NORTH STAFFORDSHIRE STROKE UNIT MANUAL

Editor C. Roffe

This is a working document aiming to provide guidance on the management of stroke patients on the stroke unit. It should be available for use for all professionals working with stroke patients within the stroke service. It is as yet incomplete, and any the stroke team would be grateful for comments on completed sections and contributions for sections not completed yet.

Completed sections are indicated by the initials of the author and the date of completion in the index. Underlined words in the index are hyperlinks. Clicking on these words will take you to the section. The appended documents are not accessible outside my office since they link to files on my computer. If you need copies of these documents please email christine.roffe@northstaffs.nhs.uk.

A paper copy of this document should be available for ward use and the document should also be saved to the desktop on the ward and in your office and replaced by the new version when an update is mailed.

The guideline is general, and individual patients may require deviations from the recommended treatment.

Index

General points Philosophy of care needs review The stroke service

Admission procedures Triage for Admission to the ASUThe hot transfer protocolTransfer criteria for the RSU

Acute stroke management Diagnosis of stroke CR May 05

Causes of stroke CR May 05

Stroke classification and prognosis CR May 05

Why is acute stroke management important? CR May 05

Care pathway for acute stroke management Thrombolysis CR 30 05 2010

EarlyMobilisation and stimulation E Hall June 2005

72 hour monitoring and intervention protocol 06 07 2011 Airway management RW 2002

Hypoxia CR 15 05 2010 Pyrexia JC/CR 2003

Early Blood Pressure Management JC/CR 2003 revised 15 05 2010

Hypotension JC CR 2003

Hypertension within the first week JC CR 2003

Medical management of severe hypertension CR 2002 needs review

Hyperglycaemia CR 15 05 2010 Neurological deterioration Crescendo TIAS CR 15 05 2010 Intracerebral haemorrhage needs to be fully delveloped Correction of abnormal INR CR 30 06 2010

Assessment of swallowing RW 02, needs reviewThrombosis prophylaxis CR 20 04 2010AssessmentsMedical treatmentsThe first day meetingWard routines and ward rounds on the ASU

Communication and The relatives' clinic information Carers Group meetings

Complications Cerebral OedemaConfusion and agitationHaemorrhagic conversion of a cerebral infarctDVT and PE CR 20 04 2010Depression CR 1.12.04IncontinenceUrinary Retention CR 17.17.10Shoulder Pain CR 29.11.04

Post Stroke SeizuresSpasticity A. Ward, 30.12.04Drooling A. Ward ?

Reducing Stroke Risk SmokingHypertension (long term management)Hyperlipidaemia CR 29.11.04AlcoholDiabetesAtrial fibrillation R. Campbell Sept 08Anticoagulation with warfarin CR 22.06.2010Other sources of emboliAvoidance of HRTPolycthaemiaCarotid endartrectomyDietExercisePFO, ASD CR May 2010

Rehabilitation Hemiparesis/ hemiplegiaPerceptual difficulties after stroke E.Hall 6.6.05

AphasiaHemiparesis/ hemiplegia

Work and Leisure Resuming hobbies and interests E Hall June 05

Driving E Hall June 05

Travel E. Hall June 05

Common problems

Discharge Discharge planningThe collaborative care discharge documentationThe stroke checklistDischarge letter

Out-patient review One month follow-up callLiaison with the Stroke AssociationThe stroke clinic CR 1.5.2010

Audit

Education and Training

Research

Sources of information

Appendix Stroke care pathway day 1Stroke care pathway day 2 and 3

ASU Acute Stroke Monitoring Actions Chart CR 15 05 2010Scandinavian Stroke ScaleNIHSS Scale

Rankin ScaleBarthel ScaleMMSEHospital Anxiety and Depression Scale (HAD) proforma linkWhamm falls risk toolWaterlow ScaleNutrition assessmentCare plan for starting enteral feedingSwallowing assessmentCollaborative Care Discharge DocumentationDischarge letter template CR 30.04.2010Stroke Clinic 6 week follow-up proforma CR 1.5.1010Stroke Clinic 6 week patient questionnaire CR 1.5.1010Stroke 6 month follow-proforma CR 1.5.2010Stroke 6 month follow-up questionnaire CR 1.5.2010

Stroke clinic 3-month follow-up proforma (not in use 2010)CR 2.12.04Three months follow-up Questionnaire (not in use 2010) CR 2.12.04Annual Warfarin Review Form CR 7.10.2008

Ward Team Philosophy of the Acute Stroke Unit

The multi-professional team of the Acute Stroke Unit is committed to providing the best treatment, care and emotional support to patients and their relatives during the acute stage of their stroke. Our aim is to promote independence, health and well-being.

Patients will be treated, monitored and cared for by skilled and knowledgeable staff with a strong interest in stroke. All members of the multi-professional team will work closely together to provide up-to-date, evidence based care in a welcoming, caring, safe and progressive environment.

The team will work together with patients, their relatives and carers to achieve the best outcome for each individual. Patients and their families will be encouraged to take an active part in developing their independence as soon as possible after a stroke.

The team will strive to ensure that patients are kept fully informed about their condition, treatments, investigations and progress, and will be happy to respond to any queries and concerns. Wherever possible and acceptable to the patient, we will endeavour to involve relatives and carers in this process.

The treatment and care provided on the Acute Stroke Unit will prepare patients for their return home or to further rehabilitation, wherever possible. In spite of all efforts, some patients may not recover from their stroke. The team is committed to provide support and comfort to these patients and their families.

Criteria for transfer to specialist stroke rehabilitation I

The ideal setting

These would be the criteria for transfer if the number of stroke rehabilitation beds was not limited. These criteria can be used for determining bed numbers, but will not be usable clinically until the number of rehabilitation beds has increased to 30-40.

Who should be transferred for specialist stroke rehabilitation?

All stroke patients who :Are medically stableAre not moribundAre foreseen to need more than 10 days of continued rehabilitation once stable

When should stroke patients be transferred to specialist stroke rehabilitation?

As soon as thy are medically stable after the stroke. This would usually be within 3-10 days of admission.

Which patients should be transferred to rehabilitation and care settings other than the specialist stroke rehabilitation ward?

The stroke rehabilitation ward should combine input from stroke specialists and specialists in general rehabilitation allowing seamless care for older and younger stroke victims.

Patients who are moribund should be cared for in appropriate palliative care settings.

Patients who have cerebrovascular disease or a CT diagnosis of stroke but no significant stroke-related disability which requires specialist stroke rehabilitation (new hemiparesis, dysphasia, ataxia) should be referred to general rehabilitation beds.

Criteria for transfer to specialist stroke rehabilitation IHow to prioritise given limited stroke beds

While there is good evidence that all but moribund stroke patients and those who are sufficiently recovered to be discharged home with appropriate support benefit from specialist rehabilitation, limited capacity of the unit necessitates selective transfer of those most likely to benefit.

Criteria for patient selection are not absolute, and may vary depending on bed availability. However, the principles of prioritisation will apply.

The main criteria for acceptance on the stroke rehabilitation unit are that:

1. The patient has a realistic chance of getting back home.2. The patient requires specialist help to get back home.

In exceptional circumstances stroke patients who have no realistic chance to get back home may be transferred to the stroke ward if their stroke-related care and rehabilitation needs are so severe and complex that they can only managed by a specialist team.

Detailed criteria for screening are given on the next page.

SCREENING CRITERIA FOR ADMISSION TO THE STROKE REHABILITATION UNIT

Absolute criteria (must be fulfilled in patients considered for transfer)

New stroke with definite new clinical symptoms No terminal illness Medically stable

Other criteria A Patient was living at home before the stroke The patient is likely to benefit from rehabilitation The patient is able to co-operate with rehabilitation The patient has had a positive change in abilities since stroke onset

Other criteria B The patient has not progressed, cannot co-operate with rehabilitation and has no potential to benefit from

rehabilitation but

The patient wants to go back home The carer wants the patient to go back home The carer is aware that there will be no improvement in the patient's abilities at the time of discharge and

still keen and willing to take the patient home The carer is physically and mentally able to take the patient home given appropriate training and support

If the patient fulfils the absolute criteria and A or B he/she should be listed for the specialist stroke ward.

If the patient fulfils the above criteria, but has the potential to go back to work, or has specific needs for reintegration, which would best be met by a service targeted at younger patients. Such patients will be referred to Haywood hospital for rehabilitation.

If the patients fulfils the absolute criteria, but not A or B then he/she will be considered for generalist rehabilitation. The patient will be put on the general waiting list for Bucknall Hospital by a member of the stroke team or ASU staff, if appropriate (Please also refer to next page and to the Admission policy for Bucknall Hospital).

PROTOCOL FOR TRANSFER TO GENERAL REHABILITATION BEDS AT BUCKNALL HOSPITAL

The patient is unlikely to go back home but will have better quality of life if specific stroke-related disabilities such as poor sitting balance, dysphagia or incontinence are addressed.

The patient has spent less than 6 weeks in hospital The patient spent more than 6 weeks in hospital but has been medically unstable most of the time and will

improve with some time for recuperation The patient is unlikely to go back home bit will have better quality of life if specific stroke related

disabilities such as poor sitting balance, dysphagia or incontinence are addressed.

Or

The patient has no stroke-specific rehabilitation needs and will get better in any rehabilitation environment).

All patients transferred to generalist rehabilitation will have the following documented in the notes:

1. Reason for transfer2. Goals to achieve3. Time frame in which the goals are expected to be achieved:4. Specific instructions for the management of stroke related problems (if considered necessary):

Note: An Admission Policy for Bucknall Hospital is currently being developed. The above guidance may change with time depending on the Bucknall admission criteria.

CRITERIA FOR REFERRAL OF PATIENTS TO THE HAYWOOD REHABILITAION UNIT

Criteria as for the specialist stroke ward, in addition

The patients should have the expectation to return to working life or homemaking.

Have specific needs for reintegration that could best be met by a service targeted at younger patients.

Triage of patients presenting with possible stroke

Definite Stroke

=> Fast track to ASU. Ring 07623 675 973 for bed availability. Must fit the below specifications

New hemiparesiswith weakness affecting at least 2 out of 3 body parts on one side of the body (e.g face, arm, leg)

With sudden onsetFirst noted on waking or patient must be able to tell the day and time of onset

In a patient who was previously well, mobile and has not had a head injury to cause the symptoms.

Refer to neurosurgeons if cause of symptoms is trauma, and to neurology if Subarachnoid haemorrhage or unusual non atherothrombotic cause of stroke suspected.

May be a stroke

=> Doctor to review and make a diagnosis of stroke/ non-stroke/ unclear. Refer only to ASU if diagnosis of stroke confirmed by a doctor.

Sudden unsteadiness with slurred voice or double vision

New sudden onset weakness of one side of the body involving only arm, or face, or leg

Sudden onset of jumbled speech (not confusion)

In a patient who was previously well, mobile and has not had a head injury to cause the symptoms.

Possible stroke, but other causes more likely

=> Look for other causes and admit to an acute medical or geriatric ward

Coma

Increase in weakness or speech problem in a patient with remaining neurological deficit from a prior stroke.

Stroke unlikely

=> Look for other causes, admit to a geriatric ward

Patient /carer unable to tell when the symptoms started

'Off legs'

Confusion

WHO Definition of stroke

A clinical diagnosis of stroke made when the patient suffers a sudden onset of focal neurological deficit which persists for more than 24 h and is not caused by obvious other pathology (such as a blow to the head).

A focal neurological deficit is one which can be located to one specific area of the brain. For practical purposes, typical focal signs to look out for when trying to diagnose a stroke are 1. hemiparesis or hemisensory loss 2. aphasia (problems with production or understanding of speech) 3. hemianopia (inability to see one half of the visual field) or blindness in one eye.

The sudden onset is important to distinguish the stroke from other neurological problems such as brain tumors.

The duration of symptoms is important to distinguish a stroke (which persists for more than 24 h) from a TIA which lasts for a shorter time.

Patients who present only with non-specific symptoms such as confusion, frequent falls, dizziness or blackouts are unlikely to have a stroke as their main problem.

Patients who are unconscious on arrival may have had a very severe stroke, but other options such as a seizure, alcohol excess, an overdose, a subarachnoid haemorrhage or a diabetic coma are more likely and need to be excluded.

What is the cause of the stroke?

and why is it important to know the cause?

Most strokes (80%) are caused by cerebral infarcts, 15% are caused by intra-cerebral haemorrhage, 5% by other underlying pathologies.

Infarcts and haemorrhages are difficult to distinguish clinically. A definite diagnosis can only be made by CT head scan.

In most patients knowing the results of the san will not significantly alter management in the first few days. However, some patients need more urgent investigation on the day of admission.

Look out for:

A history of head injury suggests a possible subdural or epidural bleed. These patients must be scanned immediately and may need neurosurgical referral.

More gradual onset of symptoms, prominent pyrexia, headaches and confusion may point towards the possibility of encephalitis or meningitis. If untreated, such patients will rapidly deteriorate. Patients where encephalitis is suspected clinically need an urgent CT head scan and a lumbar puncture. The prognosis worsens the more treatment is delayed.

A history of neck injury or whiplash may indicate carotid artery dissection. These patients need urgent investigation (doppler, angiography).

A subarachnoid haemorrhage is associated with sudden onset extremely severe headaches, photophobia and neck stiffness. Treatment with nimodipine will improve outcome.

The distinction between an intracerebral haemorrhage and an infarct is difficult on clinical grounds alone. Severe headaches, vomiting, a history of alcohol abuse and treatment with warfarin may point to a diagnosis of a bleed. Anticoagulated patients must be scanned on admission. In patients with intracerebral haemorrhage anticoagulation must immediately be reversed by FFP infusion or vitamin K to prevent deterioration. Reversal of anticoagulation may result in rapid clinical improvement.

A history of personality change and gradual onset of symptoms, especially if there are also headaches, suggests a possibility of a brain tumour.

The OCSP classification of strokes into TACS, PACS, LACS, and POCSi

What does it all mean?

There are two main types of stroke. First, the anterior circulation type stroke, caused by ischaemia in the carotid artery territory, and, second, the posterior circulation type stroke caused by infarction in the posterior circulation (i.e. vertebral and basilar arteries). The most common of these is the anterior type stroke.

Total anterior circulation syndrome: TACS

hemiparesis (or hemisensory loss) and hemianopia and aphasia or heminattention

Poor prognosis. 30% of patients die within a month. After a year 60% will be dead and only 4% will become independent again.

The partial anterior circulation syndrome: PACS

two out of the three symptoms above

Low mortality, 50% will become independent again. these patients may benefit from carotid endarterectomy soon after the stroke.

Lacunar symdrome: LACS

hemiparesis without other associated symptoms

Low mortality. 50% will become independent again.

Posterior circulation syndrome: POCS

Multiple symptoms, often including:

hemianopia, squints, double vision vertigo impaired balance and co-ordination

Why is acute stroke management important?

