Frontiers - Summer 2013

SUMMER 2013

Special Stroke Edition

The University of Tennessee Medical Center & the University of Tennessee Graduate School of Medicine

A Coach's

Winning Battle for Recovery

Stroke Advancements For East Tennessee

Carter High School’s Heath Woods

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Plus…Ask the Expert - Your Medical Questions Answered on Page 20 8/28/13 9:19 AM

Contents The University of Tennessee Medical Center and the University of Tennessee Graduate School of Medicine Frontiers

Summer Issue 2013 Editor

Becky Thompson

Publishers

12

Joseph Landsman James Neutens, PhD

Cover Story

Contributors

Coach Heath Woods One Man’s Story to Overcome a Life-Threatening Stroke

Features 4 Neurointerventional Radiology Brings Leading-Edge Treatments for Brain and Spine Patients

8 Comprehensive Stroke Center The Medical Center’s Advanced Treatment for Stroke Patients

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11 N eurosurgery

Quick Response and a Protocol That’s Saving Lives

12 Coach Heath Woods One Man’s Story to Overcome a Life-Threatening Stroke

16 Neurocritical Care Bringing Great Advances to Patients and Neurosciences

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18 C ommitment to Excellence In Stroke Education

22 T he Gold Standard

Leslie Hamilton, PharmD Jennifer Henry, RN Kandi Hodges Bonnie Horner Russ Langdon, MD Brian F. Wiseman, MD

Design/Creative

Dean Baker Frontiers is a magazine produced

by The University of Tennessee Medical Center and the University of Tennessee Graduate School of Medicine. This publication was designed to showcase the unique benefits of having an academic medical center in East Tennessee.

Copyright © 2013 The University of Tennessee Medical Center All Rights Reserved EEO/TITLE VI/TITLE IX Sec. 504/ADA

Send correspondence to Frontiers

2121 Medical Center Way, Ste. 300 Knoxville, Tennessee 37920-3257 Telephone: 865-305-6845 Fax: 865-305-6959 E-mail: frontiers@utmck.edu www.utmedicalcenter.org or http://gsm.utmck.edu

The Role of Pharmacists in the Management of Acute Ischemic Stroke

25 Stroke Facts by the Numbers In Every Issue 16

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Q & A: Ask the Expert

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Continuing Education Course Calendar

Use your smart phone to scan and learn more about our Comprehensive Stroke Center.

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&Friends,

Dear Alumni

T

he University of Tennessee Medical Center and UT Graduate School of Medicine are pleased and honored to have received advanced certification from The Joint Commission/American Heart Association as a Comprehensive Stroke Center. This recognition reflects the dedicated efforts of our physicians, nurses, allied health professionals and other team members and their single focus on providing the most complete and comprehensive care for our patients and their families each and every day. The criteria for this designation are rigorous, but we welcome the opportunity to be judged and evaluated against the best of the best. Our patients and their families who have suffered the effects of devastating strokes benefit greatly from this advanced certification.

The University of Tennessee Medical Center has also been nationally recognized for the second consecutive year by the respected magazine U.S. News & World Report. In the publication’s 2013-14 “America’s Best Hospitals” edition, 11 specialties at The University of Tennessee Medical Center are listed as high-performing. Additionally, the medical center is ranked No. 3 in the state of Tennessee and No. 1 in the region, with more recognized specialties than any other hospital in the Knoxville area.

In this issue of Frontiers, you will have an opportunity to learn more about neurointerventional radiology and the other leading treatment protocols available to our patients; you will read about the actual experiences of a stroke patient, Coach Heath Woods of Carter High School, and about collaborative research and education taking place at the Graduate School of Medicine. We’ll share with you facts about stroke and early-warning signs important to you, your family and your friends.

Congratulations to our team members, whose dedicated focus on quality patient care has resulted in this advanced certification as a Comprehensive Stroke Center and has helped us achieve national recognition for excellent patient care.

Sincerely, Joseph R. Landsman, Jr. President and Chief Executive Officer University Health System, Inc.

Our Mission

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To serve through healing, education and discovery

We Value

Integrity • Excellence • Compassion Innovation • Collaboration • Dedication

James J. Neutens, PhD Dean UT Graduate School of Medicine

Our Vision

To be nationally recognized for excellence in patient care, medical education and biomedical research.

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Healing

Neurointerventional

Radiology

Brings Leading-Edge Treatments for Brain and Spine Patients

By Bonnie Horner

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N

eurointerventional radiologists see some of the most complex blood vessel conditions in the brain and spine.

These physicians use minimally invasive procedures to treat intricate cases in the shortest amount of time—cases that until recently were considered untreatable. Advances in medicine and technology created the opportunity for this growing medical specialty­: neurointerventional radiology.

“Emergency room physicians are often the first responders in treating neurological conditions,” says Andrew Ferrell, MD, assistant professor in neurointerventional and neurodiagnostic radiology within the Graduate School of Medicine and neurointerventional radiologist at The University of Tennessee Medical Center. “When a brain aneurysm or stroke occurs, our physicians want their patients to receive the most advanced care in the shortest amount of time possible. Every patient deserves the very best treatment by a dedicated team of physicians.”

This is why the medical center’s neurointerventional radiology service, a subspecialty of radiology, was developed in 2003 and collaborates with the Brain and Spine Institute.

