The-Changing-Face--of-Stroke-Care.ppt

*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,The Changing Face of Stroke Care,Amanda Jones,Stroke Nurse Consultant,Sheffield Teaching Hospitals NHS FT,Aim of session,Background about stroke,National drivers,NICE and RCP Guidelines,Stroke awareness,Some stroke facts,Stroke is the 3rd leading cause of death in the UK.,Leading cause of disability.,Kills twice as many women as breast cancer.,130,000 people suffer a stroke in the UK each year(a stroke is happening every 5 minutes to some-one),Approx 20-30%of people who have a stroke will die within the first month.,1000 children suffer strokes per year,Some stroke facts,Approx 12,000 under the age of 55-of all strokes are in the under 65s.,Approx 900,000 people are living with stroke in England and around 50%of those are dependant on others for help with everyday activities,Approx 1 in 4 people who live until the age of 85 can expect to have a stroke,National guidance-whats new?,National Drivers for stroke,1st evidence based document;National Clinical Guidelines for Stroke,1st ed 2000,2,nd,ed 2004,3,rd,Edition-RCP,2008,4,th,Edition September 2012,NSF for Older People,Standard 5,DoH 2001,National Audit Report 2005(a damming report about stroke services)which led to:-,Reducing Brain Damage-DoH 2006,Mending Hearts and Brains-DoH,2006,National Stroke Strategy-DoH December 2007,Diagnosis and initial management of Acute Stroke and TIA-NICE,July 2008,Draft NICE stroke rehabilitation guidelines-due for publication 2013 following major review,National Drivers for stroke,SINAP-,SSNAP,-Sentinel Stroke National Audit Programme-mandatory from April 2012-continuous audit instead of National Sentinel Audit-quarterly reports in the public domain,Accreditation-Peer review,Infoflex-our local database,Accreditation-levels of stroke care,Level,Terminology,Elements of Service provision,1,Comprehensive Acute Stroke and thrombolysis centre,Tertiary neurosciences disciplines,TIA&minor stroke management,Acute stroke management,Thrombolysis,service,Stroke rehabilitation,2,Acute stroke and thrombolysis centre,TIA&minor stroke management,Acute stroke management,Thrombolysis,service,Stroke rehabilitation,3,Local acute stroke centre,TIA&minor stroke management,Acute stroke management,Stroke rehabilitation,4,Stroke recovery and rehabilitation centre,Stroke rehabilitation,Stroke,Strategy,Prevention and Public Awareness,Post-Hospital Care,Workforce,Hospital Care,TIA and Minor Stroke,Emergency,Care,Time is brain,Active symptoms,Person Experiences Stroke Like Symptoms,999 call;ambulance,confirms likely stroke,and pre-notifies hospital,GP refers to,TIA clinic(low risk),or direct to,Hospital(high risk),advises no,driving and prescribes aspirin,(unless strong suspicion of,haemorrhage/contraindications,),GP refers to,TIA service,Recent resolved symptoms,Older resolved symptoms,Direct to stroke,service,One-stop specialist service;investigated,treated in 24 hours,Time is brain-Stroke Pathway,Management of Stroke,Stroke Unit,Specialised,assessment and care,Swallowing test,Brain scan within,24hrs,Acute Stroke Unit,Specialised clinical assessment,Urgent brain imaging,for those who need it(next CT slot or,within 1hr out of hours)/MRI,Thrombolysis if appropriate,Swallowing test,Intensive(hyper-acute)stroke unit care,for 24/48 hours,Minority,Specialist rehabilitation/inpatient and ESD,Specialist review at 6 weeks and 6 months,Long-term community stroke and,support services,Carotid intervention,Majority,End-of-life care,High risk TIA,Specialist validated immediate assessment-Recognition Of Stroke In the Emergency Room(,ROSIER,),Validated scoring system.,For use by health professionals.,ROSIER,Symptom onset:Date&Time.,Assessment:Date&Time.,BP GCS Eyes Motor Verbal,Has there been loss of consciousness or Syncope Y(-1)N(0),Has there been any seizure activity Y(-1)N(0),Is there New acute onset(or awakening from sleep)of:-,Asymmetrical facial weakness Y(+1)N(0),Asymmetrical arm weakness Y(+1)N(0),Asymmetrical leg weakness Y(+1)N(0),Speech disturbance Y (+1)N(0),Visual field defect Y(+1)N(0),Total score:(Stroke is unlikely but not completely excluded if total score is 4 or 25.),Useful for post thrombolysis,monitoring,NIH Stroke scale,HASU-Hyper Acute Stroke Units,Hyper acute nursing care,Hypoxia-O2 sats92%,Hyper/hypoglycaemia,Hypertension-closely monitored-no clear consensus on optimal management-should be treated post stroke(usually after 7 days),Intracranial pressure-drowsiness/gaze palsy/breathing problems,Pyrexia-worsens infarct-needs to be lowered if over 37.5,Dehydration-maintain hydration,Aspiration,DVT/PE,Seizures,Saver,Stroke 2006,0246,30,20,10,0,Number making full recovery per 100 treated,Impact of thrombolysis,Time(hours),Benefit,Harm,Time is Brain,How many stroke patients per year in UK*might avoid being dead or dependent with each treatment?,%treated with this intervention,Number treated per year,Benefit per 1000 treated,Number who avoid death or dependency,Aspirin,80%,104000,13,1350,Stroke