REMINDER: Please ensure all stroke and TIA patients admitted to hospital are designated as "Stroke Service" in Cerner.

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Lindsay McDaniel
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1 ACUTE STROKE CLINICAL PATHWAY QEH/HH PCH KCMH Souris Western Stewart Memorial O'Leary PATIENT ID INCLUSION CRITERIA* All patients admitted to hosptial with a suspected diagnosis of acute ischemic stroke (AIS), non-surgical intracerebral hemorrhage (ICH), post surgical/medical managed subarachnoid hemorrhage, transient ischemic attack (TIA) or venous sinus thrombosis. Patients with co-morbid diagnoses where care is focused on non-stroke illness will initially be managed outside the Acute Stroke Clinical Pathway. When appropriate, the patient will be transfered to the Acute Stroke Clinical Pathway. REMINDER: Please ensure all stroke and TIA patients admitted to hospital are designated as "Stroke Service" in Cerner. EXCLUSION CRITERIA Patients with significant complications where care is focused on their non-stroke illness Patients who are palliative, due to the severity of stroke, are generally not included. Patients who do not have an acute stroke or TIA. If patient is excluded please state reason: TRANSFERS TO THE PROVINCIAL ACUTE STROKE UNIT * Transfers to the Provincial Acute Stroke Unit (PSU) should be considered high priority as per the Canadian Best Practice Recommendations for Stroke Care. Process is as follows: Contact QEH Admitting for bed availability Referring physician then contacts hosptialist/ GP for possible to PSU Referring physician writes orders * The final decision to admit to the Provinicial Acute Stroke Unit will be the responsibility of the attending physcian Canadian Best Practice Recommendations for Stroke Care (update 2010): DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

Patients with co-morbid diagnoses where care is focused on non-stroke illness will initially be managed outside the Acute Stroke Clinical Pathway.

2 HOW TO USE THE CLINICAL PATHWAY 1. This is a proactive tool to facilitate communication and coordination of patient care based on evidence informed practice. The clinical pathway is designed to promote timely treatment, enhance quality of care, optimize patient outcomes and support effective transition/discharge planning. These are not orders, only a guide to usual orders. 2. Place the Clinical Pathway in the front of the chart. Attach label sticker to each page of the Pathway. All health care professionals should fill in the Master Signature Sheet at the front of the Pathway. 3. Check off appropriate boxes and indicate any appropriate reasons why task not met. 4. TRANSFER PATIENTS: If patient is transferred to another facility in Prince Edward Island or to Home Care, send a copy of the following to the receiving site/agency: Discharge Summary MAR Sheet Anticoagulant Record Teaching Checklist Caregiver Checklist DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

These are not orders, only a guide to usual orders. 2. Place the Clinical Pathway in the front of the chart. Attach label sticker to each page of the Pathway.

3 NAME (Please Print) INITIAL SIGNATURE TITLE DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

4 TRANSITION MEASURES ACUTE STROKE CLINICAL PATHWAY PATIENT ID Patient transferred to Provincial Acute Stroke Unit If yes: within 3 hrs of hospital arrival for non thrombolytic patients If no: please indicate reason: PROCESS ASSESSMENT (OBSERVATIONS/ MEASUREMENTS) Date: Vital signs, including Sp02 and Glasgow Coma Scale with pupils Non- Thrombolytic Patient: q4hrs x 48hrs Thrombolytic Patient: q15min x 2hrs; q30min x 6hrs; q1hr x 4hrs; q2hrs x 12hrs After 48 hrs every shift or as per unit protocol Temp q4h x 24hrs, and then as appropriate; treat temps >37.5 Celsius Chest assessment daily Pain assessment daily Monitor intake/ output q shift Braden risk assessment initially, and then weekly Conly falls risk assessment initially, and then weekly TLR assessment initially, and then weekly Advance directives considered, discussed and documented by Physician If not, why not Canadian Neurological Scale (CNS) first 48 hours Non Thrombolytic Patient: q4 hrs x 48hrs Thrombolytic Patient: q2 hrs x 24hrs; q4hrs x 24hrs Toronto Bedside Swallowing Screening Test (Tor-BSST) Initial: Venous thromboembolism (VTE) assessment Oral Care assessment CRITICAL and ACUTE PHASE Date/Initial Screened for bladder incontinence and/or retention (with or without overflow) Screened for bowel incontinenence and/or constipation (time and frequency) Nutritional and hydration status screened within 48 hrs of Alpha FIM assessment within 72 hours Hospital Anxiety Depression Screen (HADS) DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

q15min x 2hrs; q30min x 6hrs; q1hr x 4hrs; q2hrs x 12hrs After 48 hrs every shift or as per unit protocol Temp q4h x 24hrs, and then as appropriate; treat temps >37.

