TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Recommendations Guide (updated January 23, 2014)

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1 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) Objective: To enhance system-wide performance and outcomes for persons with stroke in Toronto. Goals: Timely access to geographically located acute stroke unit care with a dedicated interprofessional team Earlier access to high intensity rehab Increase access to high intensity rehab for severe strokes Enhance outpatient rehab programs with timely access from acute care post mild stroke Improved functional outcomes Desired State: The literature stipulates that organized acute stroke care 1 and early access to intense rehabilitation improves patient outcomes. The desired state is described as: All acute stroke patients admitted to a stroke unit 40% of total stroke patients discharged from acute care to inpatient rehab with the admission to rehab day 5 for ischemic stroke and day 7 for hemorrhagic strokes System wide admissions to inpatient rehab by stroke severity (9% mild, 49.5% moderate, 41.5% severe at admission) and length of stay targets based on rehab patient group (RPG) 3 hours minimum therapy time/patient/day in rehab with direct to indirect staff to therapy ratio 80:20 Minimum 10 rehab beds per organization 7 day/week admissions and therapy/activity Patient transfers (inter and intra organizational) are minimised, if at all, once admitted Target admission to outpatient from acute within 2 weeks post stroke Referral as necessary to CCAC for early supported discharge from acute care Purpose of this document: The Toronto Stroke Networks have developed this document to assist organizations with prioritization and implementation of best practice to create a common standard of care across the system. This includes a summary of the key best practices, administrative and clinical processes required to meet these recommendations, and core and suggested process indicators. As the Quality-Based Procedures: Handbook for Stroke (HQO & MOHLTC, released January 2013) provides required best practice care procedures for all admitted acute stroke patients as part of the new funding model under the Health Services Funding Reform initiative, this best practice guide has been updated to reflect these procedures. To support successful uptake of best practice, a knowledge translation (KT) strategy has been developed to achieve: Professional development to enhance practice utilizing a combination of evidence-based KT education strategies Inter-professional collaborative team development for better patient outcomes Evaluation framework for monitoring and reporting Evaluation framework for monitoring and reporting Updated January 23, 2014 Page 1 of 8

2 STROKE UNIT REHAB Post acute stroke care should be delivered in a setting in which rehabilitation care is formally coordinated and organized. 4 All persons with stroke should be referred to a specialized rehabilitation team on a geographically defined unit. 5 Persons with moderate or severe stroke who have rehabilitation potential and rehabilitation goals should be given an opportunity to participate in inpatient stroke rehabilitation. 6 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) A specialized, geographically defined rehabilitation unit dedicated to the rehabilitation of persons with stroke. 7 Persons with stroke should move to the stroke rehabilitation unit as soon as possible, ideally within 5 days of stroke onset (note: hemorrhagic strokes may require more time in acute care before transfer to rehab). 8 Procedures should enable admission 7 days/week (OSN Stroke Reference Group) System-wide percent of rehab admissions by rehabilitation patient group (RPG):9% mild, 49.5% moderate, 41.5% severe; with target LOS by RPG Stroke Severity RPG Severe Moderate Mild Target LOS /Activities The goal of the stroke rehabilitation unit is to maximize potential recovery so that persons with stroke may be able to function at the highest physical and mental ability they can achieve post stoke. 9 Based on current literature, it is recommended that stroke rehabilitation units have a minimum of 10 beds to support a dedicated complement of nursing and allied healthcare professions (such as OT, PT, S- LP, and SW). 10 (year 1) Comprehensive, evidence-based written protocols, order sets and care pathways/algorithms should be in place to guide stroke rehabilitation. 11 (year 1) Protocols and strategies to prevent complications (e.g. falls, DVT, pneumonia, etc.) and the recurrence of stroke developed and communicated to all staff. 12 (year 2) to manage re-admissions to acute care. (year 2) Proportion of persons with mild, moderate and severe stroke (by RPG) admitted directly from an acute care unit to a high intensity stroke rehabilitation unit (core). Number of persons with stroke treated in a geographically defined stroke rehabilitation unit at any time during their inpatient rehabilitation phase following an acute stroke event (core). Final discharge disposition for persons with stroke following inpatient rehabilitation: o Percentage discharged home o Percentage discharged to a long-term care facility o Percentage requiring readmission to an acute care hospital for stroke-related causes (core). Median length of time between stroke onset and admission to stroke inpatient rehabilitation. Average LOS in inpatient rehabilitation, by stroke severity (RPGs). STAFFING MIX The interprofessional rehabilitation team should consist of a physician, nurse, physical therapist, occupational therapist, speech-language pathologist, social worker, Services are provided by a dedicated interprofessional team with expertise in stroke rehabilitation. 14 Stroke rehabilitation units adequately staffed with healthcare providers with expertise in Stroke unit teams should conduct at least one System and process changes to allow therapists Healthcare providers (by formal interprofessional meeting per week 17 to to spend approximately 80 percent of their time profession OT, PT, S-LP, and SW) identify rehabilitation challenges, to set rehab with persons with stroke 18 to support the to person with stroke ratio. goals, to monitor progress, discuss discharge appropriate intensity of rehab (see section on plans and to support persons with stroke Assessment and Management). (year 2) during and after their inpatient stay. Minimum allied health staffing (6bed unit) Updated January 23, 2014 Page 2 of 8

