The Grampian Stroke Pathway

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The Grampian Stroke Pathway Powered By Docstoc
					The Grampian Stroke

   Acute Stroke Unit
                      Patient pathway
                          Patient has stroke/TIA

                                                                       Red is BAD
              A&E               NHS 24             GP

                         Stroke bleep notified                      Clinic

          AMAU                                           D.o.M.E.
Decant/                   Acute Stroke Unit
 things      M.S.T.
     Ward 6 WE          Ward 12 WE       Home           Care home/           hospitals
                                                        interim care

 CHSS nurse follow up      GP and primary care     Clinic review         Horizons etc
    Getting it right from the beginning

• CHSS FAST campaign due to begin in

• 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)

                                                             YES                                                   NO                             If resolved anterior circulation
                                                                                                                                                  symptoms and/or AF, discuss with
                                                                                                                                                  stroke bleep holder re urgent
                                                                                                                                                  Refer other patients to neurovascular
                                                                                                                                                  clinic (fax letter to 559506)
Known time since onset <4.5 hours?                                         Time since onset >4.5 hours or
          No contraindication to thrombolysis?**

           Arrange urgent CT scan                                                                            Contact stroke team to arrange admission
     contact stroke bleep via switchboard
(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
•   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
                       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
                                                                 Research staff
            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

• Implement SIGN guidelines

• Continue to aim towards QIS standards

• Development of early supported discharge team

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