Where should a patient with suspected stroke or TIA be treated?

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Definition of Stroke and Transient Ischaemic Attack (TIA)

  • A stroke is a sudden focal neurological deficit of presumed vascular origin which lasts for more than 1 hour
  • A Transient Ischaemic Attack is a sudden focal neurological deficit of presumed vascular origin which usually resolves within 20 minutes or less and leaves no signs or symptoms after 1 hour
Decision to stay home
  • For TIA and stroke patients at home refer to the Neurovascular Clinic for an URGENT appointment
  • CT scanning, Carotid Dopplers and other investigations will be carried out at the clinic
  • Consider referral to Rehab locally or Community Rehab Teams
  • All patients should be referred to the Stroke Coordinator for advice and support
  • Secondary Prevention should be commenced

Typically, a patient can be looked after at home if:

  1. They have had a definite TIA (i.e usually recovered within a few minutes, and fully recovered within 1 hr; OR
  2. Reasonable certainty regarding diagnosis of stroke, AND
  3. Swallowing is not impaired (Refer to Protocol for Management of Dysphagia); AND
  4. No significant disability affecting functioning in the home; AND
  5. Patient is in an environment with appropriate support (social, physical and emotional); AND
  6. Required rehabilitation (staff and facilities) and support is available; OR
  7. Death is anticipated and the family has a strong desire for care to be given at home.
  8. Referral to the neurovascular clinic should be completed

Note: If the patient is a carer, refer the dependent spouse/partner to Social Work for appropriate care

Decision to admit to hospital
  • All patients considered as suitable for Stroke Thrombolysis
  • Impaired swallowing
  • Measurable deficits / progressive deficits
  • Patients on anticoagulants
  • Require nursing, support or rehabilitation that is NOT available in the community

Admit to Belford, Caithness, Lorn and District or Raigmore if:

  • Uncertainty re diagnosis
  • Patient unstable or progressing
  • Suspected subarachnoid haemorrhage or cerebellar stroke
  • Impaired swallowing and Dysphagia Assessment and support is not available
  • Complicating conditions e.g. Hypertension, Anticoagulant use etc
  • ALL patients should be admitted to a Stroke Unit / designated stroke bed

Admit to Community hospital if:

  • Clinical diagnosis secure
  • Admission to stroke unit unavailable and patient aware of options
  • Patient stable but requiring nursing / medical support
  • Impaired swallowing but Dysphagia Assessment and support is available
  • Patients have access to appropriate rehabilitation (staff and facilities)
Rehabilitation and Support

Multidisciplinary rehabilitation and support for TIA and stroke in hospital, day hospital or home
Assessment may identify further rehabilitation / support needs or admission to hospital

Typically, this should include:

  1. Multi-disciplinary assessment and use of recommended Tool and Outcome Measure [FIM/FAM]. Refer to protocol for AHP Services
  2. Multi-Disciplinary rehab and patient orientated goal setting (short and long term)
  3. Pro-active and early involvement of carers and family (with appropriate approval)
  4. Patient will be discharged from rehabilitation when goals have been met or there ceases to be any benefit from active rehab
  5. Referral to all appropriate Services using agreed documentation and procedures including the Neurovascular Clinic
  6. Secondary prevention measures and life style advice should be provided

Provision of information support pack

Suitability for Secondary Prevention

Is TIA or stroke patient suitable for Secondary Prevention?

  • Immediate CT scan within 12 hours
  • Start aspirin 300mg for Stroke or 75mg for TIA immediately unless contraindication see secondary prevention protocol

Assessment for Secondary Prevention

  • Assess the need for antiplatelets or anticoagulants, hypertension control, ACE inhibitor, statin, thiazide, warfarin as laid out in the Secondary Prevention Protocol

Typically suitable where a confident clinical diagnosis of stroke has been made or after recommendation at the Neurovascular Clinic

  1. A further vascular event would have important clinical consequences; AND
  2. If appropriate, patients could tolerate, or co-operate with, antiplatelet or anticoagulant and other drug treatment; OR
  3. In the case of carotid duplex scanning and consideration for carotid endarterectomy, has suffered a carotid distribution stroke with good recovery and was otherwise fit for surgery
  4. Refer to Protocol for Secondary Prevention

Notes:

  • There is no upper age limit for Secondary Prevention, although age will influence assessment for carotid surgery;
  • Stroke is a Clinical Diagnosis - Only 50-60% will have an appropriate lesion visible on CT
Refer for CT Scanning
  • Patients with a true TIA do not routinely require a CT Scan.
  • For patients within the 4.5 hr Thrombolysis window urgent and immediate CT should be requested.
  • For patients with a clinical diagnosis of stroke, a CT scan should ideally be carried out within 12 hours.
  • To refer a patient contact the relevant radiology department and request an urgent CT for stroke / suspected stroke.
  • For acute stroke patients in the community CT scanning can be accessed via the Neurovascular Clinic or by faxing in a CT request.
  • For further information contact 01463 704000; Ext 4295; Bleep 5047.
Transfer of care

Transfer of care out of hospital to home or residential / nursing home

  • Refer to Highland's Social Care Admission and Discharge Protocol
  • Refer tp the Stroke Unit Admission and Discharge Protocol

Timely planning of discharge should be carried out in consultation with patients and carers.  It should be carried out in accordance with NHS Highland’s Joint Health and Social care Admission and Discharge Protocols.  Appropriate information should be provided to patients and carers including relevant contact details, including nearest CHSS Stroke Nurse/Coordinator.

Typically, discharge will be appropriate when:

    • Patient is medically stable and has an appropriate place to be transferred to
    • Community Hospitals should be notified of potential transfers at the earliest opportunity
    • AHPs have completed assessment of Home circumstances (if appropriate) and Premorbid function and activities
    • Appropriate physical, psychological and social support is in place
    • 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 support

Primary care team to consider appropriate follow-up assessment

Patients treated in the stroke unit will be followed up at the medical clinic 3 months post discharge.
Ideally, a further assessment should be performed by a member of the Primary Health Care Team 3 to 6 months after stroke (if at home) or discharged (if at hospital) to monitor: Level of impairment  post-stroke/discharge; Potential for further rehabilitation; Patient and Carer  adjustment and Concordance with secondary prevention measures.  Appropriate advice should be sought and provided from specialist staff/services including specialist stroke nurses.

Editorial Information

Last reviewed: 31 January 2019

Next review: 31 January 2020

Author(s): Stroke Clinical Network

Version: 2.2

Approved By: TAM subgroup of the ADTC

Reviewer Name(s): Stroke Co-ordinator