3 psychologist, recreation therapist, and persons with stroke, their families and/or caregivers. 13 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) stroke rehabilitation. 15 Post acute stroke care should be delivered by a variety of treatment disciplines, experienced in providing post-stroke care, to ensure consistency and to reduce the risk of complications. 16 /Activities 1FTE OT 1 FTE PT S-LP 1:12 (year 1) (OSN Stroke Reference Group) ASSESSMENT AND MANAGEMENT The interprofessional rehabilitation team should assess persons with stroke within 24 to 48 hours of admission and develop a comprehensive individualized rehabilitation plan, which reflects stroke severity and the needs and goals of persons with stroke. 19 Ensure staff have access to training of standardized, valid assessment or screening tools. Shared decision-making and goal setting should involve the interprofessional team, persons with stroke and their families/caregivers. The care management plan should include: o A pre-discharge needs assessment to ensure a smooth transition to the community. o A home visit by a healthcare professional (ideally before discharge) to assess home environment and suitability for safe discharge. o Assessment of equipment needs and home modifications. o Caregiver training on how a person with stroke will manage activities of daily living and instrumental activities of daily living in his/her environment. 20 Healthcare providers to maintain credentialing and competency on standardized assessment tools. These include: MOCA, FIM Instrument, Berg Balance Scale and Chedoke McMaster Stroke Assessment. (year 2) Protocols and processes in place to guide stroke rehabilitation care., protocols, and resources for assessing equipment needs and conducting home assessments by interprofessional team members soon after the stroke. Proportion of persons with stroke who have rehab goals established within 48 hours. Healthcare providers should use standardized, valid assessment tools when evaluating stroke-related impairments and functional status (Appendix B). The FIM Instrument should be used as a standardized assessment tool (OSN Stroke Reference Group) Patients who fail a swallowing screen or present with features indicating dysphagia or aspiration should receive a full clinical assessment of their swallowing ability by an S-LP. 21 Updated January 23, 2014 Page 3 of 8

4 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) /Activities All patients with stroke should be screened using a validated tool to determine if they have a history of or risk factors for depression. Patients identified as being at risk of depression during screening should be referred to a health care professional with expertise in diagnosis and management of depression in stroke. 22 All patients with stroke should be screened at admission for risk of falls by an experience clinician. This screening should include comprehensive interprefessional assessment of medical functional history and examination of mobility, vision, perception, cognition, and cardiovasulcar status. Based on assessment, an individualized fall-prevention strategy should be implemented. 23 All stroke patients with vascular risk factors should be considered at high risk of vascular cognitive impairment and should be assessed for screened for cognitive impairment using the Montreal Cognitive Assessment. Patients with identified cognitive impairments should receive additional cognitive or neuropsychological assessments to guide management. 24 Persons with stroke should receive, through an individualized treatment plan, a minimum of three hours of direct task-specific therapy by the interprofessional stroke team for a minimum of six (OSN Stroke Reference Group) days per week. 25 Resources and processes to enable persons with stroke to access the appropriate type and intensity of rehabilitation services throughout their stay, including weekends when required 26 (i.e. while ensuring flexibility in scheduling persons with stroke, the ratio for direct to indirect therapy time should be 80:20). All patients with should begin rehabilitation therapy within an active and complex stimulating environment. 27 Therapy should include repetitive and intense use of novel tasks that use the involved limb during functional tasks and activities. 28 The team should promote the practice of skills gained in therapy into the daily routine Ratio for direct to indirect therapy time should be 80:20. (year 1) Staffing ratios should support, at minimum, the amount of therapy recommended. 31 (year 1) Protocols and strategies to prevent complications and the recurrence of stroke developed and communicated to all staff. 32 (year 2) Change in functional status scores (FIM Instrument) from inpatient rehabilitation admission to discharge. Average hours per day of direct therapy provided by the interprofessional stroke team. Average days per week of direct therapy provided by the Updated January 23, 2014 Page 4 of 8