Neurointerventional radiologists work closely with board-certified neurologists, neuroanesthesiologists, neurosurgeons, vascular surgeons and a Comprehensive

Stroke Center team to offer innovative, minimally invasive treatments for lifethreatening conditions related to the brain and spinal cord.

“Every patient deserves the very best treatment by a dedicated team of physicians.”

“In the past, certain conditions that would have required open surgery, such as aneurysms, strokes, blood clots, neurovascular malformations, and tumors of the head, brain, neck and spine, can now be considered for minimally invasive treatment using an endovascular approach to reach the problem,” says Ferrell. Procedures of this kind are less invasive than traditional surgery. For patients, they result in shorter hospital stays, quicker recovery times, reduced pain and less risk of complications.

State-of-the-Art Treatment The University of Tennessee Medical Center’s Comprehensive Stroke Center offers the latest technology in the neurointerventional biplane suite, which is a state-of-the-art treatment environment, converting instantly from a neurointerventional radiology suite to a microsurgical suite for vascular brain surgery. To expedite treatment, the biplane suite is adjacent to the emergency department for easy access.

Patient safety, always a top priority, is greatly enhanced by faster assessment and transition to treatment.

The suite’s biplane system provides the most advanced digital imaging capabilities. It is designed to offer ideal projection angles, patient access, and integrated software that speeds diagnosis with real-time evaluations and study comparisons. The system produces three-dimensional images of a patient’s head along two planes.

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Neurocritical Care After diagnosis and treatment, patients may be admitted to the neurocritical care unit located at The University of Tennessee Medical Center. This highly specialized unit is staffed with an elite team of specially trained critical care nurses, respiratory therapists, nurse practitioners, physician assistants and nursing assistants, all dedicated to helping patients toward recovery. The critical care team also includes social workers, physical therapists, speechlanguage pathologists, occupational therapists, nutritionists and clinical pharmacologists. Completing the team are patients and their families, who participate in discussions and decisions concerning goals, treatment options and plans of care.

Coordinated Care At the only academic medical center in the region, patients receive 24-houra-day care from a Comprehensive Stroke Center team and are served by a dedicated group of specialtytrained neurologists, neurosurgeons and neurointensivists (specialists in neurocritical care). All these professionals work collaboratively with neurointerventional radiologists to provide many treatment options.

“Merging sophisticated technology with a unique collaboration of healthcare professionals among various neurospecialties allows us to give our patients the best chance of survival and fast recovery,” says Ferrell. All members of the medical center’s multidisciplinary teams are committed to patient safety and comfort—a crucial mission in high-quality care. This commitment is evidenced at a weekly neuro-vascular case conference that is held to review difficult cases and discuss options to ensure best patient outcomes.

Andrew Ferrell, MD, and Peter Kvamme, MD, perform a cerebral angiography in the biplane suite. By injecting a special dye (called a contrast agent) into the patient’s artery, they can detect an aneurysm.

Neurological disorders can be challenging and difficult. But genuine collaboration, like that at The University of Tennessee Medical Center, strengthens treatment and improves patients’ chances of a full recovery.

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Figure 1

How It Works Treating neurovascular conditions has traditionally been a risky prospect that required an open procedure on the brain. Conditions such as strokes, aneurysms and vascular malformations now can be considered for an endovascular approach to reach the affected area.

Most aneurysms are balloonlike, with a narrow neck at the origin and a large expanding dome. During a coiling procedure, a catheter is inserted into the aneurysm and coils are packed inside the dome. The coils promote blood clotting, which closes off the aneurysm and eliminates the risk of rupture.

Figure 2

Specialists at The University of Tennessee Medical Center are successfully treating these conditions in revolutionary ways. One of the minimally invasive procedures involves a tiny mesh tube (stent) inserted into a patient’s artery with a very fine catheter (see Figure 1 at left). The neurointerventional radiologist guides the catheter into position in the area where the stroke is occurring.

This removes the blood clot, and blood flow is directed back toward the brain. Or a millimeter microcatheter is inserted into the femoral artery in the groin and advanced through many twists and loops of vessels to reach the site of the bleed (aneurysm) in order to insert a coil that may be only two or three millimeters in size (pictured in Figure 2). Once the microcatheter is positioned inside the aneurysm, a series of specifically shaped coils are inserted into the aneurysm to fill it. The neurointerventionist chooses the coils’ sizes according to the shape and size of the bleed. Procedures of this kind are highly intricate and require years of specialized training.

Our Physicians Peter Kvamme, MD Specializes in neurointerventional radiology at The University of Tennessee Medical Center. He serves as associate professor of interventional radiology, nuclear medicine and neurointerventional radiology at the Graduate School of Medicine. Kvamme earned his medical degree from Tulane University School of Medicine. He completed his internship of categorical general surgery at The University of Texas Medical Branch in Galveston. He later went on to complete his residency in nuclear medicine at Baylor College of Medicine and diagnostic radiology at St. Francis Medical Center in Pittsburgh. He completed his fellowship in endovascular surgical radiology at Louisiana State University Medical Center in New Orleans, and later completed his second fellowship in interventional radiology at Johns Hopkins University School of Medicine.

Andrew S. Ferrell, MD Specializes in neurointerventional radiology at The University of Tennessee Medical Center. He also serves as assistant professor in neurointerventional and neurodiagnostic radiology within the Graduate School of Medicine. Ferrell completed a bachelor of science in biology at The Citadel in South Carolina. He earned his medical degree and later completed an internship in general surgery at the Medical University of South Carolina. Ferrell went on to complete his residency in diagnostic radiology at the University of Alabama at Birmingham and his fellowship in diagnostic neuroradiology and interventional neuroradiology at Duke University.

