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Stroke Center
Update for CMC EM Physicians
Andrew W. Asimos, MD
Medical Director, Carolinas Stroke Network
Carolinas Healthcare System
Professor, Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC
Overview of Joint Commission Comprehensive
Stroke Center certification

Review of CMC ED Code Stroke Protocol

Discuss pertinent issues related to Ischemic Stroke,


Overview of CMC Code Stroke Process and

Outcome metrics tracking
What is CSC Certification?
CSC is the highest level of Stroke Certification from TJC
Adhere to best practice recommendations
Approximately 130 CSC centers in the US 10% of 1300 certified
stroke centers
Local/Regional: UNC CH, Duke, NC Baptist, MUSC, Mission, Novant
Presbyterian and Forsyth

Dr. Rahul Karamchandani (CMC Stroke Director) Lauren Macko (CMC Neurosciences CNS)
Dr. Andrew Asimos (ED/Stroke Network) Julie Pagel (CMC Neurosciences Educator)
Dr. Joe Bernard (CNSA) Mary Traynor (Neurology ACP)
Dr. Alan Heffner (Critical Care) Kathy Barnard (CMC ED Educator)
Dr. Gary Little (CMO, CMC) Jennifer Cline (CMC Therapy Manager)
Mike Mullowney (VP, Neurosciences) Steve Keller (NM, Neuro ICU)
Tina Ralyea (AVP, CMC Neurosciences) Russell Tremblay (NM, 9A)
Jeremy Rhoten (CMC Stroke Coordinator) Sidonne Brown (NM, 9T)
Joan Stewart (Director, Neurosciences) Dale Strong (Consultant Stryker)
Lindsay Leahy (Neurosciences - Neurology Manager) Sarah Hendrix (Director, Neurosciences)
Review Days: October 23-24, 2017
Two Reviewers
Departments targeted
Emergency Department, Interventional Radiology, Neuro ICU, Stroke Units (9A,
9T, Observation)
Will audit inpatient and closed Ischemic, ICH, SAH patient records
Can ask attending or resident physicians, ACPs, nurses, and techs
questions regarding processes, policies, CPGs, and current goal
Any of the ED staff can be interviewed
JC Stroke Performance Measures
CMC ED Code Stroke Protocol
Functional Independence Based on
Time to Treatment

Effect of timing of
IV tPA treatment to
Good Outcome

Embersen J Jetet
al. al. Lancet
Lancet 2014;384:192935.
2014;384:192935 Saver JL et al. JAMA 2016;316(12):1279-1288.
Code Stroke Process Time Goals

<25 min
0 min <10 min <15 min <45 min <60 min

ED Arrival ED MD Eval Code Stroke Imaging Imaging Decision for

By EMS or BE FAST screen Response Completed Interpreted Intervention
Private Vehicle Activate Code Neurology Non-contrast CT Ischemic
Stroke responds to CTA IVtPA
patient location CTP Thrombectomy
NIHSS Hemorrhagic
Draw labs Neurosurgery

Last known well < 6hr CODE STROKE

2017 CMC ED Code Stroke Data
# of Cases N=248 %*
No Revascularization 174 70%
IV tPA 44 18%
IA 22 9%
Hemorrhagic 18 7%
*Percentages add up to more than 100, since some cases
received both IA and IV tPA
Adoption of Best Practice
Coming soon to an ED near you
Partner with EMS
Prehospital notification
Feedback process
Severity-Based Stroke Triage Initiatives
MEDIC Stroke Committee
Discrete Event Simulation Modeling
EMS Feedback Form
Code Stroke Criteria
Neurological screening exam consistent
with acute deficit referable to a potential
vascular distribution in the brain

LKW (last known well) < 6 hours

Wake-up stroke and <3 hrs since waking up

Trial Stopped after first
scheduled interim analysis

206/500 patients enrolled

Trevo Retriever decreased stroke disability and improved
functional independence at 90 days c/w medical management alone
(48.6% vs. 13.1%)
NNT 2.8
SICH (4.8%) and mortality both NS
Triage Screen: BE-FAST

Aroor S et al. Stroke 2017;48:479-481.

