Vascular Neurology
Overview of fellowship schedule
fellow bat tip sheet
1. Know most recent AHA/AAN/ACEP guidelines for acute stroke treatments.
a. Scientific Rationale for the Inclusion and Exclusion Criteria
for Intravenous Alteplase in Acute Ischemic Stroke Stroke. 2016;47:581-641.
b. 2018 American Heart Association/American Stroke
Association Guidelines for the Early Management of Patients With Acute Ischemic
Stroke. Stroke. 2018;49:e46– e99
c. Class 1 & 3 recommendations – if you are deviating from guideline, note reason why in your consult.
2. TIME IS BRAIN.
a. Answer all calls immediately.
b. Give MEC a back-up number (home/office) or pager.
3. Determine quickly whether patient has a contraindications to IV alteplase
a. Last know normal – biggest exclusion criteria
b. Document clinical syndrome or imaging finding NOT diagnostic for ischemic stroke
i. Frank hypodensity of initial head CAT – recheck last known well, consider tumor or abscess.
ii. Inconsistent clinical findings – aphasia with bilateral leg weakness, no gaze preference.
iii. Baseline focal neurological deficit – are they different.
iv. Remember unless improved to NORMAL (i.e. diagnosis of TIA not stroke), rapidly improving symptoms ARE NOT a contraindication to IV tPA.
c. Document and tell OSH to document and inform family of exclusion.
i. Issue with patient “not considered” for tPA is biggest cause of malpractice claims related to tPA.
d. Most ERs have checklists but consider reviewing/confirming the following
i. Medications /Allergies
ii. Finger stick – only lab required unless:
1. Suspicion of warfarin use – need INR
2. Suspicion for thrombocytopenia – need CBC
iii. Blood pressure prior to IV tPA (<185/110) and during/after tPA (<180/105) (request nicardipine or clevidipine drip early if pt above target).
4. Once IV tPA decision made, determine quickly if patient likely to have large vessel occlusion
a. Clinical syndrome of middle cerebral artery/internal cerebral artery occlusion
i. NIH SS >= 6. The higher the NIH SS the more likely large vessel occlusion
ii. Hyperdense MCA sign
iii. Normal baseline exam that does not cloud presentation.
5. If anterior circulation LVO suspected, is patient potentially eligible for IA thrombectomy?
a. 0-6 hour criteria
i. Baseline mRS <2. ER does not accurately evaluate. Determine:
1. Check meds for dementia or antipsychotic meds
2. Lives alone or with family?
a. BY DEFINITION, assisted living is mRS 2 or greater.
3. Walking independently
4. Leave alone for two weeks.
5. Handle money/pay bills/cook/shop/drive car.
b. >6 hours
i. See slides summarizing DAWN and DEFUSE
c. Try to locate and advise family (get contact info for IR team to consent), but IA as above is considered standard of care <6 hours.
d. Normal renal function
e. Severe renal/hepatic/cardiac/systemic disease. Prognosis for independent survival at least 6 months.
i. Troponin/EKG changes
f. Hemodynamic instability – not septic, not requiring IV pressors
g. IF NOT ELIGIBLE, identify and document exclusion. Have OSH discuss with family or discuss with family yourself.
6. Not eligible for IA – is there another need for tertiary transfer?
a. Large hemispheric stroke in patient < age 60
b. Posterior circulation stroke –
i. risk for cerebellar mass effect
ii. minor symptoms with basilar artery occlusion
c. Suspicion for cerebral venous sinus thrombosis
d. Suspicion for tumor/abscess/endocarditis
7. If patient appropriate for transfer: Let MEC know immediately and begin arranging transport (can get further details (labs, complete med list, etc.) after that process is started)
8. Documentation is critical. Must be timely.
a. Brain Attack Addendum should be completed for all calls.
i. Especially if not transferred, important to documents our clinical understanding at that time.
b. If patient is in EPIC system, please use ‘Documentation Only’ encounter to put in BAT addendum.
i. Use system dot phrases as templates: .UMHNEUROBAT and .UMHNEUROBATPHONEONLY (abbreviated version).
ii. Route to your back-up BAT attending for review.
iii. Route or send “Staff message” linked to patient’s chart to Epic pool: "P UMMC stroke coordinator team" informing them that BAT addendum is in chart)
c. If the patient is not in EPIC system, please complete a BAT addendum on paper or PDF form.
