BATs

A "BAT" is short for Brain Attack Team and represents a clinical situation in which there is a concern for a patient experiencing an acute ischemic stroke. While every BAT is slightly different, the general process is outlined below. More BAT protocols can be found on the UMMC Intranet.

• Outside hospital calls

• in-house (ED or inpatient) BAT calls

• Documentation required for all BAT calls (stroke or not)

• Telestroke cart

• RESPONSIBILITIES OF THE BAT TEAM DURING/AFTER IA CASES

• ORDERS

• NIH Stroke Scale resources on the Web

• IMAGING ACCESS

• BAT Mechanical Thrombectomy Guidelines

Outside Hospital Calls

The BAT fellow/attending takes Maryland Express Care (MEC) acute stroke (BAT) calls from outside hospitals.

• Residents will be advised by the BAT fellow/attending if a patient is being transferred from an OSH, and the plan of evaluation upon arrival.

• The BAT fellow/attending changes in shifts during the day.

  • The BAT schedule can be accessed through: ummsneuro.ezcall.com

  • MEC also has the schedule, and you can always call MEC (8-1234) to reach them if you don’t know who is on for BAT.

in-house (ED or inpatient) BAT calls

GUIDELINES FOR NEUROLOGY RESIDENTS IN RECEIVING IN-HOUSE BAT CALLS (ED OR INPATIENT)

The Neurology resident (stroke senior or on-call resident) will receive the initial call for BAT alerts in the UMMC Emergency Department (ED) or UMMC inpatient Floors via Maryland Express Care (MEC) call to the Stroke On-Call iPhone, number: (443) 683-3001.

• Before connecting stroke resident to ED/floor, MEC operator will tell resident the BAT fellow/attending on-call.

• MEC will also send a DocHalo to the BAT attending to alert them of consult.

The resident will obtain only the necessary information over the phone, and request that imaging and labs be done ASAP. The resident will evaluate this patient immediately:

• if that resident is unable to evaluate immediately due to dealing with a BAT or unstable patient

  • BAT fellow/attending needs to be notified immediately

  • Backup should be called in.

The “one stroke” page should be sent out for all in-house BATs, especially if they are high probability. This page can be found by searching the intranet paging system online by searching 413 or “one stroke”.

• This page alerts: 1) ED CT, 2) pharmacy, 3) stroke pager, 4) stroke coordinator (Chad Schrier), 5) stroke programs director (Karen Yarbrough).

• Page format: “From (your name) 443-683-3001: BAT in (location), (patient info and LKW if known)”

Resident will evaluate the BAT patient quickly and call/ DocHalo the BAT fellow/attending within 15 minutes of the initial call, regardless of how much info is known at that time.

• High probability case: Call BAT fellow/attending or send DocHalo stating that you will call within a few minutes (e.g. “in CT now, will call when done”, etc.)

• Low probability case: DocHalo BAT fellow/attending with quick description of why low probability.

  • Cases that are very unlikely to be stroke should receive standard neurology consultation, including discussion with the on-call senior (required if PGY2), but do not necessarily need to be discussed with the BAT fellow/attending—however, there should be a low threshold for contacting the BAT fellow/attending.

Documentation required for all BAT calls (stroke or not)

For ALL calls that come in as BAT: Note should be sent to Chad Schrier
(Epic pool: "P UMMC stroke coordinator team")

For all strokes use stroke H&P and complete required information:

• Time of initial BAT consult call, Consulting provider, location

• mRS at baseline

• NIHSS time and score

• Last known well date and time

• Treatment with IV tPA (yes/no) and consent dot phrase .TENECTEPLASECONSENTSTROKE

• Treatment with IA clot retrieval (yes/no)

For non-strokes called as BAT: Write standard General consult/H&P but include phrase: .UMHNEURONOTBAT:

• Consult called to Brain Attack Team

• Time of consult: ***

• Consulting Provider & location: ***

• Upon evaluation of patient, case not felt to be a stroke ***

Telestroke cart

There is a telecart in the Adult ED with camera that allows the stroke fellow/attending to teleconference in and be able to see the patient/exam and talk with patient and family.

• The cart is stored by the RESU nursing desk which is by RM 19, immediately when you enter the Adult ED. If you ask someone and they don’t know where it is, ask to speak to the charge nurse.

