Bridging the Gaps in

Singapore Stroke Nursing

Tan Il Fan

Advanced Practice Nurse

Department of Neurology

National Neuroscience Institute

Fu Liqing

Nurse Clinician

Department of Neurology

National Neuroscience Institute

Population: 5.64 Million in June 2018 (Straits Time, 2018) One of the fastest ageing populations in the world Age over 65 is expected to double the number from 430,000 today to more than 900,000 in 2030 (Straits Time, 2016)

Stroke in Singapore

• 8000 cases in Singapore per annum

• 1 in 6 persons suffer stroke once in their lifetime

IMPACT OF STROKE IN SINGAPORE

NO. 1

Leading Cause of

Death Cause of

Adult Disability

4th

Call For Action – LOS 5-6 days

6

Stroke Onset Emergency

Department Acute Stroke Unit

Community Hospital

Home/ Outpatient/ Community Services

Stroke Journey

Change Management

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Build our own Logic Model

What? Evidence-based

Intervention

How? Implementation

Strategies

Implementation Outcomes Feasibility

Fidelity Penetration

Acceptability Sustainability

Uptake Costs

Service Outcomes Efficiency

Safety Effectiveness

Equity Patient-

centeredness Timeliness

Health Outcomes

Satisfaction Function

Health status/ symptoms

Core of Implementation Science

Identify your resources

Trainers Staff

Funding Baseline Expertise

Technology Stakeholders

Pre-hospital Phase

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Stroke activation: 58-year old/ M /

S1234567A / ETA 5 mins

Pre-hospital Phase

Pre-Hospital - Gaps

- Lack of stroke awareness

- Lack of data on stroke activations

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Pre-Hospital – Bridging the Gaps

• Screen the pre-hospital stroke activations

• CPSS positive predictive value is 72.3%

• Conduct training to Singapore Civil Defence Force (Paramedics) by Stroke Service Improvement team

• Need data, find a new tool in the future

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Pre-Hospital – Bridging the Gaps

• Increase public awareness about stroke in NNI Brain Awareness Day

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Hyperacute Phase - Gaps

Stroke Activation Phase: • Inadequate knowledge

• Lack of “stroke team” or trained personnel

• Lack of coordination between multi-disciplinary teams

• Disparity in NIHSS assessment and scoring

• Lack of monitoring / data

Suboptimal door-to-needle/groin puncture time

Hyperacute Phase – Bridging the Gaps

• Nursing Workshop on Reperfusion Management in Hyperacute Stroke Aim: To prepare and equip nurses with an appropriate attitude, knowledge and skills in relation to hyperacute stroke care; and competency in performing nursing role in stroke activation as part of the team.

Improve Knowledge ,

Communication & Coordination on Stroke Code

Optimise door-to-needle/groin puncture time

Nursing Workshop on Reperfusion Management in

Hyperacute Stroke

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Hyperacute Phase – Bridging the Gaps

NIHSS Workshop for Doctors and Nurses

Aim: To share & highlight the common issues and common

mistakes made when performing NIHSS To achieve appropriate scoring of NIHSS

for complicated neurological cases

Improve consistency in scoring NIHSS among doctors & nurses

Shorten door to needle time

NIHSS workshop

Acute Phase - Gaps

Acute Stroke Unit (ASU): • Suboptimal ASU utilisation

• Inadequate knowledge and skills on stroke care

• High complication rates in non ASU: UTI, DVT,

Pneumonia

• Lack of communication among the multidisciplinary team members

High post stroke complication rate

Acute Phase – Bridging the Gaps

Increased acute stroke unit utilization rate

Reduce post stroke complication

Quality improvement project to improve ASU utilization rate

Aim: Improving right-siting of eligible ischaemic stroke

patients to Acute Stroke Unit (ASU) Improve post stroke complication rate Improve patient satisfaction rate

Quality Improvement Project on ASU Utilization

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TIA/Ischaemic Stroke

CP patients (B, C class) admitted to Acute Stroke Unit (ASU - Ward 10B)

Total patients (B, C class) : 2016 Jun-Dec (N= 836), 2017 (N = 1507), 2018 Jan-Apr (N = 455)

Acute Phase – Bridging the Gaps

Stroke Inter-Professional Education (STRIPE) Program

Journal club 3-6 monthly Stroke seminar once in 2 years E-learning platform- Video Annotated

Presentation Simulation workshop

Short concise summaries on important

stroke topics Can be used for education sessions as pre-session learning, essential core knowledge training for new staff and personal learning.