Visit UTMEDICALCENTER.ORG for more information.

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Patrick Dreyer, BSAH, RT (R)(CT), a radiologic technologist at The University of Tennessee Medical Center, prepares a patient for an MRI.

Comprehensive Stroke Center

By Russ Langdon, MD

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he Comprehensive Stroke Center at The University of Tennessee Medical Center is unlike any other facility in the region.

Our stroke team is always available to provide around-the-clock care, starting with prehospital notification by the Tennessee regional EMS systems and our own LIFESTAR aeromedical service. This level of care continues with the constant availability of a neuroendovascular interventional service and the only Level I Trauma Center in East Tennessee. Our multidisciplinary team evaluates and treats the most complex cases of stroke. Designated by the American Heart Association/American Stroke Association and The Joint Commission as exceeding standards of care for stroke patients, our Comprehensive Stroke Center has joined an elite group of providers focused on complex stroke care.

This new and advanced level of certification, launched in 2012, recognizes the significant resources in staff and training that Comprehensive Stroke Centers must have to treat complex stroke and other neurological disorders.

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The University of Tennessee Medical Center’s Brain and Spine Institute is the largest and most experienced program in East Tennessee dedicated to caring for stroke patients with neurological and neurosurgical problems.

From the trained regional EMS providers who quickly recognize stroke symptoms to the expert emergency room physicians and nurses who start the process of identification to the use of sophisticated imaging capabilities and the continuous availability of specialized treatments, our stroke team is a regional leader in providing advanced care to patients with stroke.

At the region’s only academic medical center, in partnership with UT Graduate School of Medicine, physicians and staff engage in research aimed at improving care for stroke patients.

“UT Medical Center is thoroughly committed to providing our patients with the highest-quality stroke care based on current scientific research to ensure continuous improvement in care,” says Ann Giffin, vice president of the Brain and Spine Institute.

The Benefits and Responsibilities of a Comprehensive Stroke Center Include: • Providing a dedicated neurointensive care and acute neuro/stroke unit for complex stroke patients that offers coordinated neurological and neurosurgical care 24 hours a day, seven days a week • Making use of advanced imaging capabilities • Meeting rigorous care standards for patients experiencing all types of stroke • Performing endovascular coiling or surgical clipping procedures for a cerebral aneurysm • Administering advanced treatments for ischemic stroke, including intravenous (IV) plasminogen activator (t-PA) and endovascular clot retrieval • Coordinating posthospital care for patients • Utilizing a peer-review process to evaluate and monitor the care provided to patients with ischemic stroke and subarachnoid hemorrhage • Participating in stroke research

The UT LIFESTAR flight crew arrives at the medical center with a patient in need of rapid evaluation and treatment.

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A Round-the-Clock Stroke Team Night or day, the center brings together leading experts from a variety of disciplines, who collaborate using the latest clinical advances and technologies so patients can expect a uniformly high level of care.

The comprehensive stroke team is made up of highly experienced stroke specialists, who include neurologists, neurointensivists, surgical intensivists, medical intensivists, neurointerventional radiologists, neurosurgeons, nurses, nurse practitioners and physician assistants specially trained in stroke and neurocritical care, social workers, dietitians, rehabilitation professionals, therapists and specialty-trained neuropharmacists. Altogether, they provide quality care to meet the unique and specialized needs of stroke patients.

A critical part of the journey to recovery involves evaluation and treatment by physical, occupational and speech therapists. Stroke impacts a person’s ability to walk, communicate, eat and complete simple daily tasks. The medical center’s stroke team therapists develop treatment plans directed at getting the patient started on that journey to recovery. The rehabilitation team also participates in ongoing stroke-focused education and specialization. Our commitment to providing exceptional patient care is demonstrated by the achievement of the American Physical Therapy Association’s Neurologic Certified Specialist (NCS) designation by the stroke team’s physical therapist, Blair Saale, PT, DPT, NCS. The certification, achieved by only 1,260 physical therapists since 1987, provides formal recognition for the advanced clinical knowledge, experience and skills necessary to provide treatment for complex stroke patients.

Meet Our Stroke Director Jennifer Henry, BSN, RN, CNRN Jennifer Henry has been with the medical center for 23 years and has spent her nursing career caring for patients. Jennifer’s leadership role is critical to the success of the Comprehensive Stroke Center, its operational functions and quality stroke patient care.

Among her many duties coordinating the Stroke Center, she participates in daily in-patient rounds and management of stroke care. Jennifer serves as the leader of the emergency stroke response team which is a central part in the decision to administer t-PA to patients who have suffered an ischemic stroke. In addition to in-patient responsibilities, Jennifer is a recognized stroke expert and resource for the implementation and development of stroke education for hospital team members and health professionals throughout Tennessee.

Jennifer’s driving force at The University of Tennessee Medical Center can personally be seen in the community as she provides education on stroke warning signs and stroke risk reduction as well as quality patient care to patients and their families.

“The composition and collaboration of our team is truly the biggest strength of our Stroke Center,” says Brian Wiseman, MD, Stroke Center medical director. The physician team includes the region’s only certified neurocritical care physician and two fellowship-trained, certified neurointerventional radiologists. Experienced, committed neurologists and neurosurgeons work together with these professionals to provide care for the most complex and vulnerable patients.