i. E-mail, fax or drop off to Chad Schrier or Karen Yarbrough.
d. Complete as much of BAT addendum as needed for clinical/administrative review.
i. Critical information for all patients includes :
1. Name and DOB of patient
2. Date and time of consult,
3. Name of referring hospital
4. Last known normal time.
5. Time of decision to give IV alteplase
6. Time of acceptance for transfer
7. Exclusion reason for IV alteplase
8. Exclusion reason for IA treatment
9. For UMMC BAT calls:
a. Send page (through UMMC intranet) to “One stroke” (type into function field). This will send page to: CT scanner, stroke senior, stroke coordinator, pharmacy and other staff that might be helpful when dealing with acute strokes.
i. Include your name and phone # if there are any questions
b. Stroke resident pager (0395) will get One Stroke page (but you can also call/page resident to give more info if appropriate).
c. If IV tPA or IA therapy is to be given/done, on-call fellow needs to be present regardless of the time (but IV tPA administration should not wait for fellow if travel delays).
d. Assess patient: Allow residents to initiate NIHSS and evaluation. Fellow should direct the resident if assessment is not being performed in a timely manner.
e. Attempt to reach family to either obtain more information (mRS, etc.) and/or to introduce/explain the need for further intervention.
10. If IA therapy is indicated: contact NeuroIR fellow on call and present the case and discuss need for any additional imaging.
a. contact NeuroIR fellow on call and present the case and discuss need for any additional imaging.
Pagers: NeuroIR fellow pager: 11175; NeuroIR attending pager: 11174
b. Order thrombectomy procedure in Epic so IR team can start set-up. Type “thrombectomy” or “IMG6387” or “TCT” in the order box.
If you cannot find that order, it is also acceptable to order “IR Angio Carotid” (team will change order)
c. Post-procedure: Fellow should talk to ICU team taking care of patient to update regarding outcome of intervention and treatment plan (BP parameters, antithrombotic meds, etc.).
Triaging Work Flow For Potential LVO Mechanical Thrombectomy Cases:
1. BAT on call attending/fellow on call will assess referred patients via Maryland Express (MEC).
a. Potential IA cases who meet AHA criteria are accepted by BAT attending.
*Please remember to ask OSH to send rapid turn around COVID19 testing prior to transfer. *
i. ASAP - Notify Neuro IR Fellow via pager 410-328-BEEP pager 11175 of incoming transfer and ETA.
ii. Information for Neuro IR Fellow should include patient identifiers (Name, DOB/MR#, what neuroimaging has been done and how it can be accessed (i.e. EPIC/CRISP/LIfeimage/Other), two contact numbers for patient's medical decision maker.
iii. NeuroIR Fellow/Attending will review case and initiate process for IA.
iv. If there are concerns about case selection, Neuro IR attending will contact BAT attending on call via MEC or Doc Halo.
b. For cases where IA treatment is not supported by AHA guidelines (outside of time windows, imaging with established ischemia, severe baseline disability, serious co-morbid conditions, etc.), BAT on call should involve NeuroIR attending in decision to accept for transfer.
c. NIR attending should be included ASAP for potential IA candidates who will be enhanced droplet precautions upon arrival to UMMC (COVID positive patients, as well as PUI's with a high pretest probability of COVID). There are limited COVID compatible IR rooms where these patients can be treated and requires additional planning.
d. Contacting NIR attending:
i. Maryland Express Care may be able to bring NeuroIR attending on to line.
ii. Page NeuroIR attending on call by pager 410-328-BEEP, Pager 11174.
iii. Check from intranet who is covering pager 11174 and call Neuro IR attending directly.
Numbers for Neuro IR Attending:
Dr. Jindal 202 -425-4876
Dr. Gandhi 248-497-8856
Dr. Miller 215-514-2785
Dr Jacob Cherian 512-228-0051
e. As a Joint Commission accredited Comprehensive Stroke Center, NeuroIR has process in place to accommodate multiple acute LVO mechanical thrombectomy cases at once. In the event of emergent situation where accommodating a second case will be challenging, the NeuroIR Attending/Fellow will notify BAT on call of issue and when issue is resolved.
fellow independent call guidelines
At the beginning of training, fellows will take BAT calls with the attending on the line, initially with the fellow listening in, then with the fellow taking the lead and the attending listening. When it is felt that the fellow has reached a level of competence and familiarity with the UMMC BAT system they will take initial call independently with the attending available for back-up. Maryland Express Care (MEC) will be instructed to make initial call only to the fellow.
