Stroke for Patient not Receiving tPA, Ischemic; Admission for (Order Set)
Stroke for Patients Receiving tPA, Ischemic; Admission for (Order Set)

Scope and Target Population:
The scope of the following guideline is the 48 hours beginning when a patient age 18 years or older presents to a provider with symptoms of ischemic stroke or transient ischemic attack. For most stroke patients who are hospitalized, the guideline's temporal scope will expire before discharge. The guideline work group on Diagnosis and Initial Treatment of Ischemic Stroke recognizes that two time frames are critically important in the overall outcome, and fall outside the defined scope. They are prehospital care, and continuing care of stroke patients after 48, hours which includes the development of a long-term secondary prevention strategy. While the group has not itself performed a systematic review of the primary evidence on these matters, we recommend the following guidelines from the American Heart Association, American Stroke Association, and the Council on Cardiovascular Radiology and Interventions and the American Academy of Neurology.

Clinical Highlights and Recommendations:

• Patients presenting with signs and symptoms of TIA should be evaluated for risk of immediate future events using the ABCD score.
  
• Patients who present in time to be candidates for treatment with tPA should be evaluated by a physician within 10 minutes, undergo a CT scan within 25 minutes of arrival in the ED, and have CT interpreted within 20 minutes of test completion.
  
• Intravenous tissue plasminogen activator, (tPA) if given, should be administered within three hours of stroke onset and less than 60 minutes of arrival at the ED.
  
• Patients presenting with stroke onset who are not candidates for intravenous tPA should promptly be given aspirin, after exclusion of hemorrhage on CT scan.
  
• Education regarding early stroke symptoms, risk factors, diagnostic procedures, and treatment options should be offered to the patient and family. This should be documented in the patient chart.
  
• Medical management for prevention of complications within the initial 24-48 hours of diagnosis and initial treatment of ischemic stroke include:
  - continue appropriate blood pressure management;
  - continue to treat hyperthermia;
  - continue to treat hypo- or hyperglycemia;
  - continue IV fluids;
  - initiate deep vein thrombosis prophylaxis;
  - perform swallow evaluation;
  - initiate early rehabilitation; and
  - perform nutritional status assessment.

Priority Aims:

1. Increase the percentage of patients presenting within three hours of stroke onset who are evaluated within 10 minutes of arriving in the ED.
   
2. Increase the percentage of patients presenting with TIA symptoms within 24 hours at high risk for stroke who are admitted to the hospital.
   
3. Increase the percentage of patients receiving appropriate thrombolytic and antithrombotic therapy for ischemic stroke (use of tPA and aspirin).
   
4. Increase the percentage of non-tPA recipients who have hypertension appropriately managed in the first 48 hours of hospitalization or until neurologically stable.
   
5. Increase the percentage of patients who receive appropriate medical management for prevention of complications within the initial 24-48 hours of diagnosis:
   
   • Continue to treat hypoglycemia and hyperglycemia
     
   • Continue to treat hyperthermia
     
   • Continue IV fluids
     
   • Continue to treat hypoxia
     
   • Initiate deep vein thrombosis prophylaxis
     
   • Perform swallow evaluation
     
   • Initiate early rehabilitation (early mobilization)
     
   • Perform nutritional status assessment
6. Improve patient and family education of patients with ischemic stroke in both the ED and the admitting hospital unit.