Canadian Stroke Best Practices Prevention of Acute Stroke and Transient Ischemic Attack (TIA) Order Set (Order Set 4)

Transcription

1 Canadian Best Practice Recommendations for Stroke Care: All patients presenting to an emergency department or outpatient setting (family physician s office, ambulatory clinic, out-patient setting etc.) with suspected stroke or transient ischemic attack must have an immediate clinical evaluation and investigations to establish the diagnosis, rule out stroke mimics, determine eligibility for thrombolytic therapy, and develop a plan for further management. Does the patient have allergies or hypersensitivities? No Yes: Refer to allergy documentation and process Date of Stroke Prevention Assessment and Management Visit: (dd/mm/yyyy) Precautions Contact - Droplet- Airborne - Stroke Symptom History Obtain and document stroke symptom history: Document most recent stroke event: Date of Onset/Last Seen as Normal/Last Known Well (dd/mm/yyyy) (hh:min) Determine and Document type of stroke: Acute Ischemic Stroke Subarachnoid hemorrhage Transient Ischemic Attack Intracerebral Hemorrhage Venous Sinus Thrombosis Other Signs and Symptoms (Describe): Stroke Severity and Focal Deficits Baseline assessment with standardized stroke scale National Institute of Health Stroke Scale (NIHSS) Document: Baseline Score: Canadian Neurologic Scale (CNS) Document: Baseline Score: Neurovital signs (Glasgow Coma Scale (GCS), motor strength, sensory) Diagnostics Neuroimaging CT Head Non Contrast (as per Stroke Protocol) Urgency: STAT Within 24 hours Within week(s); Document * Date of scan: (dd/mm/yyyy) Time of scan start: (hh:min) Diffusion Weighted MRI (as per Stroke Protocol) Urgency: STAT Within 24 hours Within week(s) Document * Date of scan: (dd/mm/yyyy) Time of scan start: (hh:min) * If scan booked for a future date, indicate the booked appointment date/time: SIGNATURE V2 Page 1 of 7

2 Diagnostics Continued Cardiac 12-lead ECG: Is Atrial Fibrillation or Flutter noted on ECG? Document: Yes No Holter Monitor Transthoracic Echocardiogram Transesophageal Echocardiogram Include Bubble Study Cardiac CT (per Stroke Protocol) Carotid Imaging Cardiac MRI (per Stroke Protocol) Carotid ultrasound Dopplers Urgency: STAT Within 24 hours CT Angiogram Urgency: STAT Within 24 hours MR Angiogram Urgency: STAT Within 24 hours Document date of carotid imaging: (dd/mm/yyyy) and: Time of scan start (hh:min) General CXR PA + Lateral EEG Consults MD Consults Stroke Prevention Clinic App't booked: (Date) Stroke Neurologist/Stroke Specialist App't booked: (Date) Neurosurgeon App't booked: (Date) Vascular Surgeon App't booked: (Date) Interdisciplinary Stroke Team Members/External Services Consults App't booked: (Date) Dietitian Pharmacist Psychologist Home Care Services Physical Therapist Speech Language Pathologist Occupational Therapist Physiatrist Social Worker Palliative Care Specialist/Team Vitals Psychiatrist Document: Actual Weight kg Estimated Weight kg Height: cm Body Mass Index (BMI): Calculated: kg/metre 2 Waist Circumference Baseline temperature, heart rate, respiratory rate, blood pressure SpO2 via pulse oximetry Maintain SpO2 at % cm SIGNATURE V2 Page 2 of 7

3 Assessments Baseline swallowing screen. Document date: (dd/mm/yyyy) and Result: Normal Abnormal If swallowing screen abnormal, initiate referral to SLP or OT for a detailed assessment, diet recommendations and therapy plan Baseline Functional Assessment: Alpha-FIM Modified Rankin Score Other: Baseline Cognitive Assessment: Assessment Tool (e.g. MOCA) Document: Baseline Depression Screen: Screening Tool (e.g. HADS, PHQ) Document: Score Score Baseline Fitness to Drive Assessment Document: Tool: Outcome Baseline Sleep Apnea screening (if applicable) Document: Tool: Lab Investigations CBC APTT INR Capillary Blood Glucose STAT Electrolytes (Na, K, Cl) Creatinine, GFR Glucose BUN CK Troponin Ca, Mg, Phosphate LDH A1C Fasting Glucose Outcome Fasting Lipid Profile (12 hour fasting HDL, LDL, Total Cholesterol, Triglycerides, Total Cholesterol/HDL ratio) AST, ALT, ALP, Bilirubin TSH If female less than 50 years of age: Serum β HCG Urine β HCG (urine pregnancy test) ABG Coagulopathy screens: Anticardiolipin (Antiphospholipid) Antibody Protein S Prothrombin Gene Mutation PNH screen (Paroxysmal Nocturnal Hemoglobinuria) Antithrombin III Lupus Anticoagulant Protein C Factor V Leiden Mutation/APC resistance Homocysteine ESR C-Reactive Protein (CRP) Antinuclear antibody (ANA) Syphilis Screen Sickle Cell Screen Blood C + S x 3 (endocarditis cultures) Urine C + S Urine R + M Additional Lab Investigations SIGNATURE V2 Page 3 of 7