Our multidisciplinary Stroke Center team focuses on top-notch care for our patients, as well as providing stroke education, outreach and prevention measures to our entire region.

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Neurosurgery

Quick Response and a Protocol That’s Saving Lives

By Jennifer Henry, RN

Alert and ready, the stroke team at The University of Tennessee Medical Center is always prepared for the arrival of patients with hemorrhagic stroke. This type of stroke occurs when a blood vessel in the brain ruptures. Patients with bleeding in the brain are critically ill, requiring the services of neurosurgeons, neurointerventional radiologists, intensivists, and critical care nurses. Thanks to an auto-accept protocol and partnerships with surrounding facilities, patients throughout our region who experience hemorrhagic stroke can reach the stroke team at the medical center swiftly, with no unnecessary delays and no questions asked.

Time is of the essence, and the stroke team works quickly to locate and diagnose the bleed. Advanced imaging of blood vessels in the brain assists the team in determining the source of the bleeding. The neurosurgeon works with the other team members to develop the best treatment plan for the patient. “The auto-accept program is a great service for our community, allowing rapid access to high-quality care,” says Joshua A. Miller, MD, a neurosurgeon at the medical center.

Patients with brain hemorrhages require prompt neurosurgical evaluation and treatment. This can involve a craniotomy to reduce the pressure on the brain or to secure a ruptured aneurysm and prevent continued bleeding (also known as clipping). The neurosurgical team includes neurosurgeons, physician assistants, nurse practitioners and registered nurses. Team members follow the patient’s progress during the hospital stay and after discharge.

Neurosurgeons William Snyder, MD, and Michael Walsh, MD, perform a neurosurgical procedure to repair bleeding in the brain (a hemorrhagic stroke).

Treatment Options Rapid evaluation, diagnosis and treatment provide the best opportunity for recovery from hemorrhagic stroke.

Expert neurosurgical care, along with procedures like craniotomy and clipping (where a neurosurgeon places a tiny clip across the neck of an aneurysm to stop or prevent it from bleeding), has advanced the treatment of this type of stroke. With the collaboration of neurointerventional radiologists, sophisticated procedures like the coiling (when tiny coils are packed into an aneurysm to promote blood clotting) of ruptured aneurysms are an option for many patients, allowing CLIPPING for less invasive stroke management.

This combination of skill and swiftness is another crucial aid in the process of saving lives and minimizing COILING disability after stroke.

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Cover Story “As I was in the ambulance being driven away, I thought to myself, ‘I can’t believe this is happening to me. I was fine just an hour ago.’”

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Coach

Heath Woods One Man’s Story to Overcome a Life-Threatening Stroke

By Bonnie Horner

F

ew medical emergencies draw a finer line between life and death than a stroke. For Carter High School coach Heath Woods, this line was drawn on familiar turf: an season-opening football game.

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rom the moment a stroke occurs, patients must race against the clock to get treatment that can prevent lasting damage. Not everyone is as lucky as Heath Woods, who, one year after suffering a major stroke, is well on his way to full recovery and looking to get back on the field.

Ejected from a season-opening game after a disagreement with officials, Woods was upset. Then he started to feel sick. Thinking the problem was just dehydration, he was on the phone with his wife when he began to get dizzy and nauseated. In just a few minutes, his right side went numb and he could no longer stand up straight. Emergency medical technicians, on the sidelines in case the players needed care, ran over to help and diagnosed the problem as a stroke.

Woods recalls, “As I was in the ambulance being driven away, I thought to myself, ‘I can’t believe this is happening to me. I was fine just an hour ago.’” Woods, who was only 45 at the time, had no family history or prior symptoms of stroke.

But the University of Tennessee Medical Center physician who treated him, Peter Kvamme, MD, says, “A stroke can happen to anyone, at any time, anywhere.”

When Woods arrived at the medical center, the EMT crew had already initiated Code Stroke, a system of fast assessment and treatment. After performing initial tests, the medical center’s stroke team immediately gave Woods tissue plasminogen activator—a clot-busting drug that must be used within three hours—to help restore blood flow to his brain and improve his chances of survival.

But Woods’ stroke was a very rare one, and the clot-busting drug wasn’t enough. “When we ran further tests, we saw that the back of his brain stem was black—it wasn’t receiving any blood. The clot was severe, and he was literally minutes from death,” says Kvamme.

The stroke team swiftly transferred Woods to the biplane angiography suite adjacent to the emergency room.

“The best thing that happened to me was being at the right place,” he says. “And everything went so quickly. Everyone at the medical center had a purpose and knew what they needed to do to save my life.”

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Coach Woods getting ready for his first game since his stroke last fall. He’s shown preparing plays in the locker room for his players.

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Neurointerventional radiologists performed minimally invasive surgery, using a thin catheter tube to insert a stent into the blocked artery and remove the blood clot. The procedure was successful, and Woods spent a few days in the hospital, returning to his family stronger and healthier every day.

Coach Woods continues to take things one day at a time, but looking at him today, no one could guess he’d ever had a stroke. “His condition was much more serious than anything now indicates,” says Kvamme—underlining the importance of recognizing stroke symptoms and of being treated at a certified Comprehensive Stroke Center like the one at The University of Tennessee Medical Center.

Someone suffering from a stroke may not be able to speak or call for emergency help. The University of Tennessee Medical Center’s stroke team emphasizes that you should call 911 if you feel something is amiss, even if you don’t know the person who might be having a stroke.

