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201409269

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Patient Care,

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Clinical Hub,References,Comprehensive Stroke Program,UW Neurology/Stroke Service Resident Orientation Manual

Admitting Patients

Admitting Patients - Clinical Hub, References, Comprehensive Stroke Program, UW Neurology/Stroke Service Resident Orientation Manual

Focus

Stroke patients are admitted to “Neuro Stroke” which has the abbreviation “NST.” This is to differentiate the stroke service from the general neurology inpatient service, “NRH.”

Stroke Data: There are a few data points that must be captured electronically for external quality
reporting . To facilitate this, and to facilitate the creation of electronic H&P’s, one of the first
steps in the admission workflow is to fill out the stroke evaluation Clinical Data flowsheet:

Stroke Data

Stroke H&P SmartText: To facilitate documentation of the H&P, there is “SmartText” that can be used to template the note and pull in the information you entered in the Stroke Data flowsheet. It’s named “Ischemic Stroke H&P”:

Finding the stroke SmartTexts

Stroke Admission Panels: All stroke patients should be admitted using the stroke admission
order panels:

Stroke Admission Panels

Stroke Admission Panels Open

Vital signs/neuro checks: Post-thrombolysis patients require a specific frequency of vital
assessments: Q15min x 2hrs, Q30min x 6hrs, and then Q1hr x 16 hrs. Therefore, it is
important to document the time that the tPA bolus was given; the order sets have a space for
this.

Vital signs

end of tPA

For non-thrombolysis patients, those in the ICU are usually monitored Q1hr, and floor patients Q2hrs for the first 24 hours after their stroke, followed by Q4hrs.

Post-endovascular procedure patients: Stroke code patients who go to the angiography suite for intra-arterial thrombolysis or mechanical embolectomy are generally admitted to the neurosurgery service for post-operative care. Those who are immediately extubated and stable may be admitted to NST. In such cases, please use the post-thrombolysis order set, using the time of procedure completion as the “tPA bolus time.”

Blood pressure: In post-thrombolysis patients, BP must be maintained below 180/105 mm Hg. In other stroke patients, current guidelines recommend against acute treatment unless the hypertension is symptomatic (headache, visual disturbance, renal dysfunction) or above 220/120 mm Hg.

Diet: All patients with persistent deficits must remain NPO until evaluated they pass a swallow evaluation. This is extremely important, as aspiration pneumonia is the #1 cause of death in stroke patients who survive the stroke itself. There are two ways to do this: You (in the ED) or the nurse (on D6/4 or F8/4) can administer a bedside test in TIA and minor stroke patients; the tool for this is built into the admission navigator (see below). Following are the eligibility criteria for this kind of swallow assessment:‌

Bedside swallow assessment tool

Otherwise, a formal evaluation by SLP is required. There is actually a swallow specialist on call until 16:30 every day; you can page the on-call speech language pathologist even while the patient is still in the emergency department to ensure that your patient misses the fewest number of meals as is feasible.

Paging stroke team speech

When you are ready to order a diet, the recommended diet is the DASH diet.

Telemetry: All patients should have cardiac monitoring for the first 48 hours. It is not uncommon for a patient to present in sinus rhythm and then develop atrial fibrillation during admission, thus establishing the likely cause of the stroke.

DVT prophylaxis: There is a venous thromboembolism (VTE) prophylaxis order panel built into the admission order sets. For most of our patients, with high VTE risk and low bleeding risk, enoxaparin 40 mg daily is prescribed. Post-thrombolysis patients should receive it beginning 24 hours after treatment. Patients who cannot receive anticoagulants should have sequential compression devices placed on their legs.

IV fluids: Please use isotonic saline; hypotonic and dextrose-containing fluids may aggravate cerebral ischemia.

Antithrombotic medication: These should be held for 24 hours in post-thrombolysis patients. Most other patients should receive aspirin, Plavix, or Aggrenox. Patients who are NPO can receive aspirin rectally or via NG tube. Patients with atrial fibrillation will usually be treated with heparin and warfarin, although the timing of initiation is an unsettled issue in the field and will vary according to the patient’s specific situation.

