Bright Idea Series: How Stroke Protocol Saves Lives

A stroke can change a person’s life in a matter of minutes. A stroke occurs when the blood supply to the brain is blocked by a clot or tear in a blood vessel. Speed is essential—both in recognizing the signs of a stroke and then getting medical attention- before a lack of blood to the brain causes severe deficits or even loss of life to the patient.

Because of the importance of reacting quickly to provide medical support for stroke victims, Hardter Medical Center in Olla, Louisiana, set out to improve their proficiency in administering stroke care. The hospital is recognized by the Louisiana Emergency Response Network (LERN) as a Level 3 Stroke Center. This title is given to facilities that provide acute care in rural areas where transportation and access are limited.

The Hardter team realized they had a very low volume of patients with acute stroke diagnoses due to not identifying stroke victims who were coming into their emergency department. The team implemented monthly mock drills to both develop the skills needed to recognize the signs of stroke and improve workflow dynamics. Hardter staff then set out to shorten in-hospital treatment intervals by creating a rapid-response system similar to that of cardiac arrest. This would allow the stroke team to be available within a few minutes to care for stroke victims. They called the protocol “Code Purple.”

“We decided that implementing Code Purple, both as an overhead callout and stroke protocol system, was the right thing to do. No one knew what the other one was doing when we had a stroke victim in our emergency room,” says Cherry Beth Salter, a practicing registered nurse for 31 years and Hardter’s director of nurses for eight years. “We used the acronym FAST, which helps us to remember the signs of a stroke and what we need to do. This educated our registration people, our x-ray lab people, ancillary people, and all different employees that worked at our facility. The American Heart Association and American Stroke Association recommend a target time of fewer than 15 minutes from the arrival of the patient to the treatment of the patient. We’re working against the clock.”

A stroke alert or code stroke should run as efficiently as a code blue. Nurses should have preassigned roles that include drawing blood for lab work, maintaining communication with the patient’s family, and communicating with physicians and computed tomography (CT) staff. When “Code Purple” was called overhead, it alerted staff that a stroke victim had entered the emergency department. Registration staff would meet the patient and immediately compile a face sheet, a document that gives a patient’s information such as contact details, a brief medical history and the patient’s level of functioning, along with patient preferences and wishes at a quick glance. This face sheet would then be sent to the referral center to reduce the neurological consult time.


Teamwork and Telemedicine

Research by healthcare delivery network Kaiser Permanente has shown that less than 30% of stroke victims receive clot-dissolving medication inside a recommended window of an hour or less for maximum effectiveness. Because of this, Hardtner implemented the use of telemedicine through carts equipped with telestroke systems.

A telestroke system requires a neurologist and attending nurse to have a high-speed Internet connection and videoconferencing capabilities on a laptop, tablet or desktop computer. This system enables a consulting neurologist to be able to talk to the patient or an emergency response team about what symptoms the patient is experiencing, evaluating the patient’s motor skills, viewing a computed tomography (CT) scan, making a diagnosis and prescribing treatment.

“By using the Code Purple, we sped up our neurological expertise time by faxing that face sheet up to our referral center. While they’re getting ready and set up, the radiology tech also goes now to our CT room to warm up the table. Instead of patients going to the ER, the ER nurse and the ER physician go into the CAT scan room to do a quick assessment, and the lab tech also draws blood work prior to the scan,” says Salter.

To keep skills sharp, hospitals should provide ongoing stroke recognizance education to all ER staff and ancillary department members. At Hardter, the team performs mock stroke drills and places great emphasis on the importance of consulting neurological expertise members in a timely manner.


Code Success

The team at Hardter succeeded in meeting time goals such as having a doctor in the ED within 10 minutes of patient arrival, for a patient to be seen by a neurologist within 15 minutes, CTs to be performed within 25 minutes and to have labs completed and CT interpreted within 45 minutes. Salter agrees that committing to meet these time constraints have kept the staff focused.

