Fourth Edition. Lindsay MP, Gubitz G, Bayley M, Phillips S (Editors), on Behalf of the Canadian Stroke Best Practices and Standards Working Group

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1 CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE Furth Editin Lindsay MP, Gubitz G, Bayley M, Phillips S (Editrs), n Behalf f the Canadian Strke Best Practices and Standards Wrking Grup CHAPTER 4 Acute Inpatient Strke Care (UPDATE May 2013) Casaubn LK, Suddes M (C-Chairs) n Behalf f the Acute Strke Best Practices Writing Grup 2013 Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 0 f 40

2 Table f Cntents Canadian Best Practice Recmmendatins fr Strke Care Acute Inpatient Strke Care Chapter ~ Furth Editin (Updated May 2013) Table f Cntents Tpic Page CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE - INTRODUCTION 2 CHAPTER 4: ACUTE INPATIENT STROKE CARE 3 Highlights f Acute Strke Care Update Definitins f Acute Strke Care 5 Canadian Strke Best Practices Framewrk fr Optimal Strke Services Delivery 6 Develpment f the CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE 7 ACUTE STROKE CARE BEST PRACTICES WRITING GROUP ACUTE STROKE CARE NEUROSURGERY SUB-GROUP ACUTE STROKE CARE PEDIATRIC STROKE SUB-GROUP ACUTE STROKE CARE YOUNG ADULT STROKE SUB-GROUP ACUTE STROKE CARE EXTERNAL REVIEWERS CANADIAN STROKE BEST PRACTICES AND STANDARDS ADVISORY COMMITTEE 11 CANADIAN BEST PRACTICE RECOMMENDATIONS FOR ACUTE INPATIENT STROKE CARE Strke Unit Care Inpatient Management and preventin f Cmplicatins Cardivascular Investigatins Venus Thrmbemblism Prphylaxis Temperature Management Mbilizatin Cntinence Nutritin and Dysphagia Oral Care Seizure Management 20 Table 4.2 Swallw Screening and Assessment Tls Palliative and End-f-Life Care Advanced Care Planning 37 Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 1 f 40

3 Overview CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE The Canadian Best Practice Recmmendatins fr Strke Care are intended t prvide upt-date evidence-based guidelines fr the preventin and management f strke. The gal f disseminating and implementing these recmmendatins is t reduce practice variatins in the care f strke patients acrss Canada, and t reduce the gap between knwledge and practice. Recmmendatins are updated n a rtating cycle every tw years t ensure they cntinue t reflect cntemprary strke research evidence and leading expert pinin. Each update invlves critical review f the current medical literature, which infrms decisins regarding mdificatin f the recmmendatins and the perfrmance measures used t assess their impact. Every attempt is made t crdinate with ther Canadian grups wh are develping guidelines that relate t strke, such as hypertensin, atrial fibrillatin and diabetes. As well, if significant new evidence becmes available in between update cycles, a prcess is in place t cnduct a mdified Delphi prcess t rigrusly review the new evidence and gain cnsensus n the impact f that evidence n current recmmendatins. Mdificatins that are required thrugh the cnsensus prcess will be made as sn as they are available, which is readily enabled thrugh the web-based frmat f the Canadian Strke Best Practices. This is the furth editin f the Canadian Best Practice Recmmendatins fr Strke Care, which was first released in The theme f the update is TAKING ACTION, and stresses the critical rle and respnsibility f healthcare prviders at every stage f the cntinuum f care t ensure that best practice recmmendatins are implemented and adhered t. TAKING ACTION will lead t ptimal utcmes fr each strke patient by prviding the best care within the mst apprpriate setting. This includes rapid and efficient access t diagnstic services, strke expertise and medical and surgical interventins, rehabilitatin and supprt fr nging recvery and cmmunity reintegratin. TAKING ACTION requires a cmmitted team apprach and strng crdinatin f care acrss regins and netwrks, with pre-hspital, acute care, rehabilitatin and cmmunity-based healthcare prviders wrking tgether t ensure ptimal utcmes fr patients and their families, regardless f gegraphic lcatin. TAKING ACTION als applies t patients wh have experienced a strke, their families and infrmal caregivers. Strke patients and their families need t actively participate in their recvery and penly cmmunicate with their healthcare team. Patients and families must participate in setting the gals they want t achieve during recvery frm a strke, and share cncerns, as well as physical, md and cgnitive issues with their team, which will lead t the care required fr ptimal recvery in all aspects f health. ALL CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE, AS WELL AS SUPPORTING DOCUMENTS AND IMPLEMENTATION TOOLS CAN BE ACCESSED THROUGH OUR STROKE BEST PRACTICES WEBSITE AT: Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 2 f 40

