acute stroke care · acute stroke care lesson from ewhaewhastroke care (esc) program stroke care...

Acute stroke careAcute stroke careLesson from Lesson from EwhaEwha Stroke Care (ESC) ProgramStroke Care (ESC) Program

2011년 한국의료QA학회 QA연수교육-심화

한국의료QA학회한국의료QA학회

이대목동병원 뇌졸중센터김 용 재

Background

• Burden of Stroke in Korea

한국의료QA학회2

Emergent Stroke Care and the Chain of Survival

Patient Calling EMS ED Stroke Stroke

Knowledge 911 System Staff Team Unit

한국의료QA학회

• Detection – early recognition• Dispatch – early EMS activation,

prompt response• Delivery – rapidly and to

appropriate facility• Door – ED triage


• Door – ED triage• Data – ED evaluation• Decision – about potential

therapies• Drug therapy if appropriate

Time is Brain

• According to Dr. Jeffrey Saver, director of the UCLA Stroke Center:

• ONE MINUTE = – 1.9 billion neurons


– 1.9 billion neurons– 14 billion synapses– 7.5 miles of myelinated fibers

• A pea sized piece of brain dies for every 12 minutes that treatment is delayed

Benchmarks for Primary Benchmarks for Primary

Stroke Center CareStroke Center Care�� Acute Stroke Team member at bedside Acute Stroke Team member at bedside << 15 15 min of call*min of call*

�� CT or MRI performed CT or MRI performed << 25 min of order25 min of order�� Interpretation of image Interpretation of image << 20 min of 20 min of

7

�� Interpretation of image Interpretation of image << 20 min of 20 min of completion*completion*

�� Lab results completed Lab results completed << 45 min of order45 min of order�� Door to needle time for IV tPA Door to needle time for IV tPA << 60 min60 min�� All services available 24/7/365All services available 24/7/365

* May use telemedicine/teleradiologyAlberts MJ et al. JAMA 2000;283:3102-3109

NINDS Symposium Proceedings, 1997

뇌졸중 치료실 (Stroke Unit)

• 뇌졸중 치료에 관련된 병실 혹은 영역• Disease specified care, DSC• 기본목적: 뇌졸중의 진단과 치료• 뇌졸중 환자의 진단과 치료과정을 포함하는 체계화된 뇌졸중

환자 관리


환자 관리– 표준화된 진료지침이용

• Disease specified care program, DSCP

– 집중 모니터링– 의료진(간호사,각과전공의,물리치료사 등), 환자, 일반인을

위한 교육

흔히 언급되는 ‘sub-ICU’ 개념과는 다릅니다.

뇌졸중 치료실은 왜 필요한가?

• 혈전용해치료– 출혈성 변화

• 뇌졸중 증상의 악화– 뇌부종– 병의 진행

• 항응고제의 사용• 영양상태 및 탈수증• 감염

– 삼킴장애– 비뇨기계감염

급성기 뇌졸중 환자들의 문제점들


– 병의 진행

• 생체징후의 변화 및 내과적 문제– 고혈압, 저혈압– 심근허혈 /심근경색– 고혈당

– 비뇨기계감염

• 심부정맥혈전증

1. 혈전 용해 치료

• 증상 발생 3시간 이내에 내원한허혈성 뇌졸중 환자의 경우, 재조합 조직 플라스미노겐 활성제(rt-PA) 치료를 고려하여야 한다. (근거수준 Ia, 권고수준 A) The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study


Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587.

1. 혈전 용해 치료

• 치료를 받은 환자의 6.5%에서 치명적인 뇌출혈이 발생한다.

• 출혈을 발생하게 하는 원인– 치료 후 혈압 조절의 실패– 환자의 상태 (고혈압, 고혈당, 혈소판 수치의 감소)– 고용량의 약물 사용 등


– 고용량의 약물 사용 등

• 뇌출혈 이외에도……– 위장관 출혈, 잇몸 출혈, 피부 및 근육 내 출혈, 소변출혈

, 대변출혈 등……

1. 혈전용해치료

• 출혈을 예방하기 위한 Guideline (AHA/ASA)– 환자는 반드시 중환자실 혹은 뇌졸중 치료실로 입원한다.– 혈전용해제 투여 후 1시간 동안 15분마다 진찰하고, 6시간 동안 30분,

24시간까지는 한시간 마다 진찰 (33번 진찰)– 두통, 고혈압, 구토, 구역 증상이 있는지 확인 할 것– 혈압을 처음 2시간 동안은 15분 마다, 6시간 동안은 30분 마다, 24시간

까지는 1시간 마다 혈압을 체크해야 한다.(36번 BP)


까지는 1시간 마다 혈압을 체크해야 한다.(36번 BP)– 혈압이 높으면 (180/105이상) 혈압을 바로 낮춘다.– 소변줄, NG tube 등은 나중에 삽입한다.– 24시간 후에 반드시 CT혹은 MRI 검사를 한다.

