtPA within 3 to 4.5 hours after stroke in patients with these exclusion criteria is not well established (Class IIb Recommendation, Level of Evidence C) and requires further study.
Ancillary care for patients receiving rtPA at 3 to 4.5 hours after ischemic stroke should be similar to that included in the 2007 American Heart Association Stroke Council Guidelines.1
These recommendations, which are based on peer-reviewed publications, should be reevaluated after the results of regulatory agency review of detailed, nonpublicly available data are known. The recommendations use the American Heart Association’s classification of recommendations and levels of evidence shown in the Table.
