2012-06-08 best practice in ischaemic stroke [red] team

7/22/2019 2012-06-08 Best Practice in Ischaemic Stroke [RED] Team

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OPEN-N-Older People in Europe:

New Needs Intensive Erasmus Programme8th June 2012


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A stroke is a clinical syndrome characterised by rapidly

developing clinical symptoms and / or signs of focal, and attimes global loss of cerebral function, with symptoms lasting

more than 24 hours or leading to death, with no apparent

cause other than that of vascular origin (WHO, 1978).

Ischaemic Stroke 85% of cases

2.3 million cases of ischaemic stroke in the elderly across

Europe each year (Launer & Hofman, 2000),

1.05 million older people die and 15-30% permanently

disabled (EHN, 2008).

Average cost 16,500 for each case of ischaemic stroke so it

costs the EU 4 billion annually (Truelsen et al , 2005)


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Best Practice Initial Response (Arianna)

Thrombolysis

Country Review

Management (Michelle)

Stroke Units

Country Review Nursing Care (Tiago)

Nursing Care

Country Review

Rehabilitation (Katerina & Siobhan)

Very Early Mobilisation

Early Supported Discharge

Country Review

Conclusion


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Thrombolysis: is the lysis of blood clots by pharmacological

means. It works by stimulating fibrinolsysis by plasmin through

infusion of tissue plasminogen activator (t-PA), the protein thatnormally activates plasmin. By breaking down the clot, the

decrease process can be arrested, or the complications reduced

(Vatankaha et al, 2005).

Diagnostic test before the therapy: CT, MRI, blood tests,

specialist advice if necessary (cardiological, neurosurgical,

intensivist) (Brunner & Suddarth, 2006)

When thrombolisys can be administrated: the rt-PA therapy

had been licensed for patient up to 75 years in age in many

European country and was recently extended to 80 years. This

age restriction results from the potential higher risk of cerebral

bleeding in the elderly. At any rate age is an independent risk

factor for the stroke and its good or bad prognosis (Ryan &

Harbison, 2011)


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When thrombolysis cannot be administrated: in case of

hemorrhagic diathesis, history or suspect of intracranial

hemorrhage, central nervous system disease (neoplasia,aneurysm..), severe uncontrolled hypertension, ulcer disease of the

gastro-intestinal, platelet count


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Greece Ireland Italy NorthernIreland UK Portugal

CT scan takes 1 hour,

Thrombolysiswithin 2 hoursof onset ofstrokesymptoms.

Urgent brain scan(CT/MRI),

Thrombolysiswithin 4.5 hours ofinitial symptoms,

Contraindications

CT/MRI brainscan,

Blood tests,

Thrombolysiswithin 3 hours.

Stroke teamcalled,

CT Scan,

Thrombolysiswithin 4.5hours of initialsymptoms.

Greenwaypre-hospital

assessment,

CT scan,

Thrombolysiswithin 3 hours.


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STROKE UNITS - A major objective in the treatment of stroke is

represented by the organisation of care for acute patients and the access

to so called stroke units have been recommended by Helsinborgdeclaration (1995) for all patients with stroke in Europe.

The first dedicated units for stroke patients were organised in Europe and

the USA in the beginning of the 1960s they had an experimental character

and resembled the organisation of coronary care units. In the 1970s and

80s stroke units were developed in Northern Europe and had mainly a

rehabilitative character, while in the 1990s some intensive units for stroke

care were organised, with controversial efficacy results (Candelise et al,

2005).

Effective stroke units have 3 essential components

1) Specialist multidisciplinary team,

2) Discrete, defined ward area for caring for patients,

3) Robust government structure with evidence based pathways

& protocols to define care (Ryan & Harbison, 2011).


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Stroke Units vs Neurological/Medical wards

The Stroke Unit Trialists Collaboration (2007) meta-analysis have shown thatcare in stroke units substantially reduces the risk of both death and permanent

disability by 1/3,

This is supported by evidence published from the Canadian Stroke Network

register in 2010. They found that stroke units benefit the whole stroke population

and increased availability of stroke unit care is associated with a reduction in 6

month stroke mortality at 36% and an increase in discharge home at 28% (Smith

et al, 2010).


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Although several studies have now confirmed that all age groups benefit from

stroke unit care.

The degree of early benefit may not be as great in older people as those younger. However even those over 80 years have consistently been found to derive benefit

from active investigation and management of stroke,

It is arguable given that their expected outcomes may actually be poorer than for

younger subjects that such active management is in fact proportionally more

important in older stroke patients (Ryan & Harbison, 2011)

Mobile Stroke Units only 2-5% of patients who have a stroke receive

thrombolytic treatment mainly because of delay in reaching the hospital,

Evidence suggests that mobile stroke units in the form of specialised ambulance

equipped with a CT scanner, point of care laboratory and telemedicine connection

substantially reduced median time from alarm to therapy decision. The MSU

strategy offers a potential solution to the medical problem of the arrival of most

stroke patients at the hospital too late for treatment (Walter et al, 2012).


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Author Study Design FindingsKrespi et al (2003) Stroke Unit vs Neurology Ward

Before and after study

Shorter length of stay

Fjaertoft et al (2004) Stroke Unit vs Neurology WardRCT

Reduce stay in hospital

Evans et al (2001) Stroke Unit vs Neurology WardThree groups

Better functional status at 3, 6 and12 monthsReduction in complications

Diez-Tejedor and Fuentes (2001) Stroke Unit vs Neurology WardProspective

Better functional status at discharge

Fuentes et al (2006) Stroke Unit vs Neurology WardHistorical controlsNeurological setting

Reduction in complicationsReduction in long stayhospitalisationReduction in health costs

Cadilhac and Ibrahim (2004) Stroke Unit vs Neurology WardProspective single blind

Higher rates of adherence to keyprocesses of care in SU than inother models

Walter et al (2012) Mobile Stroke UnitRCT

Reduces time from alarm totherapeutic decision.


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Greece Ireland Italy NorthernIreland UK

Portugal

Few strokeunits

Mainly caredfor inpathologicalward

Few strokeunits

Mainly caredfor inneurological/medical ward

Stroke Unitsmainly in thecentral hospital

Regionalhospitalsmedical orneurologicalward

Mainly strokeUnits

Few inmedical wards

Mainly strokeunits


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Acute Phase

preserving one's life;

prevent complications;

meet human needs changed;

After patient stabilization :

develop greater functional independence of the person and

the family (AHA, 2009).


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NURSING DIAGNOSIS

Ineffective Breathing

provide frequent alternations of position;

teaching /instructing/ train /techniques encourage

coughing;

thin secretions with nebulizer;

aspiration of secretions (Good et al, 1996).


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Communication compromised

Manage / Optimizing Communications

Speak slowly, articulating his words in a tone of normal

voice (Waddington, 2009)

Staying within the range of focus as the person;

Use simple words and phrases and short;

Writing, reading, mime, pictures or gestures;

Speech Therapy


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Intestinal Elimination and impaired bladder

Impaired bladder

To evaluate the ability of the person to control urination;

Teach / Instruct / Train the implementation of pelvic muscle

exercises;

Advise urinary elimination before sleep;Teach / Instruct / Train autonomy bladder;

Permanent urinary catheter - Last Appeal (Nazarko, 2003)

Intestinal Elimination

Advise / educate about regular bowel habits;Planning high-fiber diet and strengthening water

Teach / Instruct / Train technique training intestinal (Booth,

2009).


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Compromised swallowing reflex

Search swallowing reflex daily oral administration

through the small amounts of water;

Inspect the oral cavity after the meal;

Planning for proper diet (Lees et al, 2006)

Provide adaptive equipment;

Inform about adaptive equipment;

Encouraging self-feeding;

Teaching about adaptive strategies for food


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IVfluids/access Medication,

ECG, Observing thepatient, Personal care Consultingthe patient

Vital signs O2 therapy IV

fluids/access Drugs, Nutrition Hydration Continence Hygiene Mobilisation

Vital signs, O2 therapy, IV

fluids/access, Medication, Mobilisation, PersonalCare

IV fluids/access ECG Routine bloods

O2 therapy Vital signs Repositioning Earlymobilisation Personal Care

Vital signs, Oxygentherapy,

Airway patent, GCS, IVaccess/fluids, Drugs, Feeding, Drinking,

Hygiene, Movement,


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Early mobil isation reduces complications such as infection,

venous thromboembolism, orthostatic hypotension, hypoxia,

subluxation of joints and infection (NICE, 2009) Very Early Mobi lisation (VEM) involves getting up out of bed

within 24 hours of the onset of a stroke,

Best Practice evidence

A simple, easy-to-deliver intervention, requiring little or no

equipment that is potentially deliverable to 85% of the acute

stroke population, May reduce death and dependency & the need for

institutionalisation (Teasell et al, 2011)

May help reduce the significant personal and community

burden of stroke (Bernhardt, 2008),

Caution

Insufficient evidence to support or refute the efficacy ofroutine very early mobilisation after stroke (Cochrane

Systematic Review, 2009)

More research needed e.g. a large high-quality clinical trial


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Early Supported Discharged (ESD) is about helping

people with stroke leave hospital as soon as possible and be

cared for at home,

Best Practice evidence

Reduced risk of death and dependency and have

fewer adverse outcomes,

Shorter hospital stay (Rudd et al, 1997),

Significantly improves patients scores on the extended

activities of daily living scale,

Improves patient satisfaction with stroke services

(Langhorne, 2005)

Cautions

Need well organised discharge teams,

Only suitable for patients with less severe strokes, No statistically significant differences in carers

subjective health status, mood or satisfaction with

services (Cochrane Systematic Review, 2009)


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MDT

Rehabilitationhospitals(private) Mobilisation

Earlymobilisation Rehabilitationunits, Clinical NurseSpecialists MDT within 72hours National

RehabilitationCentre

MDT Earlymobilisation Ward rehabstarts ASAP, Residentialrehabilitation Rehab athome with

domiciliaryservice

MDT approach Earlymobilisation Rehabilitationwards Early supporteddischarge

Continuedcare units, MDT Rehabbetween 24-48 hours


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Evidence based practice

Even though empirical research is critical to provide the support for nursingpractice, other forms of evidence can be equally important in nursing, for

example clinical pathways, protocols, practice guidelines and review articles.

Also extremely important is patient involvement,

Nursing practice has always emphasised the involvement of the patient in their

care, yet rarely is their preferences included,

For EBP to be effective application to the individual patient occurs by

combining all of this evidence

empirical studies,

non-empirical studies,

published evidence,

clinical expertise

patient preference, values, uniqueness (Keele, 2011)


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Questions ?


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Fjaertoft, H., Inderdavik, R.J., & Lydersen, S. (2004) Acute stroke unit care combined with early

supported discharge. Long-term effects on quality of life. A randomised controlled trial. Clinical

Rehabilitation, 18:580,

Walter, S., Kostopoulos, P., Haass, A. et al (2012) Diagnosis and treatment of patients with

stroke in a mobile stroke unit versus in hospital: a randomised controlled trial,

Candelise, L., Micieli, G., Sterzi, R & Morabito, A. (2005) Stroke units and general wards in

seven Italian regions: the PROSIT study. Neurological Science, 26:81-88.

Stroke Units Trialists Collaboration (2007) Organised inpatient (stroke unit care) for stroke.

Cochrane Database System Review, 4; CD000197.

Krespi, Y., Gurol, M.E., Coban, O., Tuncay, R., Bahar, S. (2003) Stroke unit versus neurologyward a before and after study. Journal of Neurology, 230:1363-9.

Evans, A., Perez, I., Harraf, F. et al (2001) Can differences in management processes explain

different outcomes between stroke unit and stroke team care? Lancet, 358:1586-92.

Diez-Tejedor, E., Fuentes, B. (2001) Acute care in stroke: do stroke units make the difference?

Cerebrovascular Disease, 11 (Suppl 1.) 31-9.

Fuentes, B., Diez-Tejedor, E., Ortega-Casarrubios, M.A. et al (2006) Consistency of the

benefits of stroke units over years of operation: an 8 year effectiveness analysis.Cerebrovascular Disease, 2,173-9.

Cadilhac, D.A., Ibrahim, J. (2004) for the SCOES Study Group: Multicentre comparison of

processes of care between stroke units and conventional care wards in Australia, 35: 1035-40.


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Bernhardt J. Very early mobilization following acute stroke: Controversies, the unknowns, and

a way forward. Ann Indian Acad Neurol 2008;11:88-98

Bernhardt J, Thuy MNT, Collier JM, Legg LA. Very early versus delayed mobilisation after

stroke. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006187. DOI:

10.1002/14651858.CD006187.pub2

Brunner Suddarth Infermieristica Medico Chirurgica Casa Editrice Ambrosiana 2006 (Cap.

62)

European cardiovascular disease statistics 2008. European Heart Network, Brussels.

Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute

stroke patients (Cochrane review). In: Cochrane Library, issue 2 [database online]. Oxford, UK:Cochrane Library; 2009

Langhorne, P (2005). Early Supported Discharge Trialists. Services for reducing duration of

hospital care for acute stroke patients. The Cochrane Database of Systematic Reviews, Issue 2.

Layton, K., White, J.B., Cloft, H.J, Kallmes, D. F., Manno, E.M., (2006) Expanding the

treatment window with mechanical thrombectomy in acute ischaemic stroke. Neuroradiology,

28:402-404.

Launer LJ, Hofman A . Frequency and impact of neurologic diseases in the elderly of Europe:a collaborative study of population-based cohorts. Neurology 2000;54(Suppl 5):S1-3.

National Institute of Clinical Excellence (2009) Stroke: National Clinical Guideline for Diagnosis

and Initial Management of Acute Stroke and Transient Ischaemic Attack.


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Parnetti, L., Silvestrelli, G., Lanari, A., Tambasco, N., Capocchi, G, Agnelli, G., (2006) Efficacy

of Thrombolytic (rt-PA) therapy in Old Stroke Patients: The Perugia Stroke Unit Experience.

Clinical and Experimental Hypertension, 28:397-404, 2006

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protocollo SITS MOST, Giovanni LinoliUnit Operativa di Neurologia/Neurofisiopatologia

Dipartimento di Neuroscienze Ospedale San Donato Azienda USL 8 di Arezzo. Arezzo, 24

febbraio 2007

Rudd AG, Wolfe CDA, Tilling K, Beech R. Randomised controlled trial to evaluate early

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Torbey, M, Jauch, E, & Liebeskind, D (2008) Thrombolysis 3 to 4.5 hours after acute ischaemic

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Truelsen, T., Ekman, M., & Boysen, G. (2005) Cost of Brain Disorders in Europe, European

Journal of Neurology, 12 Suppl 1:78-84.

Vatankahah, B., Dittmar, M.S., Fehm, N.P., Erban, P., Ickenstein, W.G., Jakob, W., Bodgahn,U, & Horn, M. (2005) Thrombolysis for Stroke in the Elderly. Journal of Thrombosis and

Thrombolysis, 20(1), 5-10.

World Health Organisation (1978)


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Teasell, R., Foley, N., Salter, K. Bhogal, S., Jutai, J, Speechley, M. (2011) Evidence based

review of stroke rehabilitation, Executive Summary (14th Edition)

AHA Scientific Statement, Comprehensive Overview of Nursing and Interdisciplinary Care of

the Acute Ischemic Stroke Patient A Scientific Statement From the American Heart Association,

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Good, D., Henkle, J.Q., Gelber, D. et al (1996) Sleep Disordered Breathing and Poor

Functional Outcomes After Stroke, Stroke, 1996 27 (2); 252-260.

Waddington, H. (2009) Psychological and communication issues in feeding post-stroke

patients with dysphagia. Nursing Times; 105: 31, early online publication.

Nazarko, L. (2003) Rehabilitation and continence promotion following a stroke, NursingTimes, 99 (44), 52-54.

Lees, L., Sharpe, L., Edwards, A. (2006) Nurse-led dysphagia screening in acute stroke

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http://www.canadianstrokenetwork.ca/index.php5/news/2010-11-annual-report/ [Accessed05/06/2012]
http://stroke.ahajournals.org/content/40/8/2911.fullhttp://www.canadianstrokenetwork.ca/index.php5/news/2010-11-annual-report/http://www.canadianstrokenetwork.ca/index.php5/news/2010-11-annual-report/http://stroke.ahajournals.org/content/40/8/2911.full

2012-06-08 best practice in ischaemic stroke [red] team

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