4 Overview SECTION 4.0 ACUTE INPATIENT STROKE CARE OVERVIEW TAKING ACTION IN ACUTE INPATIENT STROKE CARE TAKING ACTION is imperative acrss strke systems f care, healthcare prviders, patients, families, and the brader cmmunity. The primary underpinnings f acute inpatient strke care are t ptimize recvery and patient utcmes. A crdinated and seamless system f care shuld be established in all hspitals t ensure timely access t diagnstics and interventins, cnsults with ther services, and access t a range f rehabilitatin therapies. The evidence fr managing acute strke patients n dedicated inpatient strke units is strng and irrefutable. Patients wh are cared fr n strke units have better utcmes, less disability and lwer mrtality. Therefre every hspital that treats strke patients shuld TAKE ACTION t create and implement strke unit care. The Quality f Strke Care in Canada (2011), which reprted current levels f perfrmance n key quality strke indicatrs, fund that nly 23% f strke patients were admitted t designated strke units acrss Canada, and fr strke patients in hspitals that had a strke unit, nly 53% f strke patients spent any time n the strke unit during their inpatient stay. These numbers are quite disturbing given the strength f the evidence regarding the benefits f strke unit care. Recmmendatin 4.1 in this chapter clearly utlines the cre elements f strke unit care, which includes healthcare team members with specialized strke training, a gegraphically defined area within the hspital where all strke patients are clustered, evidence-based strke prtcls t address all aspects f strke care, team meetings with case reviews, and early access t rehabilitatin assessments and therapies. Hspitals that manage strke patients and currently d nt have dedicated strke units shuld all be Taking Actin and striving t implement all the cre elements f strke unit care, regardless f whether there is a designated strke unit, and at least cluster strke patients within a cnsistent area f a hspital ward and prvide staff with educatin and skills training specific t strke care. If this gal is nt pssible within sme hspitals, thse hspitals shuld then Take Actin t transfer acute strke patients t the nearest hspital that des prvide acute strke unit care. The cre strke team tgether with ther apprpriate healthcare prfessins shuld be Taking Actin t develp an individualized management plan fr each strke patient. T accmplish this effectively, cmmunicatin amng healthcare prfessinals and hspital departments are paramunt t ensure crdinated acute strke care. Prtcls shuld be established at all hspitals, based n the Canadian Strke Best Practices, and agreements shuld be in place fr high pririty rapid access t all specialists, departments and services required fr each strke patient t reduce risks f cmplicatins, ptimize utcmes and meet patient and family needs during the early pst-strke recvery phase. Taking Actin during acute strke care als includes recgnitin that strke can have devastating effects and nt all patients will survive. Fr catastrphic strkes, bth ischemic and hemrrhagic, the palliative care specialists within each hspital shuld be invited t be part f the care team as early as pssible. Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 3 f 40

5 Overview HIGHLIGHTS OF THE ACUTE INPATIENT STROKE CARE UPDATE 2013 The 2013 update f the Acute Inpatient Strke Care Chapter f the Canadian Best Practice Recmmendatins fr Strke Care reinfrces the grwing and changing bdy f research evidence available t guide assessment, diagnsis, interventins and nging management f strke patients fllwing hspital admissin. Key messages fr 2013 and significant changes t previus acute inpatient strke care recmmendatins include: ü Organized strke units with interprfessinal strke teams have the strngest evidence and a significant impact n patient utcmes fllwing strke. ü Greater effrts need t be undertaken t expand the number and lcatin f rganized strke units acrss Canada. ü If strke units are nt available, hspitals shuld make every attempt t transfer apprpriate patients t a facility with a strke unit, r t implement a clustered mdel f care where all cre elements f ptimal strke unit care are available t strke patients. ü Acute inpatient management includes prmting ptimal recvery thrugh early access t rehabilitatin assessments and early initiatin f rehabilitatin therapies, including dysphagia assessment and management, early mbilizatin, implementing cntinence prgrams, and reducing risk f cmplicatins such as pneumnia and venus thrmbemblism. ü Expanded guidance n addressing palliative care issues in patients with severe strke. ü Recmmendatins fr initiating advanced-care planning discussins with patients and family members. ü Develpment f a TAKING ACTION TOWARDS OPTIMAL STROKE CARE resurce kit including strke care infrmatin, educatinal mdules, summary tables and resurce links. ACUTE INPATIENT STROKE CARE UPDATE 2013 RESOURCE PACKAGE INCLUDES: i. Strke Best Practice Recmmendatins fr Acute Inpatient Strke Care ii. TAKING ACTION TOWARDS OPTIMAL STROKE CARE resurce kit, with implementatin materials and educatinal slide decks fr all tpic areas iii. Strke Care Assessment Tls Summary Table iv. Links t implementatin resurces fr all tpic areas Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 4 f 40

6 Overview HYPERACUTE AND ACUTE INPATIENT STROKE CARE DEFINITIONS Hyperacute and Acute Strke care invlves all direct care, service delivery and interactins frm first cntact with the healthcare system after the nset f an acute strke t discharge frm an emergency department r acute inpatient care, and mving n t the next stage f care r return t the cmmunity. HYPERACUTE STROKE CARE Hyperacute care refers t the key interventins invlved in the assessment, stabilizatin and treatment in the first hurs after strke nset. This will represent all pre-hspital and initial emergency care fr TIA, ischemic strke, intracerebral hemrrhage, subarachnid hemrrhage and acute venus sinus thrmbsis. This includes thrmblysis r endvascular interventins fr acute ischemic strke, emergency neursurgical prcedures, and same-day TIA diagnstic and risk stratificatin evaluatin. The principal aim f this phase f care is t diagnse the strke type, and t crdinate and execute the treatment plan as rapidly as pssible. Hyperacute care is time-sensitive by nature, minutes fr disabling strke and hurs fr TIA, but specific interventins are assciated with their wn individual treatment windws. Bradly speaking ''hyperacute" refers t care ffered in the first 24 hurs after strke (ischemic and hemrrhagic) and the first 48 hurs after TIA. ACUTE STROKE CARE Acute care refers t the key interventins invlved in the assessment, treatment r management, and early recvery in the first days after strke nset. This will represent all f the initial diagnstic prcedures undertaken t identify the nature and mechanism f strke, interprfessinal care t prevent cmplicatins and prmte early recvery, institutin f an individualized secndary preventin plan, and engagement with the strke survivr and family t assess and plan fr transitin t the next level f care (including a cmprehensive assessment f rehabilitatin needs). New mdels f acute ambulatry care such as rapid assessment TIA and minr strke clinics r day-units are als starting t emerge. The principal aims f this phase f care are t identify the nature and mechanism f strke, prevent further strke cmplicatins, prmte early recvery, and (in the case f severest strkes) prvide palliatin r end-f-life care. Bradly speaking "acute care" refers t the first days t weeks f inpatient treatment with strke survivrs transitining frm this level f care t either inpatient rehabilitatin, cmmunity based rehabilitatin services, hme (with r withut supprt services), cntinuing care, r palliative care. This acute phase f care is usually cnsidered t have ended either at the time f acute unit discharge r by 30 days f hspital admissin. Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 5 f 40

