Waterloo Wellington Rehabilitative Care System Integrated Care Pathway for STROKE Stream of Care HYPERACUTE URGENT TIA and SECONDARY STROKE PREVENTION

Transcription

1 Waterl Wellingtn Rehabilitative Care System Integrated Care Pathway fr STROKE Stream f Care HYPERACUTE URGENT TIA and SECONDARY STROKE PREVENTION Care Setting Activity Patients wh present t a cmmunity primary care setting within 48 hurs f a suspected transient ischemic attack r nn-disabling ischemic strke are cnsidered at highest risk f recurrent strke and shuld have an immediate clinical evaluatin and investigatins t establish the diagnsis, rule ut strke mimics, and develp a strke management plan. These high risk patients shuld be immediately transferred t the clsest emergency department that has access t neurvascular imaging facilities and strke expertise Outpatient Management f Transient Ischemic Attack and nn-disabling Ischemic Strke Symptm nset less than 2weeks? Patients wh present t a cmmunity primary care setting between 48 hurs and 2 weeks frm time last knwn well, are cnsidered at increased risk fr recurrent strke, and shuld receive a cmprehensive clinical evaluatin and investigatins within 24 hurs f first cntact with the healthcare system. If an utpatient cnsultatin is nt pssible, review by a strke expert either thrugh physician t physician telephne cnsultatin r, Transprtatin t an ED that has access t neurvascular imaging facilities and strke expertise is necessary. Symptm nset greater than 2weeks? Patients wh present t a cmmunity primary care setting with symptm nset mre than 2 weeks frm time last knwn well are cnsidered less urgent and shuld be evaluated within ne mnth in an utpatient setting. Cmplete Secndary Strke Preventin Clinic Referral Frm (Grand River Hspital). Fax number: (519) All patients with suspected transient ischemic attack r nn-disabling ischemic strke shuld underg an initial assessment that includes: brain imaging nn-invasive vascular imaging (fr cartid territry transient ischemic attacks r nn-disabling strkes), such as cartid dpplers, CT angigraphy r magnetic resnance angigraphy If yu have any questins please cntact Jennifer Breatn Integrated Strke Prgram Directr, jennifer.breatn@grhsp.n.ca Versin Date: Nvember 29, 2013

2 electrcardigram, within recmmended time frames, based n level f urgency Patients with a transient ischemic attack r nn-disabling strke and greater than 50 percent internal cartid artery stensis shuld be evaluated by an individual with strke expertise. Selected patients shuld be ffered cartid endarterectmy as sn as pssible, either in acute care r thrugh the SSPC, with the gal f perating within furteen days f the event nce the patient is clinically stable. Refer patient t: Guelph Vascular Cnsultants: Phne #: (519) r Fax: (519) r Hamiltn Health Sciences: Fax Urgent Referral: Cartid Revascularizatin t (905) Patients with TIA r nn-disabling ischemic strke wh are nt n an antiplatelet agent at the time f presentatin shuld be started n antiplatelet therapy immediately after brain imaging has excluded intracranial hemrrhage. Patients with a TIA and atrial fibrillatin, immediately after brain imaging has excluded intracranial hemrrhage r a large infarct, shuld begin ral anticagulatin with: warfarin, dabigatran, rivarxaban, r apixaban (please nte, dabigatran, rivarxaban, and apixaban are nt indicated fr valvular atrial fibrillatin) All patients with an ischemic strke r TIA shuld be prescribed antiplatelet therapy fr secndary preventin f recurrent strke unless there is an indicatin fr anticagulatin. Patients wh have had a TIA shuld have treatment t lwer bld pressure t stay cnsistently < 140/90 mm Hg. Bld glucse measurement shuld be repeated if the first randm glucse value is >11 mml/l. Additinal measures shuld include fasting glucse and HbA1c. If elevated (fasting glucse > 7 mml/l r HbA1c > 7%) cnsider using antihyperglycemic agents. If patient fund t be hypglycemic, crrect immediately. Fr patients with suspected hypercagulability r with n evident cause f strke, further cagulatin investigatin is needed. If yu have any questins please cntact Jennifer Breatn Integrated Strke Prgram Directr, jennifer.breatn@grhsp.n.ca Versin Date: Nvember 29, 2013