“This has improved our lab times tremendously. By using the Code Purple overhead, they are standing and waiting for this patient to get to our emergency room so they can perform their functions. We can place the stroke patient immediately in the CAT scan upon arrival,” says Salter. “This has also improved the interpretation time for radiologists because we’re getting our CAT scan done a lot quicker as it’s entered as soon as they get into our emergency room.”

By working together to focus on issues, improve response time and deliver more timely care to patients that present with stroke symptoms, Hardter has seen a rise in patients screened for signs of a stroke. The team can properly identify stroke patients more quickly, and the hospital is more widely recognized as a stroke care center.

“We have worked tremendously hard to improve that response time,” says Salter. “We still, every day, aim to perfect it. We’re very excited about our success thanks to implementing Code Purple.”

LHA Trust Funds supports member hospitals that provide quality care while sharing ideas to facilitate safe environments. For more information on how implementing a stroke code can help your hospital or health organization, view the webinar link here:

Hello everybody, and I am happy to introduce our next presenter in our Bright Idea webinar series.

As I mentioned earlier, as the consultants traveled throughout the state, we like to take note of unique and innovative projects that our members are doing and then we like to give to have them share with the rest of the membership and hope that you could possibly take some of the information from projects that they are doing and maybe incorporate those into your own organization.

So this morning, I am proud to introduce Cherry Beth Salter from Hardter Medical Center. Cherry has a bachelor of science degree in nursing and she’s been a practicing registered nurse for 31 years. Her nursing careers primarily been emergency room nursing, but she’s also taught in a technical college for eight years and then the rest of her nursing career, has been in administration and she’s been director of nurses for eight years.

Her topic today is utilizing Code Purple to improve stroke care. And I’m gonna turn it over to you Cherry Beth.

I would just like to say hi every one… I would like to thank HSLI and Stacey for asking me to share an issue that we had in our emergency room at our hospital, that we discovered some weaknesses that we had and how we resolved those problem.

Next Slide.

So, today I would like to talk to you about utilizing stroke care and improving or stress results and our proficiency and administering that care.

The slide you’re seeing today, this slide is our emergency room and this is some of our staff that work our ER. We are a 35 bed critical access hospital located in Central, Louisiana. We have an emergency room that’s an 8 bed er, so we’re constantly seeing all kinds of diagnoses and conditions that come into our ER, but this is one of our main trauma rooms.

So, utilizing Code Purple to improve stroke care, We decided that this was the right thing to do because no one knew what the other one was doing when we had a stroke victim in our emergency room. So the first thing we honed in on was we wanted to be able to put brochures out in about around our facility so people would know how to spot a stroke fast and we used the acronym FAST, which helps us to remember the signs of a stroke and what we need to do. So, this educated our registration people, our x-ray lab people, ancillary people, all different employees that worked at our facility by posting this brochure out.

Next Slide.

So, at Hardter Medical Center. We’re a LERN level for each stroke center and what that means is LEARN It stands for the Louisiana Emergency Response Network. We are a… We are partnered with them and the state of Louisiana and so we were given the distinguished title of a Level Three, and a Level Three Stroke Center is a facility that provides acute care in rural areas where transportation and access are limited, and it’s also intended to recognize the models of care delivery that have shown utility including the dripping chip until a medicine program.

So because level three centers can provide care faster, these centers should not be bypassed to go to a more distant level one or level two, which is a higher grade, they can provide better care. We’re known to bring them to the level three where we can have a neurological consult and also hang activate. So we had some persistent problems with meeting one or more of our required elements of the level three stroke center recommendations, so they contacted us and we were told that if we didn’t improve our care and our times, and providing stroke care from LERN that they were gonna downgrade us from a level three, so we had to critically examine how to improve in these areas and the areas that we were required to focus in on was door-to-needle time, door to physician time, door to neurological expertise time and this was one of the bullets that we had some major problems with time with, also door to CT Perform time, door to CT interpreted time and door-to-Lab result time.

Next slide,

So, in discovering the weaknesses, we had a very low acute stroke volume, and we had to implement monthly mock drills, because in our ER,  we weren’t really catching or picking up on stroke clients that were coming into our ER, we just didn’t have it, so in our ER, we had to maintain these skills and we had to improve our workflow dynamics.

