Stroke Service
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The Stroke Service is responsible for admitting stroke patients who are candidates for acute interventional (IV tPA or IA thrombectomy) and/or require complex management by a vascular neurologist. The team also fields consults related to vascular neurology. If patient admitted for possible stroke and diagnosis changes, the patient can then be discussed with the General Neurology Attending and/or PGY-3 Senior Resident, and transferred if appropriate.
DAY 1 (FOR THE PGY-2)
The day before, get sign-out from outgoing PGY-2 on patients that they have been covering.
The day before, touch base with the stroke senior regarding which patients you will be covering on day 1 (could be different from what they outgoing PGY-2 was covering)
Arrive by 7:00AM to the general stroke team room. Pre-round on your patients, which includes seeing them at bedside.
Be ready by 8:15AM to present your patients to the attending.
Team Structure
Stroke Attending
Ultimately responsible for the care of all patients on the service.
Present for rounds (08:00) and available all day for any patient care issues that arise.
Keep in mind that there is a BAT attending on-call at all times (in the afternoons, this is the on-service stroke attending, in the morning and overnight, it is one of the other stroke attendings).
After hours staffing (5 PM to 7 AM):
New Patients: Call BAT attending
Existing patients known to service attending: Call service attending.
Fellow
Usually a Vascular Neurology fellow, but may also be a rotating Neurocritical Care Fellow.
Will assist in the management of any acute neurological issues, especially in-house BATs. May take on the attending role for staffing BAT calls and on rounds.
PGY-4 Senior Neurology Resident
Responsibilities:
Lead rounds in collaboration with the attending. The senior resident should have a big picture view of all patients on the service and advise the attending of the most efficient order for rounds (e.g. which patients are likely to be discharged and should be seen expeditiously or which patients have a time-sensitive management decision to be made).
Determine patients for which each team member will have primary responsibility.
Performing some of the stroke consults from other services (consults also done by other team members).
Oversee and assist junior residents in caring for their assigned patients.
Discussing service patients at interdisciplinary rounds every weekday at 11:00 AM to facilitate discharge planning with case management, therapy services, and social work.
Print out at least 10 lists for IDR.
This meeting is to discuss disposition, not the medical plan or your on-going assessment. Only mention what is relevant to disposition.
Ultimate responsibility for care of all patients on the service, including:
Discharge planning
Tracking pending lab results
Reviewing all orders and medication daily
Ensuring that medication reconciliation is performed appropriately
PGY-2 Neurology resident
Responsible for placing orders, calling consults, admitting patients, discharging patients, performing stroke consults from other services.
Typically, ‘First-up’ for BAT calls
Psychiatry intern
Responsible for placing orders, calling consults, admitting patients, discharging patients, performing stroke consults from other services.
Clinics on Monday afternoons
Advanced Practice Provider (typically Kimberly Clark, PA, sometimes other APPs covering)
Responsible for placing orders, calling consults, admitting patients, discharging patients.
Senior resident should try to anticipate whether patient will be transferred to the APP at the end of the day to make morning pre-rounding more efficient.
APP may not join team for teaching rounds (especially if census is high)
APP quickly runs list with Attending and/or senior before rounds to advise of any patients who need to be seen in morning
During teaching rounds, APP works on discharges, etc.
Rounds on APP patients - with APP, Senior resident, and Attending immediately after teaching rounds, or at 1pm (should last ~30 min, not all patients seen together)
May respond to BAT calls (especially during rounds/conferences)
APP completes work and signs out any remaining issues to senior resident at 3pm, departs at 3:30 pm
2-3 Medical Students
Carry at least 2 patients and as many as they feel comfortable with.
They should present their patients on rounds:
They should evaluate new patients when available and present a full H&P.
For follow-up patients they will present in the SOAP format.
They should utilize the Medical Student Note functionality in EPIC to write notes on their patients. They can send these to the senior resident and/or attending for review and feedback.
If patients are amenable to having an LP performed by a medical student under the Senior Resident's direct supervision, this should be encouraged.