• Fellow should initiate consultation and have a low threshold to involve the attending.
• Regardless of whether attending is brought in on consultation, fellow is expected to write a note (either paper template or in EPIC) and to let the attending know about the case.
• Note: Fellow’s communication with attending should contain enough information that decision making is clear (clinical situation and reason for/against treatment)
How/when to let the attending know will depend on the case as below:
1. Inform Attending of consultation and plan within a few hours of end of shift (i.e. in the morning for overnight calls): email short synopsis, DocHalo in the morning, or send EPIC note for cosign/review
• Clearly not a stroke (e.g. post-ictal, encephalopathy with UTI)
• Stroke outside of tPA treatment window (>4.5 hr from LKW) and no LVO
2. Inform Attending of consultation and plan immediately after MEC call: DocHalo or call
• Uncomplicated stroke within tPA treatment window (giving tPA or clear contraindication) without LVO
• Stroke with LVO within standard IA treatment window (<6 hours from LKW)
• Stroke with LVO within extended IA treatment window (6-24hr) meeting DAWN/DEFUSE criteria or with clear contraindication to treatment
3. Have MEC call attending and connect them into consultation
• Possible candidate for IV or IA treatment, but not straightforward
• Possible transfer patient with question for need of tertiary care transfer, or if being pushed by outside hospital to transfer
• Any questions or concerns about any case
• Any call from St. Joseph’s hospital (based on our contract to provide BAT coverage they expect to have faculty on every case)
guidelines for icu fellows on stroke service
The plan is for you to be in the same role that the stroke fellows typically fill. This will include:
Rounding with the stroke team 8:00-11:00 every weekday (except when called out for BAT calls – see below).
Serve as a resource for the residents and students on the team.
Research about interesting/unusual patients or questions that arise and teaching team about your findings.
Attend neuroradiology conference (Thurs 11-12) and present interesting patients from the service
During the 14 day stroke rotation, you will be:
On call for BAT every weekday 8A-5P.
On Call for BAT 3 weekday nights 5P-8A
On call from home for BAT 1 weekend days & nights (24 hr shift 8A Sat-8A Sun or 8A Sun - 8A Mon)
During these days, you will not have to come in to round on the inpatient service. You will respond to Express Care phone consultations and will come in to the hospital if there is an acute case requiring fellow guidance.
The schedule is set to give you enough time on call to get a good experience, but not so much that you are too tired to function well. If you have a particularly busy night or series of nights, we are pretty flexible, so you can just reach out to Dr. Cronin and/or the attending you are on service with and we can make adjustments, such as having you come in later or leave early.
neuro icu stroke fellow guidelines
(Last Updated September, 2020)
RESPONSIBILITIES OF THE CRITICAL CARE TRAINEES ON THE Neuro Intensive Care Unit (NEURO ICU) ROTATION
Director: Neeraj Badjatia, MD (Department of Neurology)
I. MISSION STATEMENT
The Neuro Intensive Care Unit (NEURO ICU) mission is to provide state of the art life-saving and intensive supportive care to critically ill neurosurgical and neurological patients.
II. Patient Population
Any patient admitted to the Neurosurgery or Neurology services. This will include but is not limited to pre- or post-operative neurosurgery patients; patients with large hemispheric infarct (LHI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and patients with other acute neurological impairment, as well as any patient who is deemed critically ill and requires emergent intensive care unit care.
III. Goal of educational experience
The goal of the NEURO ICU rotation is to allow fellows, residents and medical students an opportunity to learn and apply critical care medicine principles in the above patient population. Unique aspects of this rotation are as follows:
To learn the principles of diagnosis and management of all forms of stroke, including hemorrhagic stroke caused by aneurysms, arteriovenous malformations, arteriovenous fistulas.
To learn how to evaluate for and treat secondary brain injury from acute cerebrovascular disease such as delayed cerebral ischemia from subarachnoid hemorrhage and perihematomal edema from primary intracerebral hemorrhage.
To learn how to work in a unit with a multidisciplinary provider model including critical care Nurse Practitioners (NP), residents from neurology, neurosurgery, and ENT, and critical care fellows from Anesthesiology, Neurology, Emergency Medicine and Internal Medicine.
