Table 1 Framework for situational analysis exploring phases of care, tasks, staff roles and time frames
Phase | Task | Staff | Time frame |
|---|---|---|---|
1. Pre-hospital assessment | Assess potential tPA eligibility | Paramedic | <2 h of onset |
Whether probable stroke or stroke mimic, define time of onset, consider comorbidity/frailty, estimate for survival | |||
Deliver to tPA-capable hospital | Paramedic | ||
Handover to triage or Acute Stroke Team | to ED/SCU | ||
2. Triage | Assess tPA eligibility | ED or SCU | <3.5 h of onset |
Onset time, collateral history, mRS, anticoagulants, seizure, serious or advanced terminal illness, history of intracranial haemorrhage or subarachnoid haemorrhage, major internal surgery in last 21 days, heart attack with IV thrombolysis in last 72 hours, stroke severity assessment with National Institutes of Health Stroke Scale, Glasgow Coma Scale, observations | |||
Handover to SCU | to Acute Stroke Team | ||
3. Clinical assessment | Assess tPA eligibility | SCU Nurse | |
Onset time certainty, functional independence, comorbidity, current medication, relative and absolute contraindications, NIHSS score, collect blood, notify CT scanning & organise transport, organise ECG | |||
Handover to Imaging | to Radiography | ||
4. Imaging | Non- contrast CT scan (or perfusion CT or MRI) | Radiography | |
Handover to SCU | to SCU Nurse | ||
5. Final clinical assessment | Confirm tPA eligibility | SCU Medical | |
Review information from phase 1-3, focussed history to check for stroke mimic, onset certainty, premorbid functional independence, medication, contraindications, NIHSS, rapid cardiac and vascular screen, check blood sent to lab, review ECG, review NCCT on console with radiographer and again for degree of ischaemic change & possibility of stroke mimic, discuss scenarios with patient and family | |||
6. Preparation & delivery | tPA Preparation | SCU Nurse | <4.5 h of onset |
Check serum glucose level, anticoagulant medication, International Normalized Ratio, Blood Pressure, NIHSS. | |||
Treat serum glucose or Blood Pressure if necessary and reassess | SCU Nurse | ||
Administer thrombolysis, with amount based on estimated patient weight | SCU Nurse | ||
7. Monitor | Monitor and manage neurological status (NIHSS at 0 h, 1 h, 24 hrs), blood pressure and serum glucose level | SCU/ICU staff | 24 h from tPA delivery |