Transcript The Grampian Stroke Pathway

The Grampian Stroke
Pathway
Acute Stroke Unit
Patient pathway
Patient has stroke/TIA
NHS 24
A&E
Red is BAD
GP
Clinic
Stroke bleep notified
D.o.M.E.
AMAU
Decant/
things
get
missed
Acute Stroke Unit
Vascular
M.S.T.
Ward 6 WE
Ward 12 WE
CHSS nurse follow up
Home
GP and primary care
team
Care home/
interim care
Clinic review
Community
hospitals
Horizons etc
Getting it right from the beginning
• CHSS FAST campaign due to begin in
October
• May have implications for patient
numbers and review in A&E
• GPs need to be aware of stroke
symptoms and thrombolysis service
• NHS24 are reviewing stroke protocol
IV thrombolysis
Outcome for placebo, rt-PA in clinical trials and SITS-MOST
SITS is a register of thrombolysis in clinical practice
Proportion of patients with good outcomes (0-2) is higher
in SITS group than placebo group from clinical trials
(Just in case you need evidence!)
Outcome following rt-PA
Earlier is better
Assessment of Stroke Patients in A&E
Patients who have a neurological deficit may be suitable for thrombolysis if they are scanned within 4.5 hours of symptom onset.
Has the patient got an ongoing neurological deficit?
e.g.
Facial weakness
Limb weakness
Speech disturbance (dysphasia or dysarthria)
Hemianopia
NO
YES
Known time since onset <4.5 hours?
No contraindication to thrombolysis?**
Time since onset >4.5 hours or
unknown?
Arrange urgent CT scan
then
contact stroke bleep via switchboard
If resolved anterior circulation
symptoms and/or AF, discuss with
stroke bleep holder re urgent
investigation.
Refer other patients to neurovascular
clinic (fax letter to 559506)
Contact stroke team to arrange admission
(If no response, contact Dr Macleod on page 3132, tel 645250 or 07771631243)
**Contraindications to thrombolysis
Minor neurological deficit or symptoms rapidly improving before start of infusion.
Symptoms of ischaemic attack began more than 4 hours prior to referral, or when time of symptom onset is unknown.
Severe stroke as assessed clinically (e.g. NIHSS>25) and/or by appropriate imaging techniques.
Seizure at onset of stroke.
Symptoms suggestive of subarachnoid haemorrhage, even if the CT-scan is normal.
On warfarin therapy, or administration of heparin within the previous 48 hours and a thromboplastin time exceeding the upper limit of normal for laboratory.
Patients with any history of prior stroke and concomitant diabetes.
Prior stroke within the last 3 months.
Platelet count of below 100,000/mm3 (if available).
Systolic blood pressure >185 mmHg or diastolic blood pressure >110 mmHg, or aggressive management (IV medication) necessary to reduce BP to these limits.
Blood glucose <3 or > 20 mmol/L.
Known haemorrhagic diathesis, manifest or recent severe or dangerous bleeding, known history of or suspected intracranial haemorrhage.
Thrombolysis in Grampian
• Approx 20 patients so far this year
• Still only about 2-3% of patients
• Recent audit suggested most appropriate
patients offered therapy (i.e. most are
arriving too late)
Example patient 1
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54 year old off shore worker from Kilmarnock
Walking along Market St prior to joining ship
Developed dense left sided weakness
Arrived A&E within thirty minutes
Reviewed within one hour
CT scan and thrombolysed within 1 ½ hours
• Initial dramatic improvement, but symptoms returned at
approx 1 hr after thrombolysis
• Internal capsule infarct on repeat scan at 24 hours
• Good progress with physiotherapy/OT
• Transferred back to Kilmarnock for rehab
Example patient 2
• 71 year old
• History of HBP, IHD
• 0530 at Montrose harbour, about to go prawn
fishing with brother
• Hauling creels
• Suddenly collapsed: right sided weakness and
aphasia by arrival in A&E at 0700
• Reviewed 0720
• CT scan showed L intracerebral bleed
• Slow progress, still on ward three weeks later
awaiting transfer to slow stream rehab.
Even if not suitable for thrombolysis………
• Early review of patients is associated with
improved outcomes
• Early scanning
• Immediate management protocol
• Secondary prevention protocol
• Early carotid intervention
Hemicraniectomy
Why are we proud of the ASU?
We are a TEAM!!
Social work
CHSS nurses
Links with Woodend
Vascular surgery
Speech & Language
Database coordinator
Nursing staff
Medical staff
Patient
Dietician
Radiology
Research staff
Physiotherapy
Neuropsychology
Mobile stroke team
Occupational therapy
How can we make the pathway better?
• All appropriate patients coming to ASU
– (would allow redeployment of MST)
• Quicker ‘run off’ to Wards 12, 6 and interim care
• Improve links with Radiology (new CT scanner in March 08 will allow
perfusion CT/angiography which aids in diagnosis and decision
making)
• Implement SIGN guidelines
• Continue to aim towards QIS standards
• Development of early supported discharge team
Patient Destination on Discharge from Acute Stroke Unit
60
50
Percentage
40
2006
30
2007
20
10
0
Orkney/
Shet
Links
Unit
Juniper
Ward
Oak
Ward
Cedar
Ward
Maple
Ward
Bruce
Howie
Comm
Hosp
Ward 6 Ward 12
W/End W/End
2006
4.5
0.75
2
0.5
0.25
0.25
0.25
9
8
2007
4
0.3
0.95
0.3
6
5.5
Other
Ward
N/Res
Hme
Died
Other
Trusts
Home
18
2
0.25
8.25
1
45
14
0.95
0.6
8.45
0.95
56
Still I/P
2