There is now overwhelming evidence that specialist stroke care improves outcome after acute stroke. Early specialist care prevents stroke extension facilitates recovery prevents complications

The ischaemic penumbra is an area of damaged but potentially viable brain cells which surrounds the core area of the cerebral infarct. These may either die or recover within the first 1-3 days after stroke onset. The role of acute stroke care is to provide the patient with the best chance to maintain these cells in the ischaemic penumbra alive.

Important aspects of acute stroke care Early mobilisation (within the first 24 hours) has been shown to be one of the most important predictors of

good outcome after the stroke. Mobilisation includes bed exercises and positioning, sitting up , and in less affected patients, getting out of bed as soon as possible.

Hydration: Most patients will come to the ward 12 or more hours after the stroke, and will not have had a during since the event. Even patients without dysphagia are likely to be a bit dehydrated on arrival. Infusion of normal saline should be started immediately, unless the patient can drink normally, or there is a specific contraindication (severe heart or renal failure).

Blood pressure: sudden falls of blood pressure soon after the stroke may cause stroke extension. The target blood pressure within the first few days after the stroke is higher than normal at 160-180/90-100. When the blood pressure below this antihypertensive medications should be stopped and hydration reviewed. . The most common causes of hypotension and labile blood pressure after the stroke are dehydration and infections. Both must be treated promptly.

Hypertension is common after stroke. Unless the blood pressure is very high, that is greater than 220/115 and there are signs of hypertensive encephalopathy, which can be detected by looking at the fundi, treatment with the first few days of stroke is not recommended. Simple measures to allay fears and alleviate pain and discomfort often lead to an improvement in blood pressure. In most cases the blood pressure falls spontaneously. If it remains greater than 160/90 for more than two weeks treatment should be started.

Hyperglycaemia may increase infarct size. An insulin infusion should be considered if the blood glucose is above 11.

Hyperthermia may worsen outcome after stroke. Fevers and even subfebrile temperatures should be investigated and treated.

Hypoxia. Patients with acute stroke have many reasons to become hypoxic. Keep the oxygen saturation above 90% and look for a cause of deterioration if the saturation falls by 3% or more, even if still within the normal range. Check positioning and airway in all patients with hypoxia. The most common causes for hypoxia are secretions in the upper airways, aspiration, andr chest infections.

Care Pathway for Acute Stroke Management

This pathway will help to guide acute stroke treatment and rehabilitation and will be used for all patients admitted with a working diagnosis of acute stroke.

Thrombolysis

Most strokes are caused by clots in the circulation of the brain. These clots can be dissolved by clot busting treatment (thrombolysis), but only if the treatment is given within 4.5 hours of symptom onset. This treatment may reduce death and disability buy up to 20 % but also carries a 10% risk of serious adverse events (severe, mostly fatal brain haemorrhage or haemorrhage elsewhere in the body). It can only be given by stroke and thrombolysis trained staffs in a specialist centre and after a CT head scan has been performed. Our hospital has been recognised as a specialist centre, and we can there fore provide this treatment.

Potential patients for thrombolysis would be :

Clinical signs of acute stroke Onset of stroke known and less than 4 hours ago The patient was previously fit and well The patient is not taking warfarin or INR <1.5.

Please call the thrombolysis phone 07709 638216 or bleep pager 101 (8-8 weekdays) immediately for any potential thrombolysis candidate.

All patients given thrombolysis need to be seen by a physician with a special interest in stroke, have an immediate CT head scan and an assessment of their neurological deficit using the NIHSS score at baseline, 2 hrs, 24 hr and at one week. They need to be admitted to the Acute Stroke Unit or the Neurology ward after thrombolysis and their care and observations on the ward should be guided by the Thrombolysis Nursing Care Plan.

Please click here for a link to

The Thrombolysis Assessment and treatment form http://www.stroke-in-stoke.info/acutestrokefiles/thrombolysispathway.doc

The Thrombolysis Nursing Care plan http://www.stroke-in-stoke.info/acutestrokefiles/thrombolysisnursepathway.doc

The SITS data entry site http://www.acutestroke.org/index.php?module=ContentExpress&func=display&ceid=50&bid=20&btitle=SITS%20Register&meid=4

Please follow the following links for The SITS-MOST register http://www.acutestroke.org/index.phpThe IST-3 trial http://www.dcn.ed.ac.uk/ist3/The NIHSS assessment training site http://asa.trainingcampus.net/uas/modules/trees/index.aspx

Early Mobilisation and Stimulation

Early mobilisation and stimulation is considered to be an important and integral feature of successful stroke units (Indredavik et al, 1999).

It will depend upon the patient and the severity of their stroke as to what early mobilisation and stimulation entails, however for most patients it should commence within the day of admission to the stroke unit (SIGN Guidelines, 2002), ideally within less than 3 hours admission to the ward.

It is extremely important that patients are mobilised to their optimum position as soon as possible. For the more severe stroke this may require using the profiling beds to support the patient in a more upright position, for other patients it will be sitting out of bed. Those patients admitted with only a mild or rapidly resolving event may be able to stand /walk independently shortly after admission.

Early mobilisation of patients reduces the risk of complications following stroke (SIGN, 2002; RCP, 2004) including DVT, PE and respiratory problems. Appropriate positioning of the patient is widely advocated as a strategy to discourage the development of abnormal tone and activity, contractures, pain and skin breakdown (RCP, 2004). It is important to remember that the way in which a patient is positioned from the onset of stroke will have an effect on their outcome – this has the potential to be a positive or negative affect.

Early mobilisation and stimulation of patients will also have an important psychological effect (Indredavik et al, 1999). It will allow the patients to interact within their environment and to commence participation in functional activities, albeit for some patients in a limited way.

For the principles of early mobilisation and stimulation to be adopted and be successful, it requires the ward team to work together. Early mobilisation and stimulation is not the domain if the therapy staff, but requires involvement of all ward staff to ensure success and maximise patient benefit.

Remember that for each day after admission the patient is not mobilised his/her chances of getting home reduce by 20% (personal communication Indredavik 2004).

The 72 hour monitoring and intervention protocol

Stroke is a medical emergency. With active management in the initial hours after the stroke onset ischaemic brain may be saved from infarction. Blood glucose, arterial oxygen concentration, hydration and temperature should be maintained within normal limits. Hypotension or sudden drops in blood pressure reduced cerebral perfusion and should be avoided. Infection should be managed actively, unless the patient is receiving palliative care. Blood pressure, heart rate, glucose, temperature, neurological status (abbreviated Scnadinavian Stroke Scale) and oxygen saturation should be assessed 6-hourly, any deviation from the normal range defined should be treated immediately (see ASU Acute Monitoring and Interventions Chart).ii

T>37.5 OC

Paracetamol 1g QDS Cooling strategies (reduce bedding,

fan etc) Ask Doctor to see Look for cause of pyrexia and treat

appropriately Check FBC, MSU, blood culture,

CRP, examine chest, venflon site If urinary catheter in place remove

unless required for retention or fluid balance

Ask doctor to review if pyrexia not settled within 24 hrs.

BP>200/120 Put patient at ease Check for pain or discomfort

( headaches, retention, impaction, odd posture in bed) and treat, if present

Measure BP on both arms Medical review Make sure that patients who were

on regular antihypertensive drugs have received their treatment, if nil by mouth give via NGT or prescribe parenteral alternative

Check BP 2- hourly, or hourly if >220/130

Drug treatment should be considered if: BP> 185/110 in thrombolysed

patients BP persistently >180/105 and the

patient has an acute intracerebral haemorrhage or >230/120 and hypertensive encephalopathy, or aortic dissection, or hypertensive heart failure, or AMI, or unstable angina

BP >220/120, and does not settle with rest and relief of discomfort within 1 h

Discuss with stroke consultant. Spr, staff grade before initiating treatment, treatment may be required.

Use GTN infusion (50 mg/ in 50 ml via syringe pump). Start at a rate of 0.3 ml/hr. Titrate upwards in increments of 0.3 ml/hr until BP falls by 10 mm Hg. Decrease dose if drop in BP>20 mmHg. Escalate dose faster (0.3 ml/h) if BP increases while on GTN.

Oxygen saturation <95% orOxygen saturation falls >3%

Check mouth and airway Oropharungeal and nasopharyngeal

suction if ‘rattly’ or upper airway secretions

Check position (sit out if possible) or elevate head of bed

Position drowsy patients in the left or right lateral position to allow drainage of secretions

Exclude aspiration Chest physiotherapy

If no response to above Medical review Exclude/treat pneumonia, PE,CCF,

bronchospasm or Cheyne-Stokes respiration.

Give oxygen 2l/min if saturation persistently <95%, recheck after 30 min.

ABG if no response or if history of chronic severe chest problems

The optimal BP is 160-180/90-100 early after the stroke.

BP<140/100 Stop/reduce antihypertensives Ensure adequate hydration (saline)

BP<120/80 As above Medical review Elevate end of bed Exclude/treat septicaemia

Glucose>11 mmol/l

If correct and persistent after 1 hour start sliding scale insulin (1 unit/mL in 0.9% saline) at a rate of 3 units/hour.

Monitor BM 2-hourly Aim to keep BM between 6 and 11 Increase by 1 unit/h after 2 h if

glucose still>11 and not falling significantly from initial value and recheck after 2h

If glucose falls below 6 mmol/L reduce rate to 1 unit/h give glucose 5%, and recheck after 1 h

If glucose <3 mmol/L hold insulin, call doctor, and consider glucose 20% infusion

See Medical Guidelines ‘hyperglycaemia in the ill patient’ for flow charts and detail

3-hourly assessments for first 12 h and then 6 hrly

1. Neurological observations (SSS)2. GCS (if drowsy or unconscious)

6- hourly assessment of1. Blood Pressure2. Heart rate3. Temperature4. Respiration5. Oxygen saturation

Daily assessment of 1. Blood glucoseIncrease frequency of assessment if any of the above are abnormal

Acute Stroke Unit72 hour Acute Stroke Monitoring Actions Chart

This is only a quick guide.

Please refer to the full guidance for detail.

Please note that this is a general guideline, and that individual patients may require different treatment.

Version 5 (06.07.2011)

Neurological deterioration Check airway Elevate head of bed Check BP, HR, T, oxygen, and BM,

correct all abnormalities. Check FBC, U&E, INR. Inform doctor. Doctor to do NIHSS, check above and

exclude reversible causes: Pneumonia Septicaemia PE CCF Sedative drugs

If NIHSS >4 points worse consider urgent CT

Airway Management

Intermittent airway obstruction is a common complication in patients with stroke with a reduced level of consciousness, but may also occur in alert individuals, ad may lead to hypoxia. This in turn can lead to reduced cerebral perfusion and hypercapnia, increasing intra-cranial pressure (ICP) and acidosis which are harmful to damaged brain tissue.

Patients whose airways are compromised should be nursed in a position which maintains airway patency and prevents retraction of the tongue and obstruction with the soft palate. Positioning that facilitates ventilation of the lungs should also be considered. A Guedel airway may be required.

The patient should be lying on the side with the torso and pelvis tilted 30-45 degrees and supported by a pillow along the patients back.

The patient’s head should be in a neutral position looking to the same side, supported with 1-2 pillows. The upper–most limbs will need to be supported on pillows to facilitate lung expansion and prevent

abnormal postural tone.

Aspiration is very common after stroke, even in alert patients, and is silent in many cases. Suspect silent aspiration in any patient who sounds rattly, drools saliva, and has retained food or secretions in the oral cavity. A drop in saturation of more than 2% is a sensitive marker of aspiration and should prompt review of swallowing, positioning and mouthcare. Aspiration also happens in patients who are nil by mouth. It may be reduced or prevented by positioning the patient in a more upright position.

Monitoring of respiration and oxygen saturationIn patients with impaired airway oxygen saturation needs to be monitored regularly. The patient’s lung movement should be observed for asymmetry of expansion. Rate, rhythm and depth of respirations should be observed and recorded. An increase in respiratory rate may be a sign of pneumonia, heart failure, pulmonary embolus or worsening stroke. Slow and irregular respirations may be early signs of raised intra-cranial pressure. Cheyne–Stokes respirations may occur with hypoxia, heart failure or supra-tentorial damage. All changes require medical review.

HypoxiaWhere oxygen saturation below 95%, the patient’s postion , airway and oral cavity need to be reviewed, and cleared. This may improve results without any further treatment. If the oxygen saturation is below 90% and there is no response to the above oxygen supplementation (24%) should be considered (see management of hypoxia). Patients with known severe chronic chest conditions will require medical review prior to administration with oxygen. Oxygen must always be humidified.

Administration of suctionPatients with audible pharyngeal secretions will require regular pharyngeal suction. Those with lower respiratory secretions will require Chest Physiotherapy. Oxygen saturation should be checked before and after suctioning, and high percentage oxygen administered for a few minutes before and after (unless contra-indicated). Nasogastric feeding should be discontinued during the suction. Before resuming feeding after suction correct position of the nasogastric tube must be confirmed by the usual method.

Oral Care

Patients who are Nil by Mouth due to reduced conscious level or dysphagia will require frequent and thorough oral care to reduce the risk of aspiration pneumonia. Oral hygiene may need to be given in conjunction with pharyngeal suction if there is a risk of aspiration (see Oral Care Guidelines). In some patients more limited oral suction may be appropriate, but as with deeper suction.

Hypoxia

Hypoxia within the first few days of the stroke may worsen cerebral ischaemia and lead to extension of the stroke. It may be present on admission, or develop at any time later on. Patients with reduced consciousness, airway obstruction, dysphasia or preexisting cardiovascular problems are at particular risk.

DefinitionMild hypoxia is defined as an oxygen saturation below 95%. An oxygen saturation below 90% represents severe hypoxia and requites urgent action.

AssessmmentCyanosis is a late and unreliable sign of severe hypoxia. Oxygen saturation should be assessed by pulse oximetry.

Measure oxygen saturation On admission 6- hourly for 72 hours after the stroke More frequently if the patient is unwell or hypoxic daily thereafter

Oxygen saturation <95% or Oxygen saturation falls >3% Check mouth and airway Oropharyngeal and nasopharyngeal suction to remove secretions Check position (sit up if possible) or elevate head of bed Recovery position in drowsy or unconscious patients Exclude aspiration Chest physiotherapy

If no response to above Medical review if saturation <95% give oxygen 2l/min and inform doctor, recheck after 30 min. In patients with known severe and disabling chest problems the doctor must see the patient before

commencement of oxygen. Blood gases may be required before and after starting O2. CXR, EXG and arterial blood gases may be required Exclude/treat pneumonia, PE,CCF, bronchospasm or Cheyne-Stokes respiration. Very restless patients may not be able to tolerate oxygen. Consult with the doctor.

Ongoing monitoring While on O2, monitor 6 hourly or more frequently, as condition requires If SPO2 < 93% or SPO2 deteriorates in spite of above call doctor again and increase MEWS observations

to hourly In severely hypoxic patients higher oxygen concentrations and repeat ABG may be required. If stable, review oxygen treatment every 24 hours.

These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these will be discussed with medical staff and the management plan clearly documented.

