ALBERTA PROVINCIAL STROKE STRATEGY. Inpatient Care for Acute Stroke Admissions

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1 ALBERTA PROVINCIAL STROKE STRATEGY Inpatient Care for Acute Stroke Admissions APSS Inpatient Care for Stroke 1 of 41

2 TABLE OF CONTENTS Page 1.0 INTRODUCTION INPATIENT STROKE CARE RECOMMENDATIONS INPATIENT STROKE CARE BEST PRACTICE GUIDELINES Stroke Unit Care Neurovascular Imaging Blood Glucose Antithrombotic Therapy for Noncardioembolic Stroke or TIA Acute Management of Transient Ischemic Attack and Minor Stroke Extra Cranial Carotid Artery Disease Dysphagia Assessment Management of Subarachnoid and Intracerebral Hemorrhage Components of Acute Inpatient Care Venous Thromboembolism Prophylaxis Temperature Mobilization Continence Nutrition Oral Care Blood Pressure and Antihypertensive Therapy Cholesterol Modifiable Risk Factors Diet Sodium Smoking Alcohol Obesity Physical Activity Hyperhomocysteinemia APSS Inpatient Care for Stroke 2 of 41

3 3.13 References PSYCHOSOCIAL GUIDELINES RECOMMENDATIONS & BEST PRACTICES Patient and Family Education Psychosocial Support References ORAL CARE GUIDELINES FOR CARE DEPENDENT STROKE PATIENTS Purpose Rationale Clinical Guidelines and Considerations Personnel Permitted to Perform Oral Care Equipment Patient / Family Education References ORGANIZATION OF ACUTE STROKE UNITS IN ALBERTA Best Practice Guidelines Stroke Unit Inpatient Organization for Different Sized Health Facilities Types of Patients Admitted to Stroke Units References ORDER SETS - ROUTINE INPATIENT STROKE ADMISSION ORDER SETS - ACUTE ISCHEMIC STROKE - INPATIENT CARE POST t-pa ADMINISTRATION HYPERTENSION MANAGEMENT IN ACUTE STROKE: APSS RECOMMENDATIONS MANAGEMENT OF IN-PATIENT STROKES POSITIONING OF THE STROKE PATIENT APSS Inpatient Care for Stroke 3 of 41

4 We would like to acknowledge the contribution of the following groups: Alberta Provincial Stroke Strategy Pillar 2 Pillar 2 Inpatient Care Working Group APSS Inpatient Care for Stroke 4 of 41

5 1.0 INTRODUCTION The acute care phase is a critical period for the stroke patient. A consistent and organized approach to stroke care is focused on preventing stroke progression, recurrent stroke and prevention of common complications and management of post-stroke issues. Care delivered on a stroke unit or in designated stroke beds by a multidisciplinary team with enhance stroke knowledge has been shown to improve stroke outcomes. Regardless of setting, the use of written inpatient protocols or clinical pathways provides guidance for an organized application of interventions. Teams of care providers with access to a program of regular education about stroke and stroke management speeds the adoption of evidence-based practice. The following recommendations, tools and protocols have been developed by the APSS Pillar 2 Inpatient Care Working Group to identify best practices in stroke care on the inpatient unit. INPATIENT CARE COMPONENT Inpatient protocol or clinical pathways/maps for acute stroke patients to ensure organized application of interventions for all stroke patients regardless of location (medical, rehabilitation, psychosocial, transition) Stroke Unit or geographically designated beds for stroke patients Secondary stroke prevention protocols and patient education to prevent complications Psychosocial support and education Smooth transition from acute inpatient care to home/outpatient/rehabilitation facility PROTOCOL / TOOL Inpatient Stroke Care Recommendations and Best Practice Guidelines Routine Inpatient Stroke Admission Order Set Acute Ischemic Stroke - Inpatient Care Post t-pa Administration Order Set Hypertension Management in Acute Stroke: APSS Recommendations Oral Care Guidelines for Care Dependent Stroke Patients Psychosocial Guidelines Recommendations and Best Practices Positioning of the Stroke Patient Chart Organization of Acute Stroke Units in Alberta Inpatient Stroke Care Best Practice Guidelines Psychosocial Guidelines Recommendations and Best Practices Inpatient Stroke Care - Recommendations and Best Practice Guidelines APSS Inpatient Care for Stroke 5 of 41

6 2.0 INPATIENT STROKE CARE RECOMMENDATIONS Consistent and organized stroke care, delivered on a stroke unit or in designated stroke beds by a multidisciplinary team with enhanced stroke knowledge has been shown to improve stroke outcomes. Regardless of setting, the use of written inpatient protocols or clinical pathways provides guidance for an organized application of interventions. Teams of care providers with access to a program of regular education about stroke and stroke management speeds the adoption of evidence-based practice. All patients will benefit from admission to stroke units and organized stroke care delivered on these units. Due to varying clinical presentation, not all stroke patients will require the same level of care. The goal of the APSS is to create a system of care in the province to ensure that the right patient receives the right services at the right place. To some extent the decision to transfer patients between centers will be based on availability of clinical supports that are unique to each facility as well as available bed capacity. Stroke patients may be treated initially in a Primary or Comprehensive stroke centre and subsequently repatriated to their home hospital in the post acute phase while waiting for admission to rehabilitation beds at another site. The table in Section 6.3 Types of Patients Admitted to Stroke Units describes the clinical profile of patients that would benefit from various levels of care and to provide guidance regarding the appropriate location of treatment in the system. STROKE UNIT OR GEOGRAPHICALLY DESIGNATED BEDS FOR STROKE PATIENTS (CSS) All patients with acute stroke admitted to hospital should be treated on a stroke unit or a defined area by an interdisciplinary team. The organization of inpatient stroke beds and the number of designated beds in any facility is dependent on the number of people admitted with stroke per year and other available clinical supports (Section 3.1 Inpatient Stroke Care Best Practice Guidelines /Stroke Unit Care, Section 6 Organization of Acute Stroke Units in Alberta.) Definition of stroke unit/designated beds: Is a geographically located area where patients with stroke are managed. It is a separate geographical area (larger centres) or a designated area within a general unit (smaller centres) Has staff organized into a coordinated multidisciplinary team Has staff who are knowledgeable and enthusiastic about the management of stroke Provides ongoing education about stroke for staff, patients with stroke and caregivers Has written protocols for the assessment and management of common problems related to stroke. Patients shall be triaged to the most appropriate facility that will meet their individuals care needs. Refer to Section 6 Organization of Acute Stroke Units in Alberta. APSS Inpatient Care for Stroke 6 of 41