Unit,60%,78000,56,4370,Thrombolysis,2%,2080,63,130,Thrombolysis,30%,31200,47,1470,Based on 130,000 strokes per year in the UK,IST 3 Collaborators,NICE STROKE QUALITY STANDARDS 2012,1,Ambulance staff use a validated tool to diagnose stroke/TIA,and transfer them to a specialist stroke unit within an hour,2,Brain imaging within an hour of arrival in hospital if indicated,3,Admitted directly to a stroke unit,assessed for thrombolysis,4,Swallow screen within 4 hours with a written nutrition plan,5,Assessed and managed by specialist nursing staff and at least 1 member of the specialist MDT by 24 hrs,and all relevant members within 72 hours with written MDT goals within 5 days of admission,6,Treated in a specialist rehab unit for those who need it.,7,A minimum of 45 minutes relevant therapies offered over 5 days,8,Loss of bladder control is reassessed at 2 weeks i/c an ongoing plan,9,Cognition and mood is screened within 6 weeks,10,Following discharge,stroke related disability,followed up in 72 hrs by a specialist team,11,Carers should have a named contact for info and support,NICE Stroke Rehabilitation Guidelines,(1,st,stroke rehab guideline),Draft was circulated nationally for consultation last year,Negatively received and strongly criticised by MDTs nationally mainly due to the limitations under NICE e.g.For some-one who has a stroke-consider offering physiotherapy!-significant implications for rehabilitation.,Guideline to be reviewed and changed,Hope for new guideline in 2013-vital to get it right!,As a result a delay in publication of the RCP national Clinical Guidelines for Stroke-September instead of June 2012,26,th,March Therapy consensus day event with the RCP,NICE Stroke Rehabilitation Guidelines,Types of studies considered,;Systematic reviews,double blinded and unblinded parallel RCTs,and cross over randomised studies.,No qualitative studies were included-much rehabilitative care is qualitative in nature and cannot easily be captured in an RCT.,Intensity of therapy after stroke consensus meeting-26,th,March RCP,London,Expert speakers,Voting panel,45 minutes of therapy,Appropriateness of therapy,How to capture therapy,Therapy research,Patients perspectives in relation to therapy,Limited places-10-email:therapy.,Possible new inclusions to the 4,th,Edition of the RCP National Clinical Guidelines for Stroke,Acupuncture should only be used if part of a clinical trial,Do not routinely offer Functional Electrical Stimulation or TENS,Pain control-offer amitryptyline,gabapentin or pregabalin for neuropathic pain,SALT should be provided for more than 2 hours per week if patient is able to tolerate this,Return to work enhanced section,More emphasis on the timing and giving of information to carers,Changes within the psychology section-stepped care and use of validated tools to screen and assess for mood and cognition,More about post stroke fatigue,Possible new inclusions to the 4,th,Edition of the RCP National Clinical Guidelines for Stroke,Secondary prevention-emphasis on Life style changes being of equal importance as secondary prevention medications,Emphasis on exercise programmes in secondary prevention,More detail about diet and weight loss(use of weight loss medications),Hypertension levels,Calcium Channel blockers are recommended as first line treatments(e.g.Amlodopine)-enhanced section on hypertension management,Carotid endarterectomy surgery should be undertaken ASAP and within 7 days(was 14)of symptoms-working towards 48 hours by 2017,Possible new inclusions to the 4,th,Edition of the RCP National Clinical Guidelines for Stroke,A new section on telemedicine which states that this should be regularly audited.,More emphasis on younger stroke patients,ESD and the need for the same intensity and specialist staff as inpatient stroke rehab units,Community interaction section,A section with recommendations regarding therapy/nursing and medical levels included for the first time-emphasising the need for 24/7 nursing and stroke consultant cover,New Campaign to increase public awareness,Act FAST launch 27,th,February from original campaign,TV advertising Feb 27,th,-March 25,th,March 5,th,-March 18,th,-radio advertising particularly for BME(Black Minority Ethnic)communities,The changing face of stroke-not just an inevitability of old age,But can happen to anyone at any age,What used to happen,What happens now,Act FAST,Time lost is brain lost-for every minute when a stroke first happens approximately 1.9 million neurones are lost!,Vital to get to the hospital for specialist assessment,and treated as soon as possible to help preserve as much brain as possible!,In conclusion,Significant developments in stroke care,The new RCP guidelines will provide enhanced national guidance,The new NICE stroke rehabilitation guideline should help with developments in rehabilitation,Need to continually raise awareness of stroke symptoms as people are still not accessing services early enough!,More emphasis and research is still needed in medium and long term stroke care,