Pyrexia

Fever increases metabolic rate and oxygen consumption and may exacerbate tissue hypoxia and acidosis in the ischaemic brain. Patients with acute stroke who have an elevated body temperature during the first day after a stroke have a poorer outcome than those with a normal body temperature. There is not yet enough evidence to definitely say whether treatment of an elevated body temperature improves stroke outcome in humans, but until such evidence is available aggressive prevention and treatment of pyrexia is recommended.

DefinitionFever (pyrexia) is defined as a temperature above 37.5oC.

Assessment on admission 6 hourly up to 72 hours then daily to end of second week review need for continued monitoring at end of second week.

AN ELECTRONIC TYMPANIC THERMOMETER SHOULD BE USED TO TAKE ALL TEMPERATURES

Management Paracetamol 1g po/pr is given to all acute stroke patients on admission and after 6 hours to prevent

pyrexia If temperature is >37.5oC inform the doctor The doctor will look for a source of infection and arrange for treatment where appropriate. Paracetamol may be prescribed for 48 hours if no source of infection is found or in addition to antibiotics. Other methods of cooling (fans, tepid sponging) may be required. If the temperature does not return to within normal limits within 24 hours review management with doctor.If temperature is

38.0 at any time inform the doctor immediately.

These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these will be discussed with medical staff and the management plan clearly documented.

Early Blood Pressure Management

Variations in blood pressure after the stroke can affect cerebral blood flow and lead to worsening of the stroke. Because the autoregulation of cerebral blood flow is impaired early after the stroke, even small falls in blood pressure can be detrimental. While there is no definite evidence from clinical trials to support this the current consensus opinion is that within the first 72 hours of stroke the optimal blood pressure is higher than the 140/85 threshold used for secondary prevention. In many patients blood pressure rises in the acute phase of stroke, but settles without treatment within a few days. For patients with persistent hppertension See management of chronic hypertension for patients if the blood pressure remains >140/85 after the first 1-2 weeks post stroke.

The optimal BP is 160-180/90-100 early after the stroke.

Assessment

Measure blood pressure on admission 6 hourly up to 72 hours then daily to end of second week review need for continued monitoring at end of second week

Hypotension (Too Low Blood Pressure)

Low blood pressure within the first two weeks after acute stroke may worsen outcome. In patients who have long-standing hypertension (as suggested by themedical history or antihypertensive treatment) even normal blood pressures such as 120/80mmHg may be too low, since their brains are used to higher day to day pressures.

SymptomsPatietns may not complain of any symptoms. Suspect low blood pressure or postural hypotension (blood pressure falling when the patients stands up) if the patient is reluctant to stand, complains of dizziness, or does not concentrate when standing.

AssessmentIn any patient with dizziness or suspicion of intermittent hypotension lying and standingblood pressure readings should be taken.

BP<160/100

Stop/reduce antihypertensives Ensure adequate hydration (saline)

BP<120/80 As above Medical review Elevate end of bed Exclude/treat septicaemia

In hypotensive patients the doctor will discontinue medications which lower the blood pressure and assess the patient for causes of hypotension such as myocardial infarction, septicaemia, gastrointestinal bleeds, heart failure or pulmonary embolism. An ECG, blood tests and a rectal examination may be required. An intravenous infusion may be set up.

These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these will be discussed with medical staff and the management plan clearly documented.

Hypertension within the first week

In patients with acute stroke a rapid drug induced fall in blood pressure is more dangerous than high blood pressure itself. Falls in blood pressure may induce a further stroke or worsen the current one. However: some patients are very stressed by the admission and their blood pressure rises because of this. When the patient settles the blood pressure falls. Such a natural fall in blood pressure does not worsen the stroke. Once the patient isneurologically stable after the first 72 hours to 2 weeks antihypertensive therapy should be started to achieve a blood pressure of 140/85 or below in non diabetics and 130/80 or blow in diabetics (see

Monitoring Blood pressure >200/100 inform doctor if does not settle with rest. Measurement >210/110 inform doctor, observe 2 hourly until blood pressure falls. Call doctor again if

blood pressure increases.

BP>200/120 Put patient at ease Check for pain or discomfort ( headaches, retention, impaction, odd posture in bed) and treat, if present Measure BP on both arms Medical review Make sure that patients who were on regular antihypertensive drugs have received their treatment, if nil by

mouth give via NGT or prescribe parenteral alternative Check BP 2- hourly, or hourly if >220/130

Drug treatment should be considered if: BP> 185/110 in thrombolysed patients BP persistently >180/105** and the patient has an acute intracerebral haemorrhage or hypertensive

encephalopathy, or aortic dissection, or hypertensive heart failure, or AMI, or unstable angina) BP >240/130, and does not settle with rest and relief of discomfort within 1 h* Discuss with stroke consultant. Spr, staff grade before initiating treatment, treatment may be required. Use GTN infusion (50 mg/ in 50 ml via syringe pump). Start at a rate of 0.3 ml/hr. Titrate upwards in

increments of 0.3 ml/hr until BP falls by 10 mm Hg. Decrease dose if drop in BP>20 mmHg. Escalate dose faster (0.3 ml/h) if BP increases while on GTN.

Other treatment options are: Captopril 6.25 mg o/ngt/iv or labetalol 5 mg iv

Do not lower BP by more than 20 mmHg.

*RCP guidelines 2008 do not recommend treatment of any level of BP unless ICH or complications of hypertension are present.

**EUSI 2011

These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these will be discussed with medical staff and the management plan clearly documented.

Medical Management of Acute Post Stroke Hypertensioniii

Many patients with stroke have elevated blood pressure. Cerebral blood flow autoregulation may be defective in the area of the infarction, and passively dependent on the mean arterial pressure. Drops in blood pressure must be avoided, if an adequate cerebral perfusion pressure is to be maintained.

Target BP for patients with prior known hypertension: 180/100-105Target BP for patients without a history of hypertension: 160-180/90-100

Management of moderate hypertension [BP > 200/110mmHg]

Check whether the patient is in pain or discomfort (retention? Impaction? Headaches? Odd posture? Etc) and treat appropriately.

Check whether the patient was on drugs affecting the blood pressure before, whether they are written up, and whether they have been given (watch out for patients nil by mouth). Reinstate regular antihypertensive treatment (oral or via nasogastric tube, Avoid sublingual nifedipine).

Keep patient in a calm atmosphere, and continue to observe BP.

Management of severe hypertension [>=240/130 mm Hg]

General instructions

Don’t panic. Inform SpR and consultant.Do basic measures, as above, confirm high readings.Measure in both arms and monitor on the arm with the higher pressure.

Treat immediately if Signs of hypertensive encephalopathy (seizures, seizures, reduced conscious level [out of proportion to the

severity of the stroke), papiloedema or retinal haemorrhages) Hypertensive heart failure Marked renal failure with microscopic haematuria and proteinuria Aortic dissection

Otherwise review after 1 hour and see whether it has fallen, if not start treatment.Try oral /nasogastric treatment first, if possible.If intravenous treatment is necessary stay with the patient on initiation of treatment Measure Blood pressure every 5 minutes while giving the drugs, the every 15 mites, every 30 minutes once the fall has stabilised.

Stop injection or infusion if BP falls by 10 mm Hg. If fall maintained repeat same treatment after one hour.

If the BP comes up again, restart infusion, repeat injection with same dose.

If blood pressure rises, continue until a response achieved. It may be necessary to try a number of different antihypertensives, as outlined below.

Do not lower the BP by more than 20 mm Hg in the first 2 hours.

Do not lower BP by more than a further 20 mm Hg in the next 12 hours.

Once BP <= 140/130 keep at same level for 24 hours and then gradually reduce further.

Aim to get to 160/90 in 7-10 days (e.g. not too fast).

Remember half-life of treatment and prescribe maintenance or review at the appropriate time points.

Monitor Neuro obs hourly BP half hourly Urine output hourly U&Es daily

Treatment options

Systolic BP>=240 and/or diastolic BP >=130 mm Hg

OrallyCaptopril 6.25-12.5 mgAtenolol 25-50 mg1

ParenterallyLabetalol 5-20 mg ivDihydralazine 5 mg iv plus metoprolol 5-10 mg ivClonidine 0.15-0.3 mg iv or s.c.

Diastolic BP > 140GTN infusionSodium Nitroprusside

Specific TherapiesLabetalol

Cave: in patients with asthma or heart failure, or with bradycardia.

Monitor heart rate (manually or by monitor). Keep atropine ready for bradycardia.

Labetalol 2 mg iv over 5 minutes.

Repeat after 5 minutes, if no response.

1 Clinical guidelines 2002, accelerated hypertension

Give further 10mg boluses every 10 minutes up to a total of 50 mg, if no response.

Start infusion of 2mg/min, stop when BP starts to fall, max dose of 200 mg achieved or patient develops bradycardia.

Titrate maintenance dose according to response (not more than 200 mg/24 hours).

GTN infusion [see clinical guidelines]GTN 50 mg (10 ml) diluted to 50 ml with saline or glucose.

Start with 0.3 ml/minIncrease by 0.3 ml/min every 15 min until BP falls Maximum dose 12 ml/hr.

Nitroglycerin 5 mg iv followed by 1-4 mg/h/iv

MetoprololMetoprolol 5 mg over 5 minutes IV

May be repeated after 5 minutes if no response

Side effects:As with other beta blockers, watch especially for bradycardia, excessive BP fall and dyspnoea.

Hydralazine (give this with metoprolol 5-10 mg to avoid tachycardia)

Hydralazine 5 mg iv (in 10 ml Sodium Cl) [as a slow bouls, or , better, infused over 25 minutes (which equals a recommended infusion rate of 200 mcg/min)]Once the blood pressure starts falling it is reasonable to stop and wait, only continue if the fall has been less than 20 mm Hg.

Repeat after 20-30 min if no response.

Maintenance 50-150 mcg/min

Contraindications:Tachycardia, High output heart failure, SLE

Side effects:Fall in BP may be too rapidTachycardia, flushing, fluid retention, SLE-like syndrome (with long-term therapy), rarely rashes, fever and others.

ClonidineSee BNF

Management of Diabetes and Hyperglycaemia

High blood glucose values within the first 48 hours may worsen outcome after stroke.

Measure BLOOD GLUCOSE: On admission If normal - monitor once daily up to 72 hours. If > 8 confirm by BM or venous blood glucose urine ketones check fasting venous blood

glucose/HbA1c within 24 hours If > 11 or ketones positive call doctor Monitor BMs 2 hourly for in patients on insulin pump. Review frequency for further monitoring at 72 hours.

The doctor is likely to manage the patient as follows:The doctor will prescribe an insulin infusion infusion in all known diabetics and in all patients not known to be diabetic prior to the stroke who are nil by mouth and have a BM>11. In patients able to take oral/nasogastric food and mediations continue usual treatment and monitor Blood Glucose pre meal and 10pm after discontinuation of infusion, check fasting glucose and HbAlc.

Insulin infusion regime (50 units ACTRAPID insulin in 50 ml N/Saline)

If correct and persistent after 1 hour start sliding scale insulin (1 unit/mL in 0.9% saline) at a rate of 3 units/hour.

Monitor BM 2-hourly Aim to keep BM between 6 and 11 Increase by 1 unit/h after 2 h if glucose still>11 and not falling significantly from initial value and recheck

after 2h If glucose falls below 6 mmol/L reduce rate to 1 unit/h give glucose 5%, and recheck after 1 h If glucose <3 mmol/L hold insulin, call doctor, and consider glucose 20% infusion

Insulin infusion will be continued for 72 hours or until stable. After this revert back to pre-stroke regime if patient stable and able to eat.

See Medical Guidelines ‘hyperglycaemia in the ill patient’ for flow charts and detail

These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these will be discussed with medical staff and the management plan clearly documented.

Management of crescendo TIAs

Crescendo TIAs are transient ischaemic attacks of increasing frequency and duration(several episodes occurring within a few days). They may lead up to a full blown stroke.

The doctor is likely to manage the patient as follows:

(Crescendo TIAs are to be treated as an emergency.)

Ask doctor to see patient urgently. Inform Dr Roffe/Dr Natarajan/Dr Arora or SpR deputy of the patient.

A CT head scan should be performed within hours of admission (the admitting doctor has to speak personally to the CT radiographer (daytime) or radiologist on call (night) to arrange this.

Aspirin 300mg stat should be given immediately unless contraindicated.

Thorough medical examination (to exclude AF, recent MI, other cardiac arrhythmias, severe hypotension or hypertension, endocarditis, polycthaemia, hyperviscosity syndrome, vasculitic processes, sources of emboli, other intracerebral problems mimicking TIAs, spinal problems)

Arrange urgent carotid doppler. If indicated after results received Doctor may contact vascular surgeons (after discussions with consultant or deputy). Ring extension 2176/2935 during the day or bleep general surgeon on call during the night.

If the patient has TIAs in spite of being on aspirin and the CT head does not show a haemorrhage start heparin bolus and infusion. Check KPTT 6 hours after the start of the infusion. Keep at 2.5 x the normal value (see medical guidelines for detail).

Management of intracerebral haemorrhage

This section needs to be completed meantime:

See correction of abnormal INR in patients with ICH

See AHA guidelines 2007 for management of ICH

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. A Guideline From the American Heart Association, American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38:1655-711.

These guidelines are intended for use with most patients. In cases where the patients needs require variation to the guidelines, these will be discussed with medical staff and the management plan clearly documented.

INR correction in patients with intracerebral haemorrhage

Intracranial hemorrhage is not a one off event. Extension in the first 3 hrs is common. The danger for rebleed continues for at least 48 hours. Therefore immediate correction of INR is essential. Intracranial haemorrhage in patients on warfarin has a mortality of 60%.

The target INR should be 1.

Do INR immediately (use point of care device in A&E )

If no point of care device available urgent transport of sample to lab and phone call to haematologist to ensure attention to sample as it arrives.

If INR >1.2

reverse with prothrombin complex concentrate immediately (within 30 min). Consult with consultant haematologist about dose.

vit.K 5 mg iv to prevent (works within 5-6 h) or 10 mg (if INR >2 and no need to reanticoagulate).

Stop warfarin in all patients with intracranial haemorrhage (even in patients with mechanical valves). In patients with mechanical valves and other absolute indications for warfarin do not restart until haemorrhage stabilized. If no absolute indication for warfarin stop warfarin for good2.

Also: Control blood pressure. If >200/1102 start GTN infusion (see control of blood pressure for regime).

Prothrombin complex concentrate contains high levels of vitamin K–dependent factors (II, VII, and X), and factor IX complex concentrate contains factors II, VII, IX, and X. It requires smaller volumes of infusion than FFP and corrects the coagulopathy faster. Their disadvantage is the risk of inducing thromboembolic complications, ranging from superficial thrombophlebitis, deep vein thrombosis and pulmonary embolism, and arterial thrombosis to disseminated intravascular coagulation. Concerns about viral transmission have been minimized by the current rigorous screening of blood products.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. 2007 Update. A Guideline From the American Heart Association, American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38:1655-711.

