Framework for the management of acute stroke 2016rwv.grampianshealth.org.au/images/document-library/doc_download/fwk_g... · Framework for the management of acute stroke 2016: Grampians

Department of Health

Framework for the management of acute stroke 2016

Grampians Region

A guide for clinicians in health services

Framework for the management of acute stroke 2016: Grampians Region August 2016 Page 1

Acknowledgements

The review of the Framework for the management of acute stroke 2013, Grampians Region has been developed by a working group (see appendix 1) made up of representatives from health services throughout the Grampians Region, Ambulance Victoria combined with the expert resources of the Victorian Stroke Clinical Network. Consultation also occurred with Divisions of General Practice, Neurologists and other specialist medical practitioners. The Grampians Region would like to gratefully acknowledge the time and effort of those involved in the formulation and refinement of this Framework Note: This framework aims to maintain currency in best practice. If it is identified that any areas require amendment please inform the contact below.

Contact and further copies of Framework

If you require further copies or information contact: Pat Standen Grampians Regional Emergency & Critical Care Coordinator Department of Health and Human Services PO Box 712, Ballarat 3350 Phone – (03) 5333 6026 Email – [email protected] http://grhc.org.au/emergency-care/resources

History of Document and Review Amendment

Version Date Comments

1.0 May 2012 Initial version 1

2.0 May 2013 Section 2 removed and other areas updated

3.0 August 2016 Update NSF National acute stroke services framework 2015,

update data, add ACSQHS Acute stroke clinical care

standard 2015 and Endovascular clot retrieval for acute

stroke: Statewide service protocol for Victoria

http://grhc.org.au/emergency-care/resources


Contents Page

Introduction 3

Demographics 4

Pre hospital – Ambulance Victoria 6

Stroke units and regional capacity 9

Triage and acute care 11

Victorian Stroke Telemedicine 12

Interhospital transfer 12

Thrombolytic therapy 13

Endovascular Clot Retrieval 14

Follow up/discharge 15

Rehabilitation 15

Repatriation back to local service 16

Evaluation of framework 16

Appendices

Appendix 1 - Framework working group members 18

Appendix 2 - Ambulance Victoria Clinical Practice Guideline: Suspected stroke or TIA 19

Appendix 3 - Acute Stroke Framework 2015, Recommended stroke units 21

Appendix 4 - Australasian Triage Scale 22

Appendix 5 - Recognition of Stroke in the Emergency Department Room (ROSIER) 23

Appendix 6 - Emergency Department check list 24

Appendix 7 – Brain imaging for suspected stroke 25

Appendix 8 –Statewide ECR flow pathway 26

Appendix 9 – ABCD2 Tool 27

Abbreviations & Acronyms 28

References 29

Attachment

Grampians Region: Acute stroke interhospital transfer guideline

Maps and Tables

Map 1 – Grampians Region Health Services 5

Map 2 – Ambulance Victoria regional crewing capacity 6

Map 3 – Suspected stroke travel time 7

Table 1 – Grampians Region acute stroke capacity 10

Table 2 – Guidelines for endovascular clot retrieval eligability 14


Introduction

In Australia, stroke is the second leading cause of death and a major cause of disability. The framework for the management of acute stroke 2016 Grampians Region (Framework) is designed to assist both managers and clinicians in the care of the acute stroke patient. Provision of optimal stroke care is a challenge across the Grampians Region (Region), as it is across the whole of Australia. One of the most effective ways of reducing death and disability following an acute stroke is through the provision of evidence based, dedicated hospital services.

1

In Australia there are almost 30,000 acute stroke patients admitted to participating hospitals in the National Stroke Audit 2015

2. Of these, the Region admits approximately 451. The number of

presentations of stroke is expected to rise with the aging population. As the numbers rise, the impact on individuals, families and the workforce is also expected to increase. In 2009, the majority (70%) of people who had a stroke were aged 65 and over. In the Region in 2009, the Wimmera had the highest proportion (19.9%) of population aged 65 years and over. Among Victoria's Local Government Areas (LGAs) the second highest proportion of people aged 65 years and over was Hindmarsh (24.9%) followed by Yarriambiack (24.4%). In 2010, stroke was the underlying cause of just over 8,300 deaths in Australia—on average, 23 people died from stroke every day. The good news is that the death rate has fallen by around 70% since 1979. However, although the average rate of decline in stroke death rates has accelerated for people aged 55 and over, it has slowed for those aged 35–54

3.

