Barbara Carey

Stroke MDG – ICP South

Integrated stroke service pathway

ICP-South

Total Patient Journey

YES YES

YES

NO NO

DECISION MAKING POSSIBLE PATHWAYS

1

2

Craigavon AreaHospital Patients

3

??

Daisy Hill 4

Hospital Patients

5

6

Key: Lynn Lappin, Head of Reform

20100412_StrokeFuture_Pathway_V0_4_LLappin

7

8

Click on the boxes with the thick outer lines for supporting information

Draft STROKE Pathway

CLICK HERE For the Recommendations and

Clinical & Organisation Standards for Stroke

Services in Northern Ireland

Primary Care Secondary Care Community Care

Patient presents to GP and assessed using

'FAST' guidelines

Patient/family recognises 'FAST' symptoms

999 Ambulance called

Paramedics assess patient using 'FAST'

guidelines and alert ED staff who alert

appropriate radiological/medical staff

Patient arrives at ED and is triaged using agreed assessment

tool (1)

Patient suitable for

thrombolysis

Stroke Thrombolysis Team bleeped if not

bleeped earlier

Patient CT scanned with instant reporting

Stroke confirmed and

proceed to thrombolysis

Monitoring commenced -

Nil by mouth 24hrs

Follow-up CT at 24 hours

Daily whiteboard

meetings to discuss

discharge pathways

and patient

progress

Client to return home with input

from Community Services. MDT

determine services required, Contact to

be made with

apprpriate Community

Integrated Care Team for domiciliary support and linkages

with appropriate teams (2)

CAH patient transferred to non-acute Stroke

Ward for rehabilitation phase (2)

Patient transferred to Stroke Ward in

CAH, bolus given and infusion set up

Bolus given in ED and infusion set up.

Patient transferred to HDU in DHH for

first 24 hours and then transferred to

Stroke Ward

DHH patient remains in Stroke Ward for

rehabilitation phase (2)

Patient transferred to Stroke Ward

Care pathway and MDT interventions

commenced (3)

Patient remains in hospital/Discharges home/ discharges to

nursing home to end of life with the Liverpool Care of Dying

pathway implemented (4)

Patient self-presents to A&E

FAST Guidelines and Actions

Thrombolysis

Acute Stroke Integrated Care Pathway

Patient presents to Out of Hours and is assessed using 'FAST' guidelines

Discharged to own home,

nursing/residentialhome (temporary/

placement) through Community Stroke

Team

Community Stroke Team intervention

Patient signposted to statutory/ voluntary/

community schemes/ community access officer for re-training, couselling,

interaction, support (including carer's

assessment and support groups) and respite

Discharged to other hospital eg Musgrave Park

TIA and Thrombolysis Assessment

Community Stroke Referral forms

Community Stroke Team

Voluntary/Community Services

Secondary Prevention

On alert -stroke thrombolysis team may be bleeped

Nursing staff complete Swallow Assessment

within 4 hrs

Nursing staff complete Swallow

Assessment once nil bymouth is

lifted

Daily intervention and rehabilitaion as tolerated or as appropriate

Referral to Telehealth and

Telecare if appropriate

Patient has suspected stroke while an in-

patient in acute

Referral to memoryservices if appropriate

Clinical Psychology referral if appropriate

Discharged home with Community Stroke

Team - Referrals sent to Community Stroke

Team

Home with Stroke specialist nurse input. Secondary

prevention.

Daily interventionand rehabilitation as tolerated or as appropriate

Daily White board meetings and weekly MDTs to discuss patient progress and discharge plans

Discharged home with Social service input only, no therapy follow up required.

Followed up by Stroke Specialist Nurse for

secondary prevention

Hospital SW team to liaise with Community ICT to arrange

package of care required

Discharged to Nursing /Residential / EMI

placement, no further therapy input required. Followe up by Storke specialist Nurse for

Secondary prevention

Normal procedures for procurement of bed apply

Onward referral to Dietician, Podiatry, Tissue Viability, Continence as appropriate

Discharged to other hospital eg Musgrave Park

Patient has suspected Stroke while in-patient

in Non-acute setting

Ward Staff assess patient using

'FAST' guidelines

Thrombolysis Team bleeped

Registrar assesses patient and links

directly with Craigavon area Hospital

Patient transferred to Criagavon Area

Hospital via ambulance

http://thelrc.files.wordpress.com/2013/02/mind_the_gap_logo_by_rrward1.png

ICP South – Stroke Diagnosis/Treatment what’s different ?

Patient perspective

Improved consistency of door to needle time across sites

Reduction in variability whether inside or outside working hours

Increasing direct admission to stroke unit

Rolling visible info pt chart of targeted objectives e.g. swallow within 4hrs, scan within 12 hours

Clinical perspective Baseline?

-Acute + community data entry into SIMS &SSNAP

- Stroke manager -updates LCG &SSNAP submission monthly

- Monthly Trust stroke meetings performance reviewed

Pre-alert system

- NIAS &A&E training

- confirmation &closure pre-alert FAST positive calls system

-NIAS & Trust share data re outcomes pre-alert FAST positive calls

Training

Awareness

Communication

ICP South – Stroke

TIA clinic what’s different ?

Patient perspective

TIA clinic “one stop shop” reduces risk of subsequent stroke

- Cardiology investigations e.g. dopplers

- Preventative meds prescribed +dispensed

- Electronic standardised discharge letter to GP improving communication

-Coordinated review with stroke specialist nurse as per self management models

Clinical perspective

GP education TIA service

Implement agreed TIA pathway by GPs / Trust - Electronic referral with built in risk calculator

- Identify capacity

- High risk: rapid access ambulatory hot slot system

- Low risk: reg clinic across 3 sites

Confirmed reporting of scans within 24hrs from TIA clinic

ICP South – Stroke

Discharge What’s different ?

Patient perspective

Access for all patients to a fully

resourced ESD team

-6/7 day rehab available

-Access to resident psychologist

-Improved services for young working

stroke patients

Named contact of specialist

stroke team for any issues

after discharge

Patient education: info leaflet

with CVS signposting to

include self management

Patient survey to monitor

Clinical perspective

Clarity re ESD alternative community stroke team model

Stroke manager to coordinate ESD team +performance - Traverse historical

boundaries

- In reach / Outreach capabilities

- Vocational rehab pathway

- Smoking cessation referral

- Standardisation of review and data entry

ICP South – Stroke

Medication optimisation what’s

different ? Patient perspective

Improved communication

Patient/carer’s better understanding of medicines

Improved adherence

12 month follow-up service with GP more widely available

Community pharmacy medication review

Clinical perspective Standardised electronic

discharge

Clarity re med review at discharge from CST to GP

Community pharmacy MUR to support adherence + optimisation.

Clarity re targets +responsibility? Annual stroke register risk factor review GP enhanced service for all points on TIA &stroke register to include reassessment annually to achieve BP+ lipid targets

ICP South – Stroke

Prevention What’s different ?

Patient perspective

Earlier identification of AF

Rapid appropriate

anticoagulation (warfarin

or NOAC) and

counselling

Clinical perspective

AF opportunistic

screening enhanced

service

GP / CP education AF +

NOACs with NICE and

regional guidance

Timely imaging

+reporting access for AF

patients e.g. ECHO

CP role in health

promotion

AF detection stroke prevention