So, by doing this, we begin to drill monthly.

We were doing like Code Purple drills and when we called Code Purple overhead it alerted all of our staff that it was a stroke victim, that had entered into our emergency room.

So the American Heart Association and the American Stroke Association, they recommend the target time of less than  minutes from arrival of the patient to the treatment of the patient. So as you can see, we’re working against the clock.

Some of the issues that we discovered with our weaknesses was, first of all we did not activate our stroke alertness in our ER, so that’s why we came about with the bright idea of Code Purple. two… We were not contacting our referral center, in a timely manner. So with what we found, we began to fax face sheets of our patients that arrived in emergency rooms and fax them as soon as we got the information into our referral center, because this is what was holding up our neurological consult time. three nurses failed to document initial neurological expertise contact time and that was in their documentation and their electronic health records. so we really had to work with them in regards to documentation. And four, our labs took too long to get results out. So as I go on through the slides, today you will see what we did to have our lab results.

Next slide,

So we really had to develop an action plan and we had to develop goals that were specific to our ER that were something measurable that we could measure and get results from and that were attainable and reasonable. When we set those goals, we didn’t set too high of goals that we couldn’t achieve and which would cause our employees to come disheartened and try to overcome our problems. So in this picture here, this is our Telemed card and if you’ll see hanging on it, we have different tools that we use to help the neurologist when he makes a consult and it helps us also with a patient, let’s see how severe the stroke is, we also developed the stroke box and in that stroke box, it’s a label that has emergency drugs that we don’t have to go into an MGD, we can pull out easily. We can get the stroke box, Which is behind a locked door, and we can break it the seal and then we go in and use all the medications that are needed at that time.

Next slide,

By using the Code Purple, which many hospitals have Code Red or Code Black, but we decided on Code Purple, and so what this purple did was when a patient arrived with any stroke symptoms into our ER, we call overhead a Code Purple. nd each ancillary department has a role to expedite their care in treating their stroke patient because we’re working against the clock. So the registration when the patient enters into our ER, does a quick registration. She just gets just a few simple things that she needs and she goes ahead and registers a patient then that face sheet is faxed to our referral center

And this was the issue that we found that we had trouble with, we wasn’t doing. And it does speed up our time of neurological expertise by faxing that face sheet up to our referral center.. And they’re getting ready and set up, contact the neurologist, the radiology tech also goes now to our CT room. She warms up the table. This is another issue that we had, radiology could be doing something else but now when they hear a Code Purple overhead, they know immediately what to do — go to the CAT scan room to warm up the table. the patient once they get into registration or maybe they come in by ambulance, we immediately take that patient straight into the CAT Scan Room.

You don’t go into in an ER, we just go straight into CAT scan. Then, the ER nurse and the ER Physician go in to the CAT scan room they do a quick assessment, they perform their assessments of a stroke and they obtained the last seen normal time of that patient. the lab tech also draws blood work prior to the scan. So when they hear Code Purple, they are immediately waiting in the hallway, to go into the CAT scan, to draw all of that blood work. The nurse reports back to the nurses station, we call our referral center to activate our telestroke while putting in all our orders that the physician needs, or the physician puts in all the orders, either way. When the patient returns from the CAT scan room, then our ER tech, they put our patient on the monitor and they set them up, they get a blood sugar on them and the patient gets an IV from the nurse either in the CAT scan room at this point, at this time, when they enter into our Emergency Room.

Next slide,
So improving the stroke care by initiating Code Purple to improve this care, It also improves our stroke time, when the patient presents with stroke symptoms, or when a report is called by the EMS that they have a patient that’s having stroke symptoms. We automatically call over head a Code Purple, and we call when the estimated time overall by ambulance is, we may say TA of five minutes, so that way it gets everybody ready and we’re waiting on that patient to come into our emergency room. We also perform education to all our ER staff, and ancillary department and we perform mock stroke drills and we place great emphasis on the importance of consulting that neurological expertise in a timely manner. And documentation of that notification because we had failed in that area also.