• If the stroke attending, ED staff, or yourself think it will be beneficial to bring the BAT attending on video, please ask for the cart. Think about it early.

  • If the attending is unable to control the camera for any reason there is a remote control taped to the back of the monitor that will allow someone in the room to control the camera.

RESPONSIBILITIES OF THE BAT TEAM DURING/AFTER IA CASES

(See also: BAT Mechanical Thrombectomy Guidelines below)

• If anesthesia staff are present during the case to manage sedation and vital signs, a BAT team member does not need to be physically present in the IA suite. 

  • However, the BAT team should be immediately available for consultation regarding findings during the procedure and to assume care immediately after the procedure.

• IR fellow will be responsible for contacting the BAT team at the end of the procedure (page on-call resident or call fellow or attending if their expertise needed urgently).

• The BAT team member (resident, fellow, or attending) should get a verbal sign-out from IR and anesthesia providers to make sure there is consensus regarding post-procedure care (BP goals, antithrombotic therapy, follow-up imaging)

• IR team will typically update family regarding outcome of the procedure.  BAT team member should also talk to the family post-procedure to outline post-procedure plan, set expectations, and answer questions.

• BAT team member should obtain NIHSS post-procedure: 

  • If patient sedated, note should be made for a BAT team member (on-call resident) to follow-up within a couple hours for exam off sedation.

• BAT team member should write a Post-procedure note, using Smartphrase template:

  .UMHNEUROBATPOSTIANOTE, which includes:

  • Recanalization: yes/no (see NIR note for details of procedure and TICI score)

  • BP goals:

  • Imaging plan: (dual energy CT in about 4-6 hours, dual energy CT ASAP if concerns)

  • NIHSS post-procedure:

• BAT team member will sign out verbally to the ICU staff assuming care of the patient (typically CCRU or NCCU) including the above elements.

• BAT team member will sign out verbally to neurology on-call resident (if on-call resident not the one involved in case).

*For all BAT consults (regardless of final diagnosis or treatment) - Send EPIC staff message with patient chart linked or route note to: Chad Schrier, Karen Yarbrough, and Mohammed Huq

Orders

ORDERING IV TNK IN EPIC

Tenecteplase dosing: 0.925mg/kg. Maximum total dose regardless of weight = 925mg

Some notes on ordering TNK in EPIC:

• For inpatients who receive Alteplase: Utilize the NEU Inpatient Stroke Thrombolysis Evaluation Supplemental Order Set

• For ED patients who receive Alteplase: Utilize the AED Stroke Thrombolytic order set

*It is important to use an order set because it includes post thrombolytic assessment

• Perform a TIME OUT prior to administration to verify:

  • Patient name

  • NIHSS

  • Time LKW

  • TNK dose (bolus and total)

ORDERING IA THROMBECTOMY (Do NOT do unless specifically asked by IR)

Step 1- log into EPIC but change your context to: “RAD INTRVNTNAL UMH [201001520]” if you can’t find order in your default context

Step 2- pick a patient from your list and open their chart

Step 3- Go to the area where you place orders.

Step 4- Type “thrombectomy” or “IMG6387” in the order box

Step 5- Click on the “Star” the order so that is saves to your favorite list (on the right hand side)– Accept when it asks you to confirm favorite. FYI- Please do not actually order the thrombectomy for the patient at this time

Step 6- Get out of the current chart and change your context to your default area.

Step 7- Go into a patient’s chart to confirm that the correct thrombectomy order you saved as a favorite is now accessible.

When you want to order the thrombectomy in the future it will be available in your favorites so there is no need to change context once it is a favorite.

HOW TO ORDER RAPID IMAGING

Both stand alone orders required:

• CTA Head-Neck with Perfusion (Brain Attack)

• CT Perfusion (Brain Attack)

Also available via the order set as listed below

Step 1: Search for Stroke/Focal Weakness Order Set

Step 2: CTA Head-Neck with Perfusion (Brain Attack) and CT Perfusion (Brain Attack) must be ordered

Step 3: Inform CT Tech

NIH Stroke Scale resources on the Web

• Online Calculator

• NIH Stroke Scale (PDF)

• Free online training and certification in NIH stroke scale

• AHA - Free online training and certification in NIH stroke scale

• NIHSS Stroke Pocket Cards

• NIHSS Stroke Scale in Spanish

IMAGING ACCESS

VIZ AI

• VIZ AI technology allows for quick LVO detection and perfusion mapping in our stroke patients.

