Post on 15-Jan-2017
Acute stroke total solution serviceFrom thrombolysis topost-acute care Show Chwan health system
Attaining rapid stroke thrombolysis within 30 minThrombolysis bundle initiative in Show Chwan health system
急性中風後期照護提升計畫PAC-CVD
Acute strokeReputation
establishmentFew NudgeHigh riskA possible niche
(3~4.5 hours)
1st TPA locked in syndrome
Recent challengePass the high standard of the critical care evaluation process
EBM guidanceNeurology guidelineConform the current NHI regulation
Refer to the stroke bundle implemented in Helsinki and Melbourne
Bundle care coverageFrom door to ward1 ． ER TPA or aspirin (door to
needle)2 ． ICU care (needle to ward)
Resources reconstructionTriage
ER DoctorsER NursesNeurologistsLab technicianCT room alert
ICU doctorsICU nursesStroke nurse
specialistEndovascular
specialistsNeurosurgeons
Audit, Award, Penalty
Bundle care coverageFrom door to ward1 ． ER TPA or aspirin (door to
needle)2 ． ICU care (needle to ward)
Possible advantageForm the 1st comprehensive stroke care bundle in Taiwan
Helsinki model
Meretoja 2013
Helsinski DistrictSea faced, capital of Finland
Parallel processing
Non-transferrable?
Meretoja 2013
I moved to Melbourne in Nov 2011
Meretoja 2013
20 km radius
Meretoja 2013
Other approach
• Admitting– Patient identification– Registration– Room assign
• EMS– Delivers patient to room– Reports to nursing
• Nursing– IV placement– Monitor hook-up– Vital sign monitoring– Blood glucose– Lab draw– Weight estimate of patient
• Clinical Assessment– History– Medications/allergies– Identification of witness– Time of onset/last normal– Witnesses difficult to locate
• Clinical Assessment (cont.)– NIHSS– Neurological Exam
• Labs– PT/PTT, CBC, Creatinine– Emergent transport of bloods to
lab• Imaging
– Disconnect from monitor– Transport patient to CT– CT scan– Transport from CT to room– Reconnect to monitoring
• Drug Preparation– Order tPA– Calculate tPA dose– Prepare tPA
• Bolus and infuse tPA
ISC 2012 New Orleans
Problem #1: Overwhelming # of tasks to complete in 60 min
1
2 3 4 5
6
Emergent Unit 1
Nursing Station
Trauma Critical Care
CT
CT
Ambulance Bay
Problem #2: Inefficient choreography
ISC 2012 New Orleans
Problem #3: Labs take too long • Labs needed for tPA
– Platelets– INR (PT/PTT)– Blood glucose
• On average, in 2010, it took 33 min to get results after ordering labs
ISC 2012 New Orleans
Show Chwan model
A possible niche market
Show Chwan modelStroke TPA Action Treatment group (STAT)
Within the guidance of NHI:<3 hours, many outdated exclusion
Rearrange the workflowSTAT team member training
SuggestionTriage dispatching
Inform neurologist (get the mobile phone number of the ambulance)
Arrange admission and registrationICU bookingCheck CT roomInform Point of care lab staff (INR,
glucose, platelet)
SuggestionER doctorCheck list and pre-ordered orderVerify durationCheck vital signsBasic NE: MP, BabinskiPOC video demo if needed (out of hour
neurologist)
Video source and permit signing
Signature from 2 patient’s family or friendsTelephone if needed (and document on the permit)Sign permit if no one is available after consult social
worker to document the condition and start TPA
NeurologistIn hours:
Immediate evaluation including signing document and explanation
Out of hours:Evaluate the patient with ambulance staff via mobile phone Point of care video neurological examination
ER nurseCheck vital signs and body weightSet big IV line and 3tubes (vein)Prepare IV pump for TPA
0.9*BW (1cc=1mg, max 90mg)1st min: rate: x cc *60, volume: x cc1 hour: rate: y cc, volume: y cc
ER logisticsDirect from ambulance stretch
to CT bedIV, blood sampling, vital signs
Body weight, quick (video) NE
QuestionPoint of care INR and STAT
CBC/PLTWhen to initiate IA thrombolytics?
If <6 hours (Do MRI with MRA)If personnel availableIf basilar artery occlusion
Show Chwan model
Beyond the NHI guidance
A possible niche market
Attaining rapid stroke thrombolysis within 30 minThrombolysis bundle initiative in Show Chwan health system
急性中風後期照護提升計畫PAC-CVD
10 月 7 日
白話急性中風後期照護提升計畫PAC-CVD
這次不一樣 ????
又來了
首波
沒有品質沒有核刪
特點
高給付額團隊報名
時間
急性後期下轉開始
6 到 12 週
分級
起始狀況積極復健潛能
潛能
意願體力主動家庭
結案
好了沒進步沒潛能>12 週AAD
Expire
條件
跨院際整合團隊模式
提出申請
復健人力物力每 4 床至少需
1 位 物理 or職能 or語言治療人員( 治療師 or 治療生 )
急性後期照護團隊專責醫師
神經科、神經外科、復健科內科、家醫科
至少各 1 名專任 護理人員物理治療師職能治療師語言治療師藥師營養師社工人員
，
專屬床位
急性後期照護單位
個人專屬急性後期照護計畫
急性後期照護單位床位數床位編號照護人力
( 專業別、人數、專任或兼任、各類人員醫病比 )照護設備
FRG1
FRG2
評估費用
高強度
可能策略
自轉 PAC
評估收入
體系之內彰化彰濱互轉下轉田中仁和 員林何醫院 竹山秀傳無專責語言治療師
另外結盟台中榮總台中中國台中中山彰化漢銘員林員榮署立彰化
體系之外彰基轉彰化彰濱
( 彰化市、鹿港、芳苑、福興 )彰濱轉鹿基、二基( 二林、鹿港、芳苑、福興 )
建議彰基合作
中風急性中期後期復健網
資源請行政組依規定要求擬定計畫書初稿
定日程安排院際會議增聘一位後急性中風專員績效組定立適當收案獎金
時程10 月兩次參與醫院院際討論會議10 月底
完成計畫書
最後期限11 月 8 日 完成版本11 月 15 日 最後修定
急性中風後期照護提升計畫PAC-CVD
Independence
Acute stroke total solution serviceFrom thrombolysis topost-acute care Show Chwan health system