3 Fr patients with suspected vasculitis further investigatins may be required Cmplete Rutine Orders fr Secndary Strke Preventin Clinic and Secndary Strke Preventin Clinic Referral Frm r Rutine Orders: Adult Inpatient Strke / Transient Ischemic Attack (TIA). All risk factrs shuld be aggressively managed thrugh pharmaclgical and nn pharmaclgical means. A statin shuld be prescribed t mst ischemic strke patients t achieve LDL chlesterl < 2.0 mml/l r a 50% reductin in LDL chlesterl frm baseline. Strke patients with diabetes shuld have their diabetes assessed and ptimally managed. Patients wh smke shuld be strngly advised t quit immediately and be prvided with pharmaclgical and nn pharmaclgical means t d s. Hyperacute Care and Management in the Emergency Department All strke patients shuld be assessed fr risk f develping (Venus Thrmbemblism (VTE). Fr patients wh may be eligible fr intravenus tissue plasmingen activatr (t-pa), the target is t cmplete rapid assessment and initiate treatment within 90 minutes f strke symptm nset. Dr t Needle Time shuld be less than 60 minutes (benchmark). All patients with disabling acute ischemic strke wh can be treated within 4.5 hurs f symptm nset shuld be evaluated withut delay by a physician with strke expertise (either n-site r by telestrke cnsultatin) t determine their eligibility fr treatment with intravenus tpa (alteplase). All patients presenting t an emergency department with suspected strke r transient ischemic attack must have an immediate clinical evaluatin and investigatins t establish the diagnsis, rule ut strke and TIA mimics, determine eligibility fr thrmblytic therapy, and develp a plan fr further management. Targets fr Patient Assessment: Dr t Triage 1 minute Dr t Strke Team ntificatin 15 minutes ED Strke Medical Directive initiated with CTAS 2 inclusive f INR cllected and reprted within 30 minutes Perfrm neurlgical exam t determine fcal deficits and assess If yu have any questins please cntact Jennifer Breatn Integrated Strke Prgram Directr, jennifer.breatn@grhsp.n.ca Versin Date: Nvember 29, 2013

4 strke severity (NIHSS). If the patient meets the clinical criteria fr strke, initiate ECG, bld wrk, mnitring, IV and O2 titratin accrding t Medical Directive fr Strke Symptms: Tests and Interventins. Nthing by muth (NPO) until swallwing screen is cmpleted. Stat CT upn physician rder within 25 minutes (EMS t fflad patient nt CT table) Bld glucse management Bld pressure management Implement Telestrke netwrk when n-site strke team expertise is nt available t prvide 24 / 7 acute strke assessment and treatment with tpa r if further cnsultatin is required. Fr a Prvincial Telestrke Cnsult cntact CritiCall at HELP (4357) with messaging: We need a Prvincial Telestrke Cnsult. The Telestrke Physician will then phne back t speak with ED/Strke Team Physician. tpa YES? Cmplete Rutine Orders Alteplase fr Acute Ischemic Strke ( 3 hur windw r 4.5 hur windw) fr wrk-up, tpa dsing and administratin, and mnitring as well as Inclusin / Exclusin Criteria. Patient admitistered tpa must be mnitred fr 24 hurs in ACOU and then transferred t the acute strke unit. tpa NO? Cmplete Rutine Orders: Adult Inpatient Strke / Transient Ischemic Attack (TIA). Patients with acute ischemic strke wh are nt eligible fr tpa (ie arrival utside 4.5 hur windw, Intracerebral hemrrhage, d nt meet the inclusin criteria, etc.) will be admitted t the acute strke unit. Intracerebral Hemrrhage YES? Patients with an intracerebral hemrrhage (ICH) shuld be referred fr urgent neursurgical cnsultatin and cnsideratin f evacuatin f the ICH particularly in the setting f altered level f cnsciusness r new neurlgical findings. Neursurgical Cnsultatin is accessed thrugh CritiCall at HELP (4357). If yu have any questins please cntact Jennifer Breatn Integrated Strke Prgram Directr, jennifer.breatn@grhsp.n.ca Versin Date: Nvember 29, 2013

5 Patients with suspected r cnfirmed raised glbal intracranial pressure (ICP), including decreased levels f cnsciusness (LOC), may be mre vulnerable t acute bld pressure reductins. Therefre bld pressure parameters shuld be established n an individual basis t ensure adequate cerebral perfusin. The patient shuld be admitted t the ICU if nt transferred t a Tertiary Care Centre. Medically stable patients with an acute ICH shuld be admitted t an Acute Strke Unit r Intensive Care Unit and underg interprfessinal strke team assessment t determine their rehabilitatin and care needs. Beynd the acutely symptmatic perid, patients with ICH shuld be managed similarly t thse with ischemic strke, except fr avidance f antithrmbtic medicatins. All risk factrs shuld be aggressively managed thrugh pharmaclgical and nn pharmaclgical means. A statin shuld be prescribed t mst ischemic strke patients t achieve LDL chlesterl < 2.0 mml/l r a 50% reductin in LDL chlesterl frm baseline. Strke patients with diabetes shuld have their diabetes assessed and ptimally managed. Patients wh smke shuld be strngly advised t quit immediately and be prvided with pharmaclgical and nn pharmaclgical means t d s All strke patients shuld be assessed fr risk f develping Venus Thrmbemblism (VTE). Early mbilizatin and adequate hydratin shuld be encuraged t help prevent VTE. Strke patients at high risk fr VTE shuld be put n prphylaxis prtcl immediately. Attachments: Secndary Strke Preventin Clinic Referral Frm Rutine Orders fr Secndary Strke Preventin Clinic Quick Respnse Guide If yu have any questins please cntact Jennifer Breatn Integrated Strke Prgram Directr, jennifer.breatn@grhsp.n.ca Versin Date: Nvember 29, 2013