2 RCP Guidelines 2008 i Further Reading: Bamford J et al. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1992; 337: 1522-1523.

ii Refer to Inrevik 1999, RCPguideline 2004, EUSI 2004 and AHA stroke guidance 2004.

iii Based on the EUSI recommendations for stroke (website Jan 2002 and Cerebrovasc Dis 2000;10;335;-351) unless stated otherwise. The recommended treatment threshold in Europe is BP >220/140. I have used the more conservative limits of >240/140, as used in some centres, especially in North America. The lower valuse is cited as 130 in some places and 140 in others. Needs review with 2004 guidance and cross checking with 72 hour monitoring and Acute hypertension section.

Assessment and management of swallowing problems (dysphagia)iv

Dysphagia affects around 47% -67% of stroke patients in the acute phase (Smithard et. al 1997; Hinds &Wiles 1998). A patient with dysphagia is twice as likely to develop pneumonia (Smithard 1996; Barer 1987), and mortality is higher than amongst patients without dysphagia (Schmidt et. al 1991).

Approximately a half of patients with dysphagia are likely to see their symptoms resolve within the first few days (Martino et.al), and as long as appropriately managed, their outcome is likely to be good. At the other end of the scale are the patients whose symptoms are long – term (Kidd et.al 1995) and are likely to need enteral feeding indefinitely. In between are a range of patients who have varying degrees of severity and need intervention for a varying length of time (Martino et.al.2000; Perry & Love 2001).

The risk of malnutrition amongst stroke patients is high (Smithard 1996). There is a strong association between nutrition and outcomes for stroke patients, in terms of mortality and morbidity (Davalos et.a;.1996; Smithard et.al.1996; Barer 1987). National guidelines RCP 2000) advocate nutritional assessment within 48 hours of stroke onset, and consideration of alternative feeding for patients unable to take adequate oral diet.

The purpose of these guidelines is to ensure all acute stroke admissions are screened and low -risk patients assessed by the nursing team. This will enable patients without symptoms or with non-complex/transient symptoms to be fed as soon as possible, and patients with complex/persistent dysphagia to receive early referral to Speech and Language therapy and dietetics and consideration for early alternative nutrition.

Guidelines

1. Screen for eligibility for assessment

1.1 All patients admitted to the acute stroke unit should be screened within 24 hours of stroke onset, and 12 hours of admission, to determine whether a nurse dysphagia assessment is appropriate. The screen will include a judgement about the patient’s level of alertness, ability to sit upright and respiratory symptoms.

1.2 Patients with progressive neurological disorders, tracheostomy, or history of surgery or radiotherapy to head/neck, are not appropriate for nurse assessment. These should be referred to Speech and Language therapy.

1.3 If the patient fails the screen, it should be repeated daily, or sooner if indicated by the patients condition, until the patient is able to undertake the assessment. The reason for the patient failing the screen must be recorded in the Collaborative Care Documentation. The patient will remain Nil by Mouth, until a successful assessment is achieved.

1.4 Patients unable to take normal diet and fluids should be given parenteral fluids within 12 hours of stroke onset unless blood pressure is low (see 72 hour monitoring guidelines), in which case they may be needed earlier.

1.5 The patients that fail the screens should receive nutritional assessment and be considered for alternative feeding (Naso-Gastric), within 48 hours of admission, following consultation with medical and paramedical staff, the patient where possible, and family. A dietician referral should be made.

1.5 Those patients’ who fail the screen on the 7th day of admission, should be considered for a referral to the Nutrition Team, for assessment for a PEG. Discussion should take place within the MD Team and the

patient, where possible and family. A referral should be made to Speech and Language Therapy at this point.

NB: in some circumstances, following discussion between the consultant, MD Team, patient / relatives, a decision to with-hold/ withdraw artificial hydration feeding may be made. In these circumstances there is no need to repeat screening, and the actions should be documented in the CCP.

2. Nurse Dysphagia Assessment; water test

2.1 Patients that pass the initial screen (alert and able to sit upright; no new respiratory symptoms) should receive a nurse dysphagia assessment.

2.2 The assessment must be undertaken by appropriately trained nurses (see protocol for criteria/policy for Scope of Professional practice), with at least 6 months experience in the specialist area.

2.3 Patients who fail the assessment should be managed according to guidelines 1.2-1.4., and be re-assessed daily, (or more often if the patient’s condition indicates)until day 4, when a Speech and Language referral will be made. Patients who fail toward the end of an assessment should be referred at the earliest opportunity, so that oral trials may be commenced.

3. Assessment with diet

3.0 Patients’ who pass both stages of the water test without thickener, should be assessed with appropriate diet. Where normal diet/fluids are prescribed, record fluid balance and nutritional assessment for 3 days then review.

3.1 Patients who pass the assessment with thickened fluids should then be assessed with the appropriate modified diet. Refer to dietician, and maintain food and fluid charts until patient has managed a normal diet for 3 days.

3.2 All patients requiring a modified diet, should be re-assessed within 48 hour periods, to allow for progress to a more normal diet. Patients still requiring a modified diet at 10 days will be referred to S&LT.

3.3 Patients exhibiting problems at any level, should be re-assessed, following a medical review, and referred to S&LT/ dietetics.

4. Documentation

4.1 The outcome (including symptoms of dysphagia noted) of each screen / assessment must be documented in the progress section of the CCP and an appropriate Core care plan amended to reflect individual circumstances. The Assessment document must be filed within the Speech and Language section of the CCP, along with the dysphagia pathway, where appropriate.

5. Other considerations

5.1 Patients with reduced consciousness, or otherwise unable to cope with oral/ respiratory secretions will require regular airway management, including suction, oral hygiene and chest physiotherapy.

5.2 Please refer to Oral Care Guidelines for management of oral hygiene.

5.3 It is the nursing staffs responsibility to thicken fluids, where this is indicated.

Prevention of Deep Vein Thrombosis and Pulmonary Embolism

Venous thromboembolism often occurs within the first week of a stroke, and most often in immobile patients with paralysis of the leg. Studies using radiolabeled fibrinogen suggest that deep vein thrombosis (DVT) occurs in 50% of patients with hemiplegia, but clinically apparent DVT occurs in only 5%. Although autopsy series have identified pulmonary embolism (PE) in a large proportion of stroke patients who die, clinically evident PE occurs in only 1-2% of patients. v

Measures for DVT and PE prevention1. Patients should be mobilized form the day of admission.

2. Adequate hydration

3. Aspirin 300 mg/day should be given to all infarcts (ideally on the day of admission) as long as CT has excluded a haemorrhage or there are other contraindications) for the first 2 weeks, then reduce to 75 mg per day.

4. Patients at high risk of DVT (e.g. immovility&obesity, coexistent cancer, previous history of thromboembolism) may require prophylactic heparin.

5. Patients with intracerebral haemorrhage are at particular risk of DVT and PE since they do not receive aspirin and cannot be treated with heparin once a thrombosis has occurred. Therefore prophylaxis is essential. Additional leg mobilization should be performed to prevent stasis.

6. Do not use prophylactic antiembolic stockings (Clots study 2009).

MonitoringLegs should be inspected for signs of DVT ion a daily basis until mobile. Any complaint of breathlessness should be reported to the ward doctor. Consider Doppler after 1 week in immobile patients who are not anticoagulated.

Signs of DVT and PEDeep vein thrombosis should be suspected in any patient with leg swelling, pyrexia or any pain in the leg, foot or groin. Symptoms of a pulmonary embolism are breathlessness, chest pain, tachycardia and a fall in oxygen saturation. Urgent Doppler at the first sign of possible DVT.

DVT/ PE prevention

Mobilize from the day of admission

Teach patient/Family leg exercises

Prevent dehydration

Start aspirin (unless contraindicated) as soon as possible after admission

Do Doppler after 1 week in patients at high risk of DVT

Do not use prophylactic heparin routinely, consider in patients at high risk of DVT (weigh up against risk of haemorrhage).

COLLABORATIVE CARE

Patients Name …………………………………. Persons responsible:

Unit No ………………………………….Doctor □ NursePhysio □ OTSLT □ SWDietitian □ OtherProblem No: Nutrition, Gastrostomy or Nasogastric Tube

GOAL : For Standardised Enteral Feeding Regimen to be established for newly inserted NG/PEG tubes to be used until the patient is assessed by the dietitian.

Signature ………………………….. Date …………………………….

INTERVENTIONS:INTERVENTIONS:

1 Refer to the dietitian.

2 Flush tube with at least 50mls water using a 50ml syringe.

(i) Before and after feeding.(ii) Before and after giving medication.

3 For newly inserted PEGs do not feed for the first 4 hours post PEG insertion.

Day 1Water flush 100mls.Nutrison standard 50mls/hr for 6 hours.Water flush 100 mls.Nutrison standard 75mls/hr for 6 hours.Water flush 100mls.Rest 6 hours.Total fluid = 1050mls. I.V or S.C. fluids will be required.

Day 2Water flush 200mls.Nutrison standard 100mls/hr for 15 hours.Water flush 200mls.Rest 9 hours.Total fluid = 1900mls.This will provide 1500kcals, 60g protein.

Continue on this regimen until reviewed by the dietitian.Remember to change the giving set every 24 hours. Always give feed at room temperature. Raise the head at least 30 degrees to reduce the risk of aspiration.

Review date …………………………. Review date …………………………

Goal achieved Yes No Goal achieved Yes No If no, reason for non-achievement If no, reason for non-achievement

……………………………………… ……………………………………….

JL/AJM/CHC/Collaborative Care 6 November 2001

Hypertension (long term management)

[include text on long term management of hypertension here. This document should be a reference text for nurses, medical and other staff. Please include references where necessary as endnotes. Please see suggested format below]

Prevalence of hypertension of in stroke patients , risk associated with hpoertension

Definition of hypertension

Treatment

Monitoring

Special considerations

Hyperlipidaemia (last edit 29.11.04 /CR)

DefinitionTotal cholesterol > 5 mmol /lLDL cholesterol> 3.5 mmol/lOr triglycerides > 2.2 mmol/l

RisksWhile there is no independent evidence that hyperlipidaemia by itself increases stroke risk, several studies have shown that treatment of hyperlipidaemia with statins reduces the risk of future ischaemic strokes by a third, especially in patients with coexistent ischaemic heart disease or diabetes. vi vii

TreatmentThe mainstay of treatment of hyperlipidaemia is diet, exercise and statins (see tables : treatment of hyperlipidaemia, low cholesterol diet, healthy diet).

Cautions and exceptionsWhile diet is a crucial element in the treatment of younger patients with hyperlipidaemia, there is no evidence of benefit in older patients. Unless the cholesterol is very high older patients should therefore be advised to eat a healthy balance diet high in fruit and vegetables rather than asked to adhere to a strict low cholesterol diet. Patients who have problems maintaining their weight after the stroke because of poor appetite, dysphagia or other problems should be reassured that they need not worry about cholesterol and fats and should eat what they like and are able to manage. Diet and statins should also be avoided in patients who have a very limited prognosis (<2 years) due to a disabling stroke or to other life limiting co morbidities (e.g. cancer), since they may suffer all the side effects but are unlikely to live long enough to benefit.

Information materialLeaflet for healthy diet (include details)Stroke Association Cholesterol leaflet (include details)Low cholesterol diet (include details)

Grey highlighted text applies to stroke patients only. Last edit 29.11.04 see endnotes for references viii

Targets not achieved

Targets not achieved

Targets not achieved

TAR

GET

PO

PULA

TIO

NPatients who fall into one of the following groups.1.Established CHD, Ischaemic stroke, TIA or PVD.2.Patients with a 30% of CHD over 10 y.3.Diabetic patients with > 15% risk over 10 y.4.Patients with familial dyslipidaemias.

And who have A total chol > 5.0mmol/l or A total chol >3.5 mmol/l and stroke or TIA LDL-chol > 3.0mmol/l or Triglycerides > 2.3mmol/l

TREA

TMEN

T TA

RG

ET

• Total chol < 5.0mmol/l or reduced by 20 – 25% (whichever lower).• LDL-chol < 3.0mmol/l or reduced by 30% (whichever lower).• Triglyceride below 2.3 mmol/l.

Estimate CHD event risk using the Joint British Societies Coronary Risk Predication Charts (see BNF for patients aged <76 y).

Secondary causes of dyslipidaemia should be excluded. U&Es Liver function tests TSH CK Fasting glucose Check prescribed drugs for side-effects

See below for patients appropriate for referral to Specialist.

TREA

TMEN

T N

AD

MO

NIT

OR

ING

Prescribe simvastatin 20mg at night or atorvastatin 10mg each day orPravastatin 20 mg nocte (in pts. on warfarin)providing the pt has no contraindications to statin therapy and patient’s triglycerides < 10mmol/l.

Counsel patient on diet and lifestyle.

Refer to individual drug SPCs for contraindications and interactions. Examples of common interactions are: warfarin, amiodarone, clarithromycins, eruthromycin, rifampicin.verapamil, diltiazem, cimetidine,

Advise patient to report unexplained muscle pain, tenderness or weakness.

Repeat lipid profile every 4 – 6 weeks. Double the statin dose until target achieved, maximum dose reached or dose increase not tolerated.

Monitor LFTs after each dose increase.

Max. licensed dose of simvastatin is 80mg at night and of atorvastatin is 80mg each day. Note that other prescribed drugs may limit the dose of statin that can be used. Refer to individual SPCs.Switch to more potent statin: rosuvastatin 10mg /d.

Repeat lipid profile every 4 – 6 weeks. Double the dose of rosuvastatin until target achieved, maximum dose reached, or dose increase not tolerated. ▼Black triangle drug report all adverse

reactions.Max recommended dose of rosuvstatin is 40 mg OD.This dose should only be used und specialist supervision.Prescribe

max. tol. dose of statin+ezetimibe 10mg OD.

Prescribe max. tol. dose of statin +bezafibrate 400mg SR OD Take benzafibrate after food.

Benzafibrate can be used as monotherapy in patients unable to tolerate a statin. The combination of statin + fibrate increases risk of myopathy. .

Patients over the age of 80 and those with very limited expected lifespan may not benefit from satin therapy. Balance expected benefits with potential risks and side effects.

The following pts are appropriate for specialist referral:• Suspected familial hypercholesterolaemia. • Suspected familial hyperlipidaemia.• Failure of therapy.• Severe hypercholesterolaemia (TC > 10mmol/l).• Very severe hypertriglyceridaemia (TG > 10mmol/l).

Management of hyperlipidaemia

Patients who achieve target levels should remain on lipid lowering treatment indefinitely.Lipid levels and LFTs should be checked annually.

Patients with triglycerides > 10mmol/l should be prescribed benzafibrate 400mg SR daily whilst awaiting Specialist review.

Low cholesterol diet

[Include diet sheet here]

Atrial Fibrillation (last edit Sept 08)

Patients in AF have a recurrence rate 12% per year which is reduced by treatment with warfarin to 5% per year.