7 The focus of care changes throughout the inpatient stay. Screening and/or assessments in the first 48 hours are conducted to prevent stroke progression, recurrent stroke and development of common post-stroke issues while ensuring early mobilization and rehabilitation. Initial assessments are completed and management plans developed by the medical and interdisciplinary team members in the following areas: Level of consciousness and cognitive status (arousal, alertness and orientation) NIHSS to determine stroke severity Medical co-morbidities and risk factors for stroke recurrence, or progression Swallow / dysphagia screening Nutritional status and hydration screening Continence bowel and bladder function Risk for venous thrombosis / DVT Skin integrity and risk for developing pressure areas Speech, language and other communication areas as needed Visual neglect/ / inattention or other perceptual difficulties Appropriate moving, handling, and positioning of the person with stroke, with respect to the person s abilities and need for assistance Risk for falls / safety INPATIENT PROTOCOLS AND ORGANIZED APPLICATION OF INTERVENTIONS FOR THE ACUTE STROKE PATIENT Regions shall adopt inpatient care best practice guidelines as recommended in the Best Practice Guidelines, Section 3 of this document. These are based on the Canadian Stroke Strategy guidelines and other international best practice reviews. These best practice guidelines are incorporated into the clinical protocols and order sets below. Regions shall adopt the following inpatient protocols and order sets: Routine Inpatient Stroke Admission (Section 7) Acute Ischemic Stroke Inpatient Care Post t-pa Administration (Section 8) Oral Care Guidelines for Care Dependent Stroke Patients(Section 5) Psychosocial Guidelines Recommendations and Best Practices (Section 4) Hypertension Management in Acute Stroke: APSS Recommendations (Section 9) STROKE PREVENTION AND ACCESS TO NEUROSURGICAL/NEUROINTERVENTIONAL SERVICES Secondary stroke prevention begins in hospital. Regions shall adopt the Inpatient Care Best Practice Guidelines related to the secondary prevention of stroke and complications. Refer to Section 3 Inpatient Stroke Care Best Practice Guidelines Stroke patients shall be referred to stroke prevention services upon discharge from hospital. Regions shall have access to neurosurgical/neurointerventional services through tertiary care centres. APSS Inpatient Care for Stroke 7 of 41

8 Neurological Vital Signs Regular use of a consistent valid neurological vital signs scale is recommended for use in the emergency medical management of patients to assist with the identification of stroke complications and to facilitate communication about the clinical status of the patient, between attending physician and consultant. NATIONAL INSTITUTE OF HEALTH STROKE SCALE APSS Pillar 2 is recommending the adoption of the National Institute of Health Stroke Scale for use in Alberta. National Institute of Health Stroke Scale training should take place for Emergency Room, Intensive Care Unit and Stroke Unit staff at Comprehensive and Primary Stroke Centres with yearly re-education as a minimum requirement. (APSS Pillar 2) All patients with acute stroke should have a rehabilitation screen within 48 hours of admission. Refer to Pillar 3 Rehabilitation and Community Reintegration document for rehabilitation recommendations and information on the appropriate assessments and management strategies for dysphagia screening and management, rehabilitation interventions and the need for ongoing stroke rehabilitation in other settings. The primary focus of rehabilitation in the acute phase is management of common post-stroke issues, factors related to stroke severity (e.g. positioning to avoid skin breakdown and aspiration) as well as improving the patients capacity for functional independence. Once the acute phase has passed rehabilitation staff on the acute stroke unit shall assess the need for provision of coordinated stroke rehabilitation in another setting directed at the management of stroke related activity limitations and enhancing participation in pre-morbid and/or new life roles. Discharge planning needs to begin early. A smooth transition from inpatient to community and outpatient care is a critical element to ensure stroke survivors are well supported once they leave hospital. Discharge plans shall be comprehensive and involve the stroke survivor, informal caregivers, primary health care providers and other community providers in their development. Discharge plans shall include: Available supports on discharge (formal and informal) - caregiver / family support and involvement Discharge environment Need for community care / home care services (pre-stroke and post-stroke functional status) Referrals to Stroke Prevention Services, Chronic Disease Management, and other health, recreation/leisure and community social support programs to promote self-management, access to education and information, and caregiver support services Mood Cognitive status, including attention and memory Perceptual status, including visual / spatial orientation and apraxia Safety risk secondary to persisting cognitive or perceptual impairments Ability to perform ADLs; if patient returning to community living, IADLs must also be addressed Work / school / leisure situation and ability to resume life roles Cultural / spiritual issues Education / information needs of patient and family/caregivers Medication management Requirements for optimizing nutritional status Driving status: ability to drive safely on discharge, need for alternate means of transportation, and/or need for referral for driving assessment APSS Inpatient Care for Stroke 8 of 41