The National Stroke Foundation published Clinical Guidelines for Stroke Management 2010 which made a number of evidence based recommendations including

4

Hyper acute care o that local protocols be developed to ensure health services receive early pre hospital

notification of suspected stroke patients, that there is a high priority for transfer and triage and that there is rapid referral from emergency department staff to imaging and stroke specialists

Hospital care o that all people with acute stroke should be admitted to a health service with a stroke

unit and be treated by a multidisciplinary team o smaller health services need to consider stroke services that adhere as closely as

possible to the criteria for stroke units o if people with suspected stroke present to a non-stroke unit health service there should

be transfer protocols in place to guide timely transfer o telehealth usage should be considered to enable early access to specialist physician(s).

It is in response to these recommendations that the original Framework was developed in 2012.

Objectives

The Framework objectives are to

Guide appropriate access to specialist stroke services

Improve the quality of care delivered to adults who have a stroke in the Region

Provide a structure for the Region to manage stroke presentations in a timely and appropriate way

Direct appropriate delivery destination for the acute stroke patient.

Move the Region towards a consistent approach to acute stroke care in Victoria

To link the Framework with the Australian Commission on Safety and Quality in Health Care (ACSQHC) Acute Stroke Clinical Care Standard 2015

5.

In line with the Victorian Health Priorities Framework 2012 - 2022 https://www2.health.vic.gov.au/about/publications/policiesandguidelines/vic-health-priorities-framework-2012-22-rural-plan the Framework will continue to define and improve patient care pathways to central specialist services and promote greater local service self-sufficiency where appropriate. It is anticipated that this Framework

https://www2.health.vic.gov.au/about/publications/policiesandguidelines/vic-health-priorities-framework-2012-22-rural-plan


will also contribute to clinically appropriate and cost effective care using evidence based decision making principles.

Scope

The scope of the Framework covers

The rapid recognition of symptoms and diagnosis of stroke and stroke mimics

Hyper acute & acute management of stroke

Indications & pathways for early transport/transfer of suspected acute stroke patients to an appropriate service

Initial and early pharmacotherapy including thrombolysis

Management and maintenance of homeostasis (including fluids, nutrition and oxygen therapy).

The Framework relates to the aspects of management that are specific to acute stroke; and does not specifically cover areas of routine good clinical practice.

The Framework should be used in conjunction with the Clinical Guidelines for Stroke Management, the National Acute Stroke Services Framework 2015, the Endovascular clot retrieval for acute stroke: Statewide service protocol for Victoria and local policies and procedures.

Demographics

The population in the Region in 2012 was 223,848 and this is expected to rise to 261,679 by 2021. Population growth in the Region is projected to be lower than the Victorian average between 2011 and 2021, however there is a large variation between LGAs, with the highest projected growth in Moorabool (27.7%) and population decline in Hindmarsh (-0.7%).

6

The Region has lower than average percentages of residents aged 15 to 44 years, and higher than average percentages in other age groups. This trend is projected to continue to 2021, although the percentage aged 0 to 14 will decline slightly, and the percentage aged 65 plus will increase from 15.1% to 20.6%.

6

Dependency ratios for 2011 are higher than the Victorian average in all Grampians LGAs and are particularly high in Yarriambiack and Hindmarsh. This pattern will continue in 2021, with even higher dependency ratios. Higher dependency ratios mean fewer people of working age.

6

The percentage of Aboriginal and Torres Strait Islanders in Region (1.14%) is higher than the Victorian average (0.74%), with the highest rate in Horsham (1.51%) at nearly twice the state average.

6

At 30 June 2009, 12.6% of the population in Melbourne were aged 65 years and over compared to 16.2% of the population in the balance of Victoria. Over the five years since 30 June 2004, the proportion of population aged 65 years and over in Melbourne increased by 0.2 percentage points compared to 1.0 percentage point in Victoria, an indication that the population of the balance of Victoria is ageing faster.

Grampians Region

The Grampians region is part of the Department of Health and Human Services rural West Division, and covers the area from Bacchus Marsh in the east to the South Australian border in the west, and from Patchewollock in the north to Lake Bolac in the south. The Region covers an area of 48,112 square kilometres of geographically, economically and culturally diverse sections. There are two major public health services located in the Region, Ballarat Health Services (BHS) and Wimmera Health Care Group (WHCG). Both of these health services have an emergency department with specialist nursing and medical staff available at all times to triage, assess, investigate and provide first line treatment for all categories of emergency and critical care presentations. Both BHS and WHCG are participating sites in the Victorian Stroke Telemedicine program.