• Our stroke coordinator Chad Schrier will ensure you have access to VIZ AI app

• For web access: https://login.viz.ai/login

BAT Mechanical Thrombectomy Guidelines

Goal: Timely delivery of mechanical thrombectomy to eligible patients with acute ischemic stroke

BAT Team Members

• Neurology

• Neuro Interventional Radiology

• Anesthesiology

• NeuroCritical Care

• UNIT physicians/APPs

  • UMMC ED

  • UMMC in house

  • Critical Care Receiving Unit

  • Neuro Critical Care

General Guideline of Workflow between different BAT team members:

• Quality improvement with metrics to document current performance, compare to national standards and develop strategies for continued decreases in time to reperfusion

• BAT team participants – will develop internal work flows to support the process in this guideline

Assessment and initiation of Mechanical Thrombectomy

• Neurology/NeuroCritical care team members are responsible for Identification of potential mechanical thrombectomy candidates and notification of other BAT team members needed for potential IA case.

• BAT team neurologist will consult NeuroIR for potential mechanical thrombectomy cases

  • Quick review of case, timeline and plan for assessment after arrival.

• BAT team neurologist will notify anesthesiology for all mechanical thrombectomy cases.

  • Operating room charge nurse/posting phone 410-328-7418 used for timely notification of ALL potential IA cases

  • BAT team Neurologist (attending/fellow/resident) will notify anesthesiology (see below for additional guidelines specific to different BAT presentations – ED/in-house/transfer))

    • Do not wait to obtain all information before calling anesthesiology

    • Do document information/update anesthesiology with

      • Name/DOB or other identifier

      • Allergies

      • Meds

      • Last ate if known

      • Medical history

      • name and number of next of kin/LAR

        • Obtain consent prior to procedure if possible

  • Notify same number (410-328-7418) ASAP if decision NOT to go to IR is made.

  • Update Anesthesiology (410-328-7418) of final decision for mechanical thrombectomy attempt

    • Discussion of timeline – arrival of patient (if transfer), start of procedure

    • Discussion of initial assessment of sedation needs

• Decision regarding eligibility for mechanical thrombectomy is made by BAT team including assessment of patient and neuroimaging with input from neurology, NeuroIR, ED/accepting unit practitioners.

  • NeuroIR and Neurology assess based on current AHA guidelines and stroke literature.

  • Patients with severe hemodynamic instability are not eligible for IA treatment.

    • This might include but is not limited to severe and uncorrectable hypotension (internal bleeding, sepsis, multi-trauma, etc.), unstable cardiac status (acute MI, severe heart failure, VAD, etc.), severe respiratory compromise (ECMO).

    • If patient becomes unstable during mechanical thrombectomy, BAT team NeuroIR, anesthesiology) will determine ability to stabilize and safety of continuing versus aborting case.

• Initial form of sedation based on assessment by BAT team including neurology, NeuroIR Provider, admitting unit provider (Adult ED, CCRU, Neurocare ICU, other) and Anesthesiology. See below for discussion of general criteria.

• BAT team members all aware of importance of time to reperfusion in acute ischemic stroke.

  • If joint decision that patient should be intubated, ED or accepting units (CCRU/Neurocare ICU) qualified providers may intubate patient.

    • Should not delay IV alteplase or start of IA procedure to wait for anesthesiology if other qualified staff available immediately.

  • Patient is admitted and BAT neurology team member will accompany patient to NeuroIR suite.

    • Anesthesia provider will join in NeuroIR suite ASAP.

    • Typically attending / CRNP start, then CRNP continues.

    • BAT neurologist will provide anesthesiology with assessment and hospital course to date and plan for intervention.

• All BAT team members are aware of importance of blood pressure in patients with acute ischemic stroke

  • <180/105 if post tPA

  • Minimize hypotension for patients

  • Will not routinely start A-line, use cuff pressures.

    • If hemodynamic instability, will start A-line

• Standard of care mechanical thrombectomy for acute ischemic stroke is emergency procedure for life threatening condition where time is critical for improving outcome.

  • BAT team Neurologist will attempt to get contact numbers for next of kin/LAR.