9 3.0 INPATIENT STROKE CARE - BEST PRACTICE GUIDELINES The following guidelines incorporate Best Practice statements from the Canadian Stroke Strategy (Canadian Best Practice Recommendations for Stroke Care: 2008) and other international evidence-based stroke prevention best practice recommendations and guidelines. Wherever possible, recommendations from existing guidelines that had high levels of supporting evidence were used. Best practice guidelines have been incorporated into APSS inpatient care order sets, algorithms and protocols. Definitions of classes and levels of evidence used in these guidelines are described below: Class I - Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective. Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. o Class IIa Weight of evidence or opinion is in favor of the procedure or treatment. o Class IIb Usefulness/efficacy is less well established by evidence or opinion. Class III Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful / effective and in some cases may be harmful. Level of Evidence A Data derived from multiple randomized clinical trials Level of Evidence B Data derived from a single randomized trial or nonrandomized studies Level of Evidence C Expert opinion or case studies 3.1 Stroke Unit Care Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated in an interdisciplinary stroke unit (Evidence Level A) (CSQCS, SCORE, SIGN 64; CSS Acute Inpatient Care, Stroke Unit Care). STROKE UNIT CARE (CSS) Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated in an interdisciplinary stroke unit (Evidence Level A) (CSQCS, ESO, SCORE, SIGN 64). A stroke unit is a specialized, geographically defined hospital unit dedicated to the management of stroke patients (Evidence Level A) (AU, RCP). The core interdisciplinary team should consist of people with appropriate levels of expertise in medicine, nursing, occupational therapy, physiotherapy, speech language pathology, social work and clinical nutrition. Additional disciplines may include pharmacy, (neuro)psychology and recreation therapy (Evidence Level B) (AU, SCORE, SIGN 64). The interdisciplinary team should assess patients within 48 hours of admission and formulate a management plan (Evidence Level C). Clinicians should use standardized, valid assessment tools to evaluate the patient s stroke-related impairments and functional status (Evidence Level B) (ASA, RCP). Refer to Organization of Acute Stroke Units in Alberta, Section 6.0 of this document, for discussion of the guideline and its application in various settings. APSS Inpatient Care for Stroke 9 of 41

10 3.2 Neurovascular Imaging NEUROVASCULAR IMAGING (CSS) All patients with suspected acute stroke or transient ischemic attack should undergo brain imaging immediately (Evidence Level A) (ASA, CSQCS). In most instances, the modality of choice is a non-contrast Computerassisted Tomographic (CT) scan (Evidence Level B) (ASA, CSQCS). If Magnetic Resonance Imaging (MRI) is performed, the scan should include diffusion-weighted sequences to detect ischemia, gradient echo imaging for chronic and acute hemorrhage, FLAIR sequences for old ischemia, MR angiography of the circle of willis and gadolinium bolus MRA neck. (APSS Pillar 2, CSQCS, RCP, NZ; Evidence Level B) (CSS Hyper Acute Stroke Management, Neurovascular Imaging) Vascular imaging should be done as soon as possible to better understand the cause of the stroke event and guide management decisions. Vascular imaging may include CT angiography, magnetic resonance angiography, catheter angiography and duplex ultrasonography (Evidence Level B) (ASA). Carotid imaging should be performed within 24 hours of a carotid territory transient ischemic attack or nondisabling ischemic stroke (if not done as port of the original assessment) unless the patient is clearly not a candidate for carotid endarterectomy (Evidence Level B) (CSQCS, SIGN 14). Timely brain imaging (stat under one hour), 24/7 access to CT machine and expert CT interpretation (on-site or via telestroke) are important aspects of care in the hyper-acute phase and should be in place in each primary (major regional hospitals) or comprehensive stroke centre. Protocols and communication mechanisms shall be in-place if primary stroke centres (smaller centres) are standing down and unable to provide services 24/7. (Pillar 2) All stroke patients shall undergo brain imaging as soon as possible (24-72 hours) and before antiplatelet therapy is undertaken. 3.3 Blood Glucose Hyperglycemia can facilitate lactic acid production in ischemic tissue, increasing progression of the ischemic penumbra, worsening outcomes. BLOOD GLUCOSE (CSS) All patients with suspected acute stroke should have their blood glucose concentration checked immediately. Blood glucose measurement should be repeated if the first value is abnormal or if the patient is known to have diabetes. Hypoglycemia should be corrected immediately (Evidence Level B) (AU, CSQCS, ESO). Elevated blood glucose concentrations should be treated with glucose lowering agents (Evidence Level B) (CSQCS, AU, CSQCS, ESO; CSS Hyper Acute Stroke Management, Blood glucose abnormalities) APSS Inpatient Care for Stroke 10 of 41