Patients in AF with an infarct should be considered for anticoagulation with warfarin, (they are obviously in the high risk group. Warfarin treatment is not started until 2 weeks after stroke. Until then aspirin 300 mg/d should be given.

o High risk (annual risk of CVA 8-12%)

All patients with previous CVA or TIA. All patients aged 75 and over with diabetes and/or hypertension. All patients with valve disease, heart failure, thyroid disease and/or impaired LV function.

o Moderate risk (annual risk of CVA 4%)

All patients under 65 with clinical risk factors: diabetes, hypertension, peripheral arterial disease, ischaemic heart disease.

All patients over 65 not in high risk group.

o Low risk (annual risk of CVA 1%)

All patients under 65 with no history of embolism, diabetes, hypertension or other clinical risk factors.

Treatment

o High risk:

Warfarin (target INR 2.0 - 3.0) if no contraindications.

o Moderate risk:

Warfarin or Aspirin (75-150 mg daily). Treatment must be decided in individual cases.

o Low risk:

Aspirin 75-150 mg daily.

Possible contraindications to Warfarin

o The following list shows the contraindications to Warfarin which are adapted from the exclusion criteria used in the SPAF (Stroke Prevention in Atrial Fibrillation) trial.

Gastro-intestinal or urinary bleeding in previous 6 months. History of 3 or more falls in the previous year (obtained at interview). Record of recurrent or injurious falls in preceding year. Inability to comply with treatment. Alcohol >28 units per week for men or >21 units for women. Uncontrolled hypertension. Daily use of NSAIDs.

Anticoagulation for Arial Fibrillation after Stroke (last update 22.06.2010)

Use slow anticoagulation (OATES regime) (1) for older patients, frail patients, multiple comorbidities, or multiple drugs. Younger fit stable patients can be started on the TAIT regime. Avoid rapid anticoagulation after stroke (risk of bleed and transient hypercoagulabillity). Use a nomogram to guide dosing (2). See NPSA (3) for further guidance.

The referral should be faxed to the Anticoagulant Management service. The fax should be followed up with a telephone call to ext 4630 to check that firstly the referral has arrived and secondly to get an appointment for the patient.

Specify on the referral how anticoagulation should be initiated 1. Slow anticoagulation TAIT regime2. Slow Anticoagulation OATES regime with first INR after 7 (not 14) days, days but do not alter dose until day 14 unless INR at day 7 is above 3.0.

1. Oates et al, Br J Pharmacol 1998. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873664/pdf/bcp0046-0157.pdf2. NPSA 2007/18 http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd? 3. NPSA guidance on safe anticoagulation http://www.nrls.npsa.nhs.uk/resources/?entryid45=59814

Depression (last edit 1.12.04)

Depression is a common complication of stroke, and can occur at any time, e.g. in the first few weeks, or years later. Diagnosis is often difficult, especially in dysphasic patients.

Suspect depression when the patient appears to have low mood, refuses to participate in social and rehabilitation activities, avoids eye contact, is restless, anxious, or aggressive, complains of aches and pains, has poor sleep and no appetite.

Screening

All patients should be screened for depression within one month of the stroke. Use the Hospital Anxiety and depression Scale (HAD scale) for screening depression in patients who are able to complete the questionnaire themselves.ix Use the Stroke Aphasic Depression Questionnaire (SADQ) for patients who are aphasic and cannot respond themselves to the questions.x

Diagnosis

The diagnosis should be made by clinical assessment taking the results of the screening questionnaires into account.

Treatment options

Discuss anxieties and worries with the patient in an informal and private setting, and attempt to resolve reversible precipitants of low mood before drug treatment.

Consider referral to the clinical psychologist if the patient is able to talk and may benefit from counselling.

Fluoxetine 20 mg mane (especially in patients where tiredness is a prominent feature, but cave gastrointestinal and other, often unspecific, side effects)

Paroxetine 20 mg mane (may be slightly better tolerated, but more likely to cause tiredness).

Dothiepin 75 mg at 8 pm (has more anticholinergic side effects, and is more sedating but is very useful in patients where the main feature of depression is insomnia).

Citalopram 20 mg OD is the only SSRI tested and found effective in clinical trials in stroke patients, but is not on the hospital formulary. It should be considered in patients who cannot tolerate other SSRIs .

If none of the above is effective, referral to a psychiatrist or psychogeriatricina should be considered.

Interpretation of the HAD scale xi xii

Score Depression (black bar on the left) and Anxiety (black bar on the right) responses separately. Score responses from 0,1,2,3 with 0 being normal/happy and 3 being anxious/depressed. The authors of the HAD scale usually recommend two cutoff points, 8/9 for a high sensitivity and 10/11 for high specificity, for both their anxiety and depression subscales, allowing the practitioner to choose whether to include borderline cases. However, in stroke patients the cut off points given below have been shown to be more sensitive and specific.

1. Depression

A cutoff point of 8/9 produced a sensitivity of 0.45 and a specificity of 0.85.

A cutoff point of 10/11 produced a sensitivity of 0.35 and a specificity of 0.93.

Improved sensitivity and specificity were achieved in this sample using a cutoff point of 6/7 (sensitivity, 0.8; specificity, 0.79).

2. Anxiety

A cutoff point of 8/9 produced a sensitivity of 0.5 and specificity of 0.87.

A cutoff of 10/11 produced a sensitivity of 0.42 and specificity of 0.92.

A better balance between sensitivity and specificity was achieved using a cutoff point of 6/7 (sensitivity, 0.83; specificity, 0.68).

Interpretation of the Stroke Aphasic Depression Questionnaire (SADQ)

This score is well coreelatte with the HAD and the longer (21-item) SADQ. It has only been tested in 20 patietns. The median Score was 13 with an interquartile range of 9-17. No cut off for depression was defined.

Suspect depression if a patients scores 15 or more.

Urinary Retention

Retention is common after stroke, and almost invariably reversible if the patient was able to pass urine normally before the stroke. It is caused by over stretching of the bladder in a patient who is bedbound and cannot get to the toilet when he wants to, stress, impaction, and central mechanisms. Men with pre-existing prostate problems are particularly likely to develop retention, but women are also affected.

General management Confirm retention by bladder scan. If confirmed, insert intermittent catheter to relieve retention Document the volume of urine draining straight after catheterisation. Exclude/treat faecal impaction If patient arrives on the ward with indwelling catheter remove immediately (unless the catheter is long-

term. e.g. was present before admission). If unsuccessful, repeat after 24 h. If unsuccessful again, ask for medical review. DRE to assess prostate size / VE to check for pessaries etc.

Males and females without a history of previous bladder and prostate problems Intermittent catheterisation 3-4x/day If a bladder scan is available check bladder volume and catheterise if >500. If the patient is able to pass some urine reduce frequency of catheterisation as tolerated aiming for bladder

volumes < 500 ml.

Males with a history of prostate problems Tamsolusin 400 mcg/day, TWOC after 48 h, if unsuccessful Repeat TWOC after 1 week, if unsuccessful Increase tamsolusin to 800 mcg/day, repeat TWOC after 1 week, if unsuccessful Repeat TWOC after 2 weeks, if unsuccessful Consider adding doxazosin (if BP not too low) and TWOC after 1/52, If unsuccessful Consider intermittent self catheterisation (as above), if unsuccessful Start finasteride 5mg/d and repeat TWOC at monthly intervals Refer to urologist, consider prostatic stent

Females with a history of voiding problems Refer to urologist

Females with no previous voiding problems Improve voiding by applying suprapubic pressure (Crede manoeuvre) during the void Intermittent self catheterisation Betanechol*10-25 mg TDS 30 min before meals, TWOC after 48 h

Or distigmine bromide* 5mg od (slower onset of action)Or carbachol* 2 mg TDS 30 min before meals (may have more side effects)*avoid in patients with DU, asthma, hypotension, Parkinson's, epilepsy, urethral or bowel obstruction)

TWOC after 48 hrs, if unsuccessful repeat after 1 week, if unsuccessful again, urology referral.

Shoulder painThe most common cause of post stroke shoulder pain is stress on the joint due to the hemiparetic arm dangling down unsupported and injury caused by carers pulling on the arm when sitting the patient up or during transfers. It can be avoided by positioning the hemiparetic arm on a pillow and by appropriate transfer techniques.

Approach to the patient with shoulder pain Make sure the arm is always well supported. Teach the patient not to allow the arm to hang unsupported. Check that all carers are using appropriate transfers. Discuss therapeutic options and with the physiotherapist. Simple analgesics consider NSAIDs, TENS, heat treatment.

This will relieve the discomfort in most cases. If not consider other or multiple causes:Cause Treatment options Effect of txSubluxationFlaccid low tone armPalpable gap

Postioning Physiotherapy Analgesics Strapping Suprascapular nerve block Electrical stimulation

SpasticityHigh toneTense pectoralis major tendonWrist movem. precipit. should. pain

Physiotherapy Muscle relaxants Botulinum toxin injection

OsteoarthritisH/O arthritis, neck and shoulder painsPalpable crepitus

Physiotherapy Heat treatments Ultrasound Glenohumeral joint injection NSAIDs

Frozen shoulderCan't elevate > 90 Rotat. more restr. than other movem.

Physiotherapy Glenohumeral joint injection Suprascapular nerve block

Rotator Cuff SyndromeH/O trauma, fall, painful arc syndr.Pain located to mid humerus

Rotator cuff exercises Subacromial steroid injection

Thalamic pain (rare)Anaesthesia, ParaesthesiaeShooting pains precipit. by light touch or gentle stroking of hairs all over the hemi side

Amitryptiline Carbamazepine Gabapentin Amitryptiline and Gabapentin

Sympathetic dystrophy/ shoulder arm syndome (v. rare)Skin of the hand and lower arm discoloured, warm and extremely tender to minimal touch

(Gentle) Physiotherapy Avoid extreme heat/cold Consult pain specialist ASAP Sympathetic nerve block

Satin induced myopathy (rare)On a statin, muscle tendern., high CK

Stop the statin

Consider fracture, dislocation, gout, bicipital tendinitis, brach. plexus injury and others….

Spasticity

Spasticity following stroke is characterised by increased tone and stiffness in the affected side and by spasms and abnormal movements. It is but one feature of the upper motor neuron syndrome. It does not always need treating, as it is sometimes helpful in assisting a patient to stand on a stiff limb, when the underlying weakness would not otherwise allow it. It requires treating in about 16% of patients after stroke, when it is harmful and troublesome. Spasticity may not present as a major problem during patients’ inpatient stay, but may present aftewr the patient has returned home. The six month review is therefore a good time to assess its impact, which can be as follows:

Impact of Spasticity on Health1

Unremitting pain from muscle spasms, limb deformity & pressure on pressure pointsTreatment for pressure sores and other tissue viability problemsContractures leading to abnormal body segment loading and sensory change Limb deformity and altered body mechanicsNeed for special wheelchairs and seating and pressure-relieving equipmentProgression to degenerative joint diseaseAltered body imageMood problems

Management

Successful spasticity management is a multidisciplinary activity and is based on physical management (good nursing care, physiotherapy, occupational therapy). Positioning, exercise, stretching and strengthening of limbs, splinting and pain relief are essential and all pharmacological interventions are adjunctive to a programme of physical intervention. A treatment strategy is described below. The pharmacological options depend on the pattern of the presenting problem. The figure shows the drugs of choice for the generalized and focal problems of spasticity.

Management Strategy for Adults with Spasticity 2, 3

Prevention of Provocative Factors

Team Decision Making

Treatment OptionsPhysical Medical

Generalised Spasticity

Botulinum ToxinPhenol Blockade

Focal Spasticity

Oral Agents Orthopaedic Surgery

Characteristics of Anti-spastic Drugs4

Treatment Value Problems

Oral Agents Baclofen & Dantrolene - cheapTizanidine – 7x costGabapentin - expensive

40% of patients unable either to tolerate oral agents because of side-effects or unable to produce an adequate anti-spastic effect before side-effects occur

Botulinum Toxin Effective for focal spasticitySimple to prescribeSimple intramuscular injectionNeed trained clinician to treat

Seen as expensive, but good value over the four-month effect of the drug. Budgetary limits. Reversible effects. Considerable benefit to management

Phenol Nerve &Motor Point Block

Cheap drugTime consuming to give

Expensive to give in clinical time. Painful to give. Potential for severe complications

Intrathecal Baclofen Expensive hardwareEight year life

Need for prolonged inpatient assessment required. Requires patient compliance and education. Need proper contract to deal with pump renewals

Neurosurgery & Orthopaedic Surgery

Expensive, but valuable.Limited indications and patients

Painful, irreversible, invasiveVariable results & effectiveness.

Treatment Plan 1

1. Physiotherapy is aimed at reducing the problems caused by the spasticity and at achieving a natural balance between both the affected and unaffected sides5. Painful spasticity, e.g. as in hemiplegic shoulder pain, should be controlled physically and with local and nerve blockade. See shoulder pain section.

2. Occupational therapists are responsible for providing splints and casts to allow more prolonged stretching of limbs6, 7.

3. Start baclofen at 5mg tds for one week. If there are no side effects, raise dose to 10mg tds and by a further 10mg daily at weekly intervals until the desired effect or side effects occur. Maximum dose is 80-90mg daily.

4. If spasticity not controlled, the patient should be referred to the Spasticity Service for consideration of secondary measures. The addition of, or change to, dantrolene or tizanidine may be attempted, but experience shows that they are unlikely to achieve the desired therapeutic result, if baclofen does not.

5. If the patient has cortical dysaesthesia or neurogenic pain, gabapentin should be given in typical therapeutic doses. This should be given for a minimum of six weeks and the dose titrated against effects and side effects. Dosing should start at 300mg daily along the following plan. Elderly patients may not be able to tolerate this increase and weekly increments should be applied rather than every three days. If side effects do occur, patients should be instructed to decrease to the dose below and attempt to increase it again after a few days. (Each 300mg capsule is delineated by an X).

Initiation of Gabapentin 300mg capsules (=X)Days AM PM1-3 X4-6 X X7-9 XX X

10-12 XX XX13 onwards XXX XX

The dose should then be adjusted upwards(or downwards) according to effect, but may be raised to a maximum of 3600mg daily, if required.

6. Botulinum toxin and phenol injections are indicated for the treatment of focal problems, but require specialised service to achieve optimal effects and value1. Botulinum toxin is given by intramuscular injection to the spastic muscle causing harm. Its effect lasts for three to four months and it is completely reversible. It provides a window of opportunity for physical treatment to take place. It can be given as soon as spasticity causes harm and only about 5% stroke patients will ever require it. It may only have to be given on one or two occasions, but there is a population of stroke patients, who develop chronic spasticity, who will require them more regularly. Three monthly intervals should elapse before the toxin is re-injected, in order to prevent secondary non-response from neutralising antibodies. Their indications are as follows.

a. Functional improvement, e.g. of mobility, transfers, dexterity/reaching.b. Symptom reduction, e.g. pain & spasm relief, allowing orthoses to be worn.c. Aesthetic improvement, e.g. body image or fit of clothes d. Decrease in the burden of care, e.g. allowing better patient positioning, care & hygiene and

reducing limb deformity to allow easier dressing.e. Enhancing service responses, e.g. by facilitating physical therapies, reducing use of

antispastic medication, reducing unnecessary treatments for complications, preventing or delaying surgery.