The other health service sites within the region have an emergency area or room (Urgent Care Centre UCC). These UCCs do not have dedicated nursing or medical staff. They offer triage and treatment by a registered nurse and/or GP. Across the Region the availability of medical practitioners will vary from time to time due to leave requirements and changes in employment. Within the health services, registered nurses will provide the first responder function to undertake triage, assessment and first line management in consultation with the most appropriate medical practitioner at the time. Map 1 – Grampians Region Health Services

Note - Stawell District Health is now Stawell Regional Health

0

41 km

43 km

Kaniva

Goroke

Edenhope(EDH)

89 km

Harrow

30 km

kilometres

25

Nhill(WWHS)

Rainbow

Jeparit

50

39 km

26 km

34 km

Dimboola

Natimuk

Beulah

Hopetoun

30 km

25 km

60 km

(DmHS)Rupanyip

Minyip

Warracknabeal(RNH)

Willaura50 km

Lake Bolac

Ararat(EGHS)

33 kmStawell(SRH)

33 km

49 km

Woomelang

Birchip

Donald

57 km

53 km

62 km

Charlton42 km

Wycheproof

31 km

44 km

Elmhurst

48 km

Skipton(B&SHS)

64 km

Horsham(WHCG)

Murtoa

Creswick

Beaufort(B&SHS)

Avoca

Hospital Campuses

Grampians Region (and associated) Hospital Networks

Melton

63 km (to Avoca)

43 km

St Arnaud(EWHS)

67 kms(to Ballarat)

52 km

(SJOG)

48 km

Maryborough(MDHS)

Clunes

Ballarat(BHS)

45kmDaylesford

(HHS)

Ballan

Trentham

Bacchus Marsh(DjHS)

59 km

DmHS - Dunmunkle Health ServiceRupanyup, Minyip, Murtoa

WHCG - Wimmera Health Care GroupHorsham, Dimboola

Bush Nursing Centres (Harrow, Elmhurst, Lake Bolac, Woomelang)

EDH - Edenhope District Hospital

SDH - Stawell District Hospital

WWHS - West Wimmera Health ServiceNhill, Jeparit, Kavina, Rainbow, Goroke, Natimuk,Cooinda Disability Service Nhill

RNH - Rural Northwest Health Warracknabeal, Hopetoun, Beulah

Ballan District Health & Care (Private)

B&SHS - Beaufort & Skipton Health ServiceBeaufort, Skipton

EGHS - East Grampians Health ServiceArarat, Willaura

BHS - Ballarat Health ServicesBallarat, QEGCHHS - Hepburn Health ServiceDaylesford, Creswick, Clunes, Trentham

DjHS - Djerriwarrh Health ServiceBacchus Marsh, Melton

EWHS - East Wimmera Health ServiceSt. Arnaud, Donald, Birchip, Wycheproof, Charlton

105 km Ballarat to Western General Hospital98 km Ballarat to Sunshine Hospital

Maryborough District Health Services campuses atMaryborough, Avoca


Pre hospital care – Ambulance Victoria In the hyperacute phase of stroke care Ambulance Victoria (AV) has a central coordinating role which not only prioritises the triage of these patients but also aims to get the patient to the most appropriate level of stroke care in an appropriate time frame. This may involve bypassing smaller health services in order to access the higher level stroke care services. There are a number of levels within AV operational staff. Those that have direct clinical responsibility for the care and transport of stroke patients include -

Advanced Life Support (ALS) paramedic unit consisting of a 2 person ALS crew or ALS with an Ambulance Community Officer (ACO). ALS units have capacity to transport in a stretcher vehicle, cardiac monitor in 3 leads, insert a laryngeal mask airway and administer Midazolam for seizures.

Mobile Intensive Care Ambulance (MICA) unit consisting of two MICA paramedics with the capacity to transport in an intensive care equipped stretcher ambulance vehicle. In addition to the ALS paramedic skills the MICA paramedic is able to undertake advanced airway management including intubation.

A MICA Single Responder Unit (SRU) consists of one MICA paramedic in an intensive care equipped sedan requiring ALS paramedic stretcher unit to transport.