11 3.4 Antithrombotic Therapy for Noncardioembolic Stroke or TIA ACUTE ASPIRIN THERAPY (CSS) After brain imaging has excluded intracranial hemorrhage all acute stroke patients should be given at least 160 mg of acetylsalicylic acid (ASA) immediately as a one time loading dose. (RCP, NZ, Evidence Level A, CSS Hyper Acute Stroke Management, Acute ASA Therapy) In patients treated with t-pa, ASA should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage. (Evidence Level A) (NZ, RCP). ASA ( mg daily) should then be continued indefinitely or until an alternative antithrombotic regime is started (Evidence Level A) (RCP). In dysphagic patients, ASA may be given by enteral tube or by rectal suppository. (Evidence Level A) (RCP) 1. All patients with ischemic stroke or TIA should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for anticoagulation. 2 (Evidence Level A) 2. Aspirin (50 to 325 mg/day) monotherapy, the combination of aspirin (25mg) and extended-release dipyridamole (200mg) (Aggrenox), or clopidogrel (Plavix 75mg) monotherapy are all acceptable options for initial therapy. 2,7 (Evidence Level A / I) 3. For patients with noncardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular events. 7 (Evidence Level A / I) 4. Long-term combinations of aspirin and clopidogrel are not recommended for secondary stroke prevention. 2 (Evidence Level A) 5. For patients who have an ischemic cerebrovascular event while taking aspirin, there is no evidence that increasing the dose of aspirin provides additional benefit. Although alternative antiplatelet agents are often considered for noncardioembolic patients, no single agent or combination has been well studied in patients who have had an event while receiving aspirin. 3 (Evidence Level B / II) 6. The addition of aspirin to clopidogrel increases the risk of hemorrhage. Combination therapy of aspirin and clopidogrel is not routinely recommended for ischemic stroke or TIA patients unless they have a specific indication for this therapy (ie, coronary stent or acute coronary syndrome) If cardioembolic cause is identified (atrial fibrillation) anticoagulation is warranted, however, the risk of stroke re-occurrence in stroke patients is relatively low (1-2% per week). The longer the delay in anticoagulation therapy the less likely the chance of hemorrhagic transformation, especially in larger infarcts. All stroke patients should undergo brain imaging before anticoagulation therapy is administered to determine the size of the infarct. Anticoagulation may be safely delayed for 7-10 days. Consider consultation with stroke neurologist in a comprehensive stroke centre (APSS Pillar 2) 8. With the exception of TIA, antiplatelet therapy should not be administered until brain imaging has been completed (APSS Pillar 2). APSS Inpatient Care for Stroke 11 of 41

12 3.5 Acute Management of Transient Ischemic Attack and Minor Stroke People diagnosed with a transient ischemic attack (TIA) have an increased risk of recurrent strokes and other vascular events. Risk of stroke following TIA is high, 10-20% within 90 days. 50% of these are within the first 2 days (48 hours) (Johnson et al, JAMA 2000: 284; ). Recurrent strokes are more likely than initial strokes to result in disability and death. Twenty to 40% of strokes are preceded by a TIA or non disabling stroke (2 Rothwell et al. Lancet Neurol 2006, 5, ) Appropriate prevention strategies for these individuals should include prompt access to the following four components of secondary stroke prevention: evaluate the event, implement interventions, initiate medications, and modify stroke risk factors. Emergency room patients with symptoms consistent with possible minor stroke or TIA shall be investigated using the Minor Stroke/TIA Algorithm and Minor Stroke / TIA Stroke Risk Assessment tool. Some TIA patients are at a significantly high risk of stroke and need to be managed urgently. High Risk Minor Stroke/TIA patients may be admitted to hospital for necessary diagnostics and interventions. ACUTE MANAGEMENT OF TRANSIENT ISCHEMIC ATTACK AND MINOR STROKE (CSS) Patients who present with symptoms suggestive of minor stroke or transient ischemic attack must undergo a comprehensive evaluation to confirm the diagnosis and begin treatment to reduce the risk of major stroke as soon as is appropriate to the clinical situation. All patients with suspected transient ischemic attack or minor stroke should have an immediate clinical evaluation and additional investigations as required to establish the diagnosis, rule out stroke mimics and develop a plan of care (Evidence Level B) (ASA, AU, CSQCS, ESO, EXPRESS, RCP). Use of a standardized risk stratification tool at the initial point of health care contact whether first seen in primary, secondary or tertiary care should be used to guide the triage process (Evidence Level B) (AU, CSQCS). Refer to APSS Emergency Management of Acute Stroke section 4.4 Minor Stroke / TIA Algorithm and section 4.5 Minor Stroke / TIA Stroke Risk Assessment Patients with suspected transient ischemic attack or minor stroke should be referred to a designated stroke prevention clinic or to a physician with expertise in stroke assessment and management or, if these options are not available, to an emergency department that has access to neurovascular imaging facilities and stroke expertise (Evidence Level B) (CSQCS, ESO, EXPRESS, SIGN 13). Patients with transient ischemic attack or minor stroke and > 70% carotid stenosis and select patients with acutely symptomatic 50% 69% carotid stenosis on the side implicated by their neurologic symptoms, who are otherwise candidates for carotid revascularization, should have carotid endarterectomy performed as soon as possible, within 2 weeks (Evidence Level A) (AU, CSQCS, ESO, NICE, NZ, SIGN 14). APSS Inpatient Care for Stroke 12 of 41