To learn management principles in intracranial hypertension, SAH/ICH/LHI status epilepticus and neuro prognostication.
To be exposed to neurological diseases that require intensive care treatment such as primary malignant tumors, acute neuromuscular diseases and seizure disorders
To learn how to identify and treat infections in neurologically ill patients;
To learn to manage common critical care problems such as, but not limited to, acute coronary syndrome, shock, sepsis, arrhythmias, ARDS, and AKI.
To learn to care for patients with other organ support devices such as ventilator management and CRRT.
IV. FELLOW RESPONSIBILITIES
Neurocritical Care Unit (NCCU) is a 22 bed ICU that serves as the unit for all non – trauma related patients with neurocritical care diseases. This includes subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, status epilepticus, neuromuscular disorders, and post-operative neurosurgical care, as well as other neurological conditions that do not meet these specific disease criteria. The unit functions as a semi closed unit, with patients admitted primarily under Neurosurgery, Stroke Neurology, or Neurocritical Care. The NCCU teams consists of 2 Attending Neurointensivists, NCC and CCM Fellow, house staff from Neurology and Neurosurgery, and critical care Advanced Practice Registered Nurses (APRNs). The NCCU team is the primary team for all medical management and co-manages neurological issues with the primary service. All order management and requests for consultations are done by the NCC team. The NCC team manages all aspects of medical management, including all non-surgical procedures (e.g. EVD placement, percutaneous tracheostomy, PEG placement). The most common consultation is for Infectious Diseases for the consideration of timing for device placement in the setting of an active infection.
The fellow, under the supervision of the NCC attending, is responsible for supervising and coordinating the care of all patients in the ICU they are assigned (either East or West ICU). Regardless of unit assignment, the NCC fellow should be up to date on plans for all 22 ICU patients and will (in a graduated fashion) take primary triage calls for all ICU admissions. They will be asked to be the primary physician responsible for obtaining the history, performing exam, entering orders and writing notes on 10-12 patients on night call. The fellow is also responsible for keeping the attending informed as to admissions, transfers and patient status. The fellow will arrive on the unit at 0600 to join the Neurosurgical team and overnight provider for their work rounds. The fellow may be asked to assist and supervise NPs/Residents with procedures. Because of the full time presence of Nurse Practitioners in the NEURO ICU, the fellow will utilize the NPs as a resource for learning NEURO ICU procedures and treatment algorithms. The NP will cover the fellow responsibilities when the fellow is not on the schedule or has educational requirements (i.e. conference) that will not allow the fellow presence in the ICU and vice versa. When the fellow leaves the unit for conference they must inform the NP and charge nurse of when they plan to return. The fellow will be expected to answer the beeper or Doc Halo texts for patient questions when on duty.
The fellow will also assist with neurocritical care consults from other units. The consult pager will primarily be held by the non-neurology critical care fellow who will be assigned to the East ICU. The NCC consult sees patients for the following indications: confirmed status epilepticus requiring anesthetic drips, cerebral edema, intracranial hemorrhage, post-cardiac arrest care/prognostication. All other indications should generally be managed by the other neurology consultation teams. The fellow will be expected to assist the non-neurology critical care fellow with initial assessment and management recommendations (with the on-call attending serving as back-up). Consultations will be staffed in-person with the attending on-call in the afternoons.
V. DAILY ROUTINE OF THE NEURO ICU
A. Sign-out Rounds
The incoming day practitioner will obtain a sign-out or report from the outgoing night practitioner regarding the status of the current patients in the NEURO ICU. The active bed requests and the patients that could possibly transfer out of the NEURO ICU should be reviewed. These activities should be done in a timely fashion in order to be ready for 0800 Attending Rounds. All sign in/out activities will follow a structured format that adheres to the UMMC Graduate Medical Education guidelines.