7 Overview CANADIAN STROKE BEST PRACTICES FRAMEWORK FOR OPTIMAL STROKE SERVICES DELIVERY There are variatins in the levels f strke care service prvided within the Canadian healthcare system. These services can be arranged alng a cntinuum frm minimal, nn-specialized services, prvided in facilities that ffer general medical and surgical care, t mre advanced and cmprehensive strke care centres (See Figure 1). The gal fr each rganizatin invlved in the delivery f strke care services is t cntinue t develp the expertise and prcesses needed t prvide ptimal patient care, taking int cnsideratin that rganizatin s gegraphic lcatin, patient ppulatin, structural resurces, and relatinship t ther centres within their healthcare regin r system. Once a level f strke services has been achieved, the rganizatin shuld strive t develp and incrprate cmpnents f the next higher level fr nging grwth f strke services where apprpriate, as well as cntinuus quality imprvement within the level f service currently prvided. Figure 1: CANADIAN STROKE BEST PRACTICES FRAMEWORK FOR OPTIMAL STROKE SERVICES DELIVERY FOR ADDITIONAL INFORMATION AND DETAILS ABOUT THE STROKE SERVICES FRAME-WORK, PLEASE REFER TO THE TAKING ACTION TOWARDS OPTIMAL STROKE CARE RESOURCE AT WWW. STROKEBESTPRACTICES.CA Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 6 f 40

8 Overview DEVELOPMENT OF THE CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE Fr detailed methdlgy n the develpment and disseminatin f the Canadian Best Practice Recmmendatins fr Strke Care please refer t the Strke Best Practices website at Acknwledgements The Canadian Strke Best Practices Team, Heart and Strke Fundatin and the Canadian Strke Netwrk gratefully acknwledge the writing grup leaders and members, the external reviewers, all f wh have vlunteered their time and expertise t this update. We thank the Canadian Strke Quality and Perfrmance Advisry Grup fr their wrk in updating and cnfirming the perfrmance measures that accmpany each recmmendatin. We acknwledge Nrine Fley and Katherine Salter fr their wrk n implementatin tl develpment and the evidence reviews. We are grateful t Dr. Rbert Teasell, Andrew McClure and the Evidence-Based Review in Strke Rehabilitatin (EBRSR) team fr all their wrk n the systematic reviews f the literature and evidence tables; and, we thank Marie-France Saint-Cyr and Jan Carbn fr their wrk n the French translatins. Funding The develpment f these Canadian strke care guidelines is funded in its entirety by the Canadian Strke Netwrk and the Heart and Strke Fundatin. N funds fr the develpment f these guidelines cme frm cmmercial interests, including pharmaceutical cmpanies. All members f the recmmendatin writing grups and external reviewers are vlunteers and d nt receive any remuneratin fr participatin in guideline develpment, updates and reviews. Citing the Acute Inpatient Strke Care Update 2013 Casaubn LK, Suddes M, n behalf f the Acute Strke Care Writing Grup. Chapter 4: Acute Inpatient Strke Care. In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editrs) n behalf f the Canadian Strke Best Practices and Standards Advisry Cmmittee. Canadian Best Practice Recmmendatins fr Strke Care: 2013; Ottawa, Ontari Canada: Heart and Strke Fundatin f Canada, and the Canadian Strke Netwrk. Cmments We invite cmments, suggestins, and inquiries n the develpment and applicatin f the Canadian Best Practice Recmmendatins fr Strke Care and nging updates. Please frward cmments t the Heart and Strke Fundatin Strke Best Practices and Perfrmance team at Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 7 f 40

9 Participants CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE Acute Inpatient Strke Care Writing Grup : NAME PROFESSIONAL ROLE LOCATION Hyperacute and Acute Strke Writing Grup C-Chair; Casaubn, Leanne Strke Neurlgist, Directr, TIA and Minr Strke (TAMS) Unit, C-Chair Trnt Western Hspital/University Health Netwrk; Ontari Assistant Prfessr f Medicine, University f Trnt Suddes, Michael C-Chair Manager, Calgary Strke Prgram, Alberta Health Services Alberta Blacquiere, Dylan Strke Neurlgy Fellw, University f Ottawa Ontari Bastyr, Barbara Scial Wrker, Neursurgery, Trillium Health Centre Ontari Curnyer, Rxanne Clinical Nurse Specialist fr Systematic Review f Vascular Neurlgy, Centre hspitalier de l`université de Mntréal (CHUM) Quebec Ddy, Irene Speech-Language Pathlgist Newfundland Fleetwd, Ian Lariviere, Christian Martin, Charmaine Mses, Brian Chair Neursurgical Sub-Grup Neursurgen, Assciate Prfessr, Divisin f Neursurgery, University f Victria Emergency Physician, St. Bniface General Hspital, Palliative Medicine Residency Prgram, University f Manitba Neursurgical Nurse Specialist Integrated Strke Unit, Hamiltn Health Sciences General Internal Medicine, Chief f Medicine, Suth West District Health Authrity British Clumbia Manitba Ontari Nva Sctia Steacie, Adam Family Physician, Upper Canada Family Health Team Ontari Sttts, Grant Talbt, J-Ann Taralsn, Clleen Travers, Andrew Strke Neurlgist, Medical Directr Strke Prgram, The Ottawa Hspital; Assistant Prfessr, Department f Neurlgy, University Ontari f Ottawa Emergency Physician, Saint Jhn Reginal Hspital, Assistant Prfessr, Department f Emergency Medicine, Dalhusie University Newfundland Registered Nurse, Acting Prgram Manager, Reginal Edmntn Alberta Strke Prgram Chair, Emergency Medical Services Sub-Grup Nva Sctia Medical Directr, Emergency Health Services Nva Sctia. NEUROSURGERY SUB-GROUP Fleetwd, Ian Chair Kelly, Michael Martin, Charmaine Neursurgen, Assciate Prfessr, Divisin f Neursurgery, University f Victria Neursurgen, Regina Qu'Appelle Regin, Assistant Prfessr f Surgery, Divisin f Neursurgery, University f Saskatchewan Neursurgical Nurse Practitiner Integrated Strke Unit, Hamiltn Health Sciences British Clumbia Saskatchewan Ontari Silvaggi, Jseph Tymianski, Dawn Neursurgen, Assistant Prfessr, Sectin f Neursurgery, Department f Surgery, University f Manitba Adult Nurse Practitiner, Cerebrvascular Surgery, Krembil Neurscience Practice Lead, University Health Netwrk Manitba Ontari Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 8 f 40