4 Antiplatelet Agents Not applicable No anticoagulants, no antithrombotics until CT or MRI completed and hemorrhage ruled out ***acute ASA loading dose: order at least 160 mg of acetylsalicylic acid (ASA) immediately as a one time loading dose after brain imaging has excluded intracranial hemorrhage*** enteric coated acetylsalicylic acid (ECASA) one-time loading dose mg PO ( mg) Then enteric coated acetylsalicylic acid (ECASA) mg PO daily ( mg) If patient has swallowing difficulty, administer acetylsalicylic acid 325 mg PR daily clopidogrel 300 mg PO loading dose Then clopidogrel 75 mg PO daily extended-release dipyridamole 200 mg/acetylsalicylic acid 25 mg 1 capsule PO BID (MD may consider ordering a loading dose of acetylsalicylic acid mg first) Other antithrombotic: (drug, dose, route, frequency) Note: Canadian Best Practice Recommendations for Stroke Care Recommendation: Short-term concurrent use of acetylsalicylic acid and clopidogrel (up to 90 days ) has not shown an increased risk of bleeding; however, longer-term use is not recommended for secondary stroke prevention, unless there is an alternate indication (e.g., carotid artery stent requirin g dual antiplatelet therapy), due to an increased risk of bruising and bleeding Anticoagulant Agents for Patients with Atrial Fibrillation or Other Indication Not applicable Document indication for anticoagulants: No anticoagulants until CT or MRI completed and hemorrhage ruled out ***MD to assess baseline creatinine clearance prior to ordering anticoagulant administration, then annually*** For patients with atrial fibrillation, begin anticoagulation for secondary stroke preventio n apixaban dabigatran mg PO BID mg PO BID rivaroxaban mg PO daily warfarin loading dose of mg PO daily for days Then warfarin mg PO daily for days Then When therapeutic range achieved, start warfarin maintenance dose: warfarin mg PO daily Therapeutic INR goal for patient on warfarin INR between 2.0 and 3.0 (aim for INR of 2.5) more than 70% of the time Therapeutic range goal: Lab Investigations while on warfarin Measure INR on days (list days and frequency of INR monitoring) ***concomitant antiplatelet therapy with oral anticoagulation is not recommended in patients with atrial fibrillation unless there is a specific medical indication such as a coronary stent*** SIGNATURE V2 Page 4 of 7

5 Blood Pressure Management ***recommendation: follow Canadian Hypertension Education program (CHEP) hypertension management protocols *** Glycemic Management for Patients with Diabetes Lipid Management ***recommendation: follow Canadian Diabetes Association diabetes management protocols*** ***recommendation: follow the Canadian Cardiovascular Society Dyslipidemia management protocols *** Nausea Management dimenhydrinate mg PO/NG/IV/PR q4h PRN (use lowest possible for effect for elderly/frail) dimenhydrinate mg PO/NG/IV/PR/IM q4h PRN (use lowest possible for effect for elderly/frail) ondansetron 4 mg PO/NG/IV q8h PRN. If not effective after 1 dose, notify MD Pain/Fever Management **Consider lowering the maximum daily dose of acetaminophen to 3,000 mg or less in 24 hours or, in patients at risk of hepatotoxicity with high doses e.g. chronic alcohol users, established liver dis ease, chronically malnourished*** If acetaminophen ordered, max from all sources acetaminophen mg PO/NG/PR q4h PRN for pain acetaminophen 650 mg PO/NG/PR q4h PRN for pain or if T greater than/equal to 37.5 C mg in 24 hours (max 3,000 or 4,000 mg in 24 hours) SIGNATURE V2 Page 5 of 7

6 Smoking Cessation Determine smoking status, and if smoker determines readiness to attempt to quit Referral to Smoking Cessation Program/Specialist: Appointment booked at: (Facility) (Date, Time) Smoking Cessation Medication * * *Canadian Best Practice Recommendations for Stroke Care The three classes of pharmacological agents that should be considered as first-line therapy for smoking cessation are nicotine replacement therapy, bupropion, and varenicline (Smoking Cessation recommendation 2.9, Update 2012) Other Medications Discharge/Transition Plan Education Provide patient and family education and skills training as required regarding: Stroke signs and symptoms and appropriate actions to take (Name) Contact numbers for Emergency Medical Service (EMS), neurologist, Stroke Team and other healthcare professionals Risk factor modification assist with development/update of an individualized plan Activity levels, activities of daily living Safety and avoidance of falls and injury Rehabilitation Return to work (if applicable) Driving Sexual activity Community support group resources Provide patient and family with written summary of prevention plan at end of ambulatory care visit (ED /ER, stroke prevention clinic, Family Physician's office, other community setting) SIGNATURE V2 Page 6 of 7

7 Patient and Family Education Assess patient and family for learning needs and readiness for information All team members to provide education to patient, family and caregivers throughout visits Provide education and skills training to patient, family, and caregivers Disposition Refer patient to Emergency Department Facility Admit patient to Inpatient facility Facility Refer patient to Stroke Prevention Clinic (SPC) or Service SPC: Appointm ent: Date Time Refer patient to Home Care services Refer patient to outpatient or community-based rehabilitation for assessment and treatment Facility Appointm ent: Date Time Follow-up with Family MD Send consult letter to Family Physician within 72 hours Other Follow-up Appointments Name: Specialty: Name: Specialty: Name: Specialty: Additional Orders (Name) SIGNATURE V2 Page 7 of 7