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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.
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Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.
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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