IFT Post stroke pt - does ems need to get tpa administration time?

mrhunt

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SO in the conquest of always learning and growing heres the question.
Took an IFT. Pt came in with obvious stroke symptoms via POV and was treated with TPA, Stroke symptoms resolved and upon transfer pt was entirely asymptomatic with almost perfect vital signs, CPSS negative throughout. This was a 33yo with hx of AFIB who just decided "hey! who needs my prescribed blood thinners!??! **** it!" It didnt work out super well as pt was dx with ischemic stroke...

Upon receiving hospital they literally ONLY wanted to know tpa administration time. I never asked, i was never told. I was just told pt was GIVEN tpa. I know for the hospital this is important at some advanced nursing level but is this something i should be asking in the future? Like exact time of TPA administration? Once i said i wasnt aware of the time of administration the nurse just huffed and brushed me aside. So was she just being a *****y nurse? Or what do you guys do?

I literally got everything EXCEPT for an exact tpa administration time which was all receiving hospital was interested in knowing. FML.
Not to mention RN gives a full phone report to sending facility as well.

Like i get Exact time of onset of symptoms, Last known well......911 Stroke stuff that's acute.
 

Tigger

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If you are doing anything close to emergent (and really all) IFTs, you should have a copy of all the medications the facility gave with the time and dose given. A report is of course called, but that doesn't guarantee you'll see the same care team at the receiving. Even in network, it's not always the easiest to pull the EMR from another hospital.
 

NPO

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Yes, I would like to know when the TPA was started and/or finished.

Most of my TPA patients have the TPA running during transport, then we finish the administration en route to the stroke center.

You mentioned the CPSS. The CPSS is a qualitative assessment, not quantitative. That means it only identifies if someone is having a stroke, now how significant the stoke is. (Also keep in mind that CPSS doesn't catch everything, but it's pretty good). In the hospital they should have done an NIH score, which helps them identify how significant the event is, and where in the brain is being effected. No one expects you to repeat NIH during transport; however one thing you could add to your questions is "What was their last NIH, and at what time?" The receiving nurses generally appreciate that, as it may or may not be the most recent NIH they were aware of from the report they received.
 

VFlutter

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tPA bolus time as well as infusion start and end time is very important for nursing care. As @NPO mentioned they will also ask for the NIH score. There is an entire order set associated with tPA that includes frequent timed neuro checks based off those times as well as when invasive interventions can safely be performed and anticoagulants can be initiated. This is a big deal and if not done properly can effect stroke center accreditation and reimbursement.

That being said it should have been communicated in nurse to nurse report as well as have a tPA flow sheet in the paperwork however not an excuse for the transporting provider to not know. The nurse getting phone report is not always the nurse at the bedside. No offense but if I was getting report on a post tPA patient and you did not know that information then the conversation would be over and I would promptly dig through the paperwork for the information I needed. That is a lack of basic understanding of post tPA care.

You need to know last known normal and symptom onset time but at that point it doesn't really matter as the intervention has already been done. The tPA information is what is most vital
 

E tank

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What betrays a lack of understanding is a receiving nurse leaving something apparently so important (and irrelevant to) the transferring ambulance crew.

What? If the crew gave an answer, would she take their word for it if it was that critical? She was out to bust someone's chops and this was as good a reason as any.

The people actually formulating the medical treatment did know when the dose was and were acting or not acting on it. That's why they accepted the transfer in the first place.

No one was waiting on that nurse to tell them when the pt got the tpa.
 

Peak

ED/Prehospital Registered Nurse
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Technically peer to peer report is only required under emtala for the medical provider and not nursing, unfortunately I've had several patients sent in from less than stellar facilities who didn't give a nurse to nurse report. I've also had reports from nurses that are essentially useless and we end up relying a bit on EMS and ultimately just seeing the patient when they arrived?

Is the medical provider who accepted the patient the one currently on shift/seeing the patient? Was this ED to ED, ED to inpatient, inpatient to inpatient?

It is possible that the doc who accepted the patient didn't write down the time that the TPA was give, or more likely wrote it down but can't even read their own handwriting.