    • Contact numbers shared with NeuroIR and Anesthesiology to allow contact for consent for possible procedures

    • In event that patient cannot consent and no family/LAR can be reached emergently, do not delay standard of care emergent stroke treatment.

During mechanical thrombectomy case

• NeuroIR and additional BAT member will be present during procedure

  • BAT neurology resident/fellow/attending will remain until anesthesiology arrives and hand off is given.

  • BAT neurology attending/fellow whether remotely or physically will discuss progress of case and advise NeuroIR from neurological perspective.

• When decision is made to complete case, NeuroIR and BAT neurology will discuss results of reperfusion attempts and concerns during the procedure.

  • Agreement regarding recommendations to accepting ICU including:

    • Post procedure imaging

    • Post procedure blood pressure goal

    • Determination of BAT team member who will update family.

      • Typically Neuro IR will briefly discuss results and

      • Bat neurology and receiving unit will update family on ongoing management and plan.

      • Dependent on other clinical demands, the team member may designate this notification of family to another team member.

  • Accepting unit will receive verbal handoff post procedure from BAT neurology team member

    • Accepting unit physician or practitioner may be included in NeuroIR and BAT Neurology discussion at end of case. OR

    • Accepting unit physician or practitioner may be briefed by Neurology team member prior to or on arrival to accepting unit. OR

    • Accepting unit physician or practitioner will be advised post procedure by Neurology.

  • Documentation of procedure in IR procedure note including TICI score.

  • Documentation in short BAT progress note of process of handoff

    • Post procedure blood pressure goals.

    • Family/LAR communication

    • BAT neurologist contact for questions or changes in condition

Post mechanical thrombectomy case

• BAT team member (typically anesthesia and/or BAT neurology resident/fellow) will accompany patient from neuro-intervention suite to the accepting unit.

  • Patient will be recovered in accepting unit.

• BAT team neurologist will advise accepting unit of results of procedure and recommendations for post mechanical thrombectomy care as detailed above.

• Neurology Resident will assess patient post-procedure.

SUPPLEMENTAL GUIDELINES

Assessment for need for intubation

Status of airway and assessment for initial form of sedation will be based on assessment by BAT team including neurology, NeuroIR Provider, admitting unit provider (ER, CCRU, Neurocare ICU, other) , NeuroIR Provider and Anesthesiology.

• Some elements of selection as below, others may be appropriate for specific cases.

  • Patient level

    • Hx COPD or orthopnea

    • Severe dysphagia

    • Current respiratory concern

      • Obstructive apnea

    • Labile blood pressure (will also need A-line)

    • Not maintaining immobility (attention, neglect, aphasia, encephalopathy, pain)

  • NeuroIR Level

    • Tandem lesions

    • Difficult IA access

  • Anesthesia level

    • Time last ate

Anesthesiology Notification by BAT Neurologist - Detailed Process

• Timely notification is needed.

  • Anesthesiology understands that may be many non-IA notifications

• PATIENT FROM EMERGENCY DEPARTMENT

  • Box call – do not notify

  • Arrival in ED – BAT team assess patient.

    • Initial triage assessment prior to head CAT consistent with MCA/BA syndrome

    • CALL ANESTHESIOLOGY PRIOR to head CAT: 410-328-7418

      • If bleed, call back and cancel.

      • If no LVO, call back and cancel

    • Review CAT angiogram/CTP/RAPID – LVO

      • Contact NeuroIR – time line

      • Confirm with Anesthesiology and update on timeline

    • If initial triage did not suggest MCA/BA syndrome, but an unexpected LVO seen on imaging with possibility for intervention, CALL ANESTHESIOLOGY ASAP.

      • Call BAT neurologist and Neuro IR, but do not wait for final decision to notify anesthesiology

  • BAT team member stays with patient until anesthesiology handoff and start of procedure.

• PATIENT TRANSFERRED FROM OSH to ICU

  • Initial Maryland Express Care call taken by BAT neurologist.

    • Neurocritical Care and accepting unit MD conferenced into call. .

  • BAT attending/fellow will complete call . If potential IA accepted for transfer:

    • Notify NeuroIR. Get estimation of time line for procedure.

    • Call anesthesiology 410-328-7408.

      • Continue to update anesthesiology regarding timeline especially if changes due weather, transport, patient status etc.

Last Updated: July 30, 2024