KNOW

THE WARNING SIGNS OF STROKE

An easy way to recall the major warning signs of stroke is to remember the acronym FAST: F– Face Drooping—Does one side of the face droop or feel numb? Ask the person to smile. Is the smile uneven?

A– Arm Weakness—Is one arm weak or numb? Ask the person to raise both arms.

Does one arm drift downward?

S– Speech Difficulty—Is speech slurred?

Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence like “The sky is blue.” Is the sentence repeated correctly?

T – Time to call 911!!—If someone shows any of the signs of stroke, even if the signs go away, call 911 and get the person to the hospital. Check the time so you’ll know when the problem first started.

Call 911 if you experience or observe any symptoms of a stroke.

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Healing

Neurocritical

Care Bringing Great Advances to Patients and Neurosciences

By Brian F. Wiseman, MD

Carol Zimmer, BSN, RN, in the neurocritical care unit, tends to a patient’s recovery.

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Members of the Medical Team In the neurocritical care unit, a multidisciplinary team of specially trained physicians, nurses, therapists and other professionals provide balanced, attentive care in a unique environment. They assess a patient’s vital signs, intracranial pressure, brain oxygenation and neurological response in order to identify minute changes in condition.

This meticulous, expert care allows us to be successful in the treatment of even the most challenging and difficult diseases of the neurological system. It requires a multidisciplinary team, which includes:

.. .. .. . .. ..

Neurointensivists Neurosurgeons Neurointerventional radiologists Nurse practitioners Physician assistants Critical care nurses Case managers Neuropharmacists Physical, occupational and speech therapists Dietitians Pastoral care

All nursing staff members complete a competency-based orientation program. The length of orientation is determined by the employee’s prior experience. New graduate nurses usually require six months of orientation. Advanced certifications from organizations such as the American Association of Neuroscience Nurses, Association of Neurovascular Clinicians and American Association of Critical Care Nurses are part of the professional development plan for all new RN hires.

Neurological Illnesses Treated Our neurocritical care specialists have expertise in the management of a range of disorders that necessitate urgent and intensive treatment, including: • • • • • • •

Stroke Brain tumors Brain and spinal cord injuries Nerve and muscle problems Brain infections, such as encephalitis and meningitis Persistent seizures Brain swelling

With an eight-bed closed-unit design, the neurocritical care unit provides complete intensive care management to some of the most critically ill neuro patients in East Tennessee. As the region’s only academic medical center, we use stroke education and research as integral components of our mission to deliver unparalleled care.

Brain injuries and diseases of the nervous system can be disabling and life-threatening.

But careful, thorough monitoring and innovative treatment of these problems can help ensure the best possible outcome for the patient. The specialized and dedicated neurocritical care unit at The University of Tennessee Medical Center is staffed by neurological, neurosurgical and critical care specialists; it is the only unit of its kind in the area.

An important aspect of the care provided at a Comprehensive Stroke Center is the focused team approach from start to finish. Care for the complex stroke patient begins in the Emergency Department, where nurses, nurse practitioners, pharmacists, and radiologic technologists with stroke-focused training initiate the Code Stroke protocol. Patients are then transferred to the appropriate nursing unit—neurocritical care or neuro-stroke—for the expert nursing care that assists patients and their families in their journey to recovery.

The neuro-stroke unit is a 21-bed inpatient unit located on 7 South. Stroke nurses, case managers, pharmacists, dietitians and therapists partner with physicians and nurse practitioners from UT Hospitalists to continue the multidisciplinary care necessary for stroke patients and their families. The team works to develop a discharge plan for patients that addresses their rehabilitation needs, risk-factor and chronic-disease management strategies and follow-up care from primary care providers and specialists.

The care doesn’t end when a stroke patient is discharged from the hospital. Stroke Center nurse practitioners and physician assistants conduct follow-up assessments at seven days and 90 days for the most complex stroke patients discharged to home. To ensure continued opportunity for optimal recovery, a stroke follow-up clinic has been established at UT’s Cole Neuroscience Center.

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Education

Commitment

toExcellence in Stroke Education

F

or years, academic medical centers have driven the future of healthcare in education and research. The foundation of our commitment as the region’s only academic medical center is the pursuit of collaborative research and education focused on patients, healthcare professionals and the community.

By Jennifer Henry, RN

The University of Tennessee Medical Center specializes in translating research and clinical experience into education that benefits everyday patient care.

To address the medical emergency of stroke, there are nationally accepted guidelines for treatment and primary and secondary prevention established by the American Stroke Association, the Brain Attack Coalition and The Joint Commission. Education for providers who treat stroke patients throughout the state is critical in order to ensure multidisciplinary, evidence-based care for patients experiencing stroke.

As part of our own mission to serve through education, the Stroke Center has developed educational opportunities that strengthen proficiency among nurses and other health

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professionals. These stroke-specific educational opportunities are extended to emergency medical services teams, paramedics and other healthcare providers to speed and improve stroke care in East Tennessee.

assessment, prehospital care and transport to the Stroke Center.

Advanced Stroke Life Support is a hands-on course directed at providing skills and training that prepares prehospital providers and nurses working throughout the medical center to

Recognition Is Critical Every single person working in healthcare should know what stroke looks like and what to do to access emergency care for the person experiencing stroke. All team members at the medical center complete an annual learning module addressing stroke-warning-sign recognition and response. With stroke, every second counts—everyone must know what to do when stroke happens. The module also covers risk factors for stroke and outlines strategies to manage personal risk for stroke.