Regular update and meet up, e- learning platform

Increase stroke knowledge, increase inter-professional learning

opportunities

Acute Phase – Bridging the Gaps: STRIPE

Acute Phase – Bridging the Gaps: STRIPE

Acute Phase - Bridging the Gaps

Nurse-Led Deep Vein Thrombosis prophylaxis care

Aim: To empower nurses to assess and initiate

DVT prophylaxis care in acute stroke unit

Nurse-led VTE Prevention Protocol for Patients with Acute Stroke Suspected diagnosis of stroke

Inclusion criteria Does patient has any of the followings - CRIB/RIB - Lower limb power <3 - Unable to ambulate >5meters

Exclusion Criteria (DROP A DVT) Does patient has any of the followings

- Deformity/fracture of lower limb - Rashes/skin integrity issues (requiring dressing or

treatment) - Oedema (severe) of lower limb (in congestive cardiac

failure) - Peripheral vascular disease - Anticoagulation (pre-existing) - DVT (past medical history or pre-existing)

Commence IPC, ensure adequate hydration, early ambulation, monitor skin integrity

Ensure adequate hydration Early mobilisation if no contraindications

Inform doctor that patient is not eligible for IPC Doctor to consider other appropriate alternatives

Yes

Yes

No

No

Yes

Pre-implementation (n=40) Post-implementation (n=50)

VTE risk assessment Yes, n=10 (25%)

No, n=30 (75%)

Yes, n=42 (84%)

No, n=8 (16%)

OR 15.7 (95% CI 5.6- 44.6)

P <0.001

VTE prophylaxis Yes, n=6 (15%)

No, n=34 (85%)

Yes, n=43 (86%)

No, n=7(14%)

OR 34.8

(95% CI 10.7-113.2)

P <0.001

VTE event Yes, n=1 (2.5%)

No, n=39 (97.5%)

Yes, n=0 (0%)

No, n= 50 (100%)

P=0.44

Nurse-led VTE Prevention Protocol for Patients with Acute Stroke

Results:

Acute Phase - Bridging the Gaps

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Dysphagia Screening Protocol

Bladder scan Algorithm

Acute Phase - Bridging the Gaps

Interdisciplinary round

Aim: To improve collaboration among allied

health in post stroke care To initiate early rehabilitation referral &

plan

To improve collaboration and communication among ASU

team

Early rehabilitation and right siting of care

Rehabilitation Phase- Gaps

Rehabilitation: • Delayed rehabilitation referral

• Failure of sustaining the multi-disciplinary round

• Tedious referral process- external institution

• Long waiting time for rehab bed

• Limited resources & competency of allied health &

nurses

• Lack of continuity of care

Fragmented care… Lack of continuity of care from acute setting to subacute

and/or community

Rehabilitation Phase – Bringing the Gaps

Neuro- Recovery

Aim: To develop model of care for patients

with neurological conditions To build teams of professional specialised

in stroke To create a system approach for stroke

with iterations to continually improve

To achieve seamless transition from acute to subacute/

community care

Reduce length of stay in acute hospital

Reduce mortality & morbidity

Rehabilitation Phase – Bringing the Gaps

Neuro- Recovery

To achieve seamless transition from acute to subacute/

community care

Reduce length of stay in acute hospital

Reduce mortality & morbidity

To provide “SUCCESS” care to patients with conditions affecting the

nervous system.

Seamless: Continuum, no transition gaps, hyperacute, acute,

subacute chronic

Unified: Inter-professional team, including community groups

Comprehensive: Covering physical, psychological and social aspects

Cost-effective: Minimising cost inefficiencies

Evidence-based: Proven guideline-supported measures

Subject-centric: Consideration for individual patient needs

Statistics-focused: Driven by outcome

measures

Rehabilitation Phase – Bringing the Gaps

All professionals are part of a consistent team caring for the individual patient

• No transfer of care between difference phases • Reduce wastage for formal referrals and consultations

Single Documentation Record

Prescribed stratified pathways to care for majority of patients

Coordinators to assist with continuum of care, data and audits

Neuro-Recovery Concepts

Rehabilitation Phase – Bringing the Gaps

AH OP

Path 1 – Mild Stroke

AH CH OP

Path 2 – Moderate Stroke

AH Care

Path 3 – Severe Stroke

AH CH OP Rehab

Path 4 – Young and good potential

This would entail:

• Identifying key elements of care that may potentially be

transferred between AH and CH

• Close collaboration between AH and CH on financial

counselling for patients

Neuro-Recovery Stratified Pathways

Outpatient Phase- Gaps

Outpatient stroke clinic: • Lost of follow up after patient discharge to

rehabilitation centre/ community hospital

• Patient’s investigation not complete or/ confusion with medication

• Lack of social support/ caregiver support

Lack of continuity of care from acute setting to community

Outpatient Phase – Bridging the Gaps

Clinic After Stroke Prevention Education Research (CASPER) clinic

Aim: Assess stroke neurological and functional recovery Review risk factors for secondary prevention of stroke Review medications and side effects Screen, prevent and manage stroke complications Reinforce on stroke education Identify needs of patients with stroke and refer to

community resources appropriately

Lack of continuity of care from acute setting to community

To ensure that all patients with stroke are reviewed at least once prior to right siting of care.

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Outpatient Phase – Bridging the Gaps

Stroke Journey

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Robin Sharma

THANK YOU

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NNI Stroke Nurse Ng Wai May- DDN-APN

Fu Liqing- NC Fam Su Rong- NC- APN (Intern)

Tan Il Fan- NC- APN