13 Patients with transient ischemic attack or minor stroke and atrial fibrillation should begin anticoagulation using warfarin immediately after brain imaging has excluded intracranial hemorrhage, aiming for a target therapeutic international normalized ratio of 2 to 3. [Evidence Level A] (AU, CSQCS, ESO, NICE, NZ, SIGN 14). All risk factors for cerebrovascular disease must be aggressively managed, through both pharmacologic and nonpharmacologic means, to achieve optimal control [Evidence Level A] (ESO). While evidence for the benefit of modifying individual risk factors in the acute phase is lacking, there is evidence of benefit when adopting a comprehensive approach, including antihypertensives and statin medication (EXPRESS). Refer to Inpatient Care for Acute Stroke Admissions document section Extracranial Carotid Artery Disease 1. Patients with TIA or nondisabling stroke and ipsilateral 70% - 99% internal carotid artery stenosis (measured on a catheter angiogram by 2 concordant non-invasive imaging modalities) should be offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke unless contraindicated). 2 (Evidence Level A) (CSS) 2. Carotid endarterectomy is recommended for selected patients with moderate (50 to 69%) symptomatic stenosis. These patients should be evaluated by a physician with expertise in stroke management. 2 (Evidence Level A) (CSS). 3. Carotid stenting may be considered for patients who are not operative candidates for technical, anatomical or medical reasons. 2 (Evidence Level C) (CSS). 4. Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity and mortality of <6%. 2 (Evidence Level A) (CSS). 5. Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis. (Evidence Level A) (CSS) 6. Asymptomatic carotid stenosis should be referred to a specialized stroke prevention clinic. Risk factors should be aggressively managed (APSS Pillar 1). 3.7 Dysphagia Assessment (Refer to APSS Rehabilitation Document Dysphagia Management Guidelines) DYSPHAGIA SCREEN AND ASSESSMENT (CSS) Patients with stroke should have their swallowing ability screened using a simple, valid, reliable bedside testing protocol as part of their initial assessment, and before initiating oral intake of medications, fluids or food (Evidence Level B) (CSQCS, NZ, SCORE, SIGN 78). Patients who are not alert within the first 24 hours should be monitored closely and dysphagia screening performed when clinically appropriate (Evidence Level C). Patients with stroke presenting with features indicating dysphagia or pulmonary aspiration should receive a full clinical assessment of their swallowing ability by a speech language pathologist or appropriately trained specialist who should advise on safety of swallowing ability and APSS Inpatient Care for Stroke 13 of 41

14 consistency of diet and fluids (Evidence Level A) (CSQCS, NZ, RCP, SCORE). Patients who are at risk of malnutrition, including those with dysphagia, should be referred to a dietitian for assessment and ongoing management. Assessment of nutritional status should include the use of validated nutrition assessment tools or measures (Evidence Level C) (AU). 3.8 Management of Subarachnoid and Intracerebral Hemorrhage MANAGEMENT OF SUBARACHNOID AND INTRACEREBRAL HEMORRHAGE (CSS) Patients with suspected subarachnoid hemorrhage should have an urgent neurosurgical consultation for diagnosis and treatment. (Evidence Level B). Patients with cerebellar hemorrhage should have an urgent neurosurgical consultation for consideration of craniotomy and evacuation of the hemorrhage. (Evidence Level C) Patients with supratentorial intracerebral hemorrhage should be cared for on a stroke unit. (Evidence Level C) CSS Hyper Acute Stroke Management, Management of Subarachnoid and Intracerebral Hemorrhage 3.9 Components of Acute Inpatient Care Risk for venous thromboembolism, temperature, mobilization, continence, nutrition and oral care should be addressed in all hospitalized stroke patients. Appropriate management strategies should be implemented for areas of concern identified during screening. Discharge planning should be included as part of the initial assessment and ongoing care of acute stroke patients Venous Thromboembolism Prophylaxis VENOUS THROMBOEMBOLISM PROPHYLAXIS (CSS) All stroke patients should be assessed for their risk of developing venous thromboembolism (including deep vein thrombosis and pulmonary embolism). Patients considered as high risk include patients with inability to move one or both lower limbs and those patients unable to mobilize independently. Patients who are identified as high risk for venous thromboembolism should be considered for prophylaxis provided there are no contraindications (Evidence Level B) (ESO). Early mobilization and adequate hydration should be encouraged with all acute stroke patients to help prevent venous thromboembolism (Evidence Level C) (AU, ESO, SCORE). The use of secondary stroke prevention measures, such as antiplatelet therapy, should be optimized in all stroke patients (Evidence Level A) (ASA, AU, NZ, RCP, SIGN 13). APSS Inpatient Care for Stroke 14 of 41

15 The following interventions may be used for patients with acute ischemic stroke at high risk of venous thromboembolism in the absence of contraindications: a. low molecular weight heparin (with appropriate prophylactic doses per agent) or heparin in prophylactic doses (5000 units twice a day) (Evidence Level A) (ASA, AU, ESO); b. external compression stockings (Evidence Level B) (AU, ESO). For patients with hemorrhagic stroke, nonpharmacologic means of prophylaxis (as described above) should be considered to reduce the risk of venous thromboembolism [Evidence Level C] Temperature TEMPERATURE (CSS) Temperature should be monitored as part of routine vital sign assessments (every 4 hours for first 48 hours and then as per ward routine or based on clinical judgment) (Evidence Level C) (ESO). For temperature greater than 37.5 C, increase frequency of monitoring and initiate temperature reducing measures (Evidence Level C) (ESO). Sources of fever should be treated and antipyretic medications should be administered to lower temperature in febrile patients with stroke to < 38 C (Evidence Level B) (ASA, CSQCS). In case of fever, the search for a possible infection (site and cause) is recommended, in order to start tailored antibiotic treatment (Evidence Level C) (ESO) Mobilization MOBILIZATION (CSS) Mobilization is defined as the act of getting a patient to move in the bed, sit up, stand, and eventually walk. All people admitted to hospital with acute stroke should be mobilized as early and as frequently as possible (Evidence Level B) (AU) and preferably within 24 hours of stroke symptom onset, unless contraindicated (Evidence Level C) (CSQCS). Within the first 3 days after stroke, blood pressure, oxygen saturation and heart rate should be monitored before each mobilization (Evidence Level C) (AVERT). All people admitted to hospital with acute stroke should be assessed by rehabilitation professionals as soon as possible after admission (Evidence Level A) (RCP), preferably within the first 24 to 48 hours (Evidence Level C) (NZ). Refer to section 5, Stroke rehabilitation, for related recommendations. APSS Inpatient Care for Stroke 15 of 41

