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.