10 Participants PEDIATRIC STROKE SUB-GROUP Kirtn, Adam Chair Chan, Anthny D Anju, Guy devebers, Gabrielle Dilenge, Marie- Emanuelle Rafay, Mubeen Yau, Ivanna Chair, Paediatric Neurlgist, Directr, Calgary Paediatric Strke Prgram, Alberta Children's Hspital, Assciate Prfessr, University f Calgary Paediatric Neurlgist, McMaster Children s Hspital, Prfessr, McMaster University Paediatric Neurlgist, Ste-Justine Hspital, Mntreal Prfessr, University f Mntreal Paediatric Neurlgist, Directr f the Children's Strke prgram, Trnt Hspital fr Sick Children, Prfessr, University f Trnt Child Neurlgist, Mntreal Children's Hspital, Department f Neurlgy and Neursurgery, McGill University Paediatric Neurlgist, Department f Pediatrics and Child Health Children s Hspital, Assistant Prfessr, University f Manitba Pediatric Strke Nurse Practitiner, Divisin f Neurlgy, Trnt Hspital fr Sick Children Alberta Ontari Quebec Ontari Quebec Manitba Ontari YOUNG ADULT STROKE SUB-GROUP Swartz, Richard Chair Buck, Brian Casaubn, Leanne Green, Theresa Jeerakithil, Thmas Lanthier, Sylvain Sapsnik, Gustav Strke Neurlgist, Sunnybrk Hspital, Brain Sciences Prgram, Assistant Prfessr, University f Trnt Strke Neurlgist, Grey Nuns Hspital, Assistant Prfessr Neurlgy, University f Alberta Strke Neurlgist, Directr, TIA and Minr Strke (TAMS) Unit, Trnt Western Hspital/University Health Netwrk; Assistant Prfessr f Medicine, University f Trnt Assistant Prfessr f Nursing, University f Calgary, Editr, Canadian Jurnal f Neurscience Nurses Strke Neurlgist, University f Alberta Hspital, Assistant Prfessr, University f Alberta Strke Neurlgist, Hôpital Ntre-Dame, Assistant Prfessr, University f Mntreal Strke Neurlgist, Directr, Strke Outcmes Research Unit, St. Michael's Hspital, Assciate Prfessr, University f Trnt Ontari Alberta Ontari Alberta Quebec Ontari Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 9 f 40

11 Participants CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE Hyperacute Strke Care External Reviewers 2013: EXTERNAL REVIEWER PROFESSIONAL ROLE LOCATION Susan Alcck Jean Martin Bulanger Registered Nurse, Strke Prgram, Health Sciences Centre, Winnipeg Strke Neurlgist, Chef, Service De Neurlgie, H pital Charles-Lemyne; Prfesseur Adjint, Neurlgie, Universite! De Sherbrke, H pital Charles-Lemyne Manitba Quebec Katherine Churchward Martin Dennis Marie-Andrée Dejardins Nathania Liam Shauna Martiniuk Sheila Cristina Ouriques Martins Miriam Pereira-Nv Melanie Mntague- Penn Daniel Selchen Debbie Summers Speech Language Pathlgist, Fthills Medical Centre Strke Neurlgist, Prfessr Of Strke Medicine In The Divisin Of Clinical Neursciences In The University Of Edinburgh Physitherapist, CHUM Ntre-Dame Hspital, Mntreal Physiatrist, Directr Of Rehabilitatin, Windsr Reginal Hspital Emergency Physician, Munt Sinai Hspital; Lecturer, Faculty Of Medicine, University Of Trnt Strke Neurlgist, Hspital Minhs De Vent And Hspital De Clinicas De Prt Alegre, Prt Alegre; Occupatinal Therapist, Fraser Reginal Strke Prgram Strke Nurse, Strke Rapid Assessment Unit, Vancuver Island Strke Prgram, Strke Neurlgist, Head Of The Divisin Of Neurlgy At St. Michael s Hspital And The Medical Directr Of The Reginal Strke Prgram Fr St. Michael s Hspital And The Suth East Trnt Strke Netwrk. Advanced Practice Nurse, Strke Prgram Crdinatr/Apn At Saint Luke's Hspital, Missuri Alberta Sctland, UK Quebec Ontari Ontari Brazil British Clumbia British Clumbia Ontari United States f America Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 10 f 40

12 Participants CANADIAN BEST PRACTICE RECOMMENDATIONS FOR STROKE CARE Best Practices and Standards Advisry Cmmittee MEMBER PROFESSIONAL ROLE LOCATION Phillips, Stephen C-Chair Bayley, Mark C-Chair Gubitz, Grd Lead, Best Practice Updates Graham, Ian Harris, Devin Strke Neurlgist, Queen Elizabeth II Health Sciences Centre, Prfessr, Divisin f Neurlgy, Faculty f Medicine, Dalhusie University Physiatrist; Assciate Prfessr, University f Trnt Acquired Brain Injury, Physical Medicine & Rehabilitatin Trnt Rehabilitatin Institute Strke Neurlgist, Directr, Neurvascular Clinic, Queen Elizabeth II Health Sciences Center. Assistant Prfessr f Medicine (Neurlgy), Dalhusie University Senir Scientist, Centre fr Practice-Changing Research, The Ottawa Hspital Research Institute, Assciate Prfessr, Schl f Nursing, University f Ottawa Emergency Physician, St. Paul's Hspital, Prfessr, Department f Emergency Medicine, University f British Clumbia Nva Sctia Ontari Nva Sctia Ontari British Clumbia Jiner, Ian Directr, Strke, Canada, Heart and Strke Fundatin Canada Lawrence, Stephanie LeBrun, Luise- Helene Lindsay, Patrice Markle-Reid, Maureen Senir Manager, Cmmunicatins, Heart and Strke Fundatin Strke Neurlgist, Directeur du Centre des maladies vasculairescérébrales du Centre Hspitalier de l'université de Mntréal (CHUM ) Directr, Best Practices and Perfrmance, Strke Heart and Strke Fundatin Staff Lead, Canadian Best Practice Recmmendatins fr Strke Care Nurse Specialist, Assciate Prfessr, Schl f Nursing and Assciate Member, Clinical Epidemilgy and Bistatistics, McMaster University Canada Quebec Canada Ontari Millbank, Rbin Smith, Eric Rwe, Sarah Manager, Prfessinal Develpment and Training, Canadian Strke Netwrk Assciate Prfessr, Dept f Clinical Neursciences, Radilgy and Cmmunity Health Sciences Member, Htchkiss Brain Institute, University f Calgary Physitherapy Practice Crdinatr, Vancuver Castal Health Canada Alberta British Clumbia Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 11 f 40