B. Morning Rounds
At 0600 each morning the overnight practitioner (not daytime practitioner) will attend the morning work rounds with the surgical team. Bedside rounds with the NCC attending will begin at approximately 08:00 daily. Rounds will be attended by the NEURO ICU attending, fellow, NPs, residents, medical students, nurses and ancillary staff. It is understood that fellows, NPs, residents, and medical students will have seen and evaluated all of their assigned patients in the NEURO ICU prior to rounds. Nursing input is vital to patient care. It is the responsibility of the ICU team to notify the nurse at the time that the ICU team begins rounding on their patient. During rounds, one resident / NP presents with appropriate images and labs available for review, while another inputs orders. This maintains a constant, efficient work flow, allowing for more time for teaching and for most (ideally all) orders to be placed during rounds. Interruptions from rounds should be limited to emergencies only (i.e. non-emergent phone calls should be returned later). Fellows are expected to offer teaching to residents and NPs on rounds, attend to urgent patient care issues while team is rounding, and maintain the team’s accountability for completing patient treatment plans.
C. Multidisciplinary Rounds
At 1100 each morning the charge nurses from the ICU, step down unit and floor, as well as case managers from neurology and neurosurgery will meet for 30 minutes to discuss pending transfers and begin discharge planning for patients from the intensive care unit. The purpose of this meeting is to improve patient throughput and maximize resources between patient care settings. It is the expectation the fellows and / or ICU triage attending will attend these daily am rounds. Residents may be asked to attend if the NCCU fellow is post call on Thursdays.
D. Consults
Consults will be staffed in-person during the afternoons with the on-call attending. The exact time for staffing consults should be determined by the on-call attending in conjunction with the East and West fellows and is subject to changed based on NCC unit patient care duties, family meetings, and conferences. Notes will be written by one of the fellows and sent to the attending for co-signing. It is expected that all recommendations are communicated to the primary team in-person or via telephone (to allow for questions) as well as through the written documentation.
E. Night Call
Fellows will take night call every Wednesday night while on the rotation and every other Saturday night after their regularly scheduled day shifts. Thursdays and the Sundays following their call nights the fellows will be expected to complete proper transfer of care for all patients and be sure to leave within 24h +4h from their arrival the previous day. On night call, the fellow on call should contact the attending on call at approximately 9 PM at night to “run the list”. At 630 AM daytime will receive sign out from on call fellow. Additionally, the fellow on call is expected to call the on call attending with any new admissions or significant events. The fellow on-call is expected to write “event notes” for significant events overnight and admission notes for new admissions that will be cosigned by the attending the following day. For any events on existing patients, the fellow on call provider is expected to update sign out note in Epic.
F. Procedures
Procedures will be performed by the residents or medical students under the supervision of the fellow/attending. Endotracheal intubations will be performed primarily by the critical care attending. Critical care fellows may perform intubation under appropriate supervision.
G. Notes/Orders
Medication Reconciliation shall be done on admission with history detailed from patient, family or pharmacy.
All restraint orders will be documented within 15 minutes of application and will be reassessed and re-ordered every 24 hours.
A running transfer summary is to be written on all patients daily by the responsible NP, fellow, resident or fourth-year medical student. All notes written by a resident and fellow should be co-signed by an Attending physician in a manner consistent with compliance guidelines. A medical student’s note is not considered the daily patient note; a higher level practitioner should write his/her own note.
All orders should be entered into the computer. Those orders discussed on rounds should be entered during rounds. Except for urgent orders, all orders by primary or consulting services must be reviewed by a NEURO ICU physician.
A template for the daily progress note is accessible by typing: .NCCUTRANSFER
H. Transfer, Discharge and Interim Summaries
ICU discharge summaries will be written by the ICU provider primarily responsible (NP/resident/Fellow) for the patients who expire or are discharged from the NEURO ICU to an outlying facility. Discharge. A “death note” and death certificate also need to be completed for patients who expire.
Neurology:
Transfer summaries are written for all neurology patients moving to another floor in-house phone call.
Discharge summaries and the depart process will be done by the ICU providers for all neurology patients regardless of length of stay.
Neurosurgery:
Transfer summaries are written for neurosurgery patients with a length of stay > 72 hours and will be entered into Epic. <72 hours Neurosurgery will write discharge summary or transfer summary.
Discharge plans and medications are entered by the Neurosurgery team only as they will follow the patient after discharge from the hospital. The discharge order is placed by the ICU team. A discharge summary should be written if the patient is here >72 hours.
I. Attending Sign-Out Rounds
Sign-out rounds with the Attending will be performed beginning at 1630 daily. The NP, resident, fellow and attending will participate in these brief 30 minute rounds that are focused on ensuring AM goals are being met and developing specific overnight goals of care.