Did the patient have clear evidence of thrombus or was the CT just negative for bleed and the OSH gave TPA based only on symptoms? If the patient did have clear thrombus why was TPA given rather than PCI (there is a lot of literature showing TPA does not statistically improve long term outcomes)? Does the patient have a history of seizures or any migraine disorders? Any history of prior strokes? Why does a 33 year old have A-fib? Did the patient actually have A-fib or just a past history of it? Why haven't they been placed on a stabilizer and converted rather than placed on anticoagulants, are they on a rate controller? Does the patient have any patent shunts (PFO, VSD)? Was the patient given any meds other than TPA (particularly benadryl, benzos, antiemetics, pain meds, or fluids)?

When the nurse huffed and brushed you aside where you finished with report or did she cut you off? What did she do next? Is the department busy? How many other patients does she have? How much sleep did she get last night? Does she have sick kids at home?

Have you ever been less than 100% collegial giving report?
 
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mrhunt

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Soooo to try to answer a few of those questions. Pt developed AFIB from a complication during a recent pregancy.
it was a clear ischemic stroke on CT with MRI showing possible lesion in cerrebellum.
TPA was given instead of PCI because thats all the sending hospital was capable of and pt met criteria for it within our county.
No hx of seizures or migrane disorders. Only history was AFIB. No hx of prior strokes.
Pt IS on rate controller as well as Anticoagulants but was non-compliant with all because she "felt like she didnt need to take them"
No shunts.
Pt was given tylenol for headache which resolved it, as well as the TPA. Nothing further.


Basically All the nurse asked me was "what was the time tpa was given?" and when i stated that i wasnt aware of the exact time she said she didnt want to hear anything else. This was her only pt because we dropped pt off to ER but there was a group waiting to transport directly to ICU which is obviously a 1 on 1 floor....2 on 1 at Most in my understanding.....So she's a floor nurse with ONE new pt.

And i get it, we've all been ****s during report or in general. I have, we all have. Thats not really the point. The point being is it an actually necessary thing for EMS to know and share this information on an IFT?

I get all the RN's here would love it but unless thats something directly within company or county protocols im curious as to how many of you actually DO........just because im trying to learn and grow and be better. Not because im saying "what a ***** nurse! she was in the wrong!" i dont care about that. Im just trying to see if i can improve for next time.
 
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mrhunt

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Also receiving Dr was there with 2 residents and Dr was WELL aware of pt's full history and everything. None of the other staff had any other issues or questions as it was primarily just the floor nurse who met the pt in the ER who had the questions / issues.
 

Tigger

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Dude get over yourself. You need to be in possession of some kind of list of meds that the facility gave. There’s a litany of reasons, perhaps some matter and some don’t, but who cares. Learn and move on.

Most IFTs are total non events. Until you end up in the ED of some unfamiliar hospital (or the receiving) with a deteriorating condition and the doc wants to know what the patient has already had so a new plan can be started. That’s where you come in. If you’re going to take sick patients out of small hospitals, you need to take ownership of this. Even if nothing happens, it’s nice to be able to answer questions, no?
 
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mrhunt

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Get over myself? I'm simply answering the questions of the above poster and trying to learn and grow from my mistakes.

Thanks for the advice though "dude"
 

Tigger

Dodges Pucks
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Get over myself? I'm simply answering the questions of the above poster and trying to learn and grow from my mistakes.

Thanks for the advice though "dude"
You continue to provide excuses as to why it wasn’t important for you to have this information. It is.
Though the “why” has been provided, sometimes it’s also worth remembering that the why doesn’t really matter and you are still responsible, like it or not.
 
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mrhunt

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I'm not offering excuses. I'm giving a clear picture of the situation and answering questions of the above posters.

I'm well aware that I'm responsible for my pt, thanks for that. But your missing the entire point.

I'm not looking to argue here. I've seen multiple people's views on the subject and I appreciate it. That's all I wanted.
 

VFlutter

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What betrays a lack of understanding is a receiving nurse leaving something apparently so important (and irrelevant to) the transferring ambulance crew.

