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Care Process Model MARCH 2016 EMERGENCY MANAGEMENT OF Acute Ischemic Stroke This care process model (CPM) was created by the Neurosciences, Intensive Medicine, and Cardiovascular Clinical Programs at Intermountain Healthcare. These groups include multidisciplinary representation from neurovascular medicine, interventional radiology, cardiology, anesthesia, hospitalists, and others. The CPM provides expert advice for the emergency management of acute ischemic stroke and summarizes current medical literature and national practice guidelines. (See guideline references on page 8.) Intermountain’s care management system for stroke also includes: • Education materials and programs for providers and patients. • Data systems that help providers and facilities track stroke management success. • Multidisciplinary coordination of stroke care. Why Focus ON ISCHEMIC STROKE? • Incidence and mortality. In the U.S., about 795,000 strokes occur each year, 610,000 of which are first attacks, and nearly 134,000 of which are fatal. About 87% of all strokes are ischemic strokes.MOZ When considered separately from other cardiovascular diseases, stroke is the 5th leading cause of death.CDC • Impairment. Stroke is a leading cause of disability. Six months after a stroke, 26% of patients still need institutional care; 15% to 30% are permanently disabled. MOZ WHAT’S INSIDE? ALGORITHMS: Diagnosis and Classification. . . . . . . . . . . . . . . . . 2 Emergency Management of Acute Ischemic Stroke. . . . . . . . . . . . . . . . . . . . . . . . 4 Assessment for Endovascular Therapy. . . . . . . . . . . . . . . . . . . . . . . . 7 ED Acute Stroke Process Checklist. . . . 6 Patient/Family Education Resources.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 PROGRAM GOALS AND MEASUREMENTS % of all stroke patients who have NIH Stroke Scale score documented time from ED arrival to imaging • Cost. Direct and indirect costs related to stroke in 2011 were $33.6 billion. Between GOAL: < 25 min from ED arrival to imaging 2012 and 2030, total direct medical stroke-related costs are projected to triple.MOZ • Improved outcomes when key processes are followed. Multiple studies have shown that patients suffering from stroke are more likely to have improved outcomes and fewer complications when hospitals use standardized care processes. JOI Key processes for emergency management of ischemic stroke include: –– Initial assessment, rapid transport, and early notification by EMS personnel. –– A system for prompt evaluation, diagnosis, and treatment decisions by ED personnel, incorporating limited laboratory testing, stat brain imaging, and a stroke rating scale such as NIHSS. ALB Smaller or rural facilities should treat to capacity using the Telestroke process and transport to a stroke center as quickly as possible. 60 time from ED arrival to treatment 60 GOAL: < 60 min from ED arrival to tPA treatment JAU % of eligible ED patients treated with endovascular therapy % of eligible ED patients treated with tPA within 3 to 4.5 hours of symptom onset –– Administration of the thrombolytic drug tPA (recombinant tissue-type plasminogen activator) within 3 hours of the onset of stroke symptoms in all eligible patients, and within 4.5 hours in more carefully selected patients. What’s new IN THIS UPDATE? •• Updated treatment algorithms for diagnosis and classification, emergency management of acute ischemic stroke, and endovascular therapy (see pages 2–7) •• Telestroke process details (see page 2) •• New ED Acute Stroke Process Checklist (see page 6) •• Concentrated focus on emergency management Throughout this CPM, the icon below indicates an Intermountain measure. EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE M A RC H 2016 ALGORITHM 1: DIAGNOSIS AND CLASSIFICATION Patient / family calls 911 SIGNS AND SYMPTOMS of stroke (a) In-hospital onset of symptoms Personal transport directly to Emergency Department (ED) PERFORM EMS pre-assessment and transport Last Seen Normal time < 6 