VI. COMMUNICATION
Communication among the NEURO ICU staff and primary service / consulting services is absolutely essential to the smooth function of the NEURO ICU. The quality of patient care depends on the lines of communication being open and used frequently.
Patients in the NEURO ICU are cared for by the NEURO ICU team in collaboration with each patient’s primary and consulting services. Recommendations for care as well as the patient’s changing status should be made known to the primary service as soon as possible. Consulting service recommendations must be approved by the critical care attending.
Anticipated discharge of a patient from the NEURO ICU must be communicated in a timely fashion. Emergent admissions or discharges will be handled as judiciously as possible. Communication prevents confusion and misunderstandings and is a hallmark of quality patient care.
Any conflicts in the management of patients between the primary service and the critical care team that cannot be resolved in a timely fashion should be brought to the attention of the Medical Director immediately (24/7/365).
Neurosurgery
Text or call pager 9290 for all neurosurgical issues)
Notify for the following issues:
Elevations in ICP
Change in neurologic exam for neurosurgery patient population
Need for emergent CT scan
SAH IV Heparin protocol issues
EVD issues; clotted, leaking, level, non-occlusive dressing, CSF draws etc.
Neurosurgery in return is responsible for discussing with the NCCU team the following:
Need for further imaging
Changes in EVD settings
OR dates and times
Providing OR hand-off report to providers in the patient room “Hard Stop”
Upon transfer out of NCCU to IMC or floor, complete a transfer summary if >72 hours and page/contact Neurosurgery to notify them of the transfer and to communicate any critical information.
Port: Dr’s Simard, Aarabi, Neurosurgery NP Contact # 8-7121
Starboard: Dr’s. Woodworth, Eisenberg, Sansur / NP # 8-7122
Communicating with Stroke Neurology
Text or page 0395
Notify for the following issues:
Change in neurologic exam
Need for emergent CT or MRI scan
Stroke Neurology rounds every mid morning on their patients and will communicate the following with the NCCU team:
Need for further imaging
Changes in antithrombotic/anticoagulation management
Upon transfer out of NCCU to IMC or floor, complete a transfer summary and page/contact Neurology resident to notify them of the transfer and to communicate any critical information.
Attendings: Cole, Cronin, Kittner, Mehnidratta, Phipps, Wozniak, Chaturvedi
Communication with General Neurology (CNS service)
The Neurocritical Care service will remain the primary team responsible for all non – stroke neurology patients.
Once a decision has been made to transfer out of NCCU to IMC or floor (ie downgrade patient), there must be a full, formal sign out to the designated CNS team member and the transfer summary must be completed. Given there may be a delay of up to several days that may occur between time of down grade and time of obtaining a bed, at the time the patient receives a bed in the IMC/floor, page/contact Neurology resident to notify them of the transfer and to communicate any new critical information. The NCC service will continue to take primary responsibility for all patients during the time that the patient is downgraded but still in the ICU.
GUIDELINES FOR NEURO-ICU PRESENTATIONS
Because ICU patients can be complicated, presentations on morning rounds are most effective when they are structured and well-organized. The role of the presenting resident is to convey a coherent picture of what has been "going on" with the patient to the rest of the team. This serves as a take off point for examination of the patient, review of imaging studies, and discussion. The end-point of each discussion is to formulate a plan for the day. We expect the resident/NP (not Fellow or Attending) to initiate the discussion of a plan by systems. A systems format for organizing morning presentations follows:
1. PROBLEM LIST: Present a summary of patient and pertinent issues. eg “ 46 yo SAH HH4F3 PBD 5 POD 3 who has aspiration PNA day 5 of atb and thrombocytopenia due to HIT.” For new admissions this is replaced by a complete CC, HPI, PMH, Meds, All, SH, FH, ROS).
2. EVENTS OF PRECEDING 24 HOURS: (This should include spontaneous breathing trial performance, interventions, diagnostic test results, deterioration, etc). TO BE PRESENTED BY RN
3. VITAL SIGNS: HR, BP, RR, Temp, ICP, CPP, PBO2, Microdialysis, I+O's including EVD output.
4. DRIPS AND INFUSIONS: TO BE PRESENTED BY RN. fluids, vasoactive and sedative meds (by dose not cc/hr), feeds
5. LABS: ABG (with vent settings), BMP, CBC, AED levels, others. No need to read off all labs – provide pertinent highlights and interpretation
6. BEDSIDE EXAM: Resident/NP provides summary of exam findings noted during pre rounding. The entire team examines the patient together (this may occur here or at end of systems plan).
