In this discussion, Dr. Evie Marcolini, an emergency medicine and neurocritical care physician, sheds light on the intricate world of stroke management in community hospitals. She shares insights on the advancements in stroke care, including endovascular therapies like mechanical thrombectomy. Dr. Marcolini also delves into the complexities of administering TPA, emphasizing collaboration with neurologists. She highlights the significance of the NIH Stroke Scale in treatment decisions and reinforces the importance of patient education for informed consent in stroke management.
The advancement of acute stroke management through endovascular therapy highlights the urgency for community hospitals to implement rapid diagnosis protocols.
Effective collaboration with EMS and structured protocols is essential for optimizing stroke patient care in community hospitals with limited resources.
Ongoing education and teamwork among healthcare professionals are vital for refining stroke management protocols and enhancing patient outcomes.
Deep dives
The Evolving Landscape of Stroke Management
The management of acute stroke has significantly advanced due to the introduction of endovascular therapy, particularly mechanical thrombectomy. Trials conducted since 2015, like the Mr. Clean trial, have demonstrated the effectiveness of these procedures in improving patient outcomes, pushing for quicker action from emergency departments. Time remains critical in stroke care, underscoring the need for rapid diagnosis and intervention, especially in community hospitals where resources may be more limited. As emergency providers, understanding how to efficiently transfer patients to facilities equipped for thrombectomy is essential for maximizing treatment effectiveness.
Community Hospital Structure and System Coordination
Community hospitals should adopt structured protocols that facilitate swift identification and management of stroke patients, including effective collaboration with EMS teams. Early engagement with pre-hospital teams helps ensure readiness for stroke patients arriving at the emergency department. Having streamlined communication with CT units and ensuring that all stakeholders, such as nurses and techs, understand their roles during a stroke alert will optimize patient care. The integration of protocols for potential stroke patients can alleviate delays and enhance efficiency in recognizing and treating acute strokes.
Clinical Assessments for Stroke Diagnosis
A swift but comprehensive clinical assessment is crucial for identifying stroke signs and determining thrombolytic candidacy. Tools such as the FAST-ED or VAN scores can guide providers in assessing the possibility of large vessel occlusion during initial evaluations. Attention to critical patient history, such as anticoagulant use and recent medical interventions, ensures comprehensive care while assessing candidates for systemic thrombolysis. This robust assessment should also consider alternative diagnoses and ensure thorough documentation of clinical findings.
Thrombolysis and Risk Assessment
Providers must carefully evaluate the indications and contraindications for administration of systemic thrombolytics like TPA or TNK based on each patient's individual circumstances. The discussion regarding thrombolytic administration should prioritize informed consent and clear communication about the risks and benefits with both patients and their families. Consideration of factors like NIHSS scores and patient-specific details can influence the decision to proceed with thrombolytics or explore alternative treatments, such as dual antiplatelet therapy in non-disabling strokes. Documenting the rationale behind these decisions can provide legal protection as well as improve quality of care.
Collaboration and Continuous Learning in Stroke Care
Successful stroke management necessitates collaborative efforts among healthcare professionals, including emergency medicine providers, neurologists, nursing staff, and EMS. Quality improvement initiatives and case reviews can foster ongoing education and address systemic challenges encountered in acute stroke situations. Each stroke case offers learning opportunities that can refine protocols and enhance patient outcomes moving forward. Emphasizing a teamwork approach allows for better adaptability to current evidence and practice standards, ensuring comprehensive and effective stroke care delivery.
Managing strokes in the modern era is challenging (lytics, EVT, timestamps!). Doing so in a community hospital- far from the ivory tower endovascular suite and neurology ICU- can be even harder. We sat down with the very smart Dr. Evie Marcolini to talk managing these complex patients in these community settings.