Labs: On the morning following admission, every patient should have a fasting lipid profile and fasting glucose. Diabetics should have a hemoglobin A1C. An AST is also obtained to screen for hepatic dysfunction, since most patients will be prescribed an HMG-CoA reductase inhibitor (statin). CBC and other chemistries will usually have been obtained in the ED or at the facility from which the patient was transferred. Please do not routinely order daily labs—only order those labs that are necessary for the patient’s specific problems.

Diagnostic imaging: Imaging tests are purposefully not embedded in the admission order sets. This is to encourage you to formulate your own diagnostic plan and discuss it with your attending. When you decide to proceed with advanced imaging, be sure to use the stroke imaging order sets.

Remember that the iodinated contrast used in CT angiography is nephrotoxic. The maximum allowable creatinine will vary according to the urgency of the situation. Also note that diabetics may have marginal renal function despite a normal creatinine. Finally, remember that metformin, which is excreted by the kidneys, can build to toxic levels after contrast administration, resulting in lactic acidosis. This drug must be held prior to contrast
administration.

A screening form must be completed before MRI scanning; this is usually done by the nurse or tech. A newly reported complication of gadolinium contrast administration (used for angiography and perfusion scans) is systemic nephrogenic fibrosis, a progressive and potentially lethal disease. Thus, patients must now be screened for baseline renal impairment prior to contrastenhanced MRI just as they are for contrast-enhanced CT.

Carotid Doppler ultrasound is performed by both the vascular surgery lab and the radiology department. The radiology studies are usually preferable because the images appear in PACS, where we can review them personally. The vascular lab results are reported in text format only and thus are harder to verify. 

Echocardiography is commonly performed as part of a stroke evaluation. The test should be ordered with agitated saline (“bubble study”) in order to detect the presence of patent foramen ovale (PFO).

Consults: All patients with a diagnosis of stroke will require evaluation by the swallow service (a section within speech-language pathology) before taking anything, including medications, by mouth. Most patients will also require evaluations by speech therapy, physical therapy, and occupational therapy. Many will need a social work consult.

Please discuss with your attending before requesting consultation from a procedural service (neurosurgery or endovascular) or an emotionally-charged service, such as palliative care or ethics.

Insulin-requiring diabetics should be seen by the diabetes management service. A nutrition consult should be also be considered, especially for diabetics and patients whose body mass index exceeds 25. This is for teaching proper diabetic dietary choices or the Mediterranean diet for vascular disease prevention. If not practicable to perform this as an inpatient, the patient can be referred for outpatient nutritional consultation as well.

The acute care for the elderly (ACE) team can be very helpful in managing the multiple issues
arising in hospitalized geriatric patients. Finally, some patients will benefit from the palliative
care service; this should be discussed with your attending first.

Stroke Prevention Exercise Program (S-PEP): This is an initiative by our stroke program to encourage our patients to adopt healthful lifestyle changes in order to help prevent recurrent stroke and other vascular events. The admission order sets ask you to determine patients’ suitability to participate, which basically means excluding those with unstable coronary disease. They need not to have new atrial fibrillation or a new bundle branch block and must be able to perform 4 mets of exercise, which is equivalent to walking a flight of stairs or doing light housework. Please see Appendix 3 for more information.

Notifications: Whenever possible, please notify the patient’s primary care physician to notify him of his patient’s admission. This is both common courtesy and also an important part of the care plan. This is especially true when you plan to initiate anticoagulation or effect other major changes in the patient’s medication regimen that will need to be continued by that physician after discharge. If a patient is under the care of the transplant, oncology, or another specialized service, always inform the patient’s physician, nurse, coordinator, or case worker of the admission. This is critical to ensure that our therapies do not interfere with the patient’s immunosuppressive or chemotherapeutic drugs.

In the “Notes” activity, there is a “Route” button. Often the PCP and referring MDs will populate just by clicking their respective buttons, as below. Other times, you’ll need to search for them in the adjacent search box:

Routing notes