Nursing Orientation Stroke Lecture During orientation at the medical center, all newly hired nurses attend a two-hour stroke “boot camp” in which they learn the fundamentals of stroke, including pathophysiology; assessment, recognition and response (also known as Code Stroke); core measures; and resources.

Interactive Learning Nurses at the medical center are required to complete courses and annual learning modules that build on the basic knowledge and skills introduced in the orientation session. The curriculum is determined by the area of practice, taking into consideration the care requirements of patients that the RN will encounter on a daily basis. Each group of nurses completes the required modules annually to ensure an up-to-date knowledge of evidence-based stroke care.

• Non-stroke-unit nurses complete an online module that addresses basic pathophysiology, treatment, and assessment, recognition and response (Code Stroke).

• Stroke-unit nurses (Emergency Department, neurocritical care, TSICU, medical critical care, neuro-stroke, progressive care, interventional radiology and HLVI Registry) and neurointerventional radiology technicians attend the Advanced Stroke Life Support course and complete eight modules approved for 30-plus contact hours.

• Heart Lung Vascular Institute nurses (8 E, 3 Heart, CVICU, 6 East, CCL, CVR, EVR and endovascular lab) complete selected modules because their patients have significant risk for stroke.

Teaching Theory and Practice: A Multidisciplinary Approach First responders and emergency medical services (EMS) providers are the link between the stroke patient and potentially lifesaving treatment at the Stroke Center. The University of Tennessee Medical Center has committed to providing educational opportunities for our regional EMS partners to ensure their teams are well equipped to provide rapid

Maddie Lamb, BSN, RN, and JJ Janoyan, DO, SFHM, medical director of UT Hospitalists, review cases on the neuro-stroke (7 South) unit at the medical center.

provide care for people experiencing acute stroke. Learning is accomplished through lectures, video case scenarios, practice stations and stroke-syndrome simulations by instructors.

EMS providers are a vital part of our team; their prehospital emergent care setting and clear communication drives positive outcomes for our patients. With their help, we have physicians waiting at the door, a CT machine ready and a neurologist on standby when a patient arrives.

Coordination of Care Other stroke-related educational sessions provided to medical center team members and our partners in the region include: • Nursing Grand Rounds

– A Guide to Assessing Potential Neuro Stroke Patients

– Inpatient Code Stroke: Case Studies • Acute Stroke for Roane State Community College’s Critical Care Paramedic course • Acute Stroke for Rural Metro training days Further progress in stroke prevention and treatment depends heavily on education of the community regarding both riskfactor reduction and the need for timely implementation of treatment. As the area’s only academic medical center and Comprehensive Stroke Center, we are committed to sharing our expertise with others to improve outcomes throughout the region.

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Education

ASK THE EXPERT

Our Experts Answer Your Important Medical Questions

Brian F. Wiseman, MD Neurologist and medical director of the Stroke Center

Q: WHAT IS A STROKE? Q: WHO IS AT RISK FOR STROKE? A: S troke is a disease that affects the arteries leading to and within the A: A mong those with risk factors are: brain. It’s the No. 4 cause of death and a leading cause of disability in the United States.

A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain either ruptures or gets blocked. This prevents part of the brain from receiving the blood flow it needs and causes brain cells to die. A blocked blood vessel produces an ischemic stroke, a ruptured blood vessel a hemorrhagic stroke.

“Transient ischemic attack,” or TIA, refers to temporary stroke symptoms, again caused by disrupted blood flow to the brain. It’s important to take TIAs seriously—if a person is having one, the conditions for stroke are present.

Q: HOW IS A STROKE TREATED? A: I f you’re having a stroke, it’s critically important to get treatment at a

stroke center right away. Calling 911 at the first sign of stroke is the best way to ensure rapid evaluation and treatment at a stroke center.

Early treatment can minimize disability and prevent risk of death from stroke.

Treatment for a stroke depends on whether it is ischemic or hemorrhagic. Treatment for an ischemic stroke may include medicines such as t-PA and medical procedures. T-PA can break up blood clots in arteries of the brain that are causing the stroke.

A hemorrhagic stroke occurs if an artery in the brain leaks blood or ruptures (breaks open). The first steps in treating a hemorrhagic stroke are to find the cause of bleeding in the brain and then control it. Unlike ischemic strokes, hemorrhagic strokes aren’t treated with antiplatelet medicines (t-PA) and blood thinners. This is because these medicines can make bleeding worse. Other medicines can be administered to help the bleeding, but surgery may also be needed to treat a hemorrhagic stroke. The types of surgery used include aneurysm clipping, coil embolization and arteriovenous malformation repair.

Stroke team doctors will work together to determine which option is best.

– People with high blood pressure, high cholesterol, diabetes, heart disease or other blood-vessel diseases – People with atrial fibrillation and heart failure – People with a history of smoking – People with diseases that cause their blood to clot more readily – People who have had a stroke or TIA in the past – People who are obese – People over 55 (but keep in mind that stroke can happen to younger people too) – Men more commonly than women (but women are more likely to die of a stroke) – People with a family history of stroke in a parent, grandparent, sister or brother – African-Americans (who face a higher risk of dying of stroke) Speak with your primary care physician if you have questions related to your health. If you need a primary care physician, call 865-305-6970.

Here are some additional questions you might want to ask your doctor: • What are my chances of having a stroke if I’ve had a transient ischemic attack?

• Do the medications I’m taking increase my risk of having a stroke?

