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NINDS: Stroke Proceedings: Bock



Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

Response System for Patients Presenting with Acute Stroke

Brooks F. Bock, M.D., F.A.C.E.P. 
Wayne State University, Detroit, Michigan

Assuring an appropriate response to patients presenting to the emergency department (ED) with symptoms consistent with acute stroke is paramount in providing efficient, high-quality, cost-effective care for this patient population.

Patients arrive at the ED by private conveyance or are transported by emergency medical services (EMS) personnel. When the ED receives the patient, or receives notification that a patient will be arriving, an assessment must be made as to whether the "stroke team" should be notified. If symptoms suggest the potential for acute interventional treatment, this team should be alerted. Acute interventional treatment should be considered in patients who are found to have cerebellar hemorrhage, lobar intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic stroke.

At a minimum, the stroke team should consist of the physician who will initially evaluate the patient, probably an emergency physician; the emergency nurse who will initially care for the patient; a consulting or admitting physician (neurologist, neurosurgeon, internist, intensivist) who will provide long-term care for the patient; and CT scan personnel (technician and radiologist). Additionally, protocols should be established with the laboratory such that needed studies are processed immediately.

The early notification and timely involvement of key medical personnel is sure to improve patient outcome. Institutions will function differently in this regard. Some will mobilize the entire team through gang beepers. Others will notify individuals one at a time. The key to success will be appropriate communication and a team approach to the care of the patient. This will require meetings and careful preparation prior to the initiation of a stroke protocol or pathway.

Upon arrival in the ED the patient should have the following:

  • vital sign monitoring including pulse oximetry; supplemental oxygen should be considered;
  • rapid blood glucose level;
  • neurological monitoring;
  • cardiac monitoring;
  • intravenous access established;
  • laboratory samples obtained and studies ordered including clotting studies and type and screen;
  • head CT scan ordered; and
  • electrocardiogram and chest radiograph ordered.

In both treating and studying this patient population it is critical that the initial evaluating physician carefully establish, as closely as possible, the exact time of symptom onset. This often requires repeated inquiry of the patient, friends, or family members. At the present time thrombolytic therapy with t-PA is recommended only within a 3-hour time-frame from onset of symptoms in patients suffering ischemic stroke.

Given that time is an absolutely crucial factor in successful evaluation and treatment of this type of patient, time-frames must be established to guide an institutional response.

  • Door to physician evaluation: A candidate for acute intervention should have initial physician evaluation within 10 minutes of arrival at the ED.
  • Door to stroke team notification: Members of the stroke team should be notified within 15 minutes of arrival.
  • Door to CT scan initiation: The CT scan should be initiated within 25 minutes of arrival.
  • Door to CT scan interpretation: The CT scan should be interpreted by a capable individual within 45 minutes of arrival.
  • Door to drug (needle) time: If indicated, the patient should be receiving thrombolysis within 60 minutes of arrival. A threshold of 80% is indicated for this parameter.
  • Door to monitored bed: The patient should be transferred to the appropriate inpatient setting within 3 hours of arrival.

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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last updated May 17, 2011