13 Recmmendatins Acute Inpatient Strke Care Best Practice Recmmendatins SECTION 4.0 ACUTE INPATIENT STROKE MANAGEMENT Best Practice Recmmendatin 4.1 Strke Unit Care BOX 4.1: Optimal Acute Strke Care DEFINTION: A strke unit is a specialized, gegraphically defined hspital unit dedicated t the management f strke patients and staffed by an experienced interprfessinal strke team. Refer t the resurce Taking Actin Twards Optimal Strke Care fr detailed infrmatin abut strke unit criteria. Cre Elements f Cmprehensive Strke and Neurvascular Care: It is recgnized that nt all hspitals are able t deliver all f the strke unit elements, and every hspital shuld be Taking Actin t establish prtcls and prcesses f care t implement as many elements as pssible t achieve ptimal strke care delivery within their gegraphic lcatin, hspital vlumes and resurce availability (human, equipment, funding). Refer t Figure 1 in Chapter 4 Overview fr Canadian Strke Services Framewrk, in the Overview sectin f this chapter, and in the Taking Actin Twards Optimal Strke Care resurce kit. Specialized care fr patients with ischemic strke, intracerebral hemrrhage (ICH), and transient ischemic attack (TIA) (care may be expanded in sme institutins t include patients with subarachnid hemrrhage [SAH] and ther neurvascular cnditins); Dedicated strke team with brad expertise including neurlgy, nursing neursurgery, physiatry, rehabilitatin prfessinals, pharmacists, and thers; Cnsistent clustered mdel where all strke patients are cared fr n the same hspital ward with dedicated strke beds by trained and experienced staff, including rehabilitatin prfessinals; Access t 24/7 imaging and interventinal neurradilgy expertise; Emergent neurvascular surgery access; Prtcls in place fr hyperacute and acute strke management, and seamless transitins between stages f care (including pre-hspital, emergency department and inpatient care); Dysphagia screening prtcls in place t assess all strke patients withut prlnged time delays prir t cmmencing ral nutritin and ral medicatins; Access t pst-acute rehabilitatin services, including inpatient, cmmunitybased, and/r early supprted discharge (ESD) therapy; Discharge planning starting as sn as pssible after admissin, and anticipating discharge needs t facilitate smth transitins; Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 12 f 40

14 Recmmendatins 4.1 Recmmendatins Daily/bi-weekly patient care runds with interprfessinal strke team t cnduct case reviews, discuss patient management issues, family cncerns r needs, and discharge planning (discharge r transitin t the next step in their care, timing, transitin requirements); Patient and family educatin that is frmal, crdinated, and addresses learning needs and respnds t patient and family readiness; Prvisin f palliative care when required, ideally by a specialized palliative care team; Onging prfessinal develpment fr all staff strke knwledge, evidencebased best practices, skill building, rientatin f trainees; Invlvement in clinical research fr strke care. 4.1 Patients admitted t hspital with an acute strke r transient ischemic attack shuld be treated n an inpatient strke unit [Evidence Level A]. i. Patients shuld be admitted t a strke unit which is a specialized, gegraphically defined hspital unit dedicated t the management f strke patients [Evidence Level A]. ii. iii. a. Fr facilities withut a dedicated strke unit, the facility must strive t fcus care n the pririty elements identified fr cmprehensive strke care delivery (including clustering patients, interprfessinal team, access t early rehabilitatin, strke care prtcls, case runds, patient educatin). Refer t Bx 4.1: Cre Elements f Cmprehensive Strke and Neurvascular Care fr further infrmatin. The cre interprfessinal team n the strke unit shuld cnsist f healthcare prfessinals with strke expertise including physicians, nursing, ccupatinal therapy, physitherapy, speech-language pathlgy, scial wrk, and clinical nutritin (dietitian) [Evidence Level A]. a. All strke teams shuld include hspital pharmacists t prmte patient safety, medicatin recnciliatin, prvide educatin t the team and patients/family regarding medicatin(s) (especially side effects, adverse effects, interactins), discussins regarding adherence, and discharge planning (such as special needs fr patients, e.g., individual dsing packages) [Evidence Level B]. b. Additinal members f the interprfessinal team may include discharge planners r case managers, (neur) psychlgists, palliative care specialists, recreatin and vcatinal therapists, spiritual care prviders, peer supprters and strke recvery grup liaisns [Evidence Level B]. The interprfessinal team shuld assess patients within 48 hurs f admissin t hspital and frmulate a management plan [Evidence Level B]. a. Clinicians shuld use standardized, valid assessment tls t evaluate the patient s strke-related impairments and functinal status [Evidence Level B]. Refer t Canadian Strke Best Practices Table 3.3A: Screening and Assessment Tls fr Acute Strke fr mre detailed infrmatin. b. Assessment cmpnents shuld include dysphagia, mbility, functinal assessment, temperature, nutritin, bwel and bladder functin, discharge planning, preventin therapies, venus thrmbemblism prphylaxis [Evidence Level B]. Refer t Sectin 4.2 Recmmendatins fr further infrmatin. c. Alngside the initial and nging clinical assessments regarding functinal status, Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 13 f 40