hours ago? no ACTIVATE medical emergency or rapid response team MANAGE as SUBACUTE STROKE yes Symptoms completely resolved? no yes MANAGE as TIA (See Suspected TIA Clinical Guideline) ASSESS for acute stroke (Also see ED Acute Stroke Process Checklist, page 6) ED PHYSICIAN < 10 min from ED arrival to seen by MD 60 60 ED HUC •• Assess patient: ABC, PMH, medications, NIHSS (b) / other neuro assessment per protocol •• Review IV tPA contraindications (see page 5) •• Initiate Telestroke process (see Telestroke info at right and process checklist on page 6.) < 15 min from ED arrival to telestroke activation ED RN/ TECH •• Initiate stroke alert •• Document time Last Seen Normal •• Order STAT CT non-contrast (c) •• Weigh in kg •• IF Telestroke facility, activate Telestroke process (see Telestroke info at right and process checklist on page 6.) •• O2 via nasal cannula to keep sats > 94% •• Monitor VS Q 15 minutes •• 12-lead ECG •• Start IV; draw labs (BMP, CBC, PT-INR, PTT); fingerstick glucose. Use ISTAT if available. •• IF Telestroke facility: Explain Telestroke to patient and family; remain with patient to assist with on-camera neuro exam. •• If patient <18, contact PCH ED 801-662-1200 instead of telestroke. CONDUCT stat imaging (c) < 25 min from ED arrival to imaging CT Tech 60 •• Performs non-contrast CT of brain •• Performs CTA and CT perfusion if requested by neurologist and available at facility (if requested but not available, see Telestroke info at right). 60 •• Alerts radiologist to read STAT CT scan < 45 min from ED arrival to completion of labs and imaging evaluationJAU Radiologist •• Reads scan and reports to neurologist the “bleed/no bleed” and ASPECTS score. IF Telestroke facility, radiologist contacts neurologist through the Transfer Center. (See Telestroke info at right.) no Intracerebral hemorrhage? TELESTROKE — HOW IT WORKS -- Activate Process; ED HUC initiates process by: •• Calling Transfer Center at 801-3213381 (local) or 855-932-3648 (toll free) •• Saying “Telestroke” •• Providing patient name, DOB, ED room #, and ED MD name/phone -- Alert Telestroke MD: Transfer center texts message, “TELESTROKE at [hospital], room # __; please call Transfer Center at 855-932-3648.” -- Connect Neurologist & ED MD: Transfer Center sets up conference call and facilitates tech support during call, if needed. (Also include accepting physician at receiving facility if other than IMC.) -- Follow up and Transfer (if needed): Transfer Center contacts and connects with ED physician for consult (video link tech support); follows up with neurologist (30–45 minutes later); facilitates patient transfer as needed. yes 60 < 60 min from ED arrival to treatment JAU MANAGE as ACUTE ISCHEMIC STROKE (See page 4) MANAGE as HEMORRHAGIC STROKE (See AHA/ASA 2015 Guideline) Indicates an Intermountain measure 2 ©2008–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . M A R C H 2 0 1 6 (a) SIGNS AND SYMPTOMS • Sudden numbness or weakness of face, arm, or leg, especially unilateral Sudden confusion or speech impairment Sudden visual changes or visual loss in one or both eyes Sudden trouble walking, dizziness, or loss of balance or coordination Severe headache with no known cause • Can assess using BE FAST: • • • • -- Balance: sudden loss of balance or coordination -- Eyes: sudden change in vision -- Face: sudden weakness of the face -- Arms: sudden weakness of an arm or leg -- Speech: sudden difficulty speaking -- Time: time the symptoms started (b) HISTORY AND PHYSICAL — Document • • • • • • Clock time last seen normal and time of arrival in ED History of seizure, aneurysm, AV malformation, intracranial hemorrhage, or intracranial neoplasm? ANY of the following in last 3 months: head trauma, acute MI, major surgery, TIA, or stroke? On warfarin or other anticoagulant? Allergies? NIHSS score (use information at right) (c) STAT IMAGING CT non-contrast to rule out hemorrhage • CTA (brain through aortic arch) if requested by neurologist (unless contraindicated); should not delay tPA administration • ONLY when