Management of Stroke. Fiona Ryan Stroke Care Coordinator Bathurst and Orange Health Services September 2017

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1 Management of Stroke Fiona Ryan Stroke Care Coordinator Bathurst and Orange Health Services September 2017

2 Organised stroke care There is a 20% improvement of mortality and morbidity outcome after stroke, when systems for managing stroke are in place. (National Stroke Foundation 2010) Hub and Spoke model of care: Bathurst Orange Dubbo

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4 Systems in place Stroke Reperfusion Project hospital by-pass Stroke and TIA pathway Thrombolysis pathway ECR pathway Stroke Alert Stroke unit care Acute Nursing Care pathway QASC Case Conferencing Early Rehabilitation Stroke Unit Care Co-located beds. Dedicated, inter-professional team with members who have a special interest in stroke and/or rehabilitation. Inter-professional team meet at least once per week to discuss patient care. Regular programs of staff education and training relating to stroke National Stroke Foundation Acute Stroke Framework 2015

5 Goals of organised acute stroke care Protect the brain tissue by managing haemorrhagic stroke and preserving the ischaemic penumbra Assess and manage the consequences of stroke. Prevent complications Provide early rehabilitation Address secondary prevention

6 Protect the brain tissue Neurological status Blood pressure management Temperature control Oxygen saturation Glycaemic control And act

7 FeSS Protocol In the first 72 hours post stroke: Measure temperature 4-6 hourly (see flow chart) Treat if temperature > 37.5 C Measure BSL 1-6 hourly (see flow chart) Treat if BSL > 10mmols Nurses should be trained in ASSIST routinely All stroke patients should have their swallow screen completed within 24 hours of admission

8 Assess and manage the consequences of stroke. Allied Health assessment within 48 hours Allied Health Assistant for stroke (role). Decreased mobility, reduced upper limb function, impaired swallowing, impaired communication, impaired vision, impaired perception, impaired cognition, incontinence, changed mood.

9 Prevent complications Cerebral oedema Pressure injury Aspiration Dehydration, malnutrition UTI/retention/constipation Falls

10 Provide early rehabilitation Early Rehabilitation Consultation Treatment on the acute ward Stroke Allied Health Assistant to increase frequency of practice and provide stimulating environment Case conferencing

11 Address secondary prevention Establish cause of stroke if possible Medical Management. Education of patient and family re lifestyle, adherence to medications and risk factors. My Stroke Journey for education and self management

12 Effectiveness of Intervention INTERVENTION Aspirin NNT prevent further stroke or vascular death over 1 year CEA for Carotid stenosis 70-99% symptomatic prevent stroke at 5 years Clot retrieval Hypertension management Smoking cessation Stroke unit care achieve independence at 90 days prevent further stroke over 3 years primary prevention of stroke for heavy smokers over 5 yrs prevent death and dependency at 1 year Stroke unit care plus FESS prevent death and dependency 90 days Thrombolysis Warfarin for AF prevent death or dependence prevent recurrent stroke per year

13 Effectiveness of Intervention INTERVENTION NNT Aspirin prevent further stroke or vascular death over 1 year 111 Hypertension management prevent further stroke over 3 years 75 Smoking cessation primary prevention of stroke for heavy smokers over 5 yrs 45 Stroke unit care prevent death and dependency at 1 year 18 Warfarin for AF prevent recurrent stroke per year 12 Thrombolysis prevent death or dependence 8.4 Stroke unit care plus FESS prevent death and dependency 90 days 6.4 CEA Carotid stenosis 70-99% symptomatic prevent stroke at 5 years 6 Clot retrieval achieve independence at 90 days 6 Thrombolysis < 3 hours achieve 1 or more grade improvement on mrs 3.1

14 References re Interventions Hankey Graeme J. Secondary Stroke Prevention. Lancet Neurol 2014; 13: Viewed 15/09/2017 at: cdn.com/s /1-s2.0-s main.pdf?_tid=988d d2-11e7-a aacb35f&acdnat= _9af59432fb086f5b8a1e8bd61d361cfd Hankey Graeme J, Warlow Charles P. Treatment and secondary prevention of stroke: evidence costsand effects on individuals and populations* The Lancet 1999; 354: Viewed 15/09/2017 at: cdn.com/s /1-s2.0-s main.pdf?_tid=59e7c9aa-99d1-11e7-bf aab0f27&acdnat= _f645c426b6f2e72edc53885f9f51db06 Touma Lahoud; Filion Kristian B, Sterling Lee H, Atallah Renée, Windle Sarah B, Eisenberg Mark J. Stent Retrievers for the Treatment of Acute Ischemic Stroke A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Neurol. 2016;73(3): doi: /jamaneurol Published online January 25, Viewed 14/09/2017 at: Saver Jeffrey L. Number Needed to Treat Estimates Incorporating Effects Over the Entire Range of Clinical Outcomes Novel Derivation Method and Application to Thrombolytic Therapy for Acute Stroke. Arch Neurol. 2004;61(7): doi: /archneur Viewed 14/09/2017 at: Middleton Sandy The Quality in Acute Stroke Care Implementation Project - a state wide translational quality improvement project The Quality in Acute Stroke Care Implementation Project - a state wide translational quality improvement project. Viewed 14/09/2017. Available at: Middleton Sandy, McElduff Patrick, Ward Jeanette, Grimshaw Jeremy M, Dale Simeon, D Este Catherine, Drury Peta, Griffi ths Rhonda, Cheung N Wah, Quinn Clare, Evans Malcolm, Cadilhac Dominique, Levi Christopher on behalf of the QASC Trialists Group Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunctionin acute stroke (QASC): a cluster randomised controlled trial 2011Volume 378, No. 9804, p Viewed 14/09/2017 at Wannamethee SG1, Shaper AG, Whincup PH, Walker M. Smoking cessation and the risk of stroke in middle-aged men. JAMA Jul 12;274(2): Viewed 18/09/2017 at

15 Stroke Pathway Review See attached pathway

16 JMO Role Education opportunity Documentation Activity based management Discharge documentation