They should be involved with the care of their patients, including calling consults, obtaining accurate medication lists, and assist with other tasks for their assigned patients. They may pend orders for the Senior Resident to review and sign.
They should review as many of the medical student cases as possible with neurology resident.
Common workflow items that need to be addressed
BAT CONSULTS FOR DAY TEAM
The PGY-4 resident will be the first person to break away from rounds to evaluate BAT cases (NOT PGY-2 OR KIM) from 7 AM - 11 AM. The PGY-4 is communicate directly with the BAT fellow/attending regarding treatment eligibility. This will allow the PGY-2 and Kim to complete inpatient rounds with the attending and implement orders/facilitate discharges.
If there are multiple cases occurring at the same time, the sequence will be:
Mornings:
PGY-4
Kim
PGY-2
Fellow
Afternoons:
PGY-2
PGY-4
Kim
Fellow
It is expected that the PGY-4 (or other BAT evaluator) will return to rounds as quickly as possible (i.e. do not sit down to finish writing a complete H&P on the patient seen – that will need to be done later). Please run-the-list with the team upon returning so that updated plan and disposition may be discussed during IDR.
PLAN FOR ALLOWING FELLOWS TO LEAD SERVICE ROUNDS WITHOUT INTERRUPTIONS
Morning BAT calls - Fellow will continue to be on the BAT schedule in the morning and calls will go to fellow's phone.
If fellow in the middle of rounds, the on-service attending (who should be next to them) can step out of rounds to take the call.
If the service is busy with new / complicated patients requiring both the fellow and the service attending to focus on rounds, the fellow will call MEC and tell them to call the morning BAT back-up attending while rounds are ongoing and then call back MEC when rounds done to take over primary call again.
There should be a "running of the list" every day at 1pm with the entire team to review the plans for the day so that anyone who had to step out for part of rounds (senior resident, fellow, attending, APP) will be aware of the discussion and the whole team is on the same page.
Workflow Pointers Specific to Stroke Service
Medication Reconciliation
Complete medication reconciliation upon admission, transfer, and discharge.
Confirm medications upon admission and perform reconciliation: you may need to call patient’s providing pharmacy. (mark the drop down list at bottom of med rec as complete and click reviewed to complete and get credit for it, otherwise will remain incomplete).
Upon discharge you must indicate in the comment section the date of initiation for the medication and the date when the medication is complete. This information will transfer to the AVS so the patient has clear understanding.
Admission orders
Ensure Med Rec done
Daily orders
Ensure DVT prophylaxis is ordered (lovenox, subq hep, or ICDs)
Double check all orders to make sure they are consistent with the current plan
Treatment
Lab orders
Diet orders
PT/OT/SLP
Patients receiving MRI must have MRI checklist performed (frequently done by nurse)
Restraints
See details on the Inpatient Orders Information page
Sign-out
Should be continually updated throughout the day as developments arise. Please see separate Sign-out article for further guidance.
Discharge
It is never too early to start discharge planning: Home discharges may take considerably more time to coordinate services so plan accordingly.
If your patient is ready for discharge, please update senior in the morning so that case management can be notified.
Coordinate with Case Management:
ICU and 4East Case Manager is Sandra Worthington (If she is out go into paging system and type in Sandra Worthington and it should advise you who is covering)
5West Case Manager is Iesha Wise
Follow Up Appointments
If patient needs a PCP: You can consult transitional care if the patient is discharging home and then also call C3 (CoordCare clinic) 410-328-3117 to establish a follow up appointment with a PCP. There is also a CHF clinic that can be reached through this same number.
If patient needs follow-up in resident clinic: 8-6483: Resident appointments. Mr. Jonathan Williams or Ms. Javonia Harden (or message through EPIC)
If discharge to rehab: Patient should follow-up with resident or attending who knows them.