Other AV operational crews include -

Ambulance Community Officers (ACOs) are employed on a casual basis to provide advanced first aid in more remote rural communities either in support of ALS paramedics or at stand-alone ACO teams. ACOs will respond in a stretcher vehicle.

Community Emergency Response Teams (CERTs) consist of ambulance volunteers who function as ‘first responders’ within communities where the nearest ambulance station is at a distance. CERT respond in a sedan.

Both the ACO and CERT have advanced first aid capacity and can identify stroke symptoms. Map 2 - Ambulance Victoria Grampians Regional Crewing Capacity


AV operational staff operate under clinical practice guidelines authorised by the AV Medical Standards Committee. The Melbourne Ambulance Stroke Score (MASS) is the tool used by AV paramedics to assess for stroke signs and symptoms including facial droop, speech, handgrip and blood glucose. Refer to AV clinical practice guideline, Stroke/Transient Ischaemic Attack (TIA) appendix 2. (Acute stroke clinical care standard Quality statement 1

5)

The AV Stroke/TIA guideline recommends transporting suspected stroke patients directly to an appropriate specialised health service (with thrombolysis and/or Stroke Care Unit capacity) within a one hour transport time. AV will notify the receiving health service as early as possible of the pending arrival of a stroke patient in order to enable the hospital to prepare for the patient’s arrival and optimise the care delivery on patient presentation in the emergency area. In the Grampians region AV will take suspected stroke patients direct to WHCG or BHS. Map 3 Suspected stroke or transient ischaemic attack patients within 60 minutes travel time by ambulance to a thrombolysis-enabled health service, and within 180 minutes road travel time to a statewide ECR service, 2015. Source Ambulance Victoria

AV can also assist with the organisation of urgent secondary transfer of stroke patients to a centre with a stroke unit, thrombolysis and/or endovascular clot retrieval where appropriate. This may involve the AV clinician, Air Ambulance Victoria (AAV) and/or Adult Retrieval Victoria (ARV). Discussions with the AV clinician should occur as early as possible to ensure appropriate consultation and prompt coordination of resources. To consult with an AV clinician call 1300 113 312. If the patient is time critical, consultation with ARV may also aid in patient care guidance and early transfer. Further information on Ambulance Victoria is available via the website - http://www.ambulance.vic.gov.au/index.html

http://www.ambulance.vic.gov.au/index.html


Endovascular Clot Retrieval (ECR) program

This is a new procedure based on a number of research papers published in 2015 and will be implemented and supported by AV in 2016. With its introduction, the initial AV management will remain unchanged and will include the transport of patients up to 1 hour to a health service that administers thrombolytics for ischaemic stroke, or has stroke unit care (SUC), with pre notification occurring as described previously. The health service will still be required to rapidly assess the patient and arrange transfer where applicable. The mode of transport will be determined by the patient’s condition, distance to the ECR equipped hospital, and could include AV/ARV/AAV resources as necessary.


Stroke units & regional capacity

Stroke unit care is the single most important service for providing evidence based stroke care and is seen as an essential component of acute stroke care. There is evidence that stroke unit care significantly reduces death and disability after stroke compared with conventional care in a general ward.

4 (Acute Stroke Clinical Care Standard, Quality Statement 3

5)

Stroke units have the following minimum criteria

1

Co-located beds within a geographically defined unit

Dedicated, Inter-professional team with members who have a special interest in stroke and/or rehabilitation. The minimum team would consist of medical, nursing and allied health (including occupational therapy, physiotherapy, speech pathology, social work & dietetics)

Inter-professional team meet at least once per week to discuss patient care

Regular programs of staff education and training relating to stroke. (e.g. dedicated stroke inservice program and/or access to annual national or regional stroke conference).

Stroke unit care needs to be consistent, defined and measurable. According to the National Acute

Stroke Services Framework 20151 the definition includes:

a. All people with stroke should be admitted to hospital and be treated in a stroke unit with a multidisciplinary team.

b. All people with stroke should be admitted directly to a stroke unit (preferably within three hours of stroke onset).

c. Smaller hospitals should consider stroke services that adhere as closely as possible to the criteria for stroke unit care. Where possible, patients should receive care on geographically discrete units.

d. If people with suspected stroke present to non-stroke unit hospitals, transfer protocols should be developed and used to guide urgent transfers to the nearest stroke unit hospital.