15 Recmmendatins iv. a frmal and individualized assessment t determine the type f nging pstacute rehabilitatin services required shuld ccur within 72 hurs pst-strke, using a standardized prtcl (including tls such as the alpha-fim ) [Evidence Level B]. Refer t Recmmendatin 5.3 fr infrmatin n inpatient strke rehabilitatin, which shuld cmmence as early as pssible during the acute care hspital stay. Any child admitted t hspital with strke shuld be managed in a centre with paediatric strke expertise when available; if there is n access t specialized paediatric services, children with strke shuld be managed using standardized paediatric strke prtcls [Evidence Level B] In-Hspital Strke: Hspital inpatients wh have a diagnsis f a new strke cnfirmed, shuld be assessed in a timely fashin and receive apprpriate access t acute inpatient strke care dependent upn their level f strke-related impairment and ther presenting medical/surgical cnditins [Evidence Level B]. Ratinale Strke unit care reduces the likelihd f death and disability by as much as 30 percent fr men and wmen f any age with mild, mderate, r severe strke. Strke unit care is characterized by a crdinated interprfessinal team apprach fr preventing strke cmplicatins, preventing strke recurrence, accelerating mbilizatin, and prviding early rehabilitatin therapy. Evidence suggests that strke patients treated n acute strke units have fewer cmplicatins, earlier mbilizatin, and pneumnia is recgnized earlier. Patients shuld be treated in a gegraphically defined unit, as care thrugh strke pathways and by rving strke teams d nt prvide the same benefit as strke units. Access t early rehabilitatin is a key aspect f strke unit care. Fr patients with strke, rehabilitatin shuld start as early as pssible and rehabilitatin shuld be cnsidered an interventin that can ccur in any and all settings acrss the cntinuum f strke care. System Implicatins Organized systems f strke care including strke units with a critical mass f trained staff (interprfessinal team). If nt feasible, then mechanisms fr crdinating the care f strke patients t ensure use f best practices and ptimal utcmes. Prtcls and mechanisms t enable the rapid transfer f strke patients frm the emergency department t an interprfessinal strke unit as sn as pssible after arrival in hspital, ideally within the first three hurs. Cmprehensive and advanced strke care centres shuld have leadership rles within their gegraphic regins and ensure specialized strke care access is available t patients wh may first appear at general healthcare facilities (usually remte r rural centres) and facilities with basic strke services nly. Telestrke services shuld be ptimized t ensure access t specialized strke care acrss the cntinuum t meet individual needs (including access t rehabilitatin and strke specialists). Infrmatin n gegraphic lcatin f strke units and ther specialized strke care mdels available t cmmunity service prviders, t facilitate navigatin t apprpriate resurces and t strengthen relatinships between each sectr alng the strke cntinuum f care. Perfrmance Measures 1. Number f strke patients wh are admitted t hspital and treated n a specialized strke unit at any time during their inpatient hspital stay fr an acute strke event (numeratr) as a Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 14 f 40

16 Recmmendatins percentage f ttal number f strke patients admitted t hspital (cre). 2. Percentage f patients discharged t their hme r place f residence fllwing an inpatient admissin fr strke (cre). 3. Prprtin f strke patients wh die in hspital within 7 days and within 30 days f hspital admissin fr an index strke (reprted by strke type) (cre). 4. Prprtin f ttal time in hspital fr an acute strke event spent n a strke unit. 5. Percentage increase in telehealth r telestrke cverage t remte cmmunities t supprt rganized strke care acrss the cntinuum. Refer t Canadian Strke Quality and Perfrmance Measurement Manual fr detailed indicatr definitins and calculatin frmulas. Measurement Ntes Perfrmance measure 1: calculate fr all cases, and then stratify by type f strke. Definitin f strke unit varies widely frm institutin t institutin. Where strke units d nt meet the criteria defined in the recmmendatin, then a hierarchy f ther strke care mdels culd be cnsidered: a) dedicated strke unit; (b) designated area within a general nursing unit r neur-unit where strke patients are clustered; (c) mbile strke team care; (d) managed n a general nursing unit by staff using strke guidelines and prtcls. Institutins cllecting this data must nte their peratinal definitin f strke unit t ensure standardizatin and validity when data is reprted acrss institutins. Patient and family experience surveys shuld be in place t mnitr care quality during inpatient strke admissins Implementatin Resurces and Knwledge Transfer Tls Canadian Strke Best Practices Patient Order Set fr Admissin t Inpatient Strke Care Canadian Strke Best Practices Table 3.3A Screening and Assessment Tls fr Acute Strke Canadian Strke Best Practices Table 3.3B Recmmended Labratry Investigatins fr Acute Strke and Transient Ischemic Attack ) HSF Strke Nurses Assessment Pcket Cards es/apps/ka/ct/cntactcustm.asp Canadian Strke Best Practices Implementatin guide: Taking Actin Twards Optimal Strke Care RNAO Strke Assessment Acrss the Cntinuum f Care (2005) Summary f the Evidence Updated 2013 Strke patients wh receive strke unit care are mre likely t survive, return hme, and regain independence as cmpared t patients wh receive less rganized cnventinal care (Strke Unit Trialists' Cllabratin, 2009). Strke units are characterized as hspital units in which care is prvided by an experienced interprfessinal strke team (including physicians, nurses, physitherapists, ccupatinal therapists, speech therapists, etc.) dedicated t the management f strke patients, ften within a gegraphically defined space (Langhrne & Pllck, 2002). Strke units als typically invlve staff members wh have a specialist interest in strke, participate in rutine team meetings and cntinuing Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 15 f 40