• Do my cholesterol levels put me at risk of stroke?

• Is my weight within the healthy range, decreasing my risk of stroke?

• What dietary choices should I be making to reduce my risk of stroke?

Visit UTMEDICALCENTER.ORG for more information.

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Fall 2013

Continuing Education

Course Calendar

The University of Tennessee Graduate School of Medicine offers these educational courses this fall for physicians, researchers, allied health providers and other healthcare professionals seeking continuing education.

September 27-28 September 27-28 September 30Approved for AMA and AAPA Approved for AMA, AAPA and ACPE October 4 credits and CEUs credits and CEUs Heart, Lung, Vascular Update for Primary Care Providers University of Tennessee Conference Center Knoxville, Tennessee www.tennessee.edu/cme Using case-based examples, the Heart, Lung, Vascular Update for Primary Care Providers will provide direct contact with individuals focusing on these health-related issues and subsequently offer guidance on treatment outcomes for patients in the areas of COPD, hypertension, aortic emergencies and the effective use of social media.

Lean for Healthcare Haslam Business Building University of Tennessee Knoxville, Tennessee www.tennessee.edu/cme This course uses the concept of lean processes, traditionally practiced in the manufacturing industry but applied now to improving efficiencies and eliminating waste in healthcare. It is appropriate for healthcare professionals, including physicians, nurses, pharmacists and others, as well as healthcare executives and those who impact medical and financial decisions in organizations.

Approved for AMA and AAPA credits and CEUs Lean for Scheduled Healthcare Haslam Business Building University of Tennessee Knoxville, Tennessee www.tennessee.edu/cme

This course addresses the lean components taught in the Lean for Healthcare course, coupled with a program designed to address the complex problems encountered in healthcare delivery within a scheduled setting (for example a clinic).

To register or for more information about these courses, visit our website at www.tennessee.edu/cme.

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Discovery

GOLD the

standard

The Role of Pharmacists in the Management of Acute Ischemic Stroke

By Leslie Hamilton, PharmD

Prior to 1995, the only treatment available for patients who suffered an ischemic stroke was supportive; patient outcomes were mixed, and there was no standard of care from one hospital to the next.

Then, following a clinical trial coordinated by the National Institute of Neurological Disorders and Stroke, administering t-PA within three hours of symptom onset became the gold standard for treating acute ischemic stroke.

This trial marked the beginning of the era of acute-stroke intervention instead of passive observation.

Shaun Rowe, PharmD, neuropharmacist prepares a dose of t-PA for an eligible stroke patient in the emergency room.

W

hen an ischemic stroke happens, the brain is deprived of vital oxygen and nutrients. After only a few seconds, brain cells begin to die. During an ischemic stroke, brain cells die at the rate of 1.9 million per minute. There is no medication or treatment to “revive” dead brain cells, so efficient, effective treatment for ischemic stroke is a critical component of a Comprehensive Stroke Center.

The only FDA-approved treatment for ischemic stroke is tissue plasminogen activator (t-PA), also known as alteplase.

This medication works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood.

If administered within three hours (and up to 4.5 hours in certain eligible patients), t-PA may improve a person’s chances of recovering from a stroke. A significant number of stroke victims don’t get to the hospital in time for t-PA treatment, underlining the importance of immediately identifying a stroke.

Ongoing research on t-PA helps doctors continue to develop safer procedures and more effective treatment. Research studies also help expand the use of this treatment to patients with other conditions caused by blood clots.

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“The medical center is involved in one retrospective trial that looks at thromboelastographic (TEG) monitoring of hemostasis in ischemic stroke patients. We look at patients who have had an ischemic stroke and look at their hemostasis profiles with TEG. We’re comparing the TEG results of ischemic stroke patients who qualify for t-PA versus those patients who don’t qualify,” says Russ Langdon, MD, primary investigator on the TEG study.

For patients arriving at The University of Tennessee Medical Center’s Emergency Department with stroke symptoms, Code Stroke is called to mobilize the stroke team and the resources necessary to diagnose and treat stroke rapidly and efficiently.

The team includes clinical pharmacists who respond to each and every Code Stroke. Stroke team pharmacists work with Emergency Department physicians, stroke nurse practitioners and neurologists to assess the risk versus benefit of t-PA for stroke patients. Stroke team pharmacists take t-PA to the patient and mix it right there to eliminate any wasted time traveling to and from the Pharmacy Department.

Ongoing research on t-PA helps doctors continue to develop safer procedures and more effective treatment. Research studies also help expand the use of this treatment to patients with other conditions caused by blood clots.

Russ Langdon, MD; Douglas Jentilet, MD, an emergency medicine physician; and the stroke nurse practitioner, Debbie Coggins, MSN, FNP-BC, CNRN, check a patient’s symptoms for stroke.

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Because t-PA breaks clots apart, one of the possible adverse effects is bleeding. A stroke patient’s risk for bleeding must be assessed before a decision to give t-PA is made. This assessment involves obtaining a complete medical history that includes all medications and evaluating lab tests such as blood cell and platelet counts, the amount of time it takes for the patient’s blood to clot, and any existing problems with bleeding or recent strokes. Another important piece of information is when the person experiencing stroke was last known to be normal. If the history and last-known-normal information are gathered quickly, t-PA can be premixed while the CT scan and lab test results are interpreted. It takes about seven minutes for t-PA to be mixed and ready to give—and seven minutes equals 13.3 million brain cells. Once the results of the tests are known and eligibility for t-PA can established, premixed t-PA is ready to administer.

