Guidelines for Assigning Stroke Patients to Services (revised 06/05/2019)

Objective: Organize stroke in-patient care to improve quality of care and optimize resource utilization.

1. Acute ischemic stroke/BAT service responsibilities

a. Inpatient BAT service

i. Goal service size 6-10 patients

ii. Staffed by Stroke/BAT attending

iii. Target Population

  1. Treated with IV alteplase

  2. Treated with IA clot extraction

  3. Complex cerebrovascular cases

a. Large vessel occlusion – fluctuation – therapeutic hypertension

b. Malignant MCA – through decision for & post care hemicraniectomy

c. Cerebral vasculitis

d. Cerebral venous sinus thrombosis

e. TIA in young/ischemic stroke in the young

f. Moya Moya

g. s/p endovascular intervention (stent, aneurysm coils)

b. Acute Brain Attack consultations (estimate 1-7/day)

i. MEC – community referrals

ii. MEC – BAT for VA

iii. MEC – In house (UMMC, CCRU, Shock Trauma wards & TRU)

  1. In house calls go directly to BAT resident phone (443) 683-3001 (see also Guidelines for Neurology Residents in receiving in-house (ED or inpatient) BAT calls)

iv. BAT attending billing

1. BAT attending can charge critical care time if there was face to face evaluation for acute stroke treatment

a. Even if treatment not given if >==30 min for acute neurological change (i.e. at least one organ at risk for failure). Could be stroke/seizure/delirium etc.

2. This will not prevent another attending from doing E&M service (esp. if staffed on next calendar date).

c. Acute ischemic stroke in-patient consultation (estimated 1/day)

i. “Subspecialty consult” from another neurology provider

ii. Known ischemic stroke with complex management issues

  1. s/p cardiac or other surgery – initiation of anticoagulation

  2. LVAD

2. Clinical Neuroscience Service (CNS)

a. Acute Ischemic stroke – “uncomplicated”

i. Not eligible for IV/IA acute stroke treatment

ii. Traditional atherothrombotic risk factors

b. Discharges from Clinical Neuroscience ICU – NeuroCare Bed Coordinator/Neurocritical care help with triage to appropriate service (Stroke versus Hospitalist)

1. Late hemicraniectomy

2. Hypertensive cerebral hemorrhage

c. Acute TIA – traditional atherothrombotic risk factors

d. Rule out ischemic stroke/ cerebrovascular disease/TIA

e. Non-inflammatory cerebral amyloid angiopathy

3. Service volumes and effect on patient assignment:

a. The Stroke service will have a Cap of 15 patients. After that point, the senior residents and attendings on each service will work together to determine which patients would be appropriate for transfer of service.

b. This will be a “soft cap” in that if the CNS service also has a census of 15 or higher, there will not be reassignment of patients.

4. Neurology Consult Service

1. Acute ischemic stroke – “uncomplicated”

a. Not treated with IV alteplase or IA clot extraction AND

b. Acute surgical/medical issues prevent transfer/admission to General/Hospitalist Service

2. Mental status change – rule out acute ischemic stroke

3. Stroke on imaging but does not account for neurological presentation

4. NeuroCritical Care Admissions

Some patients also followed by Acute Stroke/BAT for up to 72 hours at least for beginning of hospitalization, then can be triaged as appropriate

1. Acute ischemic stroke

a. Hemodynamic ally unstable

b. Respiratory unstable

c. Therapeutic hypertension

d. Symptomatic cerebral edema

2. Acute cerebral venous sinus thrombosis

a. Symptomatic cerebral edema

b. Hemodynamic ally unstable

Last Updated: July 8, 2019