17 Recmmendatins educatin/training, engage in interprfessinal rehabilitatin, and invlve caregivers in the rehabilitatin prcess. (Langhrne & Pllck, 2002) In a Cchrane Review, the Strke Unit Trialists Cllabratin identified 31 randmized and quasirandmized trials (n=6,936) cmparing strke unit care with alternative, less rganized care (e.g., an acute medical ward)(strke Unit Trialists' Cllabratin, 2009). As cmpared t treatment in a less rganized unit, strke unit care was assciated with a significant reductin in death (OR=0.82, 95% CI 0.73 t 0.92, p=0.001), death r institutinalizatin (OR=0.81, 95% CI 0.74 t 0.90, p<0.001), and death r dependency (OR=0.79, 95% CI 0.71 t 0.88, p<0.001) at a median fllw-up perid f ne year. Based n the results frm three trials, the authrs als reprted that the benefits f strke unit care are maintained fr perids up t 5 and 10 years pst-strke. Mrever, subgrup analyses demnstrated benefits f strke unit care regardless f sex, age, r strke severity (Strke Unit Trialists' Cllabratin, 2009). In a mre recent study, Sapsnik et al. investigated the differential impact f strke unit care n fur subtypes f ischemic strke and reprted that strke unit care is assciated with reduced 30-day mrtality acrss all fur subtypes (Sapsnik et al., 2011). Seenan and clleagues cnducted a systematic review f bservatinal studies t determine if the benefits f strke unit care described in clinical trials are replicated in clinical practice (Seenan et al., 2007). Twenty-five bservatinal studies (n=42,236) cmparing strke unit care t nn-strke unit care were identified fr inclusin, althugh nly 18 prvided data n case fatality r pr utcme. The authrs reprted that strke unit care was assciated with significantly reduced dds f death (dds rati=0.79, 95% CI=0.73 t 0.86; p<0.001) and f death r pr utcme (dds rati=0.87, 95% CI=0.80 t 0.95; p=0.002) within ne-year f strke. Althugh the analyses were subject t significant hetergeneity, similar findings were reprted fr the utcme f death at ne year in a secndary analysis limited t multi-centered trials, which did nt suffer frm significant hetergeneity (OR=0.82, 95% CI 0.77 t 0.87, p<0.001) (Seenan et al., 2007). Althugh bservatinal studies are assciated with a greater risk f bias than RCTs, it is ntewrthy that the benefit f strke unit care bserved in bservatinal studies f clinical practice is cmparable t that bserved in clinical trials. In a synthesis f evidence demnstrating the benefits f rganized strke care, Kalra and Langhrne nted that an imprtant challenge fr strke units is a cnceptual shift in the philsphy f strke care frm being predminantly engaged with patient-riented interventins t a strategy in which the patient and the caregiver are seen as a cmbined fcus fr interventin, with the bjective f empwering and equipping caregivers t be cmpetent facilitatrs f activities f daily living when caring fr disabled patients after strke (Kalra & Langhrne, 2007). Research has cnsistently shwn that better utcmes are assciated with cmprehensive and early prcesses f strke-specific assessments, particularly assessments fr swallwing and aspiratin risk, early detectin and management f infectins, maintenance f hydratin and nutritin, early mbilizatin, clear gals fr functin, and cmmunicatin with patients and their families (Kalra & Langhrne, 2007). Link t Evidence Table 4.1 and References available n website at Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 16 f 40

18 Recmmendatins Best Practice Recmmendatin 4.2 Inpatient Management and Preventin f Cmplicatins Fllwing Acute Strke r TIA Refer t Sectin 4.3 fr the management f patients wh are actively dying and require end-f-life care. 4.2 Apprpriate investigatins and management strategies shuld be implemented fr all hspitalized strke and TIA patients t ptimize recvery, avid cmplicatins, prevent strke recurrence, and prvide palliative care when required. i. During acute inpatient care, strke patients shuld underg apprpriate investigatins t determine strke mechanism and guide strke preventin and management decisins [Evidence Level B]. ii. Individualized care plans shuld address nutritin, ral care, mbilizatin and incntinence, and reduce the risk f cmplicatins such as urinary tract infectin, aspiratin pneumnia, and venus thrmbemblism [Evidence Level B]. iii. Discharge planning shuld begin as a cmpnent f the initial admissin assessment and cntinue thrughut hspitalizatin as part f nging care f hspitalized acute strke patients [Evidence Level B]. Refer t Recmmendatin 6.3 fr additinal infrmatin. iv. All patients, family members and infrmal caregivers shuld receive timely and cmprehensive infrmatin, educatin and skills training by all interprfessinal team members [Evidence Level A]. Refer t Recmmendatins 6.1 and 6.2 fr additinal infrmatin. v. All acute strke inpatients shuld be screened fr histry and/r current signs f depressin r vascular cgnitive impairment [Evidence Level C]. Refer t Recmmendatins 7.1 and 7.2 fr additinal infrmatin Cardivascular Investigatins i. Fllwing an initial electrcardigram, serial electrcardigrams (i.e., daily) shuld be dne fr the first 72 hurs pst-strke t detect atrial fibrillatin and ther acute arrhythmias [Evidence Level B]. ii. iii. iv. Patients with suspected emblic strke r lack f clear strke mechanism (e.g., nrmal neurvascular imaging) shuld have serial electrcardigrams in the first 72 hurs cmbined with a Hlter mnitr during hspitalizatin t increase detectin f atrial fibrillatin [Evidence Level C]; Echcardigraphy, either 2-D r transesphageal, shuld be cnsidered fr patients with suspected emblic strke and nrmal neurvascular imaging [Evidence Level B], as well as n cntraindicatins fr anticagulant therapy. This is particularly relevant fr yunger adults with strke r TIA and unknwn etilgy. Children with strke shuld underg a cmprehensive cardiac evaluatin including echcardigraphy, as well as detailed rhythm mnitring if clinically indicated [Evidence Level B] Venus Thrmbemblism Prphylaxis All strke patients shuld be assessed fr their risk f develping venus thrmbemblism (deep vein thrmbsis and pulmnary emblism). Patients at high risk include thse wh are Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 17 f 40

