Admission & discharge from the Stroke Unit

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This pathway and protocol is intended to guide Admission to and Discharge from the Stroke Unit. 
The aim of the Stroke Unit is to maximize the physical, functional, psychological and social recovery from a stroke with the goal of reducing disability and dependence after stroke
All patients with a suspected Stroke/TIA should be referred to the Stroke Team on Ext: 4451 or Stroke Coordinator on Ext: 4086

Admission to Raigmore Hospital, A&E, GA
  • All patients with a new onset of Stroke/TIA should be notified to the Stroke Unit Team for review
  • All patients presenting with clinically suspected new stroke within 4 and a half hours of onset should be considered for Thrombolysis (Refer to Thrombolysis Protocol)
  • CT scanning to be performed on the day of admission/within 12 hrs
  • Transfer to the Stroke Unit MUST occur within 24 hrs with the exceptions of those who have had thrombolysis who will remain in MSCU for the first 24 hrs.
Stroke Unit (Ward 2A, 22 beds)
  • All patients who have a new clinical diagnosis of Stroke/TIA will be admitted to the Unit
  • Discharge planning will commence on admission with Estimated Dates of Discharge being set as appropriate
Stroke care - other wards

All patients MUST be notified to the Stroke Unit Team

  • Advice, support and information on stroke can be accessed via the Stroke Coordinator or the Stroke Unit Team
Transfer of care
  • Referrals will be made to Hospital or Community based Services (including Social Services, Community Rehabilitation Team, Community Allied Health Professionals, CHSS Stroke Nurse, Day Hospital, Voluntary services) when appropriate and by mutual agreement
  • Where the discharge from the hospital is complex an Individual Future Care Meeting will be called
  • All transfers to Community Hospitals must be mutually agreed in advance with appropriate notes, discharge letter and medication accompanying the patient
  • Advice support and information on the individual patient can be obtained from the Stroke Unit Team
  • Shadowing opportunities and/or a practical management hand-over can be arranged by mutual agreement with the Stroke Unit if the patient has many complex needs
  • Carers will be encouraged and supported to work with the stroke patient prior to discharge from the hospital
Follow up support and assessment
  • Patients will be reviewed by the stroke service within 3 months of discharge
  • Patients discharged to home will be followed up by the Stroke Coordinator for the following 12 months
  • Patients requiring ongoing support will be followed up by their relevant GP, Primary Care Team or Community Rehabilitation Team
  • Patients discharged to Care Homes will have a 6 week review completed by a Social Worker. Further follow up will be provided by the Stroke Coordinator
Notification to the stroke team

The priorities for admission are:

  • Diagnosis of Ischaemic or Haemorrhagic stroke
  • Diagnosis of TIA

A Member of Stroke Unit Team will visit GA daily to assess and review patients for the Stroke Unit.

  • Admission to the Unit must occur within 24 hours.
  • In-patients who have a new onset of Stroke/ TIA should assessed by a member of the Stroke Team.
CT scanning

A clinical diagnosis of stroke must be made prior to referral for CT

  • A CT scan MUST  be carried out on day of admission/ within 12 hours 
  • Notify CT Scanning to arrange a scan on Ext: 4304
  • CT slots are available every morning
  • Stroke is a clinical diagnosis - Only 50-60% will have an appropriate lesion visible on CT
Rehabilitation and assessment and discharge planning
  • Assessment and rehabilitation plans will be set with the patient and / or their family
  • Dates of discharge will be discussed at the Multi-Disciplinary Team Meeting and will be when:
    • Agreed goals have been met
    • When active rehab ceases to be of benefit
    • When input is refused / lack of compliance

   And / 0r

  1. Patient is transferred to a Community Hospital to meet remaining rehab goals
  2. Where needs are ongoing and transfer to a Care Home is required

Complex Discharges

  • Individual Future Planning Meetings should be held if there are many needs and issues to be met
Advice and Support
  • A clinic for patients and relatives is held on Wednesday afternoons by the Medical Team to discuss Stoke Unit patient’s progress. For patients in other wards the appropriate Medical Team should be contacted.
  • Verbal & written information is available from the Stroke Coordinator or any member of the Stroke Team.
  • A copy of the discharge letter will be given to all patients discharged from the Unit
  • The CHSS Stroke Nurse and the Stroke Coordinator will advise and support patients and families after discharge from hospital
  • The CHSS Advice Line operates Mon-Fri, 9.30-4.00, on 0808 8010899
  • Patients and carers will be encouraged to take self manage their stroke condition with the support of the stroke team follow-up services

Further information can be found at:

Transfer of care

Timely planning of discharge should be carried out in consultation with patients and carers. Appropriate information should be provided to patients and carers including relevant contact details, including information on the CHSS Stroke Nurse Service
Typically, discharge will be appropriate when:

  • Patient is medically stable and has an appropriate place to be transferred to
  • Allied Health Professionals have completed an assessment of function and activities
  • Appropriate physical, psychological and social support is in place for the patient and their carers
  • An agreed plan of transfer (including Equipment and Follow Up, Rehab / Support) is in place between the Hospital Team, and Patient and Carers, Primary Health Care Team, Social Services
Follow up services and support
  • CHSS information packs will be given to all patients when visited at home by the Stroke Nurse
  • Information on statutory benefits should be given with referral to their local Citizens Advice Bureau, Welfare Rights Office or the Benefits Promotion Team
  • Information and advice on returning to Driving will also be given where appropriate
  • Information on local stroke clubs which offer social support, activities and companionship should be offered
  • For patients transferred to Care Homes a review of care will be completed after 6 weeks by their social worker
  • A stroke nurse follow up service will be available for all patients transferred to Care Homes
Editorial Information

Last reviewed: 30 April 2017

Next review: 31 March 2020

Author(s): Stroke Clinical Network

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Stroke Co-ordinator