Jordan Ellis
Hospital emergency codes are coded messages announced over a public address system to alert staff to various classes of on-site emergencies. They are intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors. Code Stroke is an emergency protocol for the immediate assessment of patients with suspected cerebrovascular events. This protocol aims to increase the administration of currently available reperfusion therapies for ischemic stroke. Delays in activating in-hospital code strokes contribute to increased morbidity, mortality, prolonged hospitalization, and associated healthcare costs.
| Characteristics | Values |
|---|---|
| Definition | An emergency protocol for the immediate assessment of patients with suspected cerebrovascular events |
| Purpose | To reduce response times for inpatient stroke and improve patient outcomes |
| Implementation | Development of an algorithm for identification and initial management, educational intervention for nursing staff, coordination by a specialized stroke nurse or code stroke coordinator, activation of a code stroke response team |
| Treatment Options | Intravenous thrombolysis, Endovascular Clot Retrieval (ECR), Mechanical Thrombectomy, TNK (Tenecteplase), Carotid Endarterectomy Surgery |
| Performance Indicators | Time from last seen normal to initial assessment, time to brain imaging, time to treatment |
| Challenges | Delays in recognition and management, assembly of ad hoc teams, access to urgent imaging, lack of standardized codes |
| Locations | Ontario, Quebec, Saskatchewan, Yukon, UK, US, Canada, New Zealand, Australia, Romania |
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What You'll Learn
Delays in recognition and management of acute stroke
Stroke is a relatively common and challenging condition in hospitalized patients. Delays in recognizing and managing acute strokes can lead to poor outcomes, increased morbidity and mortality, prolonged hospitalization, and higher healthcare costs. These delays can occur both before and after patients reach the hospital.
Before reaching the hospital, patients may experience pre-hospital delays due to a lack of knowledge about stroke symptoms and the urgency of seeking medical attention. Studies have shown that pre-hospital delays are common, with a median delay of 9.5 hours in one study. Patients who perceive symptoms as serious, have prior knowledge of stroke symptoms, and use ambulance services are more likely to arrive at the hospital earlier. Therefore, public education campaigns focusing on stroke recognition and response are crucial to reducing pre-hospital delays.
Once patients arrive at the hospital, there may still be delays in recognizing and managing acute strokes. This can be due to factors such as less knowledge of stroke symptoms by healthcare professionals, attributing symptoms to other conditions, and monitoring patients closely instead of immediately performing neuroimaging or activating a code stroke. Implementing standardized algorithms and educational interventions for healthcare staff can help improve the recognition and management of inpatient strokes.
Code stroke protocols involve coordinating a specialized response team, including neurologists, neuroradiologists, vascular neurologists, and interventionalists. These teams work together with emergency department staff to provide rapid evaluation and initiation of interventions. Hospitals with dedicated stroke teams, such as Huntington Hospital, have been recognized for their timely performance in treating stroke patients.
Overall, reducing delays in the recognition and management of acute stroke requires a multifaceted approach. Public education campaigns can improve stroke recognition and reduce pre-hospital delays, while standardized protocols and educational interventions for healthcare professionals can enhance in-hospital response. By addressing these delays, we can improve patient outcomes and reduce the healthcare burden associated with stroke.
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In-hospital stroke protocols
Stroke is a common and challenging condition in hospitalized patients. Delays in recognition and management of acute stroke in-hospital can lead to increased morbidity, mortality, prolonged hospitalization, and higher healthcare costs. To address these challenges, standardized protocols and outcome measures are essential.
Staff education is crucial to recognizing the signs and symptoms of a stroke. Hospitals should educate their staff, including physicians, advanced practice clinicians, and nurses, to identify potential strokes and empower them to take action. Educating staff on the use of rapid screening tools, such as the FAST mnemonic (Facial drooping, Arm numbness or weakness, Slurred speech, and Recognition time within 6 hours of last known well), can improve the accuracy and timeliness of stroke diagnosis.
Simplified assessment methods and defined stroke alert activation processes are also vital components of in-hospital stroke protocols. Hospitals should have clear and efficient processes to activate a stroke code, stabilize the patient, and initiate diagnostic procedures. This includes the involvement of a code stroke coordinator or a specialized stroke nurse who can perform the NIHSS (National Institutes of Health Stroke Scale) and prepare the patient for treatment.
Dedicated response teams are essential to ensuring rapid and effective patient care. These teams should include highly trained specialists such as neurologists, neuroradiologists, vascular neurologists, and interventionalists. They work together with emergency department physicians and staff to provide the most appropriate treatment as quickly as possible.
Implementing standardized in-hospital stroke protocols can help improve patient outcomes and reduce the impact of strokes that occur during hospitalization. However, it is important to recognize that the current literature on in-hospital stroke protocols varies significantly, reflecting the heterogeneity in hospital resources and patient populations. Further research and standardized protocols are needed to optimize the evaluation and management of in-hospital strokes.
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Treatment options for acute stroke
Stroke is a challenging condition that requires emergency care. Treatment options for acute stroke include:
Thrombolysis
Also known as intravenous thrombolysis, this procedure involves administering clot-busting medication to dissolve blood clots causing ischemic stroke. The medication used is called tissue plasminogen activator (tPA), which must be given within 3 to 4.5 hours after the onset of symptoms. The sooner treatment begins, the better the chances of recovery.