7. Ensure that there is good communication between the stroke team and the spasticity service team on the aims of treatment and on follow up arrangements

8. Follow up requires consideration of goal achievement and other outcome measures. Documentation is available from the spasticity service.

Who Will Develop Spasticity?

Patients with bilateral weakness may develop problems, but the most likely patients are those with the following sensory and cognitive problems.

Sensory Loss Proprioception**Light TouchVisual Impairment e.g. uncorrected hemianopia

Cognitive Loss MemoryPerception*** particularly those with visuo-spatial and

sensory neglect)

Outcomes

There are no satisfactory measures for spasticity and the current ‘standard’, the Ashworth Score, measures limb stiffness and not spasticity8. This will change over the next year or two and the current recommended outcome measures are:

The Goal Attainment Score, as measured by a percentage of goal desired. This must be agreed with the treating team prior to treatment. Patient/Carer satisfaction can be measured using a 10cm Visual Analogue Scale of a Likert Scale9, but all other measures should be based on the International Classification of Functioning & Health (2001)10, examples of which are:

Domain Item Some Suggested Measures

Impairment PainStiffnessJoint RoMMuscle Power

10cm Visual Analogue Scale/Likert ScaleAshworth Score(Flexion & Extension) AnglesDynamometry/MRC scale

Functioning Mobility

DexterityMood

10 metre Walking Time/Stride lengthGet Up & Go Test9 Hole Peg TestHADS

Participation Quality of Life Some goal achievement

EQ5D, SF36Goal Attainment scores

References

1. Ward AB, et al. Primary care guidelines on spasticity. 2004; London. Connect Medical.2. Turner Stokes L, Ward AB. The Use of Botulinum Toxin in the Management of Adults with Spasticity. Clinical

Medicine (JRCPL) 2002; 2 (2): 128-130.3. Guidance for the use of botulinum toxin in the management of spasticity in adults. Royal College of Physicians of

London Clinical Effectiveness & Evaluation Unit. July 2002. Royal College of Physicians, London4. Ward AB. Spasticity. Chapter in ‘The Clinical Applications of the Botulinum Toxins’. Eds. Barnes MP, Ward AB.

Cambridge. Cambridge University Press – in press.5. Bower E, McLellan D L, Arney J, Campbell M J. A Randomised Controlled Trial of Different Intensities of

Physiotherapy and Different Goal Setting Procedures in 44 Children with Cerebral Palsy. Developmental Medicine & Child Neurology 1996; 38: 226-237

6. Zachewski J E, Eberle E D, Jefferies M. Effect of tone inhibiting casts and orthosis on gait. A case report. Physical Therapy 1982; 62: 453-455.

7. Moore T J, Barron J, Modlin P, Bean S. The use of tone reducing casts to prevent joint contractures following severe closed head injury. Journal of Head Trauma Rehabilitation 1989; 4: 63-65.

8. Bohannon RW, Smith MB. Inter-rater reliability of a modified Ashworth Scale of muscle spasticity. Physical Therapy 1987; 67: 206-207.

9. Wade DT.Outcome measurement and rehabilitation. Clinical Rehabilitation 199; 13: 93-95.10. Wade DT. Measurement in Neurological Disability. 1992 Oxford. Oxford University Press.11. World Health Organisation. International Classification of Functioning and Health. 2001. World Health

Organisation. Geneva.

Drooling

ASD and PFO

The Staffordshire and Shropshire Cardiac & Stroke Network Guidelines for the investigation of right to left shunts, presumed paradoxical embolism and their closure in young strokes

Version 1.0 November 2008

Background: The vast majority of strokes are ischaemic strokes (IS) and are mediated by either spontaneous rupture of atheromatous plaque in the carotid artery and consequent thromboembolism or as a result of atrial fibrillation. They occur in patients with a number of cardiovascular risk factors; increasing age, smoking diabetes, hypertension and hyperlipidaemia. A smaller number are haemorrhagic.There is a much smaller group of stroke patients who are < 55 years old, who suffer an IS in whom there is an association with right to left shunts (RLS); patent foramen ovale (PFO), atrial septal defects(ASD) and pulmonary arteriovenous malformations (pulm-AVM). This group have been termed cryptogenic stroke, because the expected association between cardiovascular risk factors and IS are absent. Current data from meta-analysis suggests that only large shunts (>5-15 bubbles on bubble contrast echocardiography, within 3 cardiac cycles for ASD/PFO) or PFOs that are greater than 4mm are likely to cause paradoxical embolism.

Device closure in RLS and stroke: PFOs are present in 40% of patients with cryptogenic stroke and may be associated with paradoxical emboli, stroke being a common result. Therapeutic options include antiplatelet agents, anticoagulation, percutaneous and surgical closure. Casaubon et al [1] recently assessed the risk of recurrent TIA or IS between patients in four treatment groups; antiplatelet agents (34%), anticoagulation (17%), device (39%) and surgical closure (11%). The initial cohort consisted of 121 patients and recurrent events occurred in 16 patients (9 antiplatelet, 3 anticoagulation, 4 device closure); 7 were strokes, 9 were TIAs. Patent foramen ovale closure was associated with fewer recurrent events. Schuchlenz et al [2] randomised 280 consecutive patients with PFO and cryptogenic stroke to receive platelet inhibitors (n = 66) or anticoagulation (n = 47) or device closure (n = 167). 33 (12%) patients had a recurrent cerebrovascular event. The annual recurrence rates were 13% in patients treated with platelet inhibitors, 5.6% in those on oral anticoagulation, and 0.6% in those after device closure. Independent predictors of recurrent cerebrovascular events were a PFO larger than 4 mm or previous strokes. Patients with a large patent foramen ovale i.e >4mm and a cryptogenic stroke had a substantial risk of recurrence even with medical treatment.

Prior studies suggest that PFO diameter >4 mm is associated with a high probability of IS with quite a degree of concordance. However the PFO may appear small on TTE, but potentially be much larger under extreme loading conditions (childbirth, stress, trauma and operations). This is evident in the catheter laboratory where a small PFO is easily opened to 15+mm, although the shunt on contrast echocardiography has usually been large.

Percutaneous shunt closure: The Liverpool experience [3] of ~150 device closures showed that the predominant indication for PFO closure was cerebrovascular accident (CVA) (42.2%, n = 46)- and for ASD, dilated right ventricle (68.4%, n = 52). Of all procedures, 94.6% (n = 175) were first time and 5.4% (n = 10) were redo for residual shunt. The overall complication rate was 5%, of which 1% was classed as serious. This is supported by many single centre series showing the procedure to be safe. It is now subject to formal national audit as part of the Central Cardiac Audit Database (CCAD), a partnership between the Department of Health and British Cardiac Society.

Imaging: Bubble contrast echocardiography has been the cornerstone in diagnosis of RLS for over four decades. Despite being a relatively invasive procedure, transoesophageal echocardiography (TOE) is considered the gold standard for detection of RLS, however other echocardiographic techniques such as transthoracic echocardiography (TTE) with second harmonic imaging and transcranial Doppler ultrasonography (TCD) have shown increased sensitivity and specificity compared to TEE for the detection of RLS. Moreover, improvement of skills and techniques used for detection of these shunts has led to greater detection of small and large sized RLS in the echocardiographic laboratory without resorting to TOE.We currently recommend transthoracic echocardiography with both a Valsalva manoeuvre and a large sniff, which create optimum loading conditions to demonstrate a RLS. This should be undertaken in a centre experienced in undertaking and interpreting these images.

Other indications: Sleep apnoea: This has a greater incidence if obesity and right to left shunting exists. Device closure has a beneficial effect only in anecdotal case reports so far.Migraine: Currently the association between R-L shunts and migraine is confirmed in a number of observational studies, but as yet no significant treatment effect from device closure has been proven. Platypnea-orthodeoxia syndrome: Dyspnea and arterial desaturation on upright position in elderly subjects is described as platypnea-orthodeoxia syndrome (POS) and in some patients it is due to right-to-left shunt across the atrial septal defect (ASD)/patent foramen ovale (PFO). This is a current indication for device closure of a RLS

EchocardiographyTransthoracic bubble study: This should be undertaken by an operator trained and experienced in the acquisition and interpretation of standard transthoracic and bubble ecchocardiography. Ideally images should be obtained in apical 4 chamber view to allow simultaneous imaging of right and left sides of the heart.A 21 gauge cannula should be used in the antecubetal fossa and an agitated mixture of 8.5ml saline, 1ml blood and 0.5ml air mL injected. One resting injection should be made followed by three injections with a forced valsalva and also with a large sniff.

Transoesophogeal echocardiogram: This should be undertake in patients who may require device closure, or where other intracardiac sources of embolisation are being sought; myxoma, left atrial appendage clot.

Investigations All patients with ischaemic stroke who are <55 years old should undergo transthoracic

echocardiography with bubble contrast All patients with dilated right hearts and suspicion of RLS on echo post stroke should

undergo bubble contrast echocardiography All shunts that are classed as large should be referred potential device closure (>5

bubbles in 3 cardiac cycles) Large shunts in < 3 beats may indicate intracardiac RLS Large shunts > 3 beats may indicate pulmonary venous arteriovenous malformations,

which should be assessed by CT angiography. Clinical sign of hereditary haemorrhagic telangiectasia should be sought

Consideration should be given to excluding paroxysmal AF as a cause of stroke.

Definite indications for device closure Young stroke with large RLS (>5 bubbles in three beats) shunt due to PFO or ASD ASD PFO > 4mm on balloon sizing Platypnea-orthodeoxia syndrome Significant ASD with dilated right heart on echocardiogram Will need cardiac catheterisation or cardiac magnetic resonance imaging first to

quantify shunt size

Management post device closure Aspirin lifelong with three months of clopidogrel initially. If patients are within the first

two years post stroke, and were on persantin prior to device closure, this should be restarted after the clopidogrel finishes

Repeat bubble study at six months. If a residual shunt is seen at six months then a further repeat bubble study should be arranged for one year

Reference List

1 Casaubon L, McLaughlin P, Webb G, et al. Recurrent stroke/TIA in cryptogenic stroke patients with patent foramen ovale. Canadian Journal of Neurological Sciences 2007 Feb;34(1):74-80.

2 Schuchlenz HW, Weihs W, Berghold A, et al. Secondary prevention after cryptogenic cerebrovascular events in patients with patent foramen ovale. Int J Cardiol 2005 May 11;101(1):77-82.

3 Egred M, Andron M, Albouaini K, et al. Percutaneous closure of patent foramen ovale and atrial septal defect: procedure outcome and medium-term follow-up. Journal of Interventional Cardiology 2007 Oct;20(5):395-401.

Perceptual Difficulties following Stroke

Perception is the word used to describe the brain's ability to interpret and understand information received by the senses. This means that patients can see and feel things, but they won't recognize what they are.

Perceptual deficits can be divided into the following areas:

Body Image – lack of visual/mental image of one’s body. Body Scheme – difficulty in perceiving the position of the body, and the relationship to other body parts. Spatial Relationship Deficits – difficulty in processing the position of two or more objects in relation to

oneself or each other. Agnosias – Lack of recognition of familiar objects.

If perceptual difficulties are suspected the patient would benefit from further assessment by the occupational therapist.

Cognitive Deficits Following Stroke

Stroke can disrupt a wide range of cognitive difficulties, resulting in difficulties in carrying out activities. Cognitive deficits may adversely affect a person’s ability to participate in therapy, performs activities of daily living and live independently. This can be both confusing and distressing for both the patient and their families.

Below are brief descriptions of the most common cognitive impairments.

Neglect

Stroke may affect a person’s awareness of the space around them and the space occupied by their body. This may present in the neglect of their upper limb or a failure to respond to things positioned in the space on the neglected side.

The left side is the most commonly neglected following stroke.

Patients should be encouraged to attend to the side in which they are neglecting, however, if it is severe neglect it may be much more appropriate to encourage the patient around to midline.

Attention and Concentration

Problems sustaining attention/concentration are common following stroke, especially right hemisphere strokes. Patients can experience difficulties in maintaining concentration, making it hard to carry out activities. This can be worse if they are tired, not interested in the activity or if there are distractions.

Dyspraxia

This is a disorder of the skilled voluntary movement that is not due to a sensory or motor impairment. People who present with dyspraxia may be unable to perform activity due to an impaired conceptual ability to organize the actions required to complete the task. Dyspraxia is most common following left hemisphere lesions.

It is important that when working with patients who have dyspraxia that all staff involved approach tasks in the same way, if tasks are repeated they are more likely to become familiar.

Executive Function

Executive functioning impairments can occur following stroke, especially if there is frontal lobe involvement. Executive functions have an organising role on the inhibition and initiation of behaviour, therefore impairments in this area may affect a person’s ability to plan, problems solve and self monitor.

Patients should be screened for cognitive impairment following stroke. Locally this tends to be done by the occupational therapist. Referrals are also made to the clinical psychologist for further assessment and guidance with patients presenting with complex problems.

Resuming hobbies and interests

This is a very important area that should be addressed with the patient and carer (if this is appropriate). It is acknowledged that many patients following stroke will lose previous roles, hobbies and interests, which may contribute to feelings of low mood, distress and depression. This may not be apparent to the patient and their family until the time following discharge from the acute, rehabilitation or community services.

RCP Guidelines, 2004, state that “long term rehabilitation needs to address issues around ‘participation’”

This may necessitate the withdrawal of the medical and traditional rehabilitation services such as day hospital services, and the substitution of these with leisure and social activities to encourage independence and reintegration.

To facilitate this, patients’ need to be given access to the statutory and voluntary agencies that can support or advise them in resuming their hobbies and interests or attempting areas of new interest.

Useful Local Contact Numbers Include:

Stokes R Us01538 751671

Stroke Association01782 845828

Different Strokes0845 130 7172

Driving Following Stroke

Following stroke the DVLA state that you should not drive for one month.

Following this you may resume driving if a doctor feels that your clinical recovery is satisfactory.

You must inform your insurance of your stroke or TIA before you get back to driving. This applies even if you are fully "back to normal".

There is no need to notify the DVLA unless there is residual neurological deficit one month after the episode. In particular these neurological deficits include visual field and cognitive deficits and impaired limb function. The DVLA will require notification if you have not fully recovered after one month but want to resume driving and if there is a restriction to certain types of vehicle where adapted controls are required.

A driver who experiences multiple TIAs over a short space of time may require three month period freedom of further attacks before resuming driving and should notify the DVLA.

Even if the doctor, the DLVA and the insurance have passed you as fit for driving it is your individual responsibility to ensure that you are fit to drive. If you feel tired, unwell, if your can't concentrate or get confused, or if your eyesight is not adequate you should not drive. Sometimes your health and fitness can change form day to day, and it is your responsibility to decide if you are fit to drive every time you get into the car.