It is recommended that hospitals that see more than 75 stroke patients per year should have organised stroke unit care. In the Grampians Region BHS and WHCG both have stroke units. See table 1 for details of the Grampians Region acute stroke capacity. In the context of a Regional hub or primary stroke service to support the smaller health services features to consider include

1

Responsibility for regional stroke planning and local stroke network

Extra capacity for specialist clinical support (outreach or via telemedicine)

Extra capacity for educational outreach (including medical, nursing [educator or consultant], allied health and research)

Extra capacity to respond to/accept additional transfers

Dedicated stroke coordinator position to coordinate care between sites

Regional coordination of hyperacute therapy

Use of telemedicine links to comprehensive stroke services The National Stroke Audit Acute Services Report 2015

2 noted that more than a quarter of the smaller

sites (less than 50 stroke admissions per year and no stroke unit) did not have protocols in place to ensure rapid transfer of stroke patients to a larger site. The attachment to this Framework, Grampians region: Acute stroke interhospital transfer guideline can be used by small health services (without a stroke unit) to assist in the rapid transfer of stroke patients to a larger health service.


Table 1 - Grampians Region Acute Stroke Capacity

Grampians Region

Health Services

*Stroke service

category

**Acute stroke presentations

2014/15

CT

access rt-PA

Stroke

Unit

Transfer protocols in

place

Ballarat Health Services

(Stroke telemedicine site)

PSS 279 24/7

+ angio

24/7 Yes Yes

Wimmera Health Care Group –

Horsham


PSS 88 24/7

+ angio

24/7 Yes Yes

Beaufort and Skipton Health

Service

GHS < 10 No No No No

Djerriwarrh Health Service –

Bacchus Marsh

GHS < 10 No No No Yes

East Grampians Health Service

– Ararat

GHS 17 Yes No No Yes

East Wimmera Health Service –

St Arnaud

GHS 11 No No No Yes

Edenhope & District Health

Service


Hepburn Health Service -

Daylesford

GHS < 10 No No No No

Rural Northwest Health –

Warracknabeal


Stawell Regional Health GHS 10 Yes No No Yes

West Wimmera Health Service -

Nhill

GHS 10 Yes No No Yes

St John of God Health Care –

Ballarat (Private)

GHS Not available Yes

+ angio

No No N/A

Neighbouring Regions

Health Services

*Service

category

Acute stroke/TIA

presentations CT access **rt-PA

Stroke

Unit

Transfer

protocols in

place

Bendigo Health Care Group

(Loddon Mallee Region)


PSS 375

2012/13

Yes

+ angio

Yes Yes N/A

Maryborough District Health


GHS 35

2012/13

Yes No No No

Swan Hill District Hospital



GHS 67

2012/13

Yes Yes No N/A

Western District Health Service,

Hamilton (Barwon South West

Region)

PSS 75

2014/15

Yes Yes Yes N/A

University Hospital Geelong

(Barwon South West Region)

PSS 657

2014/15

Yes

+ angio

Yes Yes N/A

*Service category - refer to appendix 3 – National Acute Stroke Services Framework 2015 - Recommended Stroke Services ** Source VAED, WEIS fundable episodes only. Number of separations based on list of acute stroke principle diagnosis as per Stroke care strategy for Victoria (2007) p130 State Government Victoria, Melbourne rt-PA - Intravenous Recombinant Tissue Plasminogen Activator N/A – Not applicable for this Framework CT – Computerised Tomography PSS – Primary stroke service GHS – General hospital service


Triage and acute care

Acute stroke should be treated as a medical emergency. The degree of damage caused by a stroke is dependent on the amount of time the brain tissue is denied blood supply. This ‘time to brain’ concept means that avoiding delays in diagnosis and treatment of stroke is a priority

7. All providers of stroke

care should develop and implement protocols/guidelines for the emergency management of stroke, including rapid transfer, as this will aid in enhancing patient outcomes. The development of triage processes which facilitate fast tracking of patients to brain imaging should be adopted. In view of this, acute strokes should be at least an Australasian Triage Scale (ATS) 2, refer to appendix 4. Health services serviced by GPs off site should have protocols for rapid treatment/transfer commencement. If neurological symptoms have fully resolved on presentation, then this episode should be at least ATS 3. Clinicians also need to take into account co-morbidities and the age (> 65yrs) of the patient when applying the ATS.