5 PROCESS CRITICAL and ACUTE PHASE cont. Neurology assessment within 48 hrs of hospital If not, why not Date/Initial CONSULTS Physiotherapy initial assessment within 48 hrs of hospital Occupational Therapy initial assessment within 48 hrs of hospital Speech Language Pathology initial assessment within 48 hrs of hospital Dietitian initial assessment within 48 hrs of hospital Social Worker initial assessment within 48 hrs of hospital DIAGNOSTICS/ LABORATORY MEDICATIONS Thrombolytic patient: 24 hr post thrombolytic CT scan of head Chest x-ray if ordered Blood work (CBC, electrolytes, creatinine, urea, glucose, A1c, INR, PTT, TSH, fasting lipid profile, CK, tropin test Carotid imaging unless clearly not a candidate for revascularization If yes: within 24 hours of hospital arrival Echocardiogram if ordered O2 if needed IV as ordered VTE guidelines initiated Medication history if not already completed Oral Care guidelines initiated TREATMENTS/ INTERVENTIONS Bladder Management guidelines initiated Indwelling catheter was not used Bowel Management guidelines initiated DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

of hospital Speech Language Pathology initial assessment within 48 hrs of hospital Dietitian initial assessment within 48 hrs of hospital Social Worker initial assessment within 48 hrs of hospital

6 PROCESS CRITICAL and ACUTE PHASE cont. Positioning recommendations provided: Bed Chair If not, why not Date/Initial Communication recommendations and/or device provided: Dysphagia recommendations provided TREATMENTS/ INTERVENTIONS cont. Range of Motion recommendations provided U/E L/E Functional mobility and Transfer training initiated Fall Prevention and Management Program initiated Activity of Daily Living training initiated Thrombolytic Patient: bed rest Non -Thrombolytic Patient: activity as tolerated Maintain proper body alignment using positioning techniques Bed Chair Raise head of bed to degrees Non-thrombolytic patient mobilized within 24 hrs of stroke MOBILITY/ACTIVITY symptom onset Please refer to best practice guideline 4.23 for contraindications to mobilization. Blood pressure, oxygen saturation and heart rate monitored prior to mobilization for the first 3 days following Patient NPO until dysphagia screening completed NUTRITION Therapeutic diet recommendations provided PSYCHOSOCIAL SUPPORT/ EDUCATION Orientation to unit and procedures Review visiting guidelines Introduce patient pathway Give patient education materials, including "Let's Talk About Stroke" booklet Encourage patient and caregiver (s) to ask questions Teaching checklist initiated TRANSITION PLANNING Assess readiness for rehabilitation on Day 4 Assess transition criteria daily DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

Range of Motion recommendations provided U/E L/E Functional mobility and Transfer training initiated Fall Prevention and Management Program initiated Activity of Daily Living training initiated

7 ACUTE STROKE CLINICAL PATHWAY QEH/HH PCH KCMH Souris Western Stewart Memorial O'Leary PATIENT ID TRANSITION MEASURES PROCESS ASSESSMENT (OBSERVATIONS/ MEASUREMENTS) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION TRANSITION PLANNING Transition destination: Home Stroke Rehab Unit Alternate Level of Care (ALC) Palliative Community Care Facility Long Term Care Facility Different Diagnosis Other: DATE TRANSITION CRITERIA MET Modified Rankin Scale: HADS: Score Alpha FIM: Meds explained to patient and caregiver(s) Secondary Stroke Prevention guidelines initiated, if appropriate Patient maintains adequate nutrition and appropriate hydration Diet education provided, if appropriate Discharge Score Admission score Discharge Score All consults completed/ arranged, as appropriate Secondary Stroke Prevention referal sent, if appropriate (include Teaching Record and Caregiver Record) If discharged to home: Follow up outpatient blood work arranged, if required Bowel and bladder routine initiated, if appropriate Patient safe in mobility and activities of daily living within functional ability and transition destination Equipment recommendations completed, if required Safety education provided for patient and family/caregiver(s), if appropriate Patient and caregiver(s) aware of transition management plan Patient and caregiver(s) aware of follow-up appointments Family physician aware of management plans Transfer checklist completed, if appropriate Referrals to community resources completed, if appropriate Driving status reviewed, if appropriate INITIAL DRAFT January 2011 Adapted from Grey Bruce Health Network Review Sept

Palliative Community Care Facility Long Term Care Facility Different Diagnosis Other: DATE TRANSITION CRITERIA MET Modified Rankin Scale: HADS: Score Alpha FIM: Meds explained to patient and

Hamilton Health Sciences Integrated Stroke Model of Care. Rhonda Whiteman, Stroke Best Practices Coordinator, Hamilton Health Sciences

Hamilton Health Sciences Integrated Stroke Model of Care Rhonda Whiteman, Stroke Best Practices Coordinator, Hamilton Health Sciences Integrated Stroke Model of Care Goals To provide a more comprehensive