For patients discharging home and needing Rapid Stroke follow-up: Let Chad Schier know and he can get appointment. If you want to call or epic message admin directly: 8-5803: Stroke division (all stroke faculty, including Karen Yarbrough, DNP) – Answered by Ms. Andrea Reddick or Ms. Bernice Brown-Wiggins
Neurology Clinic: 16 S Eutaw Street 3rd Floor, Baltimore MD 21201; 410-328-4323
Order Reconciliation can be performed prior to discharge date
Discharge summary:
Patients leaving for another facility need discharge summary done prior to discharge (start early)
Patients leaving for home need patient instructions (written in lay-person terms and/or utlize smart sets). Discharge Summary must be done within 24 hours
There are several key concepts to keep in mind while completing the discharge summary and preparing the patient for transition to rehab or home:
What is the etiology of the stroke?
What secondary prevention measures are being implemented?
What is the patient's discharge exam?
Has the patient been set up for outpatient follow-up with a Stroke Attending, resident, or Karen Yarborough (Stroke Coordinator and runs the Rapid Stroke Clinic)?
Any other items on the UMH stroke discharge summary
TIPs for Practice on the StRoke-Neurology Team
Presentations
Events overnights
Objective data/Any new imaging?
PE: Can describe or can demonstrate at bedside: Inquire with attending
Assessment/Plan: Date of Stroke/Vascular territories involved/Etiology
Present rest of Problems: Can list problems by system or go problem by problem but include plan (medications and or interventions) under each problem.
Rehabilitation Needs
Dr. Robynne Braun from UMROI is here on Tues/Thurs and can be consulted to optimize patients for rehab and assist with facilitation of discharge if needed. We have had discharges to rehab of patient with NG’s if they are expected to progress.
Patients should have PT and OT updates every 72 hours to stay current. If the patient needs PT, OT or Speech updates advise senior prior to IDR (11:00).
Look into the context of the last therapy notes to find out specifics on diet and specifics on therapy recs.
The list of physical therapists, occupational therapists and speech pathologists is printed every Monday morning by the clerk of 5West. Kim will retrieve the copy and place on wall-closest to team room door by bathroom for reference.
Notes
Get notes written as soon as possible: All notes should be done or almost done before rounds and signed by 11:00, they MUST be signed by 2pm.
Stroke note templates:
.UMHNEUROSTROKEHP
.UMHNEUROSTROKEPROGNOTE
.UMHNEUROSTROKEDCSUMMARY
Avoid note bloat
Update problem lists daily –do not write your daily plan in problem list “overview section”. Import your problem list to the note and then modify plan (right click and select “make editable”).
Place disease specific problems on list (e.g. Hypertension, Diabetes): this list is important for both billing and to trigger nursing education upon discharge.
Anytime you do education (you can do so daily) please document that education in your progress note.
NIHSS
You should have completed your NIHSS training prior to starting this rotation.
Patients should have NIHSS completed on Days 1,2 and upon discharge. Go under flowsheets. Type “Simple”> Select NIHSS and enter
After you put it into the Flowsheet, it can be pulled into the note from there with the phrase: .FLOW[7091970:LAST
See also NIHSS documentation Tip Sheet
Any questions re: requirements for NIHSS or how to find it you can always ask Stroke Coordinator: Chad Schier: 667-210-1232. He also responds quickly to DocHalo.
Modified Rankin Scale
All stroke patients must have mRS on discharge
Question tree for determining mRS after stroke (from Bruno et. al. Stroke 2011):
Ordering Cardiac Event Monitors
Order in EPIC:
Go to “Smart Sets” and it is listed under imaging drop down menu or search for CAR14, Cardiac Event Recorder.
In the comments section, please write: 30 day event monitor for AF in patient with embolic stroke of undetermined source.
You must also state in your note: 30 day monitor for AF in patient with embolic stroke of undetermined source.
Notify Cardiology EP lab of order to have the test scheduled and the monitor mailed. Route order in EPIC to Kiara Rockymore or Candice Wyatt -they will respond back "confirmed" after it has been ordered. Please pick either Kiara OR Candice and not both to route order. Or Call Cardiology EP lab: 8-6056.