Case . 43/M, left hemiplegia

2. 뇌졸중 증상의 악화


IA thrombolysis


24hr Diffusion & MRA


Onset부터 26시간, 의식 저하


Craniectomy

수술전 1차 수술후 2차 수술후


• 수술할 시점을 놓치면 환자는 뇌부종으로 사망함.• 환자의 의식이 변하는 시점을 모니터링 해야 함.

3. 생체징후의 변화와 내과적 문제

• 고혈압– 급성 뇌졸중 환자의 60%에서 혈압이 160mmHg이상 상

승– 뇌졸중 발생에 대한 스트레스, 방광이 꽉 찼을 때, 오심,

통증, 고혈압 과거력, 저산소증에 대한 생리적 반응 등– 갑자기 혈압 낮추면…… 뇌에 허혈된 조직 손상을 악화


– 갑자기 혈압 낮추면…… 뇌에 허혈된 조직 손상을 악화– 대부분, 특별한 치료 없이 몇시간 지나면 정상으로 됨.

조절해야 하는 경우혈전 용해제를 사용 전 후, 고혈압성 뇌증, 대동맥박리, 급성신부전, 급성 폐부종, 급성 심근 경색


• 심근허혈 /심근경색/부정맥– 한달 이내 심근경색은 뇌경색의 원인인 혈전을 만든다.– 드물지만, 급사의 위험– 뇌경색 발생 후 최소 24시간은 심장 모니터링을 해야 한다.


– 뇌경색 발생 후 최소 24시간은 심장 모니터링을 해야 한다.– The detection rate of AF in acute ischemic stroke

patients has been increased significantly by continuous ECG monitoring in the SU.

최 등, 뇌졸중학회지 2007


• 저혈당– 저혈당은 뇌졸중과 같은 신경학적 증상을 일으킴.– 바로 교정해야 한다.

• 고혈당


• 고혈당– 뇌졸중으로 입원한 환자의 1/3에서 관찰된다.– 환자의 증상악화의 원인이며, 특히 혈전용해치료시 예

후를 나쁘게 한다. (출혈,부종)– 200mg이 넘으면 치료시작하고, 80-140mg/dl에서 유지


• 체온– 이차적인 대사적 요구를 증가, 신경전달물질 증가,

free radical 형성 등으로 증상악화 및 사망률을 높임.

– 열이 나면, 반드시 원인을 찾아야 한다.• 흡인성 폐렴, 심내막염

Reith et al. Lancet 1996


• 흡인성 폐렴, 심내막염• 비뇨기계 감염(60%) : Foley 끼우지 마세요!

– 오히려 저체온을 유지하면 환자의 예후가 좋아진다.• Hypoxic brain injury model, Cardiac arrest

Bernad et al. NEJM 2002


• 기도확보, 호흡보조, 산소공급– 기도 막힘(가래 등), 저환기증, 흡인성 폐렴, 무기폐– 의식이 떨어지고, 구-인두부위의 운동성이 떨어짐– 폐렴은 급성기 뇌졸중 환자의 흔한 사망원인– Swallowing screening test를 하자.


뇌졸중치료실의 긍정적 효과

• More standardized assessment

• Early management protocols

• Better diagnostic procedures

• Better utilization of the “best evidence”


• Better utilization of the “best evidence”

• Better nursing care

• Early mobilization

• More effective rehabilitation

• Significant reduction in mortality & dependency

Education, Referral, Emergency m

anagement

Stroke Services and Stroke Units

Recommendations

� All stroke patients should be treated in a stroke unit

(Class I, Level A)

� Healthcare systems must ensure that acute stroke

patients can access high technology medical and surgical

Education, Referral, Emergency m

anagement

Guidelines Ischaemic Stroke 2008

patients can access high technology medical and surgical

stroke care when required (Class III, Level B)

� The development of clinical networks, including

telemedicine, is recommended to expand the access to

high technology specialist stroke care (Class II, Level B)

Ewha Stroke Unit

• 8-beds, Acute care base• Opened in 2006

500

600

507482 496

420

483


0

100

200

300

400

500

2004 2005 2006 2007 2008

420

21 37 51 40

117

급성환…

치료건수

EWHA 뇌졸중 치료실


2008.7.1


Following FOCUS-PDCA model

Find - FOCUS-PDCA

• Acute Stroke Care Improvement by CPOE• Generalized implementation of computerized

physician order entry based-stroke code activation program for effective thrombolytic


activation program for effective thrombolytic treatment (BEST-G study)

28

40

50

60

A

B

C

D

E 60

70

80

90

A

B

C

D

E

Door to needle Door to CBC

Time interval in each centerTime interval in each centerBESTBEST--G results reviewG results review

0

10

20

30

40 E

F

G

H

I

J

0

10

20

30

40

50

60 E

F

G

H

I

J

Before After Before After

Descriptive analysisDescriptive analysis

�� Baseline dataBaseline data

BESTBEST--G results reviewG results review

30

35

40

45

0

5

10

15

20

25

30

A B C D E F G H I J

Before BEST

After BEST

119

Out-Patient

PreventionER

Organization - FOCUS-PDCA

Management of Stroke


Prevention

Imaging study

ER

Acute Care

Rehab.