16 3.9.4 Continence CONTINENCE (CSS) All stroke patients should be screened for urinary incontinence and retention (with or without overflow), fecal incontinence and constipation (Evidence Level C) (RNAO). Stroke patients with urinary incontinence should be assessed by trained personnel using a structured functional assessment (Evidence Level B) (AU). The use of indwelling catheters should be avoided. If used, indwelling catheters should be assessed daily and removed as soon as possible (Evidence Level C) (AU, CSQCS, RCP, VA/DoD). A bladder training program should be implemented in patients who are incontinent of urine (Evidence Level C) (AU, VA/DoD). The use of portable ultrasound is recommended as the preferred noninvasive painless method for assessing post-void residual and eliminates the risk of introducing urinary infection or causing urethral trauma by catheterization (Evidence Level C) (CCF). A bowel management program should be implemented in stroke patients with persistent constipation or bowel incontinence (Evidence Level A) (VA/DoD) Nutrition NUTRITION (CSS) The nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool (Evidence Level B) (AU, RPC, SIGN 78). Results from the screening process should guide appropriate referral to a dietitian for further assessment and the need for ongoing management of nutritional and hydration status (Evidence Level C) (NZ, SIGN 78). Stroke patients with suspected nutritional and/or hydration deficits, including dysphagia, should be referred to a dietitian for: a. recommendations to meet nutrient and fluid needs orally while supporting alterations in food texture and fluid consistency based on the assessment by a speech language pathologist or other trained professional (Evidence Level C) (AU, SCORE); b. consideration of enteral nutrition support (tube feeding) within 7 days of admission for patients who are unable to meet their nutrient and fluid requirements orally. This decision should be made collaboratively with the multidisciplinary team, the patients, and their caregivers and families (Evidence Level B). (AU, SIGN 78). c. Also refer to recommendation 6.1, Dysphagia assessment, for dysphagia management. APSS Inpatient Care for Stroke 16 of 41

17 3.9.6 Oral Care ORAL CARE (CSS) All stroke patients should have an oral/dental assessment, which includes screening for obvious signs of dental disease, level of oral care and appliances, upon or soon after admission (Evidence Level C) (Canadian Dental Association). For patients wearing a full or partial denture it must be determined if they have the neuromotor skills to safely wear and use the appliance(s) (Evidence Level C). An appropriate oral care protocol should be used for every patient with stroke, including those who use dentures [Evidence Level C] (SIGN 78). An oral care protocol should address areas including frequency of oral care (twice per day or more), types of oral care products (toothpaste, floss and mouthwash) and specific management for patients with dysphagia and should be consistent with current recommendations of the Canadian Dental Association (Evidence Level B) (Canadian Dental Association). If concerns are identified with implementing an oral care protocol, consider consulting a dentist, occupational therapist, speech language pathologist and/or dental hygienist (Evidence Level C). If concerns are identified with oral health and/or appliances, patients should be referred to a dentist for consultation and management as soon as possible (Evidence Level C) Blood Pressure and Antihypertensive Therapy Hypertension 1. Antihypertensive treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in persons who have had an ischemic stroke or TIA and are beyond the hyperacute period. 2,3 (Evidence Level A / I) 2. Blood pressure lowering treatment is recommended for patients who have had a stroke or transient ischemic attack to a target of less than 140/90 mm Hg (135/85 mm Hg for home or ambulatory measurements). 2 (Evidence Level C) 3. In patients who have had a stroke, treatment with an angiotensin-converting enzyme (ACE) inhibitor/diuretic combination is preferred. The choice of blood pressure lowering agent and the target blood pressure will also depend upon other associated comorbidities (eg coronary artery disease, congestive heart failure, renal impairment, diabetes etc.). 2,3 (Evidence Level B / I) Please refer to Canadian Hypertension Education Program (CHEP) guidelines for the appropriate measuring and frequency of blood pressure measurement. 4. Several lifestyle modifications have been associated with blood pressure reductions. Patients with hypertension or at risk for hypertension should be advised of lifestyle modifications.. 2,3 (Evidence Level C / II) APSS Inpatient Care for Stroke 17 of 41