7. PLAN BY SYSTEMS (always in this order)
NEUROLOGICAL (what do you think is going on with the patient? How do you explain the findings? Are further diagnostic studies are needed? What are the therapeutic goals for the day? Do we need to adjust any on going therapies? Sedation / analgesia adequate? What needs to be communicated to Neurosurgery/Neurology?)
CARDIOVASCULAR (essential components: rate/rhythm, ischemia, pump, pressure: is cardiac performance optimized for achieving neuro goals? What is the goal BP (MAP)? hemodynamic values [CVP, CO, CI,SVI, SVRI], ECHO results], ECG & arrhythmias).
PULMONARY (current ventilator settings, performance during weaning over past 24 hrs, CXR, ABGs, secretions, vital capacity,extubate/trach?).
RENAL / UROLOGIC status (kidney failure, do meds need renal dosing adjustments, etc.)
FLUIDS, ELECTROLYTES, NUTRITION (lytes repleted? Is the patient euvolemic? What are the total fluids the patient is receiving hourly? What are our sodium and/or fluid balance goals? Is the patient receiving adequate nutritional support?)
HEMATOLOGIC (Hct & platelets, coags, are there transfusion triggers for hb, plt?)
INFECTIOUS DISEASE (Is there any signs of acute infection? Are cultures being followed up on? Are antibiotics appropriately dosed/duration? Are all lines/tubes necessary? Need for ongoing Foley catheter use must be clearly identified).
ENDOCRINE (is the serum glucose level well controlled, do we need to adjust; any signs of adrenal insufficiency, s/p pituitary tumor DI watch)
GASTROINTESTINAL status (any signs of ileus, hepatic insuff, or GI bleeding,last BM)
SOCIAL SITUATION/FAMILY STATUS: to be presented by RN.
FAST HUGS BID: to be presented by RN.
Practical Tips for Stroke Fellows:
NeuroICU:
• Vascular fellow will act as ICU fellow.
• Fellow will receive schedule before starting rotation.
• ICU rotation will be broken into 2-week blocks (total of one month of neuroICU).
• Fellow will be carrying the consult phone and will initiate consults with initial recommendations.
• Fellow should talk to attending prior to weekend in order to delineate plan (some attendings would like the fellow to round with them, other attendings will ask the fellow to start rounding in one of the units).
ICU day:
• Fellow will arrive to the unit and pre-round on most critical patients.
• If possible, fellow should be present when neurosurgery rounds (usually between 6-6:45AM).
• Residents/NP's will also pre-round and obtain appropriate data for rounds.
o Of note, some residents/interns may need help to be ready for rounds.
• Rounds start at 8AM.
o Time is the same during the weekends but there is only one attending for the 2 units and the attending will decide the appropriate timing.
• Fellow should be engaged on presentations of patients but most importantly in management.
• Fellows should be especially involved in the management of patients with SAH and ICH to gain more experience with hemorrhagic strokes.
• In the afternoon, fellow will help NP's/residents in decision making and plan of care.
• Fellow should check with resident/intern before leaving to make sure no other questions/concerns are to be answered.
o Of note, attending will always be there as back up or if fellow has any questions.
• During weekends fellow may be asked to initiate progress notes for the attendings.
Consults:
• Fellow will carry the consult phone and will be the first contact for ICU consultations.
• Fellow needs to obtain initial history and give recommendations on the phone. ICU attending can be consulted as well for initial recommendations.
• Fellow will be responsible for evaluating the patient and writing the consultation note.
• One of the attendings on service will be responsible for staffing consults.
• Ask one of the attendings on service to see which one will be staffing consults.
• Consults and follow ups will be staffed in the afternoon with the time set by the attending.
Other points:
• Fellow needs to transfer over the ICU consult phone number from night float resident upon arrival to the hospital.
• Fellow needs to transfer ICU consult phone number back to on-call resident before leaving the hospital.
• Fellow may be asked to do a journal club on Wednesday.
• Fellow will be asked to present ICH/SAH patients on Friday afternoon for ICH research rounds.
o It will be helpful to keep track of those patients throughout the week.
o Patients to be presented will be those seen in the unit since the last Friday.