In-Patient

Diagnosis

Stroke Unit

Courtesy Yonsei Stroke Team

Organization - FOCUS-PDCA

Emergency Room ER Doctors, Nurses

(Chief: Young J. Chon, MD)

Neurology & Neurosurgery Stroke Staff and Residents

(Chief: Yong J. Kim, MD & Eu K. Seo, MD)

Radiology Section Neuroradiologist, CT-MRI-Angio Units

� Follow the track


Radiology Section Neuroradiologist, CT-MRI-Angio Units

(Chief: Soo M. Lim, MD)

Nursing Stroke Unit & Stroke Cordinator

(Chief: Jae W. Choi, RN)

General Admission Admission, Discharge TrackInsurance

Pharmacy t-PA, ACS

QI Team

Clarity - FOCUS-PDCA

Acute Stroke Track Time Factor

ER arrival•Receipt•ER Nurse•ER Doctor

STROKE

Door to MD


STROKE

Stroke team•Order CT•Order Lab•Decision Making

Order to CT completedOrder to Lab completedCT Completed to Read

Patient Family•Get Consent

TreatmentDoor to tPA

Understand - FOCUS-PDCA

Track Goal Fact

Door to MD 10 min 7 min

Order to CT completed

25 min 20 min


completed

CT Completed to Read

20 min 14 min

Order to Labcompleted

45 min 9 min

Door to tPA 60 min 72 min

Understand - FOCUS-PDCA

Medical TeamDelayed notificationLack of inter-department communicationLack of awareness _TIME is BRAIN

Delay in


Patient and FamilyDelayed Decision

Lack of awareness

SystemLack of stroke code

Lack of stroke team

Delay in

Door to tPA time

Plan - FOCUS-PDCA

Acute stroke patient

Activate Stroke Code



Ewha Stroke Code

37

Plan - FOCUS-PDCA

ESC Program

EM / NR 영상의학과ER 진단검사의학과

See the Criteria

ESC I Activationby EM

ER arrival

Identification of ESC I candidates

ESC I candidates criteria

1. Symptomatology- Sudden numbness or weakness of face, arm, or leg

(Especially on one side of the body)

- Sudden confusion, trouble speaking or understanding speech

- Sudden trouble seeing in one or both eyes

- Sudden severe headache with no known cause

- Sudden trouble walking, dizziness, loss of balance or coordination

(Especially if associated with any of the above symptoms)


EM / NR Residents

영상의학과CT 검사실

ER NURSE

진단검사의학과검사실 원무과

ESC Breakby EM / NR Start Thrombolytic Tx 영상의학과

혈관 촬영실영상의학과

MRI실

ESC II Activationby NR

Identification of ESC II candidatesESC I break

by NR

(Especially if associated with any of the above symptoms)

2. Time

- 증상 발현 후 12 시간 이내 응급실에 도착.

: 마지막으로 확실히 정상이었던 것이 확인된 시간을 기준.

: 잠에서 깨어난 후 발견된 경우 잠든 시간을 기준.