8

Rapid assessment and access to computerised tomography (CT) for brain imaging and angiography are essential to achieve timely and appropriate diagnosis and treatment. Initial assessment should include the following,

FAST –

Airway – patency and ability to speak

Breathing – respiratory rate (taken for a full minute). Identify and report hypoxia, SpO2 <95%

administer oxygen

Circulation – heart rate, blood pressure and electrocardiograph. Identify and report hypotension

and arrhythmias

Disability – Glasgow Coma Scale (GCS) and full neurological observations.

Undertake a stroke screen such as:

o Recognition of Stroke in the Emergency Room (ROSIER) refer to appendix 5

Blood glucose level - identify and report hyperglycaemia. Close monitoring of the patient’s blood

glucose level is required for the first 72hrs including prompt treatment of a blood glucose level >

10mmols/L in the first 48 hours (FeSS clinical treatment protocol)

Temperature - identify and report hyperthermia. Monitoring of the patients temperature is required

with prompt treatment of a temperature > 37.4oC in the first 72 hours. (FeSS clinical treatment

protocol)

Swallowing screen - Patients should not be given food, drink or oral medications until screened

which should occur within 24 hours of admission. Screening should be undertaken by a

appropriately educated health professional and if the patient fails the initial screen they should be

referred to a speech pathologist for a full swallowing assessment. (FeSS clinical treatment

protocol)

The FeSS clinical treatment protocols for the management of Fever, Sugar and Swallow have been developed by expert panels and are available for download at http://www.acu.edu.au/about_acu/faculties,_institutes_and_centres/health_sciences/research/quality_in_acute_stroke_care/fess_intervention/intervention

http://www.acu.edu.au/about_acu/faculties,_institutes_and_centres/health_sciences/research/quality_in_acute_stroke_care/fess_intervention/intervention

http://www.acu.edu.au/about_acu/faculties,_institutes_and_centres/health_sciences/research/quality_in_acute_stroke_care/fess_intervention/intervention


Where possible, initial assessment and treatment should be done while accessing CT, arranging transfer to an appropriate level of service or communicating with the Victorian Stroke Telemedicine (VST) program (Acute Stroke Clinical Care Standard, Quality Statement 2

5)

Following the initial clinical assessment, the Grampians region General Hospital Service (GHS) should also determine

Is there a clear time of onset of clinical signs

Is the patient over the age of 18 years

Is there a measurable or clinically significant deficit using the Recognition of Stroke in the Emergency Room (ROSIER) scale – refer to appendix 5

Are there any absolute contraindications to thrombolysis The Emergency Department Stroke and Transient Ischaemic Attack Care Bundle poster (check list) may be of use as a quick reminder in the emergency setting, see appendix 6.

Victorian Stroke Telemedicine

The Victorian Stroke Telemedicine (VST) program is an initiative which enables clinicians to collaborate across organisational boundaries to deliver the best care possible to patients with stroke, irrespective of their location. The VST program is a virtual system which links rural and regional Victorian health services to a network of Melbourne-based neurologists who can provide treatment advice about patients with acute stroke symptoms. The program relies on audio-visual communication between neurologists, patients and participating health services. There is real-time access to brain imaging to facilitate the remote consultations. The service is available 24 hours a day, 7 days a week, 365 days of the year. The objectives of the program are to evaluate the potential benefits of telemedicine for enhancing capability in regional health services, reduce diagnostic delays and improve access to effective acute stroke treatments. In particular, improving access to intravenous thrombolysis and endovascular clot retrieval. The Grampians Region has two participating VST sites, one at Ballarat Health Services and the other at Wimmera Health Care Group

Interhospital Transfer

The National Acute Stroke Services Framework 20151 notes that for services admitting less than 75

stroke patients per year (General hospital service), transfer protocols should be developed and used to guide transfers to the nearest stroke unit hospital (Primary stroke service), for suspected stroke presentations. Consideration of initial consultation should be given via telemedicine where available. Patients arriving by AV from the community will have already been screened and taken to the most appropriate stroke centre. Health services within the Grampians Region with this capacity (Primary stroke service) for acute stroke unit care are BHS and WHCG. Consideration should be given to the urgency and availability of the CT scan to differentiate haemorrhagic or ischaemic cause of stroke and determine an appropriate treatment plan. The endovascular clot retrieval for acute stroke: Statewide service protocol for Victoria