• Fellow will be leading interdisciplinary rounds (IDR) at 11:00AM from Monday to Friday. During these rounds, the fellow should be able to give brief presentation of the plan and expected disposition length of stay.
• Ask attending/NP's for other instructions regarding these activities.
• Ask NP's to share EPIC list for IDR and Research Rounds. Alternatively, fellow may create own lists in order to facilitate and organize information prior to these activities.
umms acute stroke transfer criteria
ACUTE STROKE TRANSFER SCENARIOS:
Mild stroke (NIH Stroke Scale 0-5)
The majority of patients in this category will not be alteplase (tPA) candidates. The recent PRISMS trial found no definite benefit for patients with non-disabling strokes and NIHSS of 0-5 (1).
Some patients will have a low score and may be candidates for tPA treatment (e.g., isolated aphasia, hemianopsia).
The vast majority of these patients do not require transfer to a Comprehensive Stroke Center (CSC).
If the patient has a very low NIH stroke scale score (0-1) and minimal symptoms (e.g., numbness only) and the deficit is not disabling, it is not necessary to call the BAT team.
Moderate stroke (NIH Stroke scale 6-14)
Frequently, these are the ideal candidates for tPA treatment, if within 4.5 hours.
They may have a corresponding large vessel occlusion so CTA is recommended if patients meet thrombectomy eligibility criteria (see below).
If the patients are evaluated in the 6-24 hour time frame, they should not receive tPA but they should be evaluated with advanced imaging (RAPID software). If advanced imaging not available, then CTA combined with evaluation of the infarct burden on CT (ASPECTS score) can be used.
Patients in this category may require transfer to the CSC if they are thrombectomy candidates.
Severe stroke (NIH Stroke Scale >15)
Alteplase (tPA) is thought to have limited effectiveness in this category but should still be offered if patients meet the criteria for treatment, as per AHA/ASA guidelines (2).
High chance of large vessel occlusion so CTA should be performed if patients meet thrombectomy eligibility criteria (see below).
If <6 hours, no need for advanced imaging beyond CTA. Contact CSC as soon as possible.
If 6-24 hours, advanced imaging recommended (see above).
If a large completed stroke on imaging, and potentially eligible for hemicraniectomy (typically age < 60), then transfer to CSC is appropriate
Thrombectomy eligibility criteria
Brain imaging: Absence of large amount of visible, infarcted tissue. ASPECTS ≥6 commonly recommended.
Arterial imaging: Documented occlusion of internal carotid artery (ICA) or proximal middle cerebral artery (M1)*.
Baseline functional status of patient: Patient should be able to walk with no/minimal assistance and should not have moderate to severe dementia. Modified Rankin score of 0-2 typically recommended.
Modified Ranking Scoring:
0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all usual duties and activities
2 Slight disability; unable to carry out all previous activities, but able to look after own affairs
without assistance
3 Moderate disability; requiring some help, but able to walk without assistance
4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 Dead
Comorbid conditions: Life expectancy >6 months recommended.
SPECIAL NOTES
*Although not specifically mentioned in the AHA/ASA guideline, documented occlusion of the middle cerebral artery in the M2 portion is being increasingly treated with thrombectomy. Occlusion of the basilar artery is also frequently treated with thrombectomy.
In patients age ≥80 years, best available data show that approximately 1 in 4 patients will have good outcome with thrombectomy (3). Therefore, prior to transfer to CSC, discussion should be had with patient’s family about whether aggressive care is desired. If aggressive care is not desired, it is not necessary to call the BAT team.
Patients in a nursing home due to dementia or serious medical illness are not good thrombectomy candidates. It is not necessary to call the BAT team for these patients.
If the BAT team and EXPRESS CARE are not able to confirm bed availability in timely fashion and the patient has a moderate/severe stroke, it is certainly appropriate to act in the patient’s best interest and consult with another CSC.
Patients with large strokes who at risk for life-threatening brain edema are also appropriate to transfer to a CSC.
REFERENCES
1. Khatri P, et al. Effect of alteplase vs. aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: The PRISMS Randomized Clinical Trial. JAMA 2018; 320: 156-166.
2. Powers WJ, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke. Stroke 2018; 49: e46-e99
3. Hilditch CA, et al. Endovascular management of acute stroke in the elderly: A systematic review and meta-analysis. AJNR 2018; 39: 887-891