Ordering Endovascular Mechanical Thrombectomy
Open the correct patient chart.
Open the Manage Orders on the Left side of the screen.
Search “TCT” in the order box.
Click on the “After Visit Procedures” tab on the Left hand side on the screen
The correct order is called “IR TCT Intracranial Art Mechanical Thrombectomy” or Order # IMG6387
Relationship with Neuro ICU
Patients on the stroke service are frequently admitted to the NCCU for post-intervention and/or closer monitoring. When a patient is in the NeuroICU, the stroke team and critical care team co-manage the patients. Daily progress notes will still need to be written, but the NCCU will be responsible for entering orders. If there is something you would like to do for a patient while they are in the NeuroICU, please contact the ICU provider directly and ask them to put an order in.
Discharges and Transfers to Rehab
If a patient is discharged or transferred to rehab from the NCCU, the stroke team will write the transfer/discharge summary and the ICU team will complete the ADT process in EPIC (e.g., medication reconciliation, putting in follow-up appointments, etc.).
Use the stroke discharge summary template: .umhneurostrokedcsummary
Attending call schedule
The attendings are now using Kronos EZCall for scheduling. Here is a link to find the on call BAT attending:
Goals and objectives
HISTORY — PATIENT CARE
Become proficient at efficiently obtaining a complete, relevant, and organized neurologic history
NEUROLOGICAL EXAM — PATIENT CARE
Become proficient at performing a neurological exam
MANAGEMENT/TREATMENT — PATIENT CARE
Become proficient at managing treatment of common neurologic disorders
Become proficient at recognizing and managing neurologic emergencies
Become proficient at individualizing treatment based on patient characteristics and response to treatment
Become proficient at appropriately requesting consultation from non-neurologic care providers
Become proficient at appropriately requesting consultation from neurologic subspecialists
CEREBROVASCULAR DISORDERS - PATIENT CARE
Become proficient at identifying stroke syndromes and etiologic subtypes and identifying specific mechanism of patient’s cerebrovascular disorder
Become proficient at identifying cerebrovascular emergencies
Become proficient at diagnosing and managing patients with acute ischemic stroke including: indications and contraindications for intravenous thrombolytic therapy and appropriate referral for interventional or surgical evaluation
Become proficient at diagnosing uncommon cerebrovascular disorders
HEADACHE SYNDROMES - PATIENT CARE
Become proficient at diagnosing and managing headache emergencies
PSYCHIATRY FOR THE ADULT NEUROLOGIST - PATIENT CARE
Become proficient at identifying and managing psychiatric co-morbidities in patients with a neurologic disease
Become proficient at recognizing when a patient’s neurological symptoms are of psychiatric origin
NEUROIMAGING - PATIENT CARE
Become proficient at identifying basic neuroanatomy on brain magnetic resonance (MR) and computerized tomography (CT)
Become proficient at recognizing emergent imaging findings on brain MR and CT
Become proficient at identifying major vascular anatomy on angiography
Become proficient at describing abnormalities of the brain on MR and CT
Become proficient at interpreting MR and CT neuroimaging of the brain
LOCALIZATION - MEDICAL KNOWLEDGE
Become proficient at describing basic and advanced neuroanatomy
Become proficient at localizing lesions to specific regions of the nervous system
FORMULATION - MEDICAL KNOWLEDGE
Become proficient at summarizing key elements of history and exam findings
Become proficient at identifying relevant pathophysiologic categories to generate a broad differential diagnosis
Become proficient at synthesizing information to focus and prioritize diagnostic possibilities
Become proficient at correlating the clinical presentation with anatomy of the disorder
Become proficient at continuously adjusting the diagnostic differential in response to changes in clinical circumstances
DIAGNOSTIC INVESTIGATION - MEDICAL KNOWLEDGE
Become familiar with the general diagnostic approach appropriate to clinical presentation