18 3.11 Cholesterol 1. Ischemic stroke or TIA patients with LDL-C of >2.0 mmol/l, should be managed with lifestyle modification and dietary guidelines. 2 (Evidence Level A) 2. Administration of statin therapy with intensive lipid-lowering effects is recommended for patients with atherosclerotic ischemic stroke or TIA to reduce the risk of stroke and cardiovascular events. Target goal of an LDL-C of <2.0 mmol/l and TC/HCL-C <4.0 mmol/l 2 (Evidence Level A / I ) 2,7. Refer to Pillar 1 Secondary Stroke Prevention document 3. Statins are the first line agents to achieve the target cholesterol levels. Ezetimibe should be considered in patients who are intolerant to statin therapy Modifiable Risk Factors Persons who have had a stroke should be assessed for and given information about vascular risk factors, lifestyle management (diet, sodium intake, smoking, alcohol, exercise, stress management), and be counseled about possible strategies to modify their lifestyle and risk factors Diet 1. A healthy balanced diet is a diet high in fresh fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources and low in saturated fat, cholesterol and sodium in accordance with Canada s Food Guide to Health Eating. 3 (Evidence Level B / I) Sodium 1. The recommended daily sodium intake from all sources is the Adequate Intake by age. For persons 9-50 years, the Adequate Intake is 1500 mg. Adequate Intake decreases to 1300 mg for persons years and to 1200 mg for person > 70 years. A daily upper consumption limit of 2300 mg should not be exceeded by any age group. 3 (Evidence Level B / I) Smoking 1. All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke. 3 (Evidence Level C / I) 2. Interventions to promote smoking cessation may include nicotine replacement therapy and behavioral therapy. 2 (Evidence Level B / II) Alcohol 1. Patients with prior ischemic stroke or TIA who are heavy drinkers should eliminate or reduce their consumption of alcohol. 3 (Evidence Level A / I) (a) A safe level may consist of: 1-2 drinks per day Men: less than 14 drinks per week; Women: less than 9 drinks per week 2 (Evidence Level C / III) (b) For some people, 2 drinks may be considered too much (eg. Low body weight or elderly). One standard drink is equivalent to: 1 bottle (350 ml) of beer (5% alcohol) 5 oz. (150 ml) of wine (12% alcohol) 1 1/2 oz. (50 ml) of liquor (40% alcohol) ( For more information on alcohol with diabetes, please refer to the following website: APSS Inpatient Care for Stroke 18 of 41

19 Obesity 1. Weight reduction should be advised for all overweight ischemic stroke or TIA patients to maintain the goal of a BMI of 18.5 to 24.9 kg/m 2 and a waist circumference of < 88 cm for women and < 102 cm for men. 2,4 (Evidence Level B / II). Clinicians should encourage weight management through an appropriate balance of caloric intake, physical activity, and behavioral counseling. 3 (Evidence Level C / II) 2. A diet that is low in fat (especially saturated fat) and sodium, and high in fruit and vegetables is recommended. 2 (Evidence Level II/B) Please refer to the National Obesity Guidelines: ( Physical Activity 1. For those with ischemic stroke or TIA who are capable of engaging in physical activity, an accumulation of 30 to 60 minutes of moderate-intensity physical exercise (ie. brisk walking, jogging, cycling or other dynamic exercise) 4 to 7 days each week should be advised to reduce risk factors and comorbid conditions that increase the likelihood or recurrence of stroke. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended. 2,3 (Evidence Level C / II) Hyperhomocysteinemia 1. For patients with ischemic stroke or TIA and hyperhomocysteinemia, daily standard multivitamin preparations are reasonable to reduce the level of homocysteine. There is no evidence that reducing homocysteine levels will lead to a reduction of stroke occurrence. 3 (Evidence Level A / I) 3.13 References 1. Heart and Stroke Foundation of Ontario. Best practice guidelines for stroke care: A resource for implementing optimal stroke care: Available at: 2. Canadian Stroke Strategy Best Practices and Standards. Canadian Best Practice Recommendations for Stroke Care: Canadian Stroke Strategy Best Practices and Standards Working Group. December Available at: 3. Sacco et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from the American Heart Association / American Stroke Association council on stroke. American Heart Association, Available at: 4. Canadian Hypertension Education Program. Canadian hypertension education program recommendations: Available at: 5. Canadian Diabetes Association. Canadian diabetes association guidelines. Available at: 6. Heart and Stroke Foundation of Canada. Available at: 7. Adams et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke, 2008, 39; Available at: APSS Inpatient Care for Stroke 19 of 41

20 8. Diener et al. Rational, design and baseline data of a randomized, double-blind, controlled trial comparing two antithrombotic rejimens (a fixed-dose combination of extended-release dipyridamol plus ASA with clopidogrel) and telmisartin versus placebo on patients with strokes: The prevention regimen for effectively avoiding second strokes trial (PRoFESS). Cerebrovasc Dis, 2007; 23: Fuster et al. Circulation ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation; Circulation 2006;114; Amarenco et al. High-Dose Atorvastatin after Stroke of Transient Ishcemic Attack. N Engl J Med 2006;355: PSYCHOSOCIAL GUIDELINES RECOMMENDATIONS AND BEST PRACTICES Stroke often changes an individuals ability to participate in previous life roles and activities, significantly impacting quality of life of the survivor and informal caregiver. Timely psychosocial support and education are key elements that help to optimize recovery while in hospital and later after discharge. 4.1 Patient and Family Education Note: Patient, family and caregiver education is an integral part of stroke care that should be addressed at all stages across the continuum of stroke care for both adult and pediatric patients. Education includes the transfer of information and skills, and may include additional training components as required to transfer skills for self/patient management for both adult and pediatric stroke patients and their families. Education that is integrated and coordinated should be provided in a timely manner across the continuum of stroke care for all patients with stroke or at risk for stroke, as well as their families and caregivers. Educational content should be specific to the phase of care or recovery across the continuum of stroke care and appropriate to patient, family and caregiver readiness and needs (Evidence Level B). The scope of the educational content should cover all aspects of care and recovery, including the nature of stroke and its manifestations, signs and symptoms; impairments and their impact and management, including caregiver training; risk factors; post-stroke depression; cognitive impairment, discharge planning and decision-making; community resources, services, and support programs; and environmental adaptations and benefits (Evidence Level A) (AU, CSQCS, Hare et al., 56 NZ, RCP). Education should be interactive, timely, up to date, provided in a variety of languages and formats (written, oral, aphasia friendly, group counselling approach), and specific to patient, family and caregiver needs and impairments. The provision of education should ensure communicative accessibility for stroke survivors (Evidence Level B) (AU, CSQCS, NZ, RCP). 1. All patients / families have access to education resources addressing: a. normal emotional reactions to acute stroke for survivor and informal caregiver (i.e. shock, grief and loss issues, fear of the unknown etc.) b. community agencies and resources available (i.e. stroke support group) c. post stroke rehabilitation d. coping strategies e. intimate relations f. stroke and the affects of stroke APSS Inpatient Care for Stroke 20 of 41

21 g. modifiable risk factors and stroke prevention h. medications i. swallowing and feeding j. communication k. memory and problem solving l. energy conservation m. stroke in younger adults n. driving o. returning to previous or new life roles p. role of caregiver q. home modifications 2. Key Resources Let s Talk About Stroke (print) Heart and Stroke Foundation of Canada Living with Stroke (workshop) Heart and Stroke Foundation of Canada 4.2 Psychosocial Support 1. Psychosocial Service Delivery Where available, social work services should be offered to patients and families in the acute phase. Intervention may include crisis intervention, legal/ financial / discharge planning and illness adjustment. 2. Routine referral for social work services in neurorehabilitation programs and / or community support programs on behalf of patients and families. 3. Identification and Management of Post Stroke Depression (1) All patients with stroke should be considered to be at a high level of risk for depression. At the time of the first assessment, the clinical team should determine whether the patient has a history of depression or risk factors for depression (Evidence Level B) (SCORE). All patients with stroke should be screened for depression using a validated tool (Evidence Level A) (SCORE) (for recommended tools, see complete guideline). Screening should take place at all transition points and whenever clinical presentation indicates. Transition points may include: a. upon admission to acute care, particularly if any evidence of depression or mood changes is noted b. before discharge home from acute care or during early rehabilitation if transferred to inpatient rehabilitation setting c. periodically during inpatient rehabilitation d. periodically following discharge to the community Patients identified as at risk for depression during screening should be referred to a psychiatrist or psychologist for further assessment and diagnosis (Evidence Level B) (RCP, RCP-P). Patients with mild depressive symptoms should be managed by watchful waiting, with treatment being started only if the depression is persistent (Evidence Level A) (RCP). Patients diagnosed with a depressive disorder should be given a trial of antidepressant medication, if no contraindication exists. No recommendation is made for the use of one class of antidepressants over another; however, side effect profiles suggest that selective serotonin reuptake inhibitors (SSRIs) may be favoured in this patient population (Evidence Level A) (ASA). In adult patients with severe, persistent or troublesome tearfulness, SSRIs are recommended as the antidepressant of choice (Evidence Level A) (ASA). Treatment should be monitored and should continue for a minimum of 6 months, if a good response is achieved (Evidence Level A) (RCP). APSS Inpatient Care for Stroke 21 of 41

22 All patients with apparent depressive symptoms should be carefully screened for the presence of hypoactive delirium (Evidence Level C). Routine use of prophylactic antidepressants is not recommended in post-stroke patients (Evidence Level A) (ASA, RCP). Patients should be given information and advice about the impact of stroke, and the opportunity to talk about the impact of illness upon their lives (Evidence Level B) (RCP). Patients with marked anxiety should be offered psychologic therapy (Evidence Level B) (RCP). Patients and their caregivers should have their individual psychosocial and support needs reviewed on a regular basis as part of the longer-term recovery and management of stroke (Evidence Level A) (RCP). 4.3 References 1. Canadian Stroke Strategy. Canadian Best Practice Recommendations for Stroke Care: ORAL CARE GUIDELINES FOR CARE DEPENDENT STROKE PATIENTS 5.1 Purpose To provide a standard of oral care for adult stroke patients. Oral care is an integral part of total body care that must be carried out consistently. 5.2 Rationale The acute stroke population is often unable, for physical and/or cognitive reasons, to perform adequate oral care, and, in addition, may receive treatment(s) that cause or exacerbate oral health problems (e.g., xerostomia). Poor oral hygiene results in increased deposition of plaque and decreased clearance of secretions and food debris. These oral conditions have been strongly linked with the elevated presence of respiratory pathogens in oropharyngeal secretions.1 Pneumonia is the leading cause of acute care hospitalization, and in the stroke population is frequently precipitated by aspiration of oropharyngeal bacteria. Aspiration is a common feature of dysphagia, a swallowing impairment reported by various studies to be present in 45% to 76% of acute stroke patients (depending, in part, on site of lesion).2,3 Aspiration after a stroke has been reported in approximately half of stroke patients, and of patients known to have experienced aspiration, incidence of pneumonia ranges from ~ 12% to 68%.4,5,6 Patients can aspirate on their secretions at any time of the day, or during oral intake of food and liquids. Studies have found the strongest predictors of aspiration pneumonia are: (1) dependency for feeding; and (2) dependency for oral care.7,8 Other well correlated predictors of aspiration-related pneumonia are: number of decayed teeth, tube feeding, greater than one medical condition, reduced cognitive status, use of suctioning, number of medications taken, COPD, CHF, diabetes, and smoking. A growing body of literature has documented that routine oral care significantly reduces the risk of oral mucosa breakdown and the subsequent risk of aspiration pneumonia.8,9 Given the weight of this evidence, the promotion of quality oral care should be identified as a clinical priority for the stroke population. APSS Inpatient Care for Stroke 22 of 41

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