Mooney, Lesia

ABSTARCT BACKGROUND: IRRAflow is a novel active cerebrospinal fluid (CSF) exchange system for the treatment of hemorrhagic strokes and intracranial infections. It is a closed system that irrigates various medications dissolved in irrigation solutions at a speed of up to 180 mL/h, expediting resolution. Disrupting this closed system to withdraw CSF samples or infuse medications is necessary in certain circumstances. We report our novel approach for maintaining the sterility of the closed IRRAflow system using a needleless extension and assess the compatibility and safety of this technology throughout treatment. METHODS: We used a needleless extension to withdraw CSF samples and deliver medications to 5 patients treated with the IRRAflow system. We used 1 stopcock with a 3-way valve, 2 neutral needleless connectors, and 2 antiseptic caps. The stopcock was connected between the irrigation and drainage ports of the catheter. The needleless connectors were mounted at the 12 o’clock position of the attached stopcock and the irrigation port with antiseptic caps covering the distal ends. To initiate fluid exchange, the 2 needleless connectors were separated. The extra stopcock valve was connected between the drainage arm, the cassette, and the irrigation arm. The needleless connectors remained mounted at the 12 o’clock position of the stopcock and irrigation port throughout treatment. RESULTS: The needleless connectors mounted on the 12 o’clock position of the stopcock and irrigation port on the drainage and irrigation arms, respectively, provided efficient management of fluid exchange, CSF fluid sampling, and medication delivery. Our needleless extension was compatible with the IRRAflow device and prevented secondary infections despite repeated CSF sampling and medication delivery. CONCLUSION: The needleless extension facilitated a simple and safe interaction with the closed IRRAflow system without compromising the sterile environment during CSF sampling and medication delivery.

With increased patient volumes and complexity, stroke occurrence in hospitalized patients has become relatively more common. The process of activating a code stroke in-hospital differs in many institutions. An emergency team-based response to inpatient acute code stroke is warranted, with many protocols modeled similarly to the cardiac arrest response. However, several studies have demonstrated delays in recognition and management of acute stroke in-hospital as compared to those arriving directly to the emergency department (ED). Furthermore, there are several shared challenges with code stroke resuscitation in the ED and the ward, which include the assembly of ad hoc teams and requirement of access to urgent imaging. Delays in activating in-hospital code stroke contributes to increased morbidity, mortality, prolonged hospitalization, and associated health care costs. In the following commentary, we discuss the current landscape of acute in-hospital code stroke protocols, review the differences in neurologic outcomes between inpatient vs ED/out-of-hospital code stroke patients, and propose future directions for in-hospital code stroke paradigms for improved patient outcomes and quality of care.

Background/Purpose: Research about mobilization of patients who receive IV-tPA is scarce. Patients are routinely kept on bed rest for 24-48 hours after tPA for monitoring despite a lack of evidence justifying this lengthy immobilization. Several stroke rehabilitation studies report mobilizing patients within 24 hours of stroke. However, none of these studies included patients who received tPA and there are no published recommendations for safe timeframes for initiating mobilization of these patients. We completed a preliminary study to assess the hypothesis that adverse safety outcomes of early mobilization of this patient population are minor. Methods: We conducted a study between June 2011 and July 2012 involving early mobilization (i.e. PT/OT between 13 and 24 hours) of patients administered tPA. A safety screen was performed before mobilization occurred to verify hemodynamic stability of patients. Mobilization may have included sitting, standing, transferring to a chair, and ambulation. Results: Nearly 97% (30/31) of patients provided consent (12 female, 18 male; mean age: 66.8, range: 32-89; mean admission NIHSS 5.37, range 0 - 27). All consented patients were screened and 23/30 were mobilized without adverse response. Eighty-six percent (70/81) of activity events had no adverse response. The adverse events that were observed were transient and minor: 2 subjects reported “dizziness” (without a corresponding drop in BP), 3 subjects had an increase in DBP to > 105 (with resting DBPs as follows: 93, 104, and 62 mmHg), 1 subject had a HR > 100 bpm (resting HR was 96 bpm), and 1 had new-onset of neurological signs (transient L hemiparesis that resolved within an hour). Analysis is currently being performed Biostatistician. Conclusion: Early mobilization of patients post ischemic stroke 13-24 hours after IV-tPA infusion appears safe for 76.7% of patients and during 86.4% of activity events. In conclusion, adverse responses were largely minor with no sustained worsening of neurologic deficits. Study investigators recommend larger-powered studies for validation of safety findings to develop evidenced-based guidelines for early mobilization of this patient population.

Background: American Heart Association/American Stroke Association recommends treatment of eligible acute ischemic stroke patients with intravenous rtPA <60 minutes from emergency department arrival. Purpose: A quality improvement project was designed to reduce the door to needle times for intravenous rtPA administration at Mayo Clinic Florida. We hypothesized that workflow changes in emergency department evaluation of suspected stroke patients would decrease door to needle times. The goal was to treat >75% of patients eligible for IV t-PA within 60 minutes of ED arrival. Methods: We utilized LEAN methods to develop a project charter, identify stakeholders, and visually map the emergency department clinical workflow. Prior to project initiation, suspected stroke patients were taken upon arrival to an exam room for clinical evaluation followed by transport to the CT scanner and return to the exam room for decision-making and rtPA administration. The clinical workflow was changed to obtain patient weight immediately upon arrival, abbreviated patient assessment and lab draws outside of the CT scanner in a holding bay and performing CT scanning prior to transport to an examination room for decision making and rtPA administration. Results: In a 12 month period preceding project initiation, 29 patients were treated with rtPA, 55 % were treated <60 minutes of emergency department arrival. In the 11 month period following implementation of CT scanning prior to neurological evaluation, 57 patients were treated with rtPA, 80 % were treated in <60 minutes of emergency department arrival. The mean door to needle time was reduced from 66 minutes to 46 minutes following the clinical workflow change. No patients experienced clinical deterioration at the time of CT scanning. Conclusions: Non-contrast head CT scan be safely performed prior to comprehensive neurological evaluation and reduces door-to-needle times for intravenous rtPA administration in eligible stroke patients. Validated process improvement paradigms such as LEAN have the potential to reduce door to needle times and improve patient outcomes.