Mechanical Thrombectomy
For complex stroke cases, a mechanical thrombectomy may be used to remove blood clots. This procedure involves inserting a long, flexible tube called a catheter into the upper thigh and guiding it to the blocked artery in the neck or brain. Huntington Hospital reports a higher rate of patients returning home upon discharge after undergoing this procedure.
Endovascular Clot Retrieval
This treatment can be administered up to 24 hours after the onset of stroke symptoms. It involves using a clot retrieval device to open blocked blood vessels.
Angioplasty and Stenting
This procedure involves inserting a thin tube with a small balloon or mesh tube into the artery. Inflating the balloon or expanding the mesh tube creates space for blood to flow more easily to the brain. The mesh tube, called a stent retriever, can also trap the clot, allowing it to be pulled out through the tube.
Carotid Endarterectomy
For patients with carotid artery disease, this surgery involves removing plaque and debris from the carotid artery in the neck to improve blood flow to the brain.
Coil Embolization
This procedure blocks blood flow to an aneurysm by inserting a flexible tube with a tiny coil through an artery in the upper thigh and into the aneurysm. The coil causes a blood clot to form, preventing the aneurysm from bursting.
Cerebral Angiogram
This is a diagnostic procedure that involves using an interventional radiology suite to visualise blood vessels in the brain and assess for blockages.
The treatment for acute stroke depends on the type of stroke, the time elapsed since symptom onset, and the patient's medical history. A "Code Stroke" response team, consisting of neurologists, neuroradiologists, vascular neurologists, and interventionalists, is crucial for rapid evaluation and intervention to improve patient outcomes.
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Emergency team-based response
Stroke is a common and challenging condition in hospitalised patients, often resulting in delays in recognition and assessment, leading to poor outcomes. An emergency team-based response to inpatient acute code stroke is essential, with protocols similar to those for cardiac arrest.
An emergency team-based response involves a coordinated effort between various healthcare professionals, including neurologists, neuroradiologists, vascular neurologists, and interventionalists. These specialists work together with emergency department physicians and staff to ensure prompt evaluation, accurate diagnosis, and timely initiation of interventions.
One example of a successful emergency team-based response is the "Code Stroke" response team at Huntington Hospital. They have a 24-hour dedicated team of highly trained specialists who provide rapid evaluation and treatment to complex stroke patients. Their comprehensive stroke services include endovascular clot retrieval and clot-busting medication (TNK) administered within 60 minutes of arrival, improving patient outcomes and reducing complications.
Another critical aspect of the emergency team-based response is the involvement of a code stroke coordinator or a specialised stroke nurse. They play a vital role in performing the NIHSS (National Institutes of Health Stroke Scale), preparing patients for stroke treatment, and ensuring rapid triage and stabilisation. Some hospitals have implemented the role of a stroke champion, an inpatient nurse with expert knowledge, which has led to more accurate stroke diagnoses and increased eligibility for hyperacute stroke treatments.
To further enhance the emergency team-based response, hospitals should focus on education and training. In-service education sessions can be conducted to improve the knowledge of nursing staff about stroke symptoms, the importance of speed in thrombolysis, and the process of activating a code stroke. Additionally, referring physicians, nursing staff, and support staff involved in virtual acute stroke consultations should be trained in using the virtual acute stroke system and understanding their roles and responsibilities.
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Endovascular clot retrieval
ECR is a highly specialised procedure that is only available at a limited number of tertiary hospitals. It is technically challenging and must be performed by highly trained radiologists, neurologists, or neurosurgeons with specialist skills in neurointervention. The procedure requires careful patient selection, dedicated training, and specific equipment to be successful.
The goal of ECR is to restore blood flow as early as possible, as this results in the greatest benefit for the patient. ECR has been proven by randomized controlled trials to produce large, clinically meaningful benefits for patients with acute ischemic stroke due to LVO. These trials have shown that ECR improves clinical outcomes compared to conservative medical treatment alone.
To facilitate patient access to ECR, stroke systems of care must adapt. Every community must create access to a hospital that can safely and quickly provide intravenous tissue-type plasminogen activator and immediately transfer appropriate patients to a more capable centre as required. Safe and effective therapy in the community setting can be ensured through certification programs, performance measurement, and data entry into registries.
In Victoria, Australia, Safer Care Victoria has developed a statewide service protocol for endovascular clot retrieval for acute stroke. This protocol includes guidelines for EVT eligibility and patient fact sheets to help patients and their families understand the benefits and risks of EVT. The protocol also ensures that patients requiring transfer to an ECR centre are assessed for this procedure.
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Frequently asked questions
"Code stroke" is used to refer to an emergency protocol for the immediate assessment of patients with suspected cerebrovascular events. It is also used to refer to a team of specialists who are trained to respond to stroke cases.
A "code stroke" team consists of highly-trained neurologists, neuroradiologists, vascular neurologists, and interventionalists who specialize in stroke diagnosis and treatment.
The goal of a "code stroke" team is to ensure that the most appropriate treatment is initiated as quickly as possible to save brain function during an acute stroke.