ESC II criteria

- acute ischemic stroke 에 합당한

neurologic symptom & sign이 confirm 된 환자

Door to t-PA within 60 min

중증응급환자의신속한

진료프로세스확립

뇌졸증환자프로그램구축

전원절차의간소화

System

improvement

Health care

Plan - FOCUS-PDCA

Expected Effects


대외이미지향상

전원절차의간소화

사전환자상태파악

으로예측가능

Improvements

in efficiency

Improvement

to patient

satisfaction

Quality

improvement

Courtesy Yoo SW, KUMC

Do - FOCUS-PDCA


Goal– Smart and Early Decision by Standard Protocol– Door to IV within 60 min

40

Do - FOCUS-PDCA

Protocol following treatment track– Remind Safety (mainly Cb. Hemorrhage) issue


Do - FOCUS-PDCA

CPOE


SMS 및 OCS Alarm 확인

신속하게 응급실 도착, 환자 확인

정확한 의사결정에 따른 처치 시행

해당 지표 모니터링 및 분석

해당과(NR) 진단검사의학과

ESC 환자 등록 알람 확인

검사 내용 확인 후 진행

해당 환자 최우선 검사 실시

ESC

Do - FOCUS-PDCA



선 처치, 후 수납

보호자 부재 시, 신속히 연락

영상의학과/CT검사실

원무팀/약제팀 적정진료관리팀

프로그램 구축 및 보완

해당질환 의심 시 ESC 등록

해당질환 기본 검사 처방 및 진행

이송반 연락 및 최우선 이송

지속적 Monitroing

신속처리


검사 내용 확인 후 진행

해당 환자 최우선 검사 실시

응급의학과/응급센터

Courtesy Yoo SW, KUMC

EUMC Stroke Center OrganizationEUMC Stroke Center Organization

EUMC Stroke Center

Yong-Jae Kim, MD, Medical DirectorJae-Won Choi, RN, Nursing Director

EUMC Stroke Center

Yong-Jae Kim, MD, Medical DirectorJae-Won Choi, RN, Nursing Director

RehabilitationStroke Team

Neurology Stroke Team

Organization & LeadershipOrganization & Leadership

Ridiology Stroke Team

Neuro Surgery Stroke Team

Emergency Medicine Stroke Team

Vascular Surgery Stroke Team

Stroke Unit/WardNursing Staff

Stroke Quality Assurance and

Improvement Committee

Clinical Nutritionist

Pharmacy

Stroke Unit

Clinical ResearchCoordinator

Case Management/Social Work Services

Neuro ICUNeuroSonologyLab

Out-patient Clinic

Check - FOCUS-PDCA

• Time Factors in Acute Stroke Patient receiving t-PA

Track Goal before afterDoor to MD 10 min 7 min 6 min

Order to CT completed

25 min 20 min 15 min


completed

CT Completed to Read

20 min 14 min 11 min

Order to Labcompleted

45 min 9 min 9 min

Door to tPA 60 min 72 min 51 min

Before: based on BEST-G data, n=87After: 2010.4.1-5.10, n=24

Act - FOCUS-PDCA

• Feedback– Regular QI activity

• Key Time Factor• What’s make difference in each track


• What’s make difference in each track

– Multidisciplinary Stroke team meeting• Critical pathway

46

Act - FOCUS-PDCA

Critical Pathway


• PATIENT NEED– GOALS/OUTCOMES– ASSESSMENT– TESTS– CONSULTS– MEDICATION


– MEDICATION– NUTRITION/ELIMINATION– MOBILITY/ACTIVITY– SKIN CARE/HYGIENE/DRESSING– INFORMATION/EDUCATION– DISCHAGRE PLANNING

Act - FOCUS-PDCA

• Excellence stroke nursing– NIHSS


• Multidisciplinary team meeting


Next Step 1: Plan - FOCUS-PDCA



Ewha Stroke Code


Ewha Stroke Code

+Disease Specific Care

52

Do - FOCUS-PDCA

• Practice of quality indicator


Act - FOCUS-PDCA

• Feedback– Regular QI activity

• Key Time Factor• What’s make difference in each track


• What’s make difference in each track

– Multidisciplinary Stroke team meeting

56

• Personalized, Comprehensive Patient Education


• Vascular Conference– Door to Needle Time– Care Plan

Next Step 2: Find - FOCUS-PDCA


• Something Wrong in Hospital?

Find - FOCUS-PDCA


• Factors that impede recognition and assessment– Misdiagnosis– Medication effect; brainstem stroke interpreted as effect of

anaesthetics, sedatives– Dysphasia interpreted as confusion– Hemiparesis interpreted as neuropathy or as due to orthopaedic


– Hemiparesis interpreted as neuropathy or as due to orthopaedic injury

– Lack of urgent referral or review– Referring team not familiar with assessment of patients with acute

stroke– Referring team not aware of potential interventions– Triage issues– Lack of facilities for urgent stroke assessment and treatment

60

Plan - FOCUS-PDCA




Activate Stroke CodeEwha Stroke Code

+In-Hospital Stroke Care Program

61

i-ESC

• Cardiology and Cardiovascular departments and wards

• Education for nurses and doctors• Treatment protocol for strokes during cardiac


• Treatment protocol for strokes during cardiac procedures

• Activation protocol specialized for cardiac wards

62

Brain Attack Message

• Stroke is preventable• Neural damage after stroke is progressive• There is a therapeutic window for optimal

treatment of stroke


• Stroke is an emergency• Effective therapies for stroke currently exist• New therapies for stroke are currently being

developed

• Our Mission: Best Stroke Treatment and Stroke Prevention

acute stroke care · acute stroke care lesson from ewhaewhastroke care (esc) program stroke care...

Documents