So through that documentation, our ER manager, She came up with creating the stroke packets and to the right of this slide, you’ll see the stroke packet — it’s nothing elaborate. She just came up with this idea and this was used to help the ER nurses acquire data in time. So if you’ll look, it has all the times and the goals that we need to make and this just keeps reminding the ER nurse, that we’re working against the ticking clock.

So the ER manager also… she became very involved in the stroke care and she began to lead in the stroke drills and she also assisted with stroke patients that arrived in our ER room. She helped participate in them, she critiqued her staff and so she began to audit charts by looking at the times and all of the recordable events and the issues that we were having.

Next slide.

So another goal was we have a goal that the doctor had to arrive to our ER in 10 minutes he has to be there,  he has to evaluate the patient, within the 10 minutes of arrival, so as you can see with an eight bed ER, a lot of things can be going on in this time. But we immediately stopped “Hey, doc we need you in the CAT scan room, we have an active stroke going on.” And so that’s one of the ways that we just go to him ourself and get him and say “hey, we need you in the CAT scan room.”

Next one.

So, in improving the neurological expertise time, we have 15 minutes in order for that, to, for our goal to be met there be communicating with that neurological expertise time. And so in our Code Purple protocol, we now, as I said earlier, have the registration cart faxed the patient face sheet to our referral center, while the patient is in the cat scan room and then after the nurse does a quick assessment, she goes and she calls the referral center, and she goes to the Telestroke cart and begins to initiate Telestroke. we do not need a doctor’s order to initiate the Telestroke. That’s something that we said is standing  protocol, it can be cancelled at any time. If the ER physician feels a patient doesn’t need a telemedicine but that ER position makes that call,

Next slide.

So, The CTs being performed, we have a goal of conquering 25 minutes. So this goal is to have the CT head performed all within this time frame.

We meet this goal, by having the patient go straight to the CT upon arrival while either on the ambulance stretcher or straight from the ER entrance prior to registration. And you’ll see in our stats, we’ve tremendously improved that time by doing this.

Next slide.

So our other issue was labs. We were having trouble with labs being completed and CT being  interpreted within 45 minutes. So now we are working against the clock. So when a Code Purple is called overhead, the lab take reports to the CAT scan room, they draw the blood prior to the patient being scanned, they know immediately when Code Purple is called, called what colors, what they have to draw.

This has improved our lab times tremendously. Used to, our patient would come into the ER, we would have to notify lab or a… Or we would put a lab in and then put it stat, but the lab personnel wouldn’t see it but by using the Code Purple overhead, they are standing and waiting for this patient to get to our emergency room so they can perform our functions. There’s a lab tech, our CT scan is ordered stat. So, place the stroke patient immediately in the CAT scan upon arrival and this has approved the interpretation time for radiologists because we’re getting our CAT scan done a lot quicker as it’s entered as soon as they get into our emergency room.

Next slide.

So TPA. We administer TPA at our facility and CPAs order and initiate it. We have 60 minutes within the time to hang TPA and initiate it. And the ER nurses… We just felt like we’re a little… Not comfortable with TPA because we wouldn’t see in a lot of stroke victims, so we sat down and we begin to re-educate them On TPA administration and the tPA, drug rep came offered a lot of free inserts to our staff, and so this made our staff more aware and more comfortable to administer TPA.

Next slide,

So we also initiated through LERN, they had approached us about doing a van assessment and a van assessment, it’s just assessing for large artery Stroke equation and this is the tool to the right, ’cause they provided us with… And this, by checking arm weakness, looking at visual disturbance, checking aphasia and the neglect lets us know that if we have any of these issues on the form here we are dealing with a large artery occlusion and this assessment tool is really quick and it helps us make our assessments fine tune and get them accurate…
So if a patient is Van positive… We now refer them in to New Orleans, or toShreveport, we used to transfer them on Alexandria which is our closest, largest facility to us.
But if they’re van positive… We bypass Alexandria and we go straight to New Orleans or Shreveport. And this process has decreased our stroke care times also by using this assessment tool

Next slide.