5 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) /Activities for persons with stroke. 29 Therapy to promote motor and physical recovery should be provided according to the best practice recommendations i.e. SCORE recommendations for upper and lower limb post-stroke management 30 (Appendix A). interprofessional stroke team. TRANSITIONS To support transitions between care environments, persons with stroke and their families/caregivers should be provided with information, education, training, emotional support and community services specific to the transition they are undergoing. 33 Healthcare providers to take responsibility for person-centred continuity of care as persons with stroke (and their families/caregivers) transition to the next point of care. This can be achieved through: Better understanding of the system as a whole (Transition Improvement for Continuity of Care (TICC) 34 ) Strengthening relationships with other areas of the care continuum. Creating an infrastructure to communicate with other healthcare providers (e.g. TICC My Stroke Passport and Knowing Each Other s Work). Ensuring support for persons with stroke and their families/caregivers (e.g. TICC Peers Fostering Hope). Support for persons with stroke and their families/caregivers during transitions also include 35 : Written discharge instructions. Access to a contact person in the hospital or community (designated case manager or system navigator) for post-discharge queries. Access to and advice from health and social service organizations (e.g. through single points of access to all organizations). Referrals to community agencies such as peer support groups or peer survivor visiting programs (TICC Peers Fostering Hope). Established process for transferring patientrelated information. This includes an up-to-date care plan for persons with stroke and their families/caregivers, which defines ongoing medical, rehabilitation, psychosocial and functional needs in a culturally appropriate format. 36 (year 2) Patient-mediated communication tool (TICC My Stroke Passport) (year 3-5). Healthcare provider framework for clinical handover (TICC Knowing Each Other s Work) (year 3-5). Healthcare provider conversation resource (CR Trigger tool). 37 (year 3-5) Proportion of persons with stroke that have utilized the TICC Stroke Passport. Patient and family satisfaction (NRC-Picker). Conversation/self-management resources established for persons with stroke and their families/caregivers (e.g. CR CATT). 38 (year 3-5) Discharge planning Discharge plans should be initiated as soon as possible after the person with stroke is admitted to hospital. 39 Effective discharge planning is essential for smooth transitions through the continuum of stroke care. Delayed or incomplete planning leads to prolonged hospital stays and an increased risk of adverse events following discharge. A process should be established to ensure that persons with stroke and their families/caregivers are involved in the development of their care plan, which includes transition management. Discharge planning discussions should be Protocols and pathways for stroke care along the continuum that address discharge planning. (year 1) Strong relationships among healthcare providers to facilitate safe and timely transitions. (year 3-5) Percentage of persons with stroke discharged to the community who receive a referral for ongoing rehab before discharge from hospital (core). Proportion of persons by stroke Updated January 23, 2014 Page 5 of 8

6 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) Persons with stroke, families/caregivers and healthcare providers involved in each phase of care should all be involved in discharge planning to ensure effective and safe transitions. /Activities ongoing throughout hospitalization. Information about discharge issues and possible needs of persons with stroke following discharge should be provided soon after admission. Discharge planning activities should include interprofessional team meetings with persons with stroke and their families/caregivers, discharge and transition care plans, a pre-discharge needs assessment, and caregiver training. The CISCCoR Trigger tool could be used to support family and interprofessional team meetings. 40 Team to initiate referral to outpatient/community-based rehab as appropriate (E-Stroke Rehab Referral System). Access to self-management, caregiver training and appropriate support services to ensure a smooth transition. (year 3-5) Mechanisms should be in place to allow initiation of rehab referral from inpatients to outpatient/community-based rehab as appropriate. (year 2) Written discharge instructions for persons with stroke, their families/caregivers and their primary care providers should include: action plans, follow-up care and goals, significant interventions, prevention of complications, medications at discharge, plans for follow-up, functional abilities of the at time of transfer, and the delineation of respective roles and responsibilities of caregivers. severity (RPG) with stroke discharged to each disposition: o Home with services o Home without services o Outpatient/ambulatory care o Long term care Early Supported Discharge Persons with strokes should continue to have access to specialized stroke services after leaving the hospital, whether from acute care or inpatient rehabilitation. 41 Early supported discharge services provided by a well-resourced, coordinated, specialized interprofessional team can be utilized to decrease the length of stay on an inpatient rehabilitation stroke unit for select persons with stroke. Services could be home-based or ambulatory, but should maintain sufficient intensity of therapy to optimize outcomes and timely return to the community. Refer to Discharge Planning /Activities - see above. An established process or decision-making tool to delineate who would benefit most from early supported discharge (see for criteria). Protocols and processes for stroke care along the continuum that include early supported discharge and discharge planning throughout the stages of care. Proportion of persons with stroke who have participated in early supported discharge. Persons with mild to moderate disability may be offered early supported discharge if the following criteria are met: o They have access to an inhome/interprofessional community rehabilitation program, comprehensive caregiver training and/or support services from the date of transfer. o They can manage safely at home. Strong relationships among healthcare providers to facilitate safe and timely transitions. This could include enhanced coordination of services and communication with both inpatient rehabilitation and community providers., protocols, and resources for conducting home assessments by interprofessional team members soon after Updated January 23, 2014 Page 6 of 8