The only FDA-approved treatment for ischemic stroke is tissue plasminogen activator (t-PA), also known as alteplase. This medication works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood.

Shaun Rowe, PharmD, the investigator on the premixing study, will examine how premixing of t-PA by the stroke team pharmacist impacts treatment times. This study will involve a retrospective review of Code Stroke events in which patients received t-PA after premixing along with a comparison with those who received t-PA without premixing to determine whether premixing positively impacts door-to-treatment times and patient outcomes.

The stroke team evaluates every single Code Stroke in a weekly team meeting, identifying any possible opportunities to shave minutes off our stroke response times. Each step of the process is logged and performance is measured over time to ensure improvement in the process. Strategies identified by this in-depth analysis include the premixing of intravenous t-PA, based on assessment-specific criteria. The results of the trial will be used to improve the t-PA process during Code Strokes and will benefit patients at the medical center by allowing them to more quickly receive the drug.

Visit UTMEDICALCENTER.ORG for more information.

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80% of strokes can be prevented. Some stroke risk factors cannot be controlled, such as age, family history and ethnicity. But you can reduce your chances of having a stroke by assessing your risk with your primary care physician.

Stroke kills almost 130,000 Americans each year. That’s one in every 19 deaths.

EVERY YEAR MORE THAN 795,000 PEOPLE IN THE UNITED STATES HAVE A STROKE. ABOUT 610,000 OF THEM RECOGNIZE SUDDEN NUMBNESS ON ONE SIDE AS A SYMPTOM.

For every 10 years after the age of 55, the risk of stroke doubles. Two-thirds of all strokes occur in people over 65 years of age.

STROKE

BY THE NUMBERS FACTS 93% of people surveyed, recognized sudden numbness on one side as a symptom of stroke. Only 38% were aware of all the major symptoms and knew to call 911 when someone was having a stroke.

Stroke costs the nation $73.7 billion annually, including the cost of healthcare services, medications and lost productivity.

60% 40% About 40% of stroke deaths occur in males, 60% in females.

High blood pressure, high LDL cholesterol and smoking are key risk factors for stroke. About half of Americans (49%) have at least one of these risk factors.

Someone in the United States has a stroke every 40 seconds.

Every four minutes someone dies of stroke.

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Stroke Symposium

Managing the Complex Stroke Patient

By Jennifer Henry, RN

O

n May 7, 2013, the fifth annual Stroke Symposium: “Managing the Complex Stroke Patient,” was held at the UT Conference Center in downtown Knoxville.

Presentations by regional, state and national experts expounded upon the administration of thrombolytics for acute ischemic stroke, guidelines for hemorrhagic stroke and care across the continuum for these critically ill cerebrovascular patients.

Brian Wiseman, MD, medical director of the Comprehensive Stroke Center at The University of Tennessee Medical Center, serves as course director of the annual symposium. Each year the agenda is developed based on state, regional and national quality and performance data, participant feedback, and emphasis on new evidence or guidelines.

Russ Langdon, MD, serves as associate professor with UT Graduate School of Medicine’s Department of Anesthesiology and director of neurocritical care at the medical center.

During his presentation, titled “Hemorrhagic Stroke Update,” Langdon said, “In the setting of hemorrhagic stroke, time is as critical as in ischemic stroke. Rapid recognition and delivery to a stroke center with neuro ICU capability is critical.”

What was once a response to the challenges faced by a Comprehensive Stroke Center has turned into a self-imposed mandate to offer up-to-date and evidence-based information to the region’s medical providers.

Later he said, “To reduce risk for hemorrhagic stroke, be sure to eat your vegetables (eating a diet low in fat, low in salt, with a variety of colorful vegetables), control your blood pressure, and stop smoking. Patients should be educated in ways to reduce their risk for stroke.” One participant expressed an intention to “increase patient education,” based on the information from Langdon’s presentation. Another resolved to obtain a “better understanding of a patient’s medical history.”

What was once a response to the challenges faced by a Comprehensive Stroke Center has turned into a self-imposed mandate to offer up-to-date and evidence-based information to the region’s medical providers.

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BEST HOSPITAL IN KNOXVILLE. AGAIN.

RATED HIGH-PERFORMING IN 11 SPECIALTIES • Cancer • Cardiology and Heart Surgery • Diabetes and Endocrinology • Ear, Nose and Throat • Gastroenterology and GI Surgery • Geriatrics

Our Mission

To serve through healing, education and discovery

• Gynecology • Nephrology • Orthopedics • Pulmonology • Urology

1-877-UTCARES utmedicalcenter.org Summer 2013 - 27

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U.S. POSTAGE

PAID

Permit No. 575 Knoxville, TN

1924 Alcoa Highway Knoxville, Tennessee 37920-6999 www.utmedicalcenter.org

OUR JOURNEY TO EXCELLENCE IS NEVER-ENDING.

The Magnet Recognition Program速, ANCC Magnet Recognition速, Magnet速 names and logos are registered trademarks of the American Nurses Credentialing Center. Journey to Magnet ExcellenceTM and National Magnet Conference速 are trademarks of the American Nurses Credentialing Center. All rights reserved. The American Heart Association/American Stroke Association recognizes this hospital for achieving at least 24 months of 85% or higher adherence on all applicable achievement measures and at least 75% or higher adherence on select quality measures in heart failure and stroke.

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