requested by neurologist, CT perfusion (MTT, CBV, CBF) • EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE National Institutes of Health Stroke Scale NIH — Plain English Version (NIHSS-PE)* Item Title Responses and Score 1A Level of Consciousness0—Alert 1—Sleepy but arouses 2—Can’t stay awake 3—No purposeful response 1B Orientation Questions (2) -What month is it? -What is your age? 0—Both correct 1—One correct/intubated 2—Neither correct 1C Commands (2) -Open/close eyes -Make a fist/let go 0—Obeys both 1—Obeys one 2—Obeys neither 2 Lateral Gaze -Eyes open, follow examiner’s fingers or face side to side 0—Normal side-to-side movements 1—Partial side-to-side movements 2—No side-to-side movement 3 Visual Fields -Eyes open, count 1/2/5 fingers, detect movement in all 4 fields 0—Normal visual fields 1—Blind upper OR lower field, one side 2—Blind upper AND lower field, one side 3—Blind in both eyes/four fields Facial Weakness0—Normal -Smile/grimace 1—Mild one-sided droop with smile -Raise eyebrows 2—Obvious droop at rest -Squeeze eyes shut 3—Upper and lower face is weak 4 5 Arm weakness (left and right) -Patient holds arm at 90º if sitting, 45º if supine, for 10 seconds Score R: ____ and L:____ 0—No drift (X—Joint fused/amputee) 1—Drifts down, does not hit bed 2—Drifts down to hit bed 3—Can move, but cannot lift 4—No movement 6 Leg weakness (left and right) -Patient holds leg straight out if sitting, 30º if supine, for 5 seconds Score R: ____ and L:____ 0—No drift (X—Joint fused/amputee) 1—Drifts down, does not hit bed 2—Drifts down to hit bed 3—Can move, but cannot lift 4—No movement Coordination -Finger to nose, heel to shin Score only if not caused by weakness. 7 0—Normal or no movement 1—Clumsy in one limb 2—Clumsy in two limbs 8 Sensation (feeling)0—Normal -Pin prick face, arm, leg — 1—Decreased sensation compare sides 2—Can’t feel, no pain withdrawal 9 Speech (content) -Name/describe pictures or objects (e.g., glove, chair, key) -Read sentences (e.g., “Down to earth”; “I got home from work”) (Intubated pts. write; blind pts. hold objects) 0—Correct full sentences 1—Wrong or incomplete sentences 2—Words don’t make sense 3—Can’t speak at all 10 Speech (slurring) -Read or repeat word list (e.g., huckleberry, baseball) 0—No slurring (X—Intubated/barrier) 1—Slurs, but you can understand 2—Slurs (you can’t understand) or mute 11 Neglect -Ignores one side of body; test vision, then test touch on both sides at once 0—Sees & feels as both sides tested at once 1—Doesn’t see OR feel one side 2—Doesn’t see AND feel one side *Notes: • The NIHSS-PE is used with permission of the Providence Brain Institute. • The actual NIH form and instructions are available on the NIH website (http://www.ninds.nih.gov/disorders/stroke/strokescales.htm). Indicates an Intermountain measure ©2008–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 3 EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE M A RC H 2016 ALGORITHM 2: EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE Acute Ischemic Stroke Further CLASSIFY stroke based on CT findings and time since onset Symptom onset 4.5–6 hours Symptom onset < 4.5 hours REVIEW criteria for IV tPA < 3 hours (a) 3 – 4.5 hours (a) AND (b) Appropriate per criteria? no EVALUATE clinical considerations for endovascular therapy yes (See algorithm 3 on page 7) Factors include: DISCUSS tPA risk and benefits with patient/surrogate decision maker (written consent not required). • Age • Baseline functional status • Occlusion location • ASPECTS score ADMINISTER intravenous (IV) tPA (c) and monitor (d) • Time of onset Based on assessment, is patient a candidate for endovascular therapy? no ADMIT to ICU or stroke unit If Telestroke site, transport to nearest stroke center. MANAGE per yes PAGE IR for immediate intervention and OBTAIN consent; MOVE to IR suite Hospital Care and Rehabilitation for Adult Stroke and TIA Patients CPM Indicates an Intermountain measure 4 ©2008–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . M A R C H 2 0 1 6 EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE (a) Intravenous (IV) tPA relative exclusion criteria for < 3 hours since symptom onsetBER, BRU, GOY, JOV, SAV Contraindications (risk of bleeding is greater than the potential benefit) • • • • • Thrombolytic therapy initiated by another hospital prior to arrival CT findings (ICH, SAH, or major infarct signs) SBP > 185 or DBP > 110 mmHg despite maximal treatment Plts < 100,000, PTT > 40 sec after heparin use, PT > 15, INR > 1.7, or known bleeding diathesis Confirmed use, in the last 48 hours, of direct oral anticoagulants (DOACs), such as dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), edoxaban (Savaysa®) Warnings and Precautions (use clinical judgment) • • • • • • • Blood glucose concentration ≤ 50 mg/dL greater than or equal to 400 mg/dL Seizure at onset Recent surgery/major trauma (< 15 days) Active internal bleeding (< 22 days) Significant stroke or head trauma (< 3 mo) Intracranial or spinal surgery (< 3 mo) Myocardial infarction (MI) (< 3 mo) • • • • • • Non-disabling stroke symptoms Life expectancy < 1 year or severe co-morbid illness History of vascular malformation History of intracranial hemorrhage History of brain aneurysm or brain tumor Pregnant or lactating (b) Additional criteria for IV tPA at 3–4.5 hours • • • • • Age > 80 Imaging finding of infarction with hypodensity involving >33% of the cerebral hemisphere History of both stroke and diabetes NIHSS > 25 Oral anticoagulant regardless of INR (c) Sterile preparation and administration of IV alteplase (Activase®) by ED nurses 1 Reconstitute immediately before administration, using aseptic techniques at all times. IV alteplase will be reconstituted using the 100-mL vial of sterile water for injection (SWFI) provided. 2 Remove the protective cap from the top of the alteplase (Activase®) vial and the vial of SWFI. Swab the top of each vial with an alcohol wipe to reduce the risk of contamination. 3 Using aseptic technique, pierce the vial of sterile water with the provided transfer device. DO NOT invert the vial of sterile water. Holding the vial of alteplase (Activase®) powder upside down, place the center of the stopper over the exposed piercing pin and insert. 4 Invert the two vials, allowing the sterile water to flow into the altiplace (Activase®) vial. (This may take a couple of minutes.) DO NOT shake; gently swirl only. DO NOT HANG AND INFUSE THE ENTIRE VIAL! Vial contains 100 mg (1 mg/mL) when reconstituted. NOTE: Slight foaming of the solution is normal. Let the solution stand undisturbed for several minutes to allow any large bubbles to dissipate. 5 Visually inspect the alteplase (Activase®) solution for particulate matter and discoloration before dispensing. 6 Determine the total dose needed, and draw out the excess from the vial and discard. 7 Draw the bolus dose (10% of the total dose) into the appropriately sized IV syringe. Place the bolus label on the IV syringe. (If your hospital uses a tube system, put a DO NOT TUBE label on the alteplase (Activase®) bolus syringe. 8 Inject bolus dose through peripheral IV over 1–2 minutes. 9 Infuse the remaining dose over 60 minutes. 10 Flush tubing after infusion with 50 cc of 0.9% normal saline. NOTE: Reconstituted alteplase (Activase®) is stable for up to 8 hours in solution at room temperature. (d) Monitoring frequency: Monitor vital signs and conduct neuro assessment (per facility guideline) from start of tPA: • Every 15 minutes for 2 hours • Then, every 30 minutes for 6 hours • Then, every hour for 16 hours ©2008–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 5 EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE M A RC H 2016 TABLE 1. ED Acute Stroke Process Checklist Role Action (for patient presenting with stroke-like symptoms) RN Determines acuity: RN determines if patient is possible stroke alert (remains symptomatic AND LSN <6 hrs.) Notifies HUC Tips Example scripting: “Please call a stroke alert for room XX.” HUC of stroke alert Notifies Stroke Alert to ED staff and stroke team, if available, using standard