So, learn also what it does to initiate the post-thrombolysis EMS in our hospital transfer guideline because we found that when we were treating these patients in the ER,  we were so glad to see the ambulance so we could get on transfer out and get the care done quickly.

But we found that we wasn’t communicating very well to our paramedics, so LERN provided us with this tool and utilized it and this tool is in the Guide to help our EMS staff use measures that are required if they begin to have trouble or if they’re having trouble with monitoring their vital signs and they have different parameters in which they can follow. And what it did is like standing orders.

So they also do a NIHSS scale and this is where we do another reassessment prior to transferring the patient out, and when we do this NIHSS scale when we do the assessment looking at, the vocal, the commands can a patient responds to a command? and also motor or movement when we score these patients we, the nurses and that staff just don’t assess them by ourselves we have a paramedic next to us, and we agree on the scores ourselves.  So you’ll see on the bottom of far right, the last form is required that the paramedic and an RN both score the patient prior to departure and that’s very important because it just provides extra expertise. We agree on what’s going on with the patient, it’s a more accurate picture.

Next slide.

During, with a performance improvement data that we collected and we collect it, we send it to LERN this depicts our improvement measures. So I wanted to show you that if you look to the left Quarter 4 of 2016, and then we have a median time for the quarter one of 2017. and then our median time for quarter 2 2017, if you look to the left, all of these measures door to ED doc, door to neuro doc door to CT, that’s some of the criteria that we really honed in on, because if you’ll look, on this graph it will show you  that over to the right, over in Target time, the blocks in red, This is how bad we were performing with our time. And so this really brought this to our attention, like “Hey we’re really doing the bad job here. We need to perfect this we’ve got too good of expertise in this emergency room to have these kind of times.
So I just wanted to show you where… How bad we were really performing back in 2016 and 2017.

Next slide.

So this is another comparison I wanted to show you. We do receive this data… And we, track it, we send it to LERN, they log it all in. If you’ll look at our median time in quarter two and there’s a median time in quarter three, quarter four. And in quarter 3, quarter 4 2017, we didn’t have any issues, we didn’t have any stroke patients coming in that were having stroke symptoms, but in the quarter one of 2018, in quarter 2, you’ll see that we begin to pick up and we begin to see patients. So I think that was because we made our staff and our employees more aware of Stroke and the signs and symptoms. If you’ll see over on the right, the main target time. Now, we… We only have two areas that was door to neuro doc time that were in the red. And I told you, prior to this how we perfected that. And so on the table on the… Right now we’re in quarter one, quarter two, and quarter three for 2018. and if you’ll see all of the greens that we have perfected there are some yellows if you’ll look under the quarter three of 2018 for the door to neuro doc, our median target time is 15 minutes were also met so we’re so much better than where we were, we didn’t want any red blocks, we did have a red block in the quarter one it was dealing with contact time to a neurologist, and it was because our ER docs were  kind of dragging their feet not wanting to use our telemed cart, but we begin to get them involved and participated in that and we have worked tremendously to try to improve that time.

Next slide.

So in conclusion, by our staff focusing in on our issues and improving our time and delivering care to our patients that present with stroke symptoms, we have also seen a rise in our patients in our census that are screened with signs of a stroke presentation.

And what I wanna share with you was that for the year 2017, we had a total of eight patients that were treated for strokes that were telestroked on our telemed cart.

But for the years 2018, after we began to implement these measures. And with this bright idea that we had, we… Now, at the end of December, we have had a total of 32 patients, that were traded for stroke symptoms, so in conclusion I just wanted to say that we work really hard in this. It took us all to focus on and hone in on our weaknesses, but we still, every day have to perfect it but we, we’re very proud of where we… Where we were, and now where we’re at now, we’re very excited about it and this ends my slide presentation on Code Purple.Thank you for attending.

Thank you Cherry Beth. That is a wonderful presentation and we are all very proud of the success that you guys have seen. Thank you everybody for attending our presentation and if you have any questions for Cherry Beth about how they implemented their program, just notify one of the consultants on this last slide and we will be happy to either connect you with Cherry Beth directly, or we can get your questions answered by her if need be.

So thank you very much and everyone have a nice day.