What? If the crew gave an answer, would she take their word for it if it was that critical? She was out to bust someone's chops and this was as good a reason as any.

The people actually formulating the medical treatment did know when the dose was and were acting or not acting on it. That's why they accepted the transfer in the first place.

No one was waiting on that nurse to tell them when the pt got the tPA.
Sure, the information is more important for nursing care and compliance documentation than it is relevant to the ambulance crew however it still should be known and available when transferring care. The first hour post tPA has a lot of timed assessment and considerations that ideally would be performed per protocol during EMS transport but in the real world is a grey area during transport and restarted upon arrival to the receiving.

The people actually formulating the medical treatment, usually the Tele stroke team, may not have any direct communication with the ER or ICU team actually receiving the patient. There are many times the receiving physician is wanting that information. But as you pointed out is usually obtained from the paperwork, not verbal report.

I will concede it is a "nice to know" for EMS however any Medic whom does tPA transfers routinely would quickly realize it is better for everyone involved that the information is passed along.
 

Peak

ED/Prehospital Registered Nurse
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Why did this patient have a MRI? Typically we don't see tissue changes on MR until you are out of TPA window, and the post-thrombus arterial vessel ischemia places the patient at high risk of arterial hemorrhage if given TPA. We don't typically MRI until at least 24 hours after onset.

As a point of insight an ICU nurse is not a floor nurse. Working the unit is all about detail. When the patient got TPA changes when you perform certain invasive procedures like foleys, central lines, arterial puncture, et cetera. It also greatly affects when the patient is at highest risk for post TPA hemorrhage, reperfusion complications like seizures, how we expect to manage hypertension, and so on.

Most ICU nurses have no prehospital or ED experience. They also don't know paramedic scope of practice, and for better or worse she probably held you to the same expectation that she would have from another nurse. If it makes you feel better an ED nurse giving the same report would probably have gotten essentially the same reaction.
 

silver

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Why did this patient have a MRI? Typically we don't see tissue changes on MR until you are out of TPA window, and the post-thrombus arterial vessel ischemia places the patient at high risk of arterial hemorrhage if given TPA. We don't typically MRI until at least 24 hours after onset.
Its actually opposite the case, MRI (specifically DWI sequence) is more sensitive than CT for early stroke. We mostly don't see it because of access and time it takes to get an MRI.
 

Peak

ED/Prehospital Registered Nurse
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Its actually opposite the case, MRI (specifically DWI sequence) is more sensitive than CT for early stroke. We mostly don't see it because of access and time it takes to get an MRI.
That's not entirely true. The gold standard of initial exam is a CTA on a helical 64 slicer or higher scanner.

The time that a MRA takes delays the start of TPA infusion or time to needle for PCI. Our CTA takes 10 seconds for the non-con and then about 2 more for the contrast study due to the delay.

Even on a modern 3 Tesla MRI a MRA MRV will typically take at least 30 minutes.

Even in pregnancy CT is the preferred initial modality for stroke rule in/out.
 

Peak

ED/Prehospital Registered Nurse
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Its actually opposite the case, MRI (specifically DWI sequence) is more sensitive than CT for early stroke. We mostly don't see it because of access and time it takes to get an MRI.
DWI also does a poor job when there are decent collaterals, which does not preclude the need for TPA or PCI.
 
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mrhunt

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Also the believe they stated c.t. was possibly inconclusive which was their reason for MRI.

Just saying what I was told. I have no clue with advanced imaging stuff like a few of the above posters.
 

silver

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That's not entirely true. The gold standard of initial exam is a CTA on a helical 64 slicer or higher scanner.

The time that a MRA takes delays the start of TPA infusion or time to needle for PCI. Our CTA takes 10 seconds for the non-con and then about 2 more for the contrast study due to the delay.

Even on a modern 3 Tesla MRI a MRA MRV will typically take at least 30 minutes.

Even in pregnancy CT is the preferred initial modality for stroke rule in/out.

Its generally considered the gold standard because implementation into a system not because of anything innate with MRI itself.
 

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