19 Recmmendatins unable t mve ne r bth lwer limbs; thse wh are unable t mbilize independently; a previus histry f venus thrmbemblism; dehydratin; and cmrbidities such as cancer. i. Early mbilizatin and adequate hydratin shuld be encuraged fr all acute strke patients t help prevent venus thrmbemblism [Evidence Level C]. ii. iii. iv. Patients at high risk f venus thrmbemblism shuld be started n venus thrmbemblism prphylaxis immediately if there is n cntraindicatin (eg. systemic r intracranial hemrrhage) [Evidence Level A]. a. Lw mlecular weight heparin shuld be cnsidered fr patients with acute ischemic strke at high risk f venus thrmbemblism; r unfractinated heparin fr patients with renal failure [Evidence Level B]. b. The use f anti-emblism stckings alne fr pst-strke venus thrmbemblism prphylaxis is nt recmmended [Evidence Level A]. Fr patients with active bleeding, r at high-risk f bleeding, use f pneumatic antiemblic stckings may be reasnable [Evidence Level B]. There is sme evidence n the safety and efficacy f anticagulant deep vein thrmbsis prphylaxis after intracerebral hemrrhage [Evidence Level B]. Antiplatelets and anticagulants shuld be avided fr at least 48 hurs after nset [Evidence Level C]. a. Patients with intracerebral hemrrhage wh are judged t be at high risk f venus thrmbemblism may be treated after 48 hurs pst-strke nset after careful risk assessment [Evidence Level C]. Cnsultatin with a hematlgist/thrmbsis expert is advised [Evidence Level C]. Nte: Additinal research evidence frm the CLOTS3 trial will becme available May 30 th, When it is publicly released the results will be reviewed by the Acute Strke Writing Grup and apprpriate edits t this sectin will be made if required Temperature Management i. Temperature shuld be mnitred as part f vital sign assessments; ideally every fur hurs fr the first 48 hurs, and then as per ward rutine r based n clinical judgment [Evidence Level C]. ii. Fr temperature greater than 37.5 Celsius, increase frequency f mnitring, initiate temperature-reducing care measures, investigate pssible infectin such as pneumnia r urinary tract infectin [Evidence Level C], and initiate antipyretic and antimicrbial therapy as required [Evidence Level B] Mbilizatin Mbilizatin is defined as the prcess f getting a patient t mve in the bed, sit up, stand, and eventually walk. i. All patients admitted t hspital with acute strke shuld be mbilized as early and as frequently as pssible [Evidence Level B], and ideally within 24 hurs f strke symptm nset, unless cntraindicated [Evidence Level C]. ii. a. Cntraindicatins t early mbilizatin include, but may nt be restricted t, patients wh have had an arterial puncture fr an interventinal prcedure, unstable medical cnditins, lw xygen saturatin, and lwer limb fracture r injury. All patients admitted t hspital with acute strke shuld be assessed by rehabilitatin Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 18 f 40

20 Recmmendatins prfessinals as sn as pssible after admissin [Evidence Level A], preferably within the first 24 t 48 hurs [Evidence Level C]. Refer t Chapter 5 fr additinal recmmendatins n mbilizatin fllwing an acute strke Cntinence i. The use f indwelling catheters shuld be avided due t the risk f urinary tract infectin [Evidence Level A]. If used, indwelling catheters shuld be assessed daily and remved as sn as pssible [Evidence Level A]. Excellent pericare and infectin preventin strategies shuld be implemented t minimize risk f infectins [Evidence Level C]. ii. All strke patients shuld be screened fr urinary incntinence and retentin (with r withut verflw), fecal incntinence, and cnstipatin [Evidence Level C]. iii. The use f a prtable ultrasund machine is recmmended as the preferred nninvasive painless methd fr assessing pst-vid residual [Evidence Level C]. iv. Pssible cntributing factrs surrunding cntinence management shuld be assessed, including urinary tract infectin, medicatins, nutritin, diet, mbility, activity, cgnitin, envirnment and cmmunicatin [Evidence Level C]. v. Strke patients with urinary incntinence shuld be assessed by trained persnnel using a structured functinal assessment t determine cause and develp an individualized management plan [Evidence Level B]. vi. A bladder-training prgram shuld be implemented in patients wh are incntinent f urine [Evidence Level C], including timed and prmpted tileting n a cnsistent schedule [Evidence Level B]. vii. Apprpriate intermittent catheterizatin schedules shuld be established based n amunt f pst-vid residual [Evidence Level B]. viii. A bwel management prgram shuld be implemented fr strke patients with persistent cnstipatin r bwel incntinence [Evidence Level A] Nutritin and Dysphagia i. Interprfessinal team members shuld be trained t cmplete initial swallwing screening fr all strke patients t ensure patients are screened in a timely manner [Evidence Level C]. ii. iii. iv. The swallwing, nutritinal and hydratin status f strke patients shuld be screened as early as pssible, ideally n the day f admissin, using validated screening tls [Evidence Level B]. Refer t Table 4.2: Canadian Strke Best Practices Swallw Screening and Assessment Tls fr mre infrmatin. Abnrmal results frm the initial r nging swallwing screens shuld prmpt referral t a speech-language pathlgist, ccupatinal therapist, and/r dietitian fr mre detailed assessment and management f swallwing, nutritinal and hydratin status [Evidence Level C]. An individualized management plan shuld be develped t address therapy fr dysphagia, dietary needs, and specialized nutritin plans [Evidence Level C]. Strke patients with suspected nutritinal cncerns, hydratin deficits, dysphagia, r ther cmrbidities that may affect nutritin (such as diabetes) shuld be referred t a dietitian fr recmmendatins: a. t meet nutrient and fluid needs rally while supprting alteratins in fd texture and fluid cnsistency recmmended by a speech-language pathlgist r ther Furth Editin ~ FINAL4 Update: May 23 rd, 2013 Page 19 f 40

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