STROKE AND TIA MULTIDISCIPLINARY CARE PATHWAY 6 th Edition Cornwall Stroke Service (Royal Cornwall Hospital Trust Facing)

Transcription

1 STROKE AND TIA MULTIDISCIPLINARY CARE PATHWAY 6 th Edition Cornwall Stroke Service (Royal Cornwall Hospital Trust Facing) 1. Aim/Purpose of this Guideline The aim of this document to inform clinicians on pathway for patients with suspected stroke or TIA in Cornwall (RCHT facing). 2. The Guidance Page 1 of 8

2 STROKE AND TIA MULTIDISCIPLINARY CARE PATHWAY 6 th Ed Cornwall Stroke Service (Royal Cornwall Hospital Trust facing) Suspected Stroke or TIA ACUTE STROKE IS AN EMERGENCY: DIAL 999 Ambulance team follows Advanced Stroke Management Pathway ADMISSION IS REQUIRED via ED YES DOES THE PATIENT NEED HOSPITAL ADMISSION? (SEE BO 1) Admit patients to RCHT with: Acute Stroke (<6 hrs) Disabling stroke And/or swallowing problems Crescendo TIA NO ADMISSION IS NOT REQUIRED Follow Acute Stroke Pathway guideline Acute Stroke Unit, Critical care Unit Assess swallow 4 hours and mobility within 24 hours of admission Ensure nutrition within 24 hours Complete investigations, start rehabilitation, agree rehab goals with patient and start care plans as per Acute Stroke Management Guidelines Start secondary prevention as per guidelines documenting AF and treatment plan Provide patient with information pack Educate patient and carer regarding diagnosis and secondary prevention Document stroke diagnosis and prognosis and discussion with patient Consider palliation if devastating stroke Consider referral to the Early Supported Discharge Team via inpatient therapy team Aim for transfer to rehab unit or discharge home within 7 days Phoenix ward senior staff daily liaise with stroke rehab unit for bed availability Refer immediately to Daily TIA clinic by Use online TIA clinic Proforma and ABCD2 score Discharge Home Medication and discharge plan explained to patient and family Copy of discharge summary given to patient Completion of Section 2 by nursing staff if care package required or restart / increase of existing care package. MDT team to arrange equipment and further community rehab prior to discharge If complex needs (e.g. palliative management at home) the Integrated Discharge Team Liaison Nurse completes full assessments prior to discharge to establish care needs and correct funding stream and to liaise with GP and appropriate community care team Community Stroke Coordinators informed of discharge by audit data base If patient has visual field defect, double vision or ocular nerve palsies please refer to orthoptist Faye Gibson via letter, or fax Transfer to Stroke Rehabilitation Unit Camborne Redruth Community Hospital or Bodmin Hospital Inform patient and relatives of transfer Phoenix senior staff book rehabilitation bed Written and verbal handover by MDT team Discharge letter and TTO to be completed by medical staff prior to transfer Residential or Nursing Home Care Completion of nursing needs assessment within 48 hours after decision made by MDT that care home is appropriate Completion of Section 5 within 24 hours from the Section 2 ( allow minimum of 3 working days, complete only if patient fit for discharge ) Allocation of social worker within 3 working days Follow up by Community Stroke Care Co-ordinator at 0, 1 & 6 months after their hospital discharge and then annually. Referral to GP, community specialist stroke therapy staff, community rehab team or Stroke Physician by Community Stroke Coordinator. Page 2 of 8

3 STROKE AND TIA MULTIDISCIPLINARY CARE PATHWAY 6 th Ed Cornwall Stroke Service Guidance Notes This Care pathway is intended to be used as a decision making tool to assist the coordinated care of stroke patients. It is intended to provide the guidance that both clinicians, managers and patients may need at key decision points in the management of stroke. It is not intended to provide 'rules' for every possible eventuality in stroke management and should be used pragmatically, but clinicians may need to justify substantial variations from the pathway. For feedback on this protocol or for clinical advice in individual cases contact Dr Frances Harrington, Dr Abhijt Mate or Dr Katja Adie at the Royal Cornwall Hospital, extension , or [email protected]. FAST TEST 1 The Face Arm Speech Test is used for screening for diagnosis of stroke or TIA outside the hospital setting (e.g. paramedic team). FACE- is there any facial weakness or numbness ARM- is there any arm numbness or weakness SPEECH- is there any speech or language impairment TEST all 3 symptoms Any positive result means a stroke is more likely than not and the patient should be transferred to hospital as a matter of urgency (Category 1 ambulance). The FAST test is sensitive (82%) and specific (83%) and has a positive predictive value of 89%. Section 2 of Single Assessment Process Complete this section if patient requires community services (new care package, restart or increase to existing care package and the patient is ready for discharge or ready for commencement of assessments for complex discharge planning or Residential/ Nursing Care, Palliative Care). If for information only or the provisions of services is not required immanently then tick box non urgent. Tick box urgent if the patient has not been admitted within 24hrs and remains in A&E, MAU or in Outpatient clinic as the patient remains a community patient and timescales are irrelevant. Then fax to the Integrated discharge Team FA Section 5 of Single Assessment Process Once ward staff can confirm the actual discharge date complete Section 5: Part A: patient details, Part C: actual discharge date Then fax to the Integrated discharge Team FA Minimum notice 1 working day. ABCD2 Score 2 Is a prognostic score to identify people at high risk of recurrent TIA or stroke Points A- Age 60 years 1 B- BP 140/90 mmhg 1 C- Clinical signs Unilateral weakness Speech disturbance only D- Duration 60 minutes minutes Page 3 of D- Diabetes 1 Maximum score 7 A score of 4 indicates a nearly 8% of risk of TIA/stroke recurrence within the next 2 days, whereas the risk with a score of < 4 is 1% at 2 days. Therefore patients with a risk score of 4 should be investigated and treated in the TIA clinic within 24 hours. Comprehensive Health Assessment (Nursing Needs) for complex package or Residential Care or Nursing Care For patients with complex needs complete Section 2 as explained. If the patient is NOT ready for commencement of assessments tick box this is an early referral for social services. Tick the box Section 2 Notification if the patient is ready to commence with comprehensive assessments. Then fax to the Integrated Discharge Team FA Discharge plans will be coordinated through the Discharge Liaison Nurse. References 1. Harbison J, Hossain O, Jenkinson D et al. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face, arm and speech test. Stroke 2003; 34 (1): Johnston SC, Rothwell PM, Ngyuen-Huynh MN et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369 (9558): Nor AM, Davies J, Sen B et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurology 2005; 4 (11): Intercollegiate Stroke Working Party National Clinical Guidelines for Stroke. 4 th ed Royal College of Physicians Clinical Effectiveness Unit, NICE. National Clinical guidelines for diagnosis and management of acute stroke and TIA RCP Rothwell PM, Eliasziw M, Gutnikov SA et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 2004;35(12):

4 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Timely admission to Stroke Unit, Timely referral to TIA clinic Stroke Team SENTINEL STROKE NATIONAL AUDIT PROGRAMME, TIA clinic Daily Bimonthly review at Stroke Operational Group Meeting Stroke Operational Group Meeting held weekly, led by manager Debra Shields At Stroke Operational Group Meetings, led by manager Debra Shields 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 4 of 8

5 Appendix 1. Governance Information Document Title Date Issued/Approved: 02/07/2014 Stroke and TIA Multidisciplinary Care Pathway 6th Edition Cornwall Stroke Service (Royal Cornwall Hospital Trust facing) Date Valid From: 02/07/2014 Date Valid To: 02/07/2017 Directorate / Department responsible (author/owner): Dr Katja Adie, Eldercare Department Daniel Nash, Medical Student Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Pathway for patients with suspected stroke or TIA (transient ischaemic attack) in Cornwall TIA or stroke RCHT PCH CFT KCCG Rob Parry Date revised: 02/07/14 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Management of Acute Stroke Stroke Operational Group Andrew Virr Not Required Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Internet & Intranet Stroke Medicine Intranet Only Links to key external standards Related Documents: Governance Team can advise Advanced Stroke Management Pathway, Stroke Thrombolysis, Secondary Page 5 of 8

6 Training Need Identified? Prevention Guidelines Stroke and TIA, Peninsula Referral Guidelines for Early Decompressive Surgery in Acute Ischaemic Stroke, Peninsula Network Guidance on Novel Anticoagulants for Stroke and TIA No Version Control Table Date Versio n No Summary of Changes Changes Made by (Name and Job Title) 2008 V1.0 Initial Issue K Adie, consultant 2009 V2.0 Updated with new clinical evidence K Adie, consultant 2010 V3.0 Updated with new clinical evidence K Adie, consultant 2011 V4.0 Updated with new clinical evidence K Adie, consultant 2012 V5.0 Updated with new clinical evidence K Adie, consultant 2014 V6.0 Updated with new clinical evidence K Adie, consultant D Nash, medical student All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 6 of 8

7 Appendix 2.Initial Equality Impact Assessment Screening Form Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Stroke and Multidisciplinary Care Pathway 6 th Edition. Cornwall Stroke Service (Royal Cornwall Hospital Trust Facing) Directorate and service area: Existing Name of individual completing Telephone: assessment: K Adie 1. Policy Aim* The aim of this document to inform clinicians of the care pathway following stroke or TIA in Cornwall. 2. Policy Objectives* The guidance enables clinical staff to ensure patients following stroke or TIA get appropriate care and interventions to reduce risk of further cerebrovascular events. 3. Policy intended Outcomes* 5. How will you measure the outcome? 5. Who is intended to benefit from the Policy? 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? Gold standard stroke care SENTINEL STROKE NATIONAL AUDIT PROGRAMME Monthly board report Patients with new stroke or TIA in Cornwall This is existing policy and has been widely consulted Clinicians at RCHT, GPs, Managers, Stroke survivors This is not a procedure but a clinical guideline. It has been signed off by the stroke operational group (see notes of meeting 28/03/2014. c. Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Page 7 of 8

8 Race / Ethnic communities /groups Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Please sign and date this form. Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ A summary of the results will be published on the Trust s web site. Signed Date Page 8 of 8