You are the patients first line of defense Speaker Name Credentials Speaker Title Inpatient Stroke Alert Objectives Review inpatient stroke incidence and implications Identify risk factors for stroke and signs of stroke ID: 1042591
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1. Inpatient stroke alert competencyYou are the patient’s first lineof defenseSpeaker Name, CredentialsSpeaker Title
2. Inpatient Stroke Alert: ObjectivesReview inpatient stroke incidence and implicationsIdentify risk factors for stroke and signs of strokeDiscuss the RN activated Inpatient Stroke Alert Protocol
3. Epidemiology: Stroke in the U.S.CDC, 2018Prevalence: 3.1% in U.S. Increases with advancing age in both males and females11.8% of individuals over age 75Over 7.8 million >20 years of age have had a strokePeople with a disability have a higher prevalence of stroke (6.6%)Incidence: 795,000 new or recurrent strokes each yearProjections show by 2030, an additional 3.4 million will have stroke432,000 ER visits in 2018 with primary diagnosis of strokeDisability: Stroke is a leading cause of disability in the U.S. Reduces mobility in more than half of survivors > 65 years oldMortality: Stroke is the 5th leading cause of death in the U.S. 1 of every 19 deaths in the US (2018)Worldwide 6.6 million deaths due to cerebrovascular disease (2019)Every 3 minutes 30 seconds someone dies of stroke (2019)150,005 Americans each yearCost: $52.8 billion annually (2017/18 direct & indirect) (increased from $49.8 billion) Tsao et all., 2022
4. DEFINITIONSTransient Ischemic Attack (TIA):Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarctionAll Stroke:A stroke, previously known as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brainThis can be due to ischemia (lack of blood flow) caused by: a blockage (thrombosis or arterial embolism), ora hemorrhage (leakage of blood)Intracerebral Hemorrhage (ICH)Caused by a rupture of a blood vessel in or on the surface of the brain with bleeding into the surrounding tissueSubarachnoid Hemorrhage (SAH)Bleeding into the space between the arachnoid membrane and the pia mater
5. TIME IS BRAINThe average stroke patient loses approximately 1.9 million neurons every one minuteAs many as 14 billion synapses may be lost during every one minute that a stroke goes untreated4 Saver, 20063 Meretoja et al., 2014“Save a minute, save a day” 5TIME FRAMENEURONS LOSTAGES THE BRAIN BYEvery second32,0008.7 hoursEvery minute1.9 million3.1 weeksEvery hour120 million3.6 years10 hours1.2 billion36 years
6. Inpatient Stroke Alert: ImportanceLack of recognitionIn-patient strokes are under-recognized and under-reportedIn-hospital delaysEvaluation delays and lower adherence to some measures of qualitySignificantly different treatment times in-hospital and community-onset strokesOnly 1 in 5 in-hospital strokes meet the goal of 60 minutes or less Multiple concurrent acute illnesses create conflicting care prioritiesWorse prognosis Greater severity Higher rates of mortalityLess likely to return homeWorse functional outcome 2 Cumbler , 2014
7. Agerisk doubles for each decade past 55 years old10% of all strokes occur in 18–50-year-oldsSex (biological)Younger men and older women are highest riskFamily History Immediate family history of stroke increases your risk by 50%Parental ischemic stroke by age 65 years = 3-fold increase in riskRaceAfrican Americans, Hispanics and Asians are at higher riskPrior Stroke or TIAStroke Risk Factors:Non-Modifiable5 Virani, et al., 2020
8. Hypertension (High Blood Pressure)Most common risk factor41% reduction in stroke risk with of 10 mmHg reduction of systolic blood pressure (top number)Hyperlipidemia (High cholesterol)DiabetesTwice as likely to have strokeAtrial FibrillationHighest risk: ~5 foldSickle Cell DiseaseStroke Risk Factors: Modifiable5 Virani, et al., 2020
9. Heart, carotid or another artery diseaseSmokingIncreases risk of stroke 2-4xRisk increased by 30% for non-smokers exposed to second-hand smokeSleep ApneaIncreases risk of stroke x2Physical InactivityPhysical activity can reduce stroke risk by 25-30%Psychological DistressIllicit drug useStroke Risk Factors: Modifiable5 Virani, et al., 2020
10. Pre-disposing Factors 2 Cumbler et al., 2014
11. Inpatient Stroke Alert: PurposeQuickly rule-out a brain hemorrhage or other symptom etiologyMaximize options for care: IV thrombolytic, mechanical thrombectomy, angioplasty/stenting, etc…Recent surgery and other IV thrombolytic contraindications may not exclude the patient from endovascular therapy Promote awareness of symptomsIncrease awareness of emergent statusExpedite and optimize the careActivate the alert process regardless of candidacy for IV thrombolyticRemember … Time IS Brain
12. FLASHEDF …L …A …S …H …E …D …Facial asymmetry/droopLeg weakness or numbness, esp. 1 sideArm weakness or numbness, esp. 1 sideSpeech, trouble speaking or understandingSevere headache, no known causeEyes, trouble seeing, one or both sidesDizziness or loss of coordination, esp. if with other signsFLASHED may be better for clinician use than BE FAST because it includes headache
13. SPMG: B.08a< 24 hours from last known wellINPATIENT STROKE ALERT: PROCESS
14. Inpatient Stroke Alert: Order SetRN ActivatedSPMG: B.08b
15. ConclusionYou may notice patient changes Subtle changes matter!Family members and visitors may also alert you to changesQuick action at the bedside means more timely treatment for the patient and ideally, more positive outcomesYour assessment can save a life!
16. ReferencesCenters for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention. (2017a). Stroke fact sheet. Retrieved from https://www.cdc.gov/dhdsp/maps/national_maps/stroke_all.htmCumbler, E., Wald, H., Bhatt, D.L., Cox, M., Xian, Y., Reeves. M…Fonarow, G.C. (2014). Quality of care and outcomes for inhospital ischemic stroke: Findings from the National Get with the Guidelines-Stroke. Stroke, 45: 231-238. DOI: 10.1161/STROKEAHA.113.003617. Meretoja, A., Keshtkaran, M., Saver, J. L., Tatlisumak, T., Parsons, M. W., Kaste, M., …Churilov, L. (2014). Stroke Thrombolysis: Save a minute, save a day. Stroke, 49(3). https://doi.org/10.1161/STROKEAHA.113.002910Saver, J. L. (2006). Time is Brain—Quantified. Stroke, 37, 263-266. DOI: 10.1161/01.STR.0000196957.55928.ab Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., … Tsao, C. W. (2020). Heart Disease and Stroke Statistics—2020 Update. Circulation. doi: 10.1161/cir.0000000000000757Eff. 03/01/12; Rev. 12/09/21