CMC ED Code Stroke Protocol - 1
CMC ED Code Stroke Protocol - 2
CMC ED Code Stroke Protocol - 3
ED Code Stroke Assessment Orderset
CMC ED Code Stroke Protocol - 4
Guidelines for Blood Pressure
Management of Stroke Subtypes

Miller J et al. Ann Emerg Med 2014;64:248-255.

CTA to Identify LVO
CTP to Predict Salvageable Brain (if LVO)


CBF (Cerebral Blood Flow) reduction

= estimate of core infarct

MTT (Mean Transit Time) = estimate

of core infarct + penumbra + benign

MTT CBF reduction = estimate of

penumbra and benign oligemia
RAPID (Ischemaview RAPID)

Standardized (Validated?)
Fully automated
Thresholded mismatch
CTP with Small Core Infarct,
Large Mismatch Mismatch:
Good Endovascular Candidate
CTP with Large Core Infarct:
Poor Endovascular Candidate?
tPA Eligibility
ED Code Stroke Alteplase Administration Orderset
CMC ED Code Stroke Protocol - 5
Suspected Ischemic Stroke Patients not
meeting Code Stroke Criteria
Routinely consult Neurology
Not candidates for transfer to CHS-Mercy
ED ICH Orderset
The ICH Score: Predictor of Outcome?
30-day Mortality
Component ICH score
3-4 2
GCS 5-12 1 60
13-15 0
>30 1
ICH volume (cc)
<30 0 20
Intraventricular Yes 1
hemorrhage No 0 0
Overall 0 1 2 3 4 5
Infratentorial Yes 1
ICH Score
No 0
>80 1
Age (y)
<80 0
Total ICH score 0-6

Hemphill JC et al. Stroke 2015;46:2032-2060.

ICH Admission and Consultation Policies

Non-intubated ICH patients not meeting

criteria for a critical care consult will
typically be admitted by CHG

Neurosurgery should be consulted on all

ICH patients, even when neurosurgical
intervention is unlikely
PATCH Trial:
Platelet Transfusion vs Standard Care after acute
spontaneous ICH associated with antiplatelet therapy

Multicenter, open-label, masked-endpoint, randomised trial at 60 hospitals in the

Netherlands, UK, and France

Adults within 6 hours of supratentorial ICH symptom onset

Antiplatelet therapy for at least 7 days prior

GCS score of at least 8

Primary outcome: Shift towards death or dependence rated on mRS at 3 months

Analysed by ordinal logistic regression
Adjusted for stratification variables and the ICH score

Baharoglu M et al. Lancet 2016; 387: 260513.

PATCH Trial: Primary Outcome
Distribution of mRS score at 3 months

Baharoglu M et al. Lancet 2016; 387: 260513.

Post tPA Hemorrhage Reversal
Powerplans Exist for Reversal Protocols
An ED SAH Orderset currently does not exist

All SAHs get admitted by Neurosurgery

Target BP is <140 mm Hg in CMC Admission SAH Powerplan

Oral nimodipine should be administered to all patients with

aneurysmal SAH (within 24 hours)
Class I; Level of Evidence A
3 oz bedside swallow screen required before any PO medication
SL or NTG administration acceptable
Shown to improve neurological outcomes, but not cerebral vasospasm
Hunt & Hess Classification of SAH
Grade Criteria Mortality
1 Mild Headache, Alert and Oriented, 30%
Minimal (if any) Nuchal Rigidity
2 Full Nuchal Rigidity, Moderate-Severe Headache, 40%
Alert and Oriented, No Neuro Deficit (Besides CN Palsy)
3 Lethargy or Confusion, Mild Focal Neurological Deficits 50%
4 Stuporous, More Severe Focal Deficit 80%
5 Comatose, showing signs of severe neurological 90%
impairment (ex: posturing)

Hunt WE and Hess RM. J Neurosurg 1968 Jan;28(1):14-20.

TIA patients
Do not routinely consult neurology
Candidates for transfer to CHS Mercy
ED TIA Orderset
3 oz Bedside Swallow Screen
Code Stroke Process and
Outcome Metrics
Code Stroke Process and
Outcome Metrics
Core Concepts
Know the Code Stroke Activation Criteria
Know the Code Stroke protocol process
time goals
Know important Blood Pressure thresholds
Know the Stroke Screen used at triage
Be familiar with the hemorrhage severity