9 provides an outline

for brain imaging for suspected acute stroke, refer to appendix 7. (Acute Stroke Clinical Care Standard, Quality Statement 2

5)

The Grampians Region: Acute stroke inter-hospital transfer guideline, has been developed as an attachment to this Framework. This guideline is available as a template for health services to use in conjunction with local procedures. The interhospital transfer guideline incorporates a flowchart for the


management of the interhospital transfer of suspected acute stroke and is designed for self presenting patients to a GHS stroke service. Potential thrombolysis or endovascular clot retrieval patients Thrombolysis should be administered as early as possible, up to 4.5 hours post stroke onset, in carefully screened patients with acute ischaemic stroke. This group of patients requires emergency transfer to a PSS. (BHS or WHCG) or CSS for endovascular clot retrieval. Stroke Unit Care patient (not eligible for thrombolysis or endovascular clot retrieval) If the patient is not eligible for thrombolysis or endovascular clot retrieval they should be admitted directly to a stroke unit. Patients who receive care in a stroke unit are more likely to survive their stroke, return home and become independent in looking after themselves. This group of patients requires urgent transfer to a PSS (BHS or WHCG).

Thrombolytic therapy

Thrombolytic therapy is one of the most effective hyper acute interventions proven to reduce the combined end point of death and disability for ischaemic stroke

4. Intravenous Recombinant Tissue

Plasminogen Activator (rt-PA) should be given as early as possible, up to 4.5 hours post stroke onset, in carefully screened patients with acute ischaemic stroke. Intravenous rt-PA has been licensed by the Australian Therapeutic Goods Administration for use in acute ischaemic stroke

4. Follow up care in a

stroke unit will also assist in the reduction of morbidity and mortality. Thrombolysis should be undertaken in a health service setting with appropriate infrastructure and network support. This includes a multidisciplinary team trained in acute stroke care, well developed pathways/guidelines/protocols and immediate access to brain imaging, including skilled interpretation of images.

4 In the Grampians Region, BHS and WHCG, are the two regional providers who currently have

the capacity to provide thrombolytic therapy. Both of these health services have protocols and pathways in place for the management of acute stroke. (Acute Stroke Clinical Care Standard, Quality Statement 2

5)

Any pathways/guidelines/protocols developed for the administration of rt-PA should include

inclusion and exclusion criteria as defined by the National Stroke Foundation

how to gain immediate access to CT

consultation process for imaging interpretation

consultation process for specialist advice - neurologist

process for linking with a comprehensive stroke centre for neurology and/or neurosurgery consultation such as the VST progam

access to ICU or high dependency bed

access to stroke unit care To ensure patients have the opportunity to be considered for reperfusion therapy, clinicians should urgently assess and arrange imaging for all patients with suspected stroke. Using clinical judgement and taking into consideration patient comorbidities, patient circumstances and patient preferences, discuss the risks and benefits of treatment options with each patient. Following discussion with the patient, if it is clinically indicated and the patient’s preferred option, offer reperfusion treatment (e.g. intravenous thrombolysis) within the time frames recommended in the Clinical guidelines for stroke management. If a patient has a haemorrhagic stroke, consider time-critical therapies, such as blood pressure control

5

A minimum data set should be set up to monitor and benchmark key outcome measures post thrombolytic therapy. Objective measures include National Institutes Health Stroke Scale (NIHSS), Modified Rankin Scale (both of these scales should be undertaken on presentation to an emergency department and on discharge from hospital), detection of a rise in atrial fibrillation and anticoagulation, evaluation of carotid artery stenosis and time to surgery.


Endovascular Clot Retrieval

In 2016 the Endovascular clot retrieval for acute stroke: Statewide service protocol for Victoria9

was launched which outlines the Victorian approach to endovascular clot retrieval (ECR).

ECR is a highly effective treatment for acute stroke and it requires health service systems to provide a coordinated response to the acute stroke presentation. The challenges are to identify the appropriate patient, organise rapid brain imaging including a CT angiogram (CTA), provide thrombolysis where appropriate, transfer the patient to the nearest ECR centre and, once there, to get the patient to the angiography suite, commence the procedure as soon as possible, and to manage the patient after ECR. Repatriation of the patient to their local stroke service when appropriate is also a key consideration

9. (Acute Stroke Clinