stroke care pathway a resource for health...

Stroke Care PathwayA resource for health professionals

Developed by the National Stroke Foundation.Commissioned on behalf of the Australian Health Ministers’ Advisory Council (AHMAC)

by the AHMAC Care of Older Australian Working Group

July 2006

Stroke Care Pathway

A resource for health professionals

Developed by the National Stroke Foundation.Commissioned on behalf of the Australian Health Ministers’ Advisory Council (AHMAC)

by the AHMAC Care of Older Australian Working Group

July 2006

ISBN 0731162374

Published by the Metropolitan Health and Aged Care Services Division,

Victorian Government Department of Human Services, Melbourne Victoria on behalf of AHMAC

Copies of this document can be obtained from:

The COAWG Secretariat

Department of Health and Ageing

MDP 126

GPO Box 9848

Canberra City ACT 2601

This document may be downloaded from the Department of Human Services website at www.health.vic.gov.au/acute-agedcare

RCC_060401

STROKE CARE PATHWAY - A RESOURCE FOR HEALTH PROFESSIONALS v

Contents

Acknowledgements vii

Introduction 1

How to use the Stroke Care Pathway 3

Acute care and early rehabilitation 11

Ongoing rehabilitation 19

Living with stroke in the community 27

Other resources 35

STROKE CARE PATHWAY - A RESOURCE FOR HEALTH PROFESSIONALS vi

Quick Guide 1

STROKE CARE PATHWAY - A RESOURCE FOR HEALTH PROFESSIONALS vii

Acknowledgements

The development of the Stroke Care Pathway: a resource for health professionals was supported by an Expert Advisory Group.

The members of the Expert Advisory Group were:

• David Blacker, Neurologist, Sir Charles Gardiner Hospital, Western Australia

• Gloria Caruso, Department of Human Services, Victoria

• Carol Caruso, Queen Elizabeth Centre, Ballarat, Victoria

• Stephen de Graaff, Head, Neurological Rehabilitation, Caulfi eld General Medical Centre, Victoria

• Isabel Harvey, Stroke Liaison Nurse, Canberra Hospital, Australian Capital Territory

• Bryan Hewitt, Stroke Association of South Australia

• Erin Lalor, Chief Executive Offi cer, National Stroke Foundation

• Deborah Law, Director, Allied Health & Community Health Services Division, Flinders Medical Centre, South Australia

• Richard Lindley, Geriatrician, Westmead Hospital, New South Wales

• Carol Pyke, Department of Human Services, Victoria

• Christine Scott, National Stroke Foundation

• Meredith Stewart, Program Manager, Allied Health, Repatriation General Hospital, South Australia

• Jenny Stevens, Manager, Kimberley Aged and Community Services, Western Australia

• Paul Varghese, Geriatrician, Princess Alexandra Hospital, Queensland

STROKE CARE PATHWAY - A RESOURCE FOR HEALTH PROFESSIONALS viii

Quick Guide 1

STROKE CARE PATHWAY - A RESOURCE FOR HEALTH PROFESSIONALS 1

Introduction

The stroke care pathway is a resource that provides the user with a summary of the key aspects of care that should be considered for people with stroke

at any stage in their care. The content of the pathway is grounded in the evidence base for best practice management of stroke, which has been drawn from

the Clinical Guidelines for Acute Stroke and Stroke Rehabilitation and Recovery. Additional content has been drawn from information collected about what

happens in clinical practice.

The pathway is designed to facilitate the smooth transition of people with stroke through the stages of recovery, from the acute phase, through rehabilitation,

to the time when they are living with the longer term effects of stroke in the community. It is recommended that the care pathway be used in conjunction with

the Clinical Guidelines for Acute Stroke and Stroke Rehabilitation and Recovery. Details on how to obtain a copy of these guidelines are on page 37

- Other resources.

The stroke care pathway has the fl exibility to be implemented in a number of different ways, to suit the environment or circumstances in which

it is to be applied. It is recognised that the availability of different aspects of stroke care will depend on the way in which services are organised locally.

Whilst there is evidence that improved outcomes are achieved for stroke patients treated in stroke units with specialised multidisciplinary stroke teams,

many stroke patients are, by necessity, still managed within services where organised stroke care is not available. In these circumstances, it is intended that

the pathway be used as a guide for the range of services and interventions that need to be considered, and as a tool from which local level protocols may

be developed.


For ease of use, the stroke care pathway is presented in three phases:

• Acute care and early rehabilitation

• Ongoing rehabilitation

• Living with stroke in the community

Each phase provides the evidence for the key aspects of stroke care that need to be considered by health professionals, both when the patient

is admitted and when planning for the patient’s future care. The phases are organised around the areas of assessment, consultations and referrals,

coordination, management, information and support, and discharge planning. Each component of care is referenced back to the evidence base contained

in the clinical guidelines.

The care pathway can be applied in a number of different ways to support good practice in stroke management. The following are suggestions for ways

in which multidisciplinary stroke teams, as well as individual health professionals, can use the pathway as a basis for improving stroke care:

1. as the basis for the development of local protocols which describe how key aspects of stroke care will be provided at a local level

2. as the basis for the development of micro-level care pathways which describe the detail of care on a day to day basis at the clinical level

3. as a tool against which to audit an existing stroke service

4. as a macro-level checklist of stroke care provided to individual patients in different settings

5. as an occasional checklist for GPs and other health professionals who have infrequent contact with stroke patients,

to ensure that key aspects of care have been considered and organised where appropriate

6. as a training tool for students and trainees of medicine, nursing and allied health

More detailed instructions for the applications are available in the section labelled “How to use the Stroke Care Pathway”.

Quick Guide 1


How to use the Stroke Care Pathway

Used in conjunction with the Clinical Guidelines for Acute Stroke and Stroke Rehabilitation and Recovery, the care pathway can be applied in a number

of different ways to support good practice in stroke management. The following are suggestions for ways in which multidisciplinary stroke teams, as well

as individual health professionals, can use a pathway as the basis for improving stroke care.

1. To develop protocols which describe how key aspects of stroke care will be provided at a local level

Local protocols for stroke care should be developed in the context of the multidisciplinary team. Where a recognised team does not exist, the range

of disciplines should come together to develop protocols around the way they will work together to provide stroke care in a coordinated fashion.

In some settings, certain stroke care services will not be readily available (eg. psychology, palliative care). In these cases, seamless care can be achieved

through the development of local protocols that are underpinned by service agreements. Such agreements should specify how the services will be accessed

and provided when they are required.

For each aspect of stroke care, the local level protocols should include:

• Which health professional(s) will be responsible

• The level of training or support required

• Indications for that health professional to be involved

• The rationale for the assessment/intervention, what it will involve and how it will be provided (eg by telephone referral)

• Timing/sequencing of the intervention

• How the outcomes will be recorded and communicated to the multidisciplinary team and to the patient and carers.


Example 1

In the acute care and early rehabilitation phase, assessment of a number of functions is recommended. This includes continence, swallowing,

nutrition, communication, mobility and psychosocial issues. A local protocol will include an evidence based rationale for the assessment of each

of these functions (taken from the clinical guidelines), plus how each of these functions will be assessed, when and by whom.

Where it is identifi ed that an appropriately qualifi ed person is not available locally to conduct the assessment, a service agreement with an external

provider may need to be developed for the provision of the service. Training and support from hospitals and services having the necessary expertise

may be negotiated, or the purchase of the service from another provider may be considered.

For example, a regional hospital with a medium to low volume of stroke patients, and without an organised stroke service, may arrange with

a metropolitan hospital with a stroke unit and a specialised stroke team, to participate in the weekly multidisciplinary team meeting via video-conference.

Such an arrangement would provide professional development opportunities, and would enable stroke cases from the regional hospital to be presented

to the metro team for discussion regarding best practice management.

Example 2

In the ongoing rehabilitation phase, it is recommended that multidisciplinary interventions are related to the goals set by the team with the patient

and carers. There are a number of ways in which goal setting can be achieved and this may vary according to the setting.

For example, in some settings a case coordinator is assigned to each patient at the fi rst team meeting. The case coordinator works with the patient

and their family to identify key goals for rehabilitation, and these are documented and discussed with the multidisciplinary team.

At a local level, the rehabilitation team (or, where there is no team, the health professionals involved in providing care) need to develop a protocol

that describes how goal setting with patients is achieved in their own setting.


Example 3

In the living with stroke in the community phase, it is recommended that there be in place a process for regular and ongoing review by a member

of the stroke team. Local services may choose to fulfi l this aspect in a number of ways, depending on the patient’s existing relationships with different

service providers. However, in order to ensure that such a review is in place for every stroke patient, service providers need to develop a protocol that

describes the process by which all patients will be linked into a fail safe system of ongoing review. This could include a system for bi-annual review

by a specifi ed member of the multidisciplinary team, with interim telephone support where this is indicated.

2. As the basis for the development of micro-level clinical pathways

A micro-level pathway embeds both the guidelines and local level protocols into an action plan for everyday use by the multidisciplinary team.

The pathway includes each component of clinical care that needs to be considered for a stroke patient on a day to day basis, including

the appropriate sequence and timing of care.

Micro-level pathways have not been demonstrated to improve outcomes for people with stroke, when care is provided within an organised stroke service.

However, they may be helpful when applied in environments without a stroke unit.

A micro-level pathway can be developed for any phase of stroke care, but is most commonly developed in the acute phase of care, where

the implementation of some aspects of stroke care is time critical, and likely to have a signifi cant impact on outcomes.

Taking the detailed evidence from the care pathway and the clinical guidelines, the key elements of care should be extracted, with the person responsible

for each element identifi ed, and the appropriate timing and sequencing of the elements documented.

3. As a tool to audit an existing stroke service

As the care pathway provides a concise summary of best practice stroke care, existing stroke services may choose to use it as a tool against which

their service can be audited. Such an audit would address the capacity of the service to provide and respond to each of the key aspects of care provided

in the pathway.


Depending on time and resources available, the audit could be undertaken in a number of ways:

• prospectively as it is applied to individual patients with stroke e.g. on a consecutive sequence of new patients admitted to a stroke service OR

• it could be applied retrospectively to a cohort of patients in the form of a medical record audit OR

• as part of a review process conducted by a stroke team, in which their ability to provide and respond to the needs of stroke patients in a manner

that is consistent with best practice is assessed.

A quality improvement plan might result from such an audit. This would address the actions that the team proposes to take to improve the current service.

A repeat audit in 6-12 months would monitor progress with the quality improvement plan.

4. As a macro-level checklist of stroke care provided to individual patients in different settings

The pathway can be used as a simple checklist on admission to acute hospital or at the start of any new phase in the care of the person with stroke.

The checklist will ensure that each of the key aspects of care is given consideration, and organised where indicated. The checklist can also be used

as treatment and recovery progresses to check that critical aspects of future care planning have been considered in a timely fashion.

5. As an occasional checklist for GPs and other health professionals who have infrequent contact with stroke

patients, to ensure that key aspects of care have been considered and organised where appropriate

Particularly in rural and remote areas, health professionals may be required to organise care for a stroke patient on an infrequent basis. Access to organised

stroke care may be limited. In these circumstances, the care pathway can act as a prompt for what aspects of care, and care provision need to be considered

- no matter what stage of the recovery process the patient is at. A range of appropriate services consistent with those recommended in the care pathway,

may be organised locally, or alternatively the need to transfer the patient to a facility where all appropriate care can be provided should be considered.


6. As a training tool for new staff, and for students and trainees of medicine, nursing and allied health

The care pathway provides the basis for a teaching tool, because it provides a simple summary of the key aspects of evidence based stroke

care. Used in conjunction with the clinical guidelines, students are provided with the key references from which the evidence is drawn, with explanatory

preambles. A particular feature of the pathway is that it is multidisciplinary in nature, and allows students to come to an understanding of the roles

and contribution of a range of health professionals in the management of stroke. It also encourages students to appreciate the needs of people with

stroke across the entire stroke care continuum.

Quick Guide 1


Acute care and early rehabilitation 2

The acute episode starts at onset of stroke and involves the immediate diagnosis and management of the causes and consequences of the stroke.

Stroke should be treated as a medical emergency and patients with suspected stroke should, where possible, be transported to centres with stroke

units, and specialised multidisciplinary stroke teams. Tissue plasminogen activator (tPA) should only be administered in stroke units with experience

in its use and in accordance with guidelines ASM 3.4a.

If no stroke unit is available in the acute phase, consideration should be given to transfer of the patient to the nearest hospital with an organised

stroke service. Where this is not possible, the provision of ongoing rehabilitation in an organised rehabilitation service should be considered.

Rehabilitation is a proactive and goal-orientated process that begins the fi rst day after stroke.


Acute admission Future care plan

Assessment • Diagnosis

• CT as soon as possible, and within 24 hrs ASM 3.2b

• FBC, ECG, electrolytes, renal function, glucose ASM 3.3a

• Other investigations as required ASM 3.3b

• Additional tests for atypical cases, or young patients ASM 3.3c

• Multidisciplinary assessment as indicated for the following:

• Continence ASM 4.10

• Swallowing ASM 4.5

• Nutrition ASM 4.6

• Communication ASM 4.7

• Cognition and perception

• Mobility ASM 4.8

• ADL ASM 4.9

• Positioning ASM 4.11

• Psychosocial issues ASM 4.12

• Pre-morbid skills and level of function

• Need for palliation SRR 3.14

• Consideration is given to the specifi c needs of the patient in the community

• A suitable discharge destination is identifi ed that provides an appropriate level of care

Acute care and early rehabilitation



Consults\referrals • Dedicated stroke unit team with specifi c skills in management of stroke ASM 1a (in some settings this might be a mobile stroke unit team) including:

• Stroke physician

• Nursing staff

• Physiotherapist

• Occupational therapist

• Speech pathologist

• Dietitian

• Social worker

• Psychologist

• Pharmacist

• Referral to palliative care service or similar if required SRR 3.14

• Consider appropriate implementation of advance directives

• Referrals as per multidisciplinary post-discharge care plan ASM 7.1b, SRR 2.3

Coordination • Processes in place to facilitate coordination of patient care may include:

• A stroke coordinator SRR 1.1.3

• A regular team meeting to discuss management and dischargeplanning ASM 1a

• Regular meetings with patient and family SRR 2.1

• Processes in place to facilitate a safe transfer to discharge destination or home including:

• Liaison with community providers SRR 2.5

• A contact person in the hospital or the community for post-discharge queries ASM 7.1c, SRR 2.6



Management • General stroke treatment

• Medical and pharmacological management ASM 4.1

• Observation ASM 4.2

• General supportive care ASM 4.3

• Multidisciplinary interventions provided to manage the consequencesof stroke. These are related to the goals set by the team with thepatient, and carers and include:

• ADL training SRR 3.3

• Sensorimotor and physical activity SRR 3.1 – 3.2

• Cognitive capacities SRR 3.4

• Communication SRR 3.6

• Swallowing SRR 3.7

• Hydration and nutrition SRR 3.8

• Mood SRR 3.9

• Continence – bladder and bowel SRR 3.10

• Medical SRR 3.11

• Complementary and alternative therapy SRR 3.13

• Palliation SRR 3.14

• Consider secondary prevention strategies and roleof primary care practitioners in ongoing risk reductionstrategies including:

• Antiplatelet therapy ASM 6.1, SRR 3.12.1

• Carotid endarterectomy ASM 6.2

• Anticoagulation therapy ASM 6.3, SRR 3.12.2

• Blood pressure lowering therapy ASM 6.4, SRR 3.12.3

• Cholesterol lowering ASM 6.5, SRR 3.12.4

• Behaviour modifi cation to reduce risk including cessation of smoking ASM 6.6, SRR 3.12.5

• Concordance with medication SRR 3.12.6



Management

continued

• Prevention of complications

• Raised intracranial pressure ASM 5.1

• Deep vein thrombosis ASM 5.2

• Fever ASM 5.3

• Pressure sores ASM 5.4

• Shoulder pain ASM 5.5

• Falls ASM 5.6

• Pain ASM 5.7

• Early secondary prevention – consider:









Information

and support

• Consider Information and support for patient and carer including:

• Regular communication, information and education between team and the patient/family ASM 7.4a, SRR 2.7

• Family and team meetings ASM 7.5a, SRR 2.1

• Family counselling SRR 4.2.2

• Consider information and support for patient and carer including:

• Discharge destination and resources available including support agencies and volunteer

organisations ASM 7.4b

• Training for carers ASM 7.2a , SRR 2.4

• Referral to self-management programs SRR 4.1.1


• Support for carers SRR 4.2.3

Discharge planning • Early discharge planning includes:

• Discharge options considered from day 1

• Involve patient and carers in assessment of post-discharge needs ASM 7.1a, SRR 2.2

• Early supported discharge SRR 1.2.1

• Consider availability of support services and the desires of the patient and carer SRR 1.3.1

• Assessment of suitability for rehabilitation conducted by a rehabilitation team including a medical specialist with a special interest in the management of stroke

• Discharge planning involves consideration of:

• Relevant community services and/or ongoing rehabilitation

• Home visit by OT ASM 7.2b,

• Modifi cations, provision of aids and equipment and education ASM 7.2a, SRR 2.2. SRR 2.4

• Development of multidisciplinary post-discharge care plan ASM 7.1b, SRR 2.3

• Provision of information on discharge plans and post-discharge management to GP, primary health carers and community services ASM 7.3a, SRR 2.5


Discharge options that include an active rehabilitation program include: transfer to an in-patient rehabilitation program OR return home with or without

supports, PLUS rehabilitation in the home, or rehabilitation provided in outpatient settings, day care centres and community rehabilitation centres.

Community rehabilitation can also be provided by community health service providers.

Community services and supports include HACC services (meals on wheel, home help, personal care assistance), other council and privately run services

and facilities (eg. activity groups, gymnasium), case management services, peer support groups, self management programs.

Functionally dependent patients may benefi t from being discharged to residential care or to supported care in their own home. Interim or transitional care

may be provided between acute care and residential care.

Quick Guide 1


Ongoing rehabilitation 3

Ongoing rehabilitation aims to improve function and/or prevent deterioration of function to bring about the highest level of independence, physically,

psychologically, socially and economically. Rehabilitation is also concerned with reintegration of the person with stroke into the community. Rehabilitation

may be provided within a range of settings but is most effective when it is provided by a coordinated multidisciplinary team in a stroke unit SRR 1.1.1.

If no stroke unit is available, many aspects of good stroke care may be able to be organised locally, but consideration should be given to transfer

of the patient to the nearest hospital with a rehabilitation unit that most closely meets the criteria for stroke unit care. Rehabilitation (a comprehensive

multidisciplinary service) in the community may be delivered in the hospital, via outpatients or in a day hospital or community based facility SRR 1.2.2.


Rehabilitation admission Future care plan

Assessment • Multidisciplinary assessment with emphasis on functionalindependence and achievement of patient’s own goals in the following areas:

• ADL SRR 3.3

• Movement and physical activity SRR 3.1 – 3.2





• Mood SRR 3.9





• Weekend or day leave assessment

Ongoing rehabilitation



Assessment

continued

• For some patients – particularly those who are receiving rehabilitationin the home, the assessment will also include these aspects:

• Secondary prevention SRR 3.12

• Functional ability: ADL and Exercise SRR 4.1.2

• Mood SRR 3.9

• Driving SRR 4.1.3

• Leisure SRR 4.1.4

• Return to work SRR 4.1.5

• Sexuality SRR 4.1.6

• Support needs SRR 4.2.1, 4.2.3

• Need for respite care for patient or carer SRR 1.3.2

Medical issues SRR 3.11



Consults/referrals • Referrals as required to specialised neurological rehabilitation teamASM 1 including:

• Stroke rehabilitation specialist

• Nursing staff

• Physiotherapist



• Dietitian

• Social worker

• Psychologist

• Neuropsychologist

• Pharmacist

• Palliative care service or similar if required SRR 3.14

• Referrals as per inter-disciplinary post-discharge careplan ASM 7.1b, SRR 2.3

Coordination

and review

• Processes in place to facilitate coordination of patient care may include:

• A stroke coordinator SRR 1.1.3

• A regular team meeting to discuss management and discharge planning ASM 1a


• Processes in place to facilitate a safe discharge including:



• Contact with a family support/liaison worker SRR 2.6



Management • Multidisciplinary interventions provided to manage the consequencesof stroke. These are related to the goals set by the team with the patient, and carers and include:

• ADL training SRR 3.3






• Mood SRR 3.9















Management

continued

• Further management strategies are in place to address the following as required:



• Mood SRR 3.9

• Driving SRR 4.13


















Information

and support



• Family and team meetings ASM 7.5a, SRR 2.1






Family counselling SRR 4.2.2

• Support for carers SRR 4.2.3

• Information about local stroke support groups SRR 4.2.1



Discharge planning • Early discharge planning includes:

• Discharge destination considered from day 1

• Involve patient and carers in assessment of post-discharge needs ASM 7.1a, SRR 2.2

• Early supported discharge SRR 1.2.1

• Consider availability of support services and the desires of the patient and carer SRR 1.3.1

• Discharge planning involves consideration of:


• Rehabilitation services in the hospital, out patients, day hospital or in the community2 SRR 1.2.2

• Regular and ongoing review by a member of a stroke team SRR 1.3.3

• Home visit by OT ASM 7.2b, SRR 2.2

• Modifi cations, provision of aids and equipment and education ASM 7.2a, SRR 2.2, 2.4

• Provision of information on discharge plans and post-discharge management to GP, primary health carers and community services ASM 7.3a, SRR 2.5

Ongoing rehabilitation options can include rehabilitation that is provided in: out-patient settings, day care centres and community rehabilitation centres,

or through on-going rehabilitation in the home. Community rehabilitation can also be provided by community health service providers.


and facilities (eg. activity groups, gymnasium), case management services, peer support groups and self management programs.

Functionally dependent patients may benefi t from being discharged to residential care or to supported care in their own home. Interim or transitional

care may be provided between acute care and residential care.

Quick Guide 1


Living with stroke in the community 4

A primary aim of rehabilitation is to enable those with stroke to return to an active lifestyle with full participation in the community. Rehabilitation

(a comprehensive multidisciplinary service) in the community may be delivered in the hospital, via outpatients or in a day hospital or community based

facility SRR 1.2.2. Ongoing rehabilitation options can include rehabilitation that is provided in out-patient settings, day care centres and community

rehabilitation centres, or through on-going rehabilitation in the home. Community rehabilitation can also be provided by community health service providers.


Return to the community Review of ongoing needs

Assessment • Coordinated assessment process to review patient and carer needswith consideration of:



• Mood SRR 3.9







• Medical issues SRR 3.11


• Regular and ongoing review by a member of a stroketeam SRR 1.3.3 with consideration of:

• Post-discharge follow up by a relevant team member SRR 2.6

• Referral to allied health professionals SRR 4.1.2

• Access to ADL and exercise services SRR 4.1.2

• Support services for carers SRR 4.2.3

Living with stroke in the community



Consults/referrals • Rehabilitation services in the hospital, out patients, day hospital or in the community are considered3 SRR 1.2.2

• Referral to individual health professionals with specialised skills in stroke management as required ASM 1:

• Stroke rehabilitation specialist

• Nursing staff

• Physiotherapist



• Dietitian

• Social worker

• Psychologist

• Neuropsychologist

• Palliative care service or similar if required SRR 3.14

• Pharmacist








Coordination • Care coordination processes are considered, including:

• Involvement of GP SRR 2.3


• Post discharge follow up SRR 2.6



• Contact with a family support/liaison worker SRR 2.6








Management • Review of risk factors and secondary prevention managementstrategies including:








• Prevention of complications ASM 5.1 – 5.7








Management

continued

• Ongoing multidisciplinary management strategies aimed at optimisingand maintaining functional independence. These are related to thegoals set by the team with the patient and carers and include:

• ADL training and exercise SRR 3.3, SRR 4.1.2






• Mood SRR 3.9












Management

continued

• Further management strategies are in place to address the following as required:


• Mood SRR 3.9











Information

and support






• Information about local stroke support group SRR 4.2.1







Discharge planning • Discharge planning involves consideration of:

• Development of post-discharge care plan ASM 7.1b, SRR 2.3

• Information on discharge plans and post-discharge management provided to GP, primary health carers and community services ASM 7.3a, SRR 2.5

• Regular and ongoing review by a member of a stroke team SRR 1.3.3








People more than 6-12 months after stroke living in the community should have access to interventions to improve fi tness and mobility.


and facilities (eg. activity groups, gymnasium), case management services, peer support groups and self management programs.

Functionally dependent patients may benefi t from being discharged to residential care or to supported care in their own home. Interim or transitional

care may be provided between acute care and residential care.

Quick Guide 1


Other resources 5

1. Clinical Guidelines for the Management of Acute Stroke

2. Clinical Guidelines for Stroke Rehabilitation and Recovery

Copies of these publications can be downloaded from the following website address: www.strokefoundation.com.au


Notes

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