7 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) Early supported discharge should not be offered to persons with moderate to severe stroke. /Activities the stroke. Access to appropriate education on selfmanagement, caregiver training and support services to ensure a smooth transition. (year 3-5) EDUCATION FOR PERSONS WITH STROKE AND THEIR FAMILIES/CAREGIVERS Education should include information sharing, teaching self-management skills and caregiver training. 42 Specific team members should be designated to provide and document education. 43 A process is in place to coordinate education for persons with stroke and their families/caregivers, which may include a designated lead. Education should be provided to persons with stroke and their families/caregivers and should be specific to the phase of recovery and appropriate to their readiness to receive education and needs. Education should cover all aspects of care and recovery. 44 Education should be interactive, timely, upto-date, provided in a variety of languages and formats (written, oral, aphasia friendly, group counselling approach), and specific to the needs and goals of persons with stroke and their families/caregivers. 45 Education that is specific, relevant, and meaningful to support achievement of personcentred goals. Consideration should be given to all domains of community re-engagement (health management, mobility, environment, communication, life roles, caregiver support, social network and financial). 46 (year 3-5) Proportion of persons with stroke with documentation of education (core). Patient and family satisfaction (NRC Picker). 1 Stroke Unit Trialists Collaboration Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. Cochrane Database Systematic Review.; Langhorne P, Dey P, Woodman M, Kalra L, Wood-Dauphinee S, Patel N Hamrin E Is stroke unit care portable? A systematic review of the clinical trials. Age Ageing. Jul;34(4): Timeline relates to implementation of required elements to meet the recommendations. 3 Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Ibid. Recommendation Ibid. Recommendation Ibid. Recommendation Canadian Stroke System. A Guide to the Implementation of Stroke Unit Care, 2009, p.9. 8 Ibid. 9 Saskatchewan Stroke Program, Definition of a Stroke Rehabilitation Program, Canadian Stroke System. A Guide to the Implementation of Stroke Unit Care 2009, p Ibid. p Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation 5.2 (System Implications). 13 Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation Teasell R, Foley N, Salter K, Bhogal SK, Jutai J and Speechley M. (2010). Evidence-based review of stroke rehabilitation, 13 h Edition. 15 Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update (System Implications). 16 Ibid. Recommendation Ibid. Recommendation Ibid. Recommendation 5.2 (System Implications). 19 Ibid. Recommendation Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation Ibid. Recommendation Ibid. Recommendation Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation 7.5 Updated January 23, 2014 Page 7 of 8

8 TORONTO STROKE FLOW INITIATIVE - Inpatient Rehabilitation Best Practice Guide (updated January 23, 2014) 24 Ibid. Recommendation Ibid. Recommendation Ibid. Recommendation 5.2 (System Implications). 27 Ibid. Recommendation Ibid. Recommendation Ibid. Recommendation Ibid. 5.4 and Ibid. Recommendation Ibid. Recommendation 5.2 (System Implications). 33 Ibid. Recommendation Transition Improvement for Continuity of Care, Toronto Stroke Networks. TICC consists of 3 components: Knowing Each Other s Work, My Stroke Passport, and Peers Fostering Hope. 35 Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation Ibid. Recommendation CISCCoR Trigger Tool, 2010, developed by South East Toronto Stroke Network and Toronto West Stroke Network. 38 Community Re-Engagement Cue to Action Trigger Tool, developed by South East Toronto Stroke Network & Toronto West Stroke Network. 39 Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation CISCCoR Trigger Tool, 2010,developed by South East Toronto Stroke Network and Toronto West Stroke Network. 41 Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update Recommendation Canadian Stroke Strategy, Canadian Best Practice for Stroke Care Update See Recommendation Ibid. 44 Ibid. 45 Ibid. 46 CISCCoR Trigger Tool, 2010,developed by South East Toronto Stroke Network and Toronto West Stroke Network. Updated January 23, 2014 Page 8 of 8

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