Contact Details:

Driver and Vehicle Licensing AgencyDrivers Medical GroupSwanseaSA99 1DL

0879 600 0301http://www.dvla.gov.uk/ (DLVA main site)http://www.dvla.gov.uk/at_a_glance/ch1_neurological.htm (information about stroke and driving )

Derby Regional Mobility CentreKingsway Hospital, Kingsway, Derby DE22 3LZ

01332 371929http://www.drmc.uk.com

Mid Staffordshire Driving Assessment ServiceCannock Chase Hospital, Brunswick Road, Cannock, Staffordshire WS11 2XYTel: 01543 576416Fax: 01543 576401

Travel

There is no reason not to travel after the stroke. A holiday may help both the stroke patients and the carers feel better. Here are some contact numbers to help with travel arrangements and mobility problems. There is no need to consult your doctor beforehand if you feel well, but you may be more reassured and get some valuable advice if you do so. Patients on warfarin may have to arrange for INR checks in their holiday resort.

Contact numbers for local rail services offering support for disabled passengers:Central Trains 08457 056027www.centraltrains.co.uk

Connex central 08706 030405

Midland Mainline 08457 125678

Virgin Trains 08457 443366

Contact numbers for coach travel:

National Express 08705 80 80 80www.gobycoach.com

Air travel can be considered 3 months after the stroke. Before that time insurances do not usually cover and airlines are unlikely to accept the passenger, even if all or most of the symptoms of the stroke have resolved. After 3 months even stroke sufferers with persistent severe disabilities can fly as long as they can sit long enough in a chair and have no severe heart or lung problems. Wheelchairs and assistance with transport for disabled passengers are available at all airports, but will require prior booking.

Contact numbers for assistance at Airports:

East Midlands Airport 01332 852852/852885

London Gatwick Airport 01293 503124

London Heathrow Airport 0208 745 7495

Manchester Airport 0161 4893000

These contact numbers are not intended to be recommendations of services.

AppendicesDateTime

T OC

Blood Pressure

Heart rate

Respiratory Rate

250 40240 39.5230 39220 38.5210 38200 37.5190 37180 36.5170 36160 35.5150 351401301201101009080706050403530

251510

Best level of mobilisation

BM Result

Oxygen saturation

Oxygen concentration (if given)Conscious levelFully alert 6Drowsy, but can be awakened to full consc. 4Reacts to commands, can't be fully awakened 2Coma 0SpeechNo communication problems 10Problems w. expression or w. understanding 6More than yes/no, but not longer sentences 3Only yes/no or less 0Eye movementNormal eye movements 4Can look straight, but not to affected side 2Eyes look away form the affected side 0Arm motor power (on the affected side)Raises arm with normal strength 6Raises arm with reduced strength 5Raises arm with flexion in elbow 4Can move, but not against gravity 2No movement 0Leg motor power (on the affected side)Raises leg with normal strength 6Raises leg with reduced strength 5Raises leg with flexion in knee 4Can move, but not against gravity 2

A

B

C

D

E

F

No movement 0Total (max 32)

The Community Stroke Aphasic Depression Questionnaire(SADQ 10 item )

Please indicate how often in the last week the patient has shown the following behaviours:

Often3

Sometimes2

Rarely1

Never0

1. Does he/she have weeping spells?2. Does he/she have disturbed nights?3. Does he/she avoid eye contact

when you talk to him/her?4. Does he/she burst into tears?5. Does he/she complain of aches and

pains?6. Does he/she get angry?7. Does he/she refuse to participate in

social activities?8. Does he/she get restless and

fidgety?9. Does he/she sit without doing

anything?10. Does he/she keep himself/herself

occupied during the day?

Total

Discharge Summary TemplatePresenting Complaints:

right/ left hemiparesis/ other

Diagnosis:

1. Ischaemic Stroke (thrombolysed / not thrombolysed)

Total anterior Circulation Ischaemic Stroke (TACI) Partial anterior circulation ischaemic Stroke (PACI) Lacunar Ischaemic Stroke (LACI) Posterior circulation ischaemic Stroke (POCI) Small vessel disease of the brainVascular dementia secondary to small vessel disease of the brain

2. Haemorrhagic Stroke

Non traumatic Intra-parenchymal haemorrhage Traumatic Intra-parenchymal haemorrhage Subarachnoid haemorrhageSubdural Haematoma

3. TIA (give ABCD2 Score)

4. Other diagnosis – for example, migraine, seizure, mets

Co morbidities:

Diabetes HypertensionSmokerAlcohol excessAtrial fibrillationIncreased BMIHypercholesterolemiaOld age – over 65Living aloneFrailtyDementiaCOPDOthers...

Investigations:

CT brain confirms: Cerebral infarct/ haemorrhage/ non specific changes (e.g. Small vessel disease old infarcts)/ normal/ other (e.g. brain tumour)

Carotid Dopplers: give result

Normal/ mild/ moderate atheroma. Critical stenosis or non critical stenosis

ECG: Sinus rhythm / Ischaemic changes/AF

CXR: Normal /Abnormal

Bloods: relevant abnormal findings. Plus fasting or random glucose and cholesterol

Note: It is important to enter all the columns. If CXR and ECG are normal it has to be entered as Normal chest x-ray and Sinus rhythm. Abnormal blood results should be documented.

Carried out Procedures:

Thrombolysis Venous accessNG tubePEG tubeCatheterisationPhysio/OT assessmentSALT assessmentTrial participation (name of trial)

Medications:

AspirinDipyridamoleSimvastatinRamiprilBendroflumethiazideMetformin Gliclazide

Additional Comments:

NIHSS on admission

Discharge Destination: Home, NH, RH, and transfer to other (specify ward)

Level of mobility: Mobile / Immobile/ Hoisted

Continence:

Bowel: Continent / IncontinentBladder: Continent/Incontinent

Life style advice

Dietary advice

Target BP 140/ 85 or 130 /80 for Diabetic patients and CRFHb1Ac % 6 – 8Cholesterol: TC less than 4 and LDL less than 2Driving advice Flying advice

Any other recommendations to GP like monitoring renal functions or any changes to admission medications should be documented in this section

For All patients transferred to other wards hospital (rather than discharged home): Anticipated discharge destination:Goals to achieve in the other ward before discharge.

Follow up:

6 weeks or No follow up.

If the Consultant mentions a different follow up date that has to be changed accordingly

Kindly always make sure that you enter your name and bleep number for records. If not it will be difficult for us to find who did the discharge summary.

Joint discharge Plan ( to be completed by OT): All patients discharged form hospital should have a joint health and social care discharge plan, unless they are fully independent, they refuse such a plan, or a joint plan is inappropriate for other reasons.

This should be devised by the OT , discussed with social services, and the patient/family and the content of the plan documented in the discharge summary.

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Stroke follow-up 1 (6 week post discharge) Assessment form

Name DateWeightBlood pressureHeart rateECG

Diagnosis, comorbidities, and risk factors (consult and update stroke checklist)

Current medication

Progress/ Problems since hospital discharge

Any problems coping? Yes/noCarer stressed? Yes/no/na

Involvement of social or rehabilitation services ESD Stroke Association call/ visit Stroke Club / Young strokes/ Dysphasia support Psychological support Home help Other

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Scores:

Rankin:

MMTS: HAD A:

HAD D:

No of falls:

Life after stroke (yes/no/NA; check if any problems, and if help/ advice needed, document needs)

Driving

Work/ Housework

Hobbies/ Travel

Family/friends

Sex

Other

Problems which may need addressing Incontinent?

Cognitive problems?

Depression/ Anxiety?

Spasticity/ pain?

Excessive tiredness?

Anything else the patient would like help with?

Management Plan If thrombolysed, copy letter with Rankin score to C. Roffe for SITS register.

If interested in becoming involved in research/ development/ peer support/ teaching copy letter to PPI file with area of interest and contact no

Referral for psychological assessment/ treatment Yes / Not needed/ Not wanted

Other referrals

Risk factor management handed over to GP Yes / no / specify why not)

6 month follow-up handed over to GP Yes / no / specify why not

Investigations ordered (No / yes/ specify)

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Stroke Follow-up 1 Patient Questionnaire

Name: __________________________ Date____________ This questionnaire can be completed by the patient, a relative, friend or carer on the patient’s behalf .

Where do you live now? Please tick the box which applies to you In my own home / In the home of a relative In a residential home / a nursing home

Have you been admitted to hospital again for any reason after you were discharged? Yes what was the reason? No

Are you left with any symptoms or problems after your stroke? Please tick one box next to the statement which best describes your present state

0 I have no symptoms at all.

1 I have a few symptoms, but I am able to carry out all previous activities and duties.

2 I am unable to carry out all previous activities, but am able to look after my own affairs without assistance.

3 I need some help with looking after my own affairs, but am able to walk without assistance.

4 I am unable to walk without assistance and unable to attend to my own bodily needs without assistance, but I do not need constant care and attention.

5 I have major symptoms which severely handicap me. I am bedridden and incontinent and I need constant attention day and night.

Are you interested to get involved in peer support, teaching, research, or service development?

Would you be interested in getting involved in a peer support group for stroke patients and carers? Yes/ no

Would you be interested in getting involved in developing stroke services? Yes/ no

Would you be interested in helping stroke researchers develop or conduct studies? Yes/ no

Would you be interested in helping with student/postgraduate teaching? Yes/ no

Is there anything you would like to discuss with the doctor when you see him/her?

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Stroke follow-up 2 assessment form (6 months post discharge)

Name Date

WeightBlood pressureHeart rateECG

Diagnosis, comorbidities, and risk factors (consult and update stroke checklist)

Is GP checking BP/ cholesterol/ diabetes/ medications?

Current medication

Progress/ Problems since 6-week assessment

Any problems coping? Carer stressed?

Involvement of social or rehabilitation services

Still receiving rehabilitation?

Has the patient had [psychological supprt?

Stroke Club / Young strokes/ Dysphasia support

Home help

Other

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Scores:

Rankin:

MMTS: HAD A:

HAD D:

No of falls:

Life after stroke (yes/no/NA; check if any problems, and if help/ advice needed, document needs)

Driving

Work/ Housework

Hobbies/ Travel

Family/friends

Other

Problems which may need addressing

Incontinent?

Cognitive problems?

Depression/ Anxiety?

Spasticity/ pain?

Excessive tiredness?

Anything else the patient would like help with?

Management Plan

Discharge from hospital follow-up yes/ no specify why not

Hand over risk factor management and annual stroke checks to GP if not already in place

Hand over 12 month review and subsequent annual reviews to GP/ Primary care if no community long-term specialist stroke follow up service in place

Referrals for problems requiring therapy/specialist input not needed/ needed (specify)

Offer contact address/number of consultant secretary to patient in case problems occur in future.

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Follow-up 2 Patient Questionnaire

Name: __________________________ Date____________ This questionnaire can be completed by the a relative, friend or carer on your behalf.

Where do you live now? Please tick the box which applies to you In my own home / In the home of a relative In a residential home / a nursing home

Have you been admitted to hospital again for any reason after you were discharged? Yes what was the reason? No

Are you left with any symptoms or problems after your stroke? Please tick one box next to the statement which best describes your present state

0 I have no symptoms at all.

1 I have a few symptoms, but I am able to carry out all previous activities and duties.

2 I am unable to carry out all previous activities, but am able to look after my own affairs without assistance.

3 I need some help with looking after my own affairs, but am able to walk without assistance.

4 I am unable to walk without assistance and unable to attend to my own bodily needs without assistance, but I do not need constant care and attention.

5 I have major symptoms which severely handicap me. I am bedridden and incontinent and I need constant attention day and night.

Are you interested to get involved in peer support, teaching, research, or service development?

Would you be interested in getting involved in a peer support group for stroke patients and carers? Yes/ no

Would you be interested in getting involved in developing stroke services? Yes/ no

Would you be interested in helping stroke researchers develop or conduct studies? Yes/ no

Would you be interested in helping with student/postgraduate teaching? Yes/ no

Is there anything you would like to discuss with the doctor when you see him/her?

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Stroke clinic 3 months follow-up

Name:Date:Date of stroke: OCSP Classification Hemiparesis

TAC leftAetiology: PAC rightInfarct LAC nilIntracerebral Haemorrhage POC bothOther TIA

Other Diagnoses:1. 4. 7.

2. 5. 8.

Current Treatment:1. 4. 7.

2. 5. 8.

3. 6. 9.

Remediable Risk Factors:Hypertension Clinic BP:Hypercholesterolaemia Last Cholesterol:Diabetes MellitusObesitySmokingExcess alcoholAtrial fibrillationSignificant carotid stenosis

Social and Rehab Services:

Problems since discharge:

Management/ PlansDriving Advice Risk factor bookletClinical TrialsDischarge from clinicRisk factor management : GP OtherReferrals:

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Scores:Barthel on discharge:Barthel now:Rankin:Euroquol: Nottm Ext ADL:HAD A: HAD D:Falls since discharge:NoYesNumber:

Investigations Results to Clinic / GP: FBC U&E LFTs CK cholesterol Carotid Doppler

Circle true terms/statements Use to indicate no

Stroke clinic follow-up Questionnaire

Name:

Date: Date of stroke:

Where do you live now? Please tick the box which applies to you

Im my own home In the home of a relative In a residential home In a nursing home In a continuing care hospital I have not yet left hospital after my stroke

Who do you live with ? Please tick the box which applies to you

I live alone I live with a spouse/partner I live with family/friends

Have you been admitted to hospital again for any reason after you were discharged?

Yes (once) Yes (more than once) No

Are you left with any symptoms or problems after your stroke? Please tick the tick one box next to the statement which best describes your present state

0 I have no symptoms at all.

1 I have a few symptoms, but these do not interfere with my everyday life.

2 I have symptoms which have caused some changes in my life, but I am still able to look after myself.

3 I have symptoms which have significantly changed my life and I need some help in looking after myself.

4 I have quite severe symptoms which mean I need help from other people but I am not so bad as to need attention day and night.

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5 I have major symptoms which severely handicap me and I need constant attention day and night.