communication methods Example scripting: “Stroke alert in room “XX” Stroke Alert MD Assesses Notifies for stroke immediately HUC to activate Telestroke if applicable Conducts NIHSS-PE (page 3) / Reviews tPA contraindications (page 5) and eligibility for endovascular therapy (page 7) Treats BP if > 185/110 (see Tips column for medication considerations) Consults HUC Enters Calls orders for STAT non-contrast CT of brain CT tech Enters Calls with neurologist via phone; assists w/ Telestroke exam if requested orders for lab work for Neuro/Stroke TIA order set the Transfer Center at 801-321-3381 or 855-932-3648 to contact neurologist Enters orders for 12-lead ECG Arranges RN* for EMS ACLS transport when needed Responds immediately to room with i-STAT® machines and travel monitor (scale if requested) Starts IV and draws blood samples, runs i-STATs (INR, creatinine, glucose) Obtains Stroke Packet / Documents time LSN (Last Seen Normal) Determines patient for immediate transport to CT Explains Telestroke services to patient and family as appropriate Notifies to assist with Telestroke neuro exam as needed pharmacist of tPA need once determined Responds ECG/RT Tech* patient weight in kg Readies Prepares Pharmacist* to patient room ASAP Obtains brief medication history Reviews tPA eligibility criteria, as needed Prepares for possible tPA administration/pharmacy protocol Performs 12-lead ECG *Note: If these services are unavailable, RN/provider may delegate tasks as appropriate. 6 For BP treatment, consider:JAU •• Labetalol (10–20 mg IV over 1–2 minutes, may repeat 1 time) •• Nicardipine (5 mg/h IV, titrate up by 2.5 mg/h every 5–15 minutes, maximum; 15 mg/h; when desired BP reached, adjust to maintain proper BP limits) •• Hydralazine or enalaprilat may be considered when appropriate ©2008–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . Example scripting: “This is a Telestroke patient [provide patient’s name, DOB, ED room #, and ED MD name and phone number].” RN may delegate tasks as appropriate for the facility. M A R C H 2 0 1 6 EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE ALGORITHM 3: ASSESSMENT FOR ENDOVASCULAR THERAPY Patient to be assessed for endovascular therapy EVALUATE patient for ABSOLUTE inclusion criteria (all must apply)POW •• Age: 18–80 •• Occlusion location: ICA, M1, M2 •• Functionally independent •• ASPECTS > 6 •• Disabling deficit •• Onset: < 6 hours Patient meets ALL ABSOLUTE criteria? yes no PAGE IR, OBTAIN consent, and MOVE patient to IR as soon as possible (a) EVALUATE patient for RELATIVE inclusion criteriaPOW •• Age: >16 (for 16–17 year olds, call PCMC) •• Occlusion location: Cervical ICA, tandem occlusion, bailar, A1, P1 •• High risk for deterioration •• ASPECTS > 5 •• LImited disability •• Onset: < 24 hours Patient meets RELATIVE criteria? yes REVIEW case with IR, and DISCUSS with patient (a) no ADMIT to ICU or stroke unit If Telestroke site, transport to nearest stroke center. MANAGE per Hospital Care and Rehabilitation for Adult Stroke and TIA Patients CPM (a) Endovascular Therapy: Data points to be collected and reported by all endovascular sites: • IR page time • Groin puncture time • Initial TICI score • Time of first pass • Final TICI score • Time of final TICI score • Symptomatic hemorrhage within 36 hours (SITS-MOST definition) Metrics that will be monitored and reported (goal in parentheses): • Door to IR page (goal: undefined) • Door to puncture (goal: 120 min) • IR page to puncture (goal: 60 min) • Page to IR team arrival/available (tech +RN) (goal: < 30 min) • Door to final TICI score (goal: < 8 hours) • Percentage final TICI 2b/3 (goal: undefined) • Symptomatic ICH rate (based on SITS-MOST criteria) ©2008–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 7 EMERGENCY MANAGEMENT OF ACUTE ISCHEMIC STROKE M A RC H 2016 KEY GUIDELINES PATIENT / FAMILY EDUCATION RESOURCES DEL Patients and their families can find these materials and links to other reliable stroke resources in the Health Library at Intermountain’s public website (intermountainhealthcare.org/stroke). FUR Furie KL, Kasner SE, Adams RJ, et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(1):227–276. Accessed July 9, 2015. Fact sheets and other tools help educate patients and families about stroke symptoms and treatments. • • Fact Sheets on conditions that may be associated with emergency management of stroke, such as Acute Ischemic Stroke Treatments Fact Sheets on anticoagulation medication, including Dabigatran, Rivaroxaban, and Warfarin BE FAST Refrigerator magnet: includes signs of stroke and reminder to call 9-1-1. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr; American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40(8):2945–2948. Accessed July 9, 2015. JAU Jauch EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947. Accessed July 9, 2015. MOR Morgenstern LB, Hemphill JC 3rd, Anderson C, et al; American Heart Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108–2129. Accessed July 9, 2015. POW Powers WJ, Derdeyn CP, Biller J et al; 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals form the AHA/ASA. Stroke. 2015;46:3020–3035. Accessed November 19, 2015. SCH Schwamm LH, Pancioli A, Acker JE III, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force for the Development of Stroke Systems. Stroke. 2005;36(3):690–703. doi:10.1161/01.STR.0000158165.42884.4F OTHER REFERENCES ALB Alberts MJ, Latchaw RE, Jagoda A, et al; Brain Attack Coalition. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition. Stroke. 2011;42(9):2651–2665. Accessed July 9, 2015. BER Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372:11–20. doi: 10.1056/NEJMoa1411587. BRU Bruce CV, Campbell, P.J. Mitchell, T.J. Kleinig, H.M. et. al. Endovascular therapy for ischemic stroke with perfusionimaging selection. N Engl J Med. 2015;372:1009–18. DOI: 10.1056/NEJMoa1414792 HOW CLINICIANS CAN ACCESS AND ORDER THESE MATERIALS • • Viewing online: Open the appropriate topic pages via the Clinical Programs pages on intermountain.net or intermountainphysician.org. Ordering: Order from Intermountain’s Online Library and Print Store at iprintstore.org. Search for items by entering key terms or browsing the topic menu. CDC CDC. National Center for Health Statistics. Fast Stats. Deaths: Final Data for 2013, tables 1, 7, 10, 20. www.cdc.gov/ hchs/data/nvsr/nvsr64_02.pdf. Accessed July 9, 2015. GAD Gadhia J, Starkman S, Ovbiagele B, Ali L, Liebeskind D, Saver JL. Assessment and improvement of figures to visually convey benefit and risk of stroke thrombolysis. Stroke. 2010;41(2):300–306. GOY Goyal M, Demchuk AM, Menon BK, et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–1030. doi: 10.1056/NEJMoa1414905. JOI Advanced Certification for Primary Stroke Centers. The Joint Commission Web site. http://www.jointcommission.org/ certification/primary_stroke_centers.aspx. Accessed July 9, 2015. JOV Jovin TG, Chamorro A, Cobo E, et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):0063-2306. doi: 10.1056/NEJMoa1503780 MOZ Mozaffarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(14) e29–322. Accessed June 24, 2015. NIH NIH Stroke Scale (NIHSS). Know Stroke website. http://stroke.nih.gov/resources/. Accessed July 9, 2015. NIND The National Institute of Neurological Disorders and Stroke rtPA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–1587. SAV Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015; 372(24):2285–95. doi: 10.1056/NEJMoa1415061. CPM DEVELOPMENT TEAM Kelly Anderson Kevin Call, MD Gabriel Fontaine Jeremy Fotheringham 8 Karilee Fuailetolo Jeanie Hammer Robert Hoesch, MD Julie Martinez Chrisi Thompson Kristy Veale Note: This document presents an evidence-based model of care that is appropriate for most patients. It should be adapted to meet the needs of individual patients and situations and should not replace clinical judgment. Send feedback to Kevin Call, MD, Director, Stroke Development Team, Intermountain Healthcare ([email protected]). © 2008-2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. PATIENT AND PROVIDER PUBLICATIONS CPM024a - 03/16