Become proficient at individualizing the diagnostic approach to the specific patient
Become proficient at interpreting results of diagnostic testing
Become proficient at discussing the risks and benefits of tests with patient
Become familiar with diagnostic yield and cost-effectiveness of testing
Become familiar with indications and implications of genetic testing
Become familiar with indications for advanced imaging and other diagnostic studies
SYSTEMS THINKING, INCLUDING COST AND RISK EFFECTIVE PRACTICE — SYSTEMS-BASED PRACTICE
Become familiar with cost and risk benefit ratios in patient care and incorporate that knowledge into clinical decision making
Incorporate available quality measures into patient care
WORK IN INTER-PROFESSIONAL TEAMS TO ENHANCE PATIENT SAFETY - SYSTEM-BASED PRACTICE
Become familiar with team members’ roles in maintaining patient safety
Become familiar with identifying and reporting of errors and near-misses
Become familiar with potential sources of system failure in clinical care such as minor, major, and sentinel events
Participate in a team- based approach to medical error analysis
SELF-DIRECTED LEARNING - PRACTICE-BASED LEARNING AND IMPROVEMENT
Acknowledge gaps in knowledge and expertise and develop and complete an appropriate learning plan based upon clinical experience and incorporating feedback
LOCATE, APPRAISE, AND ASSIMILATE EVIDENCE FROM SCIENTIFIC STUDIES RELATED TO THE PATIENT’S HEALTH PROBLEMS – PRACTICE-BASED LEARNING AND IMPROVEMENT
Use scholarly articles and guidelines to answer patient care issues
Become proficient at critically evaluating scientific literature
Incorporate appropriate evidence- based information into patient care
Become familiar with the limits of evidence-based medicine in patient care
COMPASSION, INTEGRITY, ACCOUNTABILITY AND RESPECT FOR SELF AND OTHERS - PROFESSIONALISM
Become proficient in the compassionate practice of medicine, even in context of disagreement with patient beliefs
Become proficient at Incorporating patients’ socio-cultural needs and beliefs into patient care
ETHICAL PRINCIPLES - PROFESSIONALISM
Become proficient at analyzing and managing ethical issues in clinical situations
RELATIONSHIP DEVELOPMENT, TEAMWORK, AND MANAGING CONFLICT - INTERPERSONAL AND COMMUNICATION SKILLS
Become proficient at managing patient/family-related conflicts
Become proficient at managing conflict in complex situations and across specialties and systems of care
Become proficient at developing a positive relationship with patients
Become proficient at engaging patients in shared decision-making
Become proficient at using easy-to-understand language in all phases of communication
Participate in team-based care
INFORMATION SHARING, GATHERING, AND TECHNOLOGY — INTERPERSONAL AND COMMUNICATION SKILLS
Become proficient at effectively communicating during patient hand-overs using a structured communication tool
Become proficient at accurately documenting transitions of care
Become proficient at completing documentation in a timely fashion
Become proficient at effectively communicating during team meetings, discharge planning, and other transitions of care
Become proficient at educating patients about their disease and management, including risks and benefits of treatment options
Become proficient at completing all documentation accurately, including use of EHR, to promote patient safety
Become proficient at communicating the results of a neurologic consultation in a timely manner
Become proficient at gathering information from collateral sources when necessary
Become proficient at demonstrating synthesis, formulation, and thought process in documentation
Become proficient at leading family meetings
Become proficient at effectively and ethically using all forms of communication
Become proficient at mentoring colleagues in timely, accurate, and efficient documentation
Residents will be expected achieve the following competencies and milestones:
Anatomy:
Must be able to describe the cerebral arterial and venous structures
Must become proficient at localizing lesions to specific regions of the nervous system
Must be able to describe the vascular territories and know the major vascular syndromes:
A. Left and right MCA, PCA, ACA, Cerebellar, Brainstem.
B. Classical Lacunar syndromes
Neuroimaging:
Must be able to describe the imaging features of ICH, SAH, SDH, EDH on CT and MRI and how the pattern changes over time
Must be able to describe the early ischemic changes on CT and score ASPECTs
Must be able to identify the signs of malignant cerebral edema
Must be able to describe the imaging features of ischemic infarcts on CT and how these change over time
Must be able to describe the appearance of CNS ischemia on DWI, FLAIR, and SWI and how these evolve over time
Must be able to identify hyperdense vessel signs
Must be able to describe the imaging characteristics of venous sinus thrombosis
Must be able to identify major vascular anatomy on angiography
Stroke Evaluation:
Must be able to describe the main stroke etiology subtypes and their key features
Must be able to explain the tests used to identify specific mechanisms of stroke, their indications and the interpretation of the findings
Must be familiar with diagnostic criteria for other cerebrovascular syndromes and mimics:
A. PRES
B. CNS vasculitis
C. Vascular malformations
D. CADASIL
E. MELAS
F. Hemiplegic migraine
G. Transient Global Amnesia
H. Peripheral vertigo – BPPV, Meniere’s, vestibular neuritis
Stroke Management:
Must be able to proficiently perform the NIHSS on a patient presenting with acute stroke
Must know indications and contraindications for intravenous thrombolytic therapy and appropriate referral for interventional or surgical evaluation
Must be able to describe the process for evaluating a patient presenting with acute stroke, including the roles of the different healthcare providers and parallel processing to facilitate rapid evaluation.
Must be familiar with guidelines for Intra-arterial intervention for acute stroke.
Must be familiar with the guidelines for management of BP, glucose, and cholesterol in the acute, subacute and chronic stroke settings
Must be familiar with the guidelines for secondary stroke prevention (based on etiology of stroke)
Must be able to describe the indications for rehab service (PT, OT, SLP) consultation.
Key READINGs
PGY-2: 1ST ROTATION
Guidelines for the early management of patients with acute ischemic stroke 2019
Guidelines for the Prevention of stroke in patients with stroke and TIA 2014
If you have not reviewed them already: Acute Stroke Trials (below)
PGY-2: 2ND ROTATION
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
If you have not reviewed them already: Lacunar Stroke, Embolic Stroke, and ICH trials (below)
PGY-4
Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms
Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter)
If you have not reviewed them already: Carotid stenosis and Intracranial stenosis trials (below)
IMPORTANT STROKE TRIALS
Acute stroke
Lacunar stroke
ICH
Carotid stenosis
Resident/Fellow F.A.Q
1. Whenever the BAT phone rings for a true BAT or even a false BAT, please forward the note to “P. Stroke coordinators” group. We are tracking # of activations. Or for fellows, whenever express care calls for a consult or transfer please forward the bat addendum to same group
2. You may ask to mix Alteplase or get TNK (when we make the switch) ready when the patients has a LKW within the window, stroke like exam, and no hemorrhage seen on CT with a high likelihood of offering thrombolysis and no other absolute contraindications. You may Tiger the ED charge or ED Pharmacy (roles in Tiger) or call 410-328-7975 ( ED charge) For inpatient- Make sure pharmacy is there early
3. Document any delays in tPA/IR, I.E IV access, Controlling BP, Intubation prior to.
4. NIHSS must be done on day 0, 1, 2, and day of DC. mRS must be done- baseline- and DC.
5. Make sure to communicate LKW so attending/fellow/resident notes all match
6. Think OPTIMIST for any NIHSS under 10 and No ICU needs- contact Chad if have a candidate. Think Research for all patients. See board in stroke team room
7. Resident please use One stroke pager for all inpatient cases and ED cases- RAPID response needs to be called by unit staff as well.
8. Neurology resident orders the tPA-Make sure to use order sets for post tPA and utlize the correct vitals/ neuro checks order set. Do not change order set for first 24 hours even if patient is doing great. Confirm whichever ICU /IMC the MD knows the appropriate order set and the importance of not modifying order set in first 24 hours.
9. If your patient is going to be put on a DOAC, please send script to pharmacy ASAP to confirm pricing
10. Please introduce yourself to nurses and make sure they can tiger connect you easily
Last Updated: February 12, 2020