Mod. Rankin total:________

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This page contains some more specific questions on how the stroke has affected your day to day life and physical functioning

Barthel ADL Please circle the number for the statement that best describes each function

1.Bowels 0 Incontinent (or needs to be given an enema)1 Occasional accident (once a week)2 Continent

2. Bladder 0 Incontinent or catheterised and unable to manage alone1 Occasional accident (max. once per 24h )2 Continent (for more than seven days)

3. Grooming 0 Needs help with personal care1 Independent: face, hair, teeth, shaving (implements provided)

4. Toilet use 0 Dependent1 Needs some help but can do some things alone2 Independent (on and off, wiping, dressing)

5. Feeding 0 Unable1 Needs help in cutting, spreading butter etc.2 Independent (food provided in reach)

6. Transfer 0 Unable – no sitting balance1 Major help (physical, one or two people), can sit2 Minor help (verbal or physical)3 Independent (but may use any aid)

7. Mobility 0 Immobile1 Wheelchair independent, including corners etc2 Walks with help of 1 person (verbal or physical help)3 Independent (but may use any aid)

8. Dressing 0 Dependent1 Needs help but can do about half unaided 2 Independent (including buttons, laces, zips etc)

9. Stairs 0 Unable1 Needs help (verbal, physical, carrying aid)2 Independent, up and down

10. Bathing

0 Dependent1 Independent (Bath: must get in & out unsupervised and wash self or Shower: unsupervised/unaided

Total

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These questions will help us to find whether your wellbeing is affected by any of your medical problems. Some questions may address similar topics than the previous pages, but this will help us to get more specific information about how well you are

Euroquol

MobilityPlease tick the box which best describes your level of mobility

0 I have no problems walking 1 I have some problems walking 2 I am confined to bed

Self carePlease tick the box which best describes your ability to care for yourself

0 I have no problems with self care 1 I have some problems washing and dressing 2 I am unable to wash or dress myself

Usual activitiesPlease tick the tick one box next to the statement which best describes your ability to perform your usual activities

0 I am able to perform usual activities 1 I have some problems performing unusual activities 2 I am unable to perform usual activities

Pain or discomfortPlease tick the box next to the statement which best describes your level of pain or discomfort

0 I have no pain or discomfort 1 I have moderate pain or discomfort 2 I have extreme pain or discomfort

Anxiety and depressionPlease tick the box next to the statement which best your level of anxiety and depression

0 I am not anxious or depressed 1 I am moderately anxious or depressed 2 I am extremely anxious or depressed

Total____

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The EuroQuol Questionnaire

Score: _____%

go back to index

To help you to say how good (or bad) your health is we have drawn a scale (rather like a thermometer) on which the best health you can imagine is marked by 100 and the worst health you can imagine is marked by 0.

We would like you to indicate on this scale how good or bad your health is in your own opinion today.

Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your current health is.

Your own health today is:

0

Worst imaginable health state

Best imaginable health state

100

87

89

This is a long list of questions designed to find out if and how your medical condition has affected your ability to do day to day activities and to pursue work and leisure interests

Do you [please tick the option that describes best what you actually do]

Nottingham extended ADL 3Alone easily

2Alone with

difficulty

1With help

0Not at all

Mobility: Do youWalk around outside?Climb stairs?Get in and out of the car?Walk on uneven ground?Cross roads?Travel on public transport?Eating and Drinking: Do youManage to feed yourself?Manage to make a hot drink?Take hot drinks from one room to another?Do the washing up?Make yourself a hot snack?Domestic tasks: Do youManage your own money when out?Do your own shopping?Wash small items of clothing?Do a full clothes wash?Leisure and communication: Do youRead newspapers and books?Use the telephone?Write letters?Go out socially?Manage your own garden?Drive a car?Total:

90

91

This is the last page of the questionnaire

Memory Please tick the box next to the statement which best describes your memory

My memory is as good as before the stroke My memory has deteriorated since the stroke

Things I can't do now but would like to do again

Are you taking part in any research studies? YES NO

Would you like to find out more about research? YES NO

If there were a stroke service development group, YES NO would you be interested in attending or helping?

Would be interested in doing volunteer work with YES NO stroke patients on the wards or in the community?

I completed the form [tick what applies to you]

On my own

With some help from a relative, friend or carer

A relative, friend or carer completed the form for me

The information on this questionnaire may be used for research and audit purposes after your name has been removed. If you do not want your anonymised data to be used in research and audit please tick the boxes below.

I am happy for the data to be used for research and audit I do not want the this questionnaire be used for research I do not want this questionnaire be used for audit.

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Annual Warfarin Review

Name: Date:

Indications for warfarin Target INR:

Intended duration of treatment

Other diagnoses/ problems

Current medications

Knowledge of warfarin Any potential contraindications for warfarin?

Indications: Y N Bleeding Y NSide effects: Y N Unstable INRs Y NTarget INR : Y N Unstable comorbidity Y NDuration of treatment:Y N Falls Y NDrug interactions: Y N OtherFood interactions: Y N

If prescribed for AF/ paroxysmal AF is there still evidence of persistent AF? ECG Y / no(do annual ECG to confirm) Pulse y / no

History y/ noIf not in AF now, when was the last documented episode? _________

Yellow warfarin booklet complete? Y NCan the patient be transferred to an outreach clinic? Y NHas the patient been offered the opportunity Y N no studies not appropriate to take part in research?

Comments. actions and next appointment:

93

Stroke ChecklistName____________________ Age_______ Date of stroke____________ Unit No________________= yes o = noStroke symptoms R/L Hemiparesis Hemianopia Viaual/tactile inattention Dysphasia (language problem) Dysarthria (can' t produce sounds) Cerebellar symptoms Brain stem symptoms Hemisensory loss Swallowing problems Incontinence Other

CT head result

Non-specific changes New infarct Old infarct(s) Hemorrhage Other Not done

Final Diagnosis Cerebral infarct Intracerebral haemorrhage Other

OCSP Stroke Classification

Total ant. circulation syndrome Partial ant. circulation syndrome Lacunar syndrome Posterior circulation syndrome

Scandinavian Stroke Scale Score [Range: Normal (58)- Most severe (0)]

On admissionOn transferOn discharge

HADS score

Date Score A DCognition (MMTS/AMTS) Date ScoreDate Score

Other diagnoses and relevant information1 _____________________________ 4______________________________ 7 _______________________________

2 ______________________________ 5 ______________________________ 8 ______________________________

3_______________________________ 6 ______________________________ 9 ______________________________

NO YES Risk factors Target Secondary preventionHypertension BP on dischargeCholesterol DMSmoker>28u alcohol/weekAF -Heart Murmur - Echo :Oestrogen TxLack of exercise Other risks (specify)

NO Yes Antithrombotics/anticoagulantsAspirin/Dypyridamole/ClopidogrelWarfarin Indication: Target INR Duration of treatmentAvoid antithrombotics and anticoagulants

NO Yes Carotid surgery Dates/details/action or reason why action inappropriate Carotid doppler Doppler resultSurgical referral

Admission tests (mark N for normal)FBC INR U&E ______GLUCOSE _____LFTs ESR ECG ____________ CXR __________

Follow up

Comments (information to include in the discharge summary)

Outstanding Results

94

The stroke clinic

Clinic EnvironmentDisplay copies of stroke matters and stroke association info leaflets in the clinic area for patients to peruse while they are waiting. Make sure the information cards with the www.stroke-in-stoke.info website details are on display and the information leaflet folders are available and stocked.

New patientsAll new patients should be seen or discussed with the consultant on the first or second visit.Blood pressure should be measured while they are waiting.

6 week follow-upGo through 6 week follow-up questionnaire and address points where the patient may need help. Review stroke discharge check-list and chase missing results. Complete the Stroke clinic follow-up proforma. Tidy up secondary prevention. Do not attempt to control blood pressure or lipids in the clinic but refer to GP with precise instructions. Has the patient returned to their normal social activities (hobbies, driving, sex). Do they need help, advice, encouragement?

Check whether warfarin booklet is filled in appropriately (esp Dx, duration of RX and target INR.Check whether the patient is on antidepressants and give clear guidelines as to when they should be reviewed or discontinued.

Check whether patient has cognitive or emotional issues and document outcome. All patients with cognitive/ emotional problems must be referred for assessment and management to a psychologist (or other experienced person), unless the patient declines. This must be documented (will be audited).

Hand over risk factor management, 6 month follow-up, and any investigations required to the GP.

6 month follow-up (by a community specialist stroke team if available, otherwise on clinic or in primary care)Go through follow-up form and questionnaire and address points where the patient may need help. If followed in clinic check that GP is now managing secondary prevention and document this in the letter. Check if psychological needs identified at 6 weeks have been addressed.Check that the patients has been seen by appropriate specialist if referrals have been made at last visit. Address life after stroke needs identified in questionnaire.Document Rankin, HADS, Blood pressure, weight, ECG result, and MMTS.

This is the discharge visit. Make sure that secondary prevention has been taken over by GP, that all problems identified have been addressed, and that the patient knows what to do if future problems arise.

Advise to contact GP or consultant/secretary if any problems in future.

Advise GP of discharge of patient and give him instructions for follow up e.g. regular, but at 6 mo, 12 mo and then annual reviews of Medication / Risk factor management /Mood /Stroke complications /Need for specialist reassessment of rehabilitation/ treatment needs.

95

Young Strokes

Patients who have had a stoke when younger then 45 should be followed in the young stroke clinic (contact Dr Roffe’s secretary for dates). Information about Different Strokes and Strokes R Us should be on display.

Repeat clinic attendersRepeat attendances should be kept to an absolute minimum. The ward clerk should check whether the patient needs x-rays, bloods or results prior to seeing the doctor. This should be specified in the last clinic entry.

Blood tests, x-rays etcPlease list outstanding tests at the end of the letter. The secretary will include the results in the typed letter and you can check them as you review the letter. If you dictate the letter when the results are already available, include them in the letter, and just list the outstanding results that need to be chased in the letter.

TapesInclude a list containing the following with each tape and the notes

1. Clinic day and name of doctor2. Number on tape3. Patient name4. Unit no5. Bloods and tests requested6. Referrals to7. Follow-up yes/no when? 8. Copy all clinic letter to patients unless they indicate the do not wish a copy. 9. For nursing home patients also make a copy for the matron of the home and family

For patients followed within 1 month alert the secretary to type the letter as a priority.

96

INR patients

INR patients (CROF3) will usually be seen in the waiting area. They only attend for warfarin prescription. If they have other unrelated medical problems those should be referred to the GP or a formal clinic appointment should be made. This is to avoid delaying the rest of the clinic patients. If you have ample time it will be at your discretion to treat other conditions.

If the patient is new to you always check booklet, and whether the patient knows basics of warfarin complications and instructions before prescribing.

Check that booklet complete (page 1) at each visit.Check that the patient has had no serious health problems or bleeding since the last visit. If INR stable prescribe next dose and follow up. Use the INR follow-up stickers provided by Springfield Unit staff to document INR, follow-up and the new dose recommended.

All INR patients should have annual follow up in the stroke Clinic to formally review indications and complications (use annual warfarin review proforma to document the outcome). Check need for annual review at each visit. Patients referred to the outreach clinic will need a letter to the GP to check who will do the annual follow up (ask Jean Leverett for a standard letter proforma).

If INR unstable establish cause, if possible.

Any patient who has his/her own transport or can be taken to clinic should be discharged to the outreach clinics as soon as stable. Patients who are immobile should be referred to the GP/District nurse. Patients who cannot be followed up by either will continue follow –up in the Springfield unit.

97

Examination tray for stroke clinic1. Ophtalmoscope2. Auriscope3. Patella hammer (with plastic handle)4. Two large test tubes (eg outer container for high risk specimens)5. Cotton wool buds6. Orange sticks7. Spatulas8. Torch9. Tuning fork10. Scent bottles11. Red hat pin12. Objects: key, pen, coin

98

Stroke clinic preparation

1. Send clinic questionnaire and blood test forms (FBC, U&E, LFTs and fasting glucose and cholesterol) with the appointment letter.

2. Print out special reports CVA1 and CVA2 as well as recent Doppler results

3. Include pre clinic blood results with notes

Stroke clinic letters

Include all results available within 1 week in letters, make a note of results outstanding at the end of the letter.

Copy to patients when requested.

Copy letters to day hospital staff for patients attending the DH.

Stroke clinic questionnaires

Make sure each questionnaire is labeled with name, date and Unit No.

Copy the questionnaire. Keep one copy in the notes and file one in the office for audit purposes.

99

iv North Staffs Combined Healthcare NHS Trust Elderly Care Dysphagia Management Guideline: Acute Stroke Unit. R Wells, Draft 3; Mar 2002. Needs to be revised and updated to refer to the care pathway.v The Intercollegiate Stroke Working Party. National ClinicalGuidelines for Stroke. Royal College of Physicians, London, 2004 p 49.vi Cholesterol and risk of stroke: There is no strong evidence of any independent association between serum cholesterol and risk of stroke (Prospective Studies Collaboration. Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 450,000 people in 45 prospective cohorts. Lancet 1995; 346: 1647-53). Despite this, an overview of cholesterol lowering with statin drugs found that treatment with statins reduces risk of stroke (Hebert PR, Gaziano JM, Chan KS, Hennekens CH. Cholesterol lowering with statin drugs, risk of stroke, and total mortality. JAMA 1997; 278: 313-21. There are possible explanations for this apparent contradiction. Firstly, there is some evidence that low cholesterol is associated with increased risk of haemorrhagic stroke ( Iso H, Jacobs DR Jr, Wentworth D et al for the MRFIT Research Group. Serum cholesterol levels and six year mortality from stroke in 350,977 men screened for the Multiple Risk Factor Intervention Trial. N Engl J Med 1989;320: 904-10) , so it may be that this masks a positive association between serum cholesterol and risk of ischaemic stroke. Secondly, it may be that statins lower stroke risk indirectly by lowering risk of myocardial infarction, which is an established risk factor for stroke. Thirdly, it may be that statins do not reduce stroke risk by lowering cholesterol, but by some other mechanism. The evidence for cholesterol lowering to prevent stroke is strongest for patients with existing coronary heart disease, so in the context of the epidemiology of risk factors for stroke, serum cholesterol is of most relevance in this sub-group of patients. [ text form Mant, Wade and Winner. Health care assessment. http://hcna.radcliffe-oxford.com/strframe.htm]viiCollins R, Armitage J, Parish S, Sleight P, Peto R; Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet. 2004 Mar 6;363(9411):757-67. Simvastatin 40 mg/ d.. Also provides evidence of effectiveness in patients with preexisting cerebrovasc disease (e.g non disabling stokes or TIAs), and with normal cholesterol. In patients with preexising cerebrovasc dis it reduced cardiovascular events and revascularisatuions but not strokes. In patients with other vascular evernts or diabetes as risk factor it reduced strokes by 1/3. The effect starts rapidly. Reduction of stroke not significant during the first year, but was already significant in the second year. No increase in ICH in treated group. Reference also contains metanalysis of previous trials of statins for stroke prevention.viii UHNS Hyperlipidaemia Guidelines 2004 Dr Neary and Angela Davis Medicines Management Interface Pharmacist, UHNS 01782 552076, e-mail. Angela.Davis@uhns.nhs.uk

Grey shaded areas have been added by Dr C. Roffe

Notes for stroke patients:

The Intercollegiate Stroke Working Party. National ClinicalGuidelines for Stroke. Royal College of Physicians, London, 2004. ( suggests to treat all patients with a total Chol >3.5 mmol/l. references summarised in table 3.5.4.)

There is still little evidence for patients aged > 80.

There is no evidence for frail patients with disabling strokes (they have been excluded from all trials).

Statins prevent stroke risk by about 1/3 in patients with a history of IHD.

100

ix ? O'Rourke S, MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after stroke: comparison of the GHQ and the HAD Scale. Stroke. 1998;29:980-5.x Sutcliffe LM, Lincoln N. The assessment of depression in aphasic stroke patients: the development of the Stroke Aphasic Depression Questionnaire. Clinical Rehabilitaiton 1998;12:506-513.xi Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–370.xii O'Rourke S, MacHale S, Signorini D, Dennis M. Detecting psychiatric morbidity after stroke: comparison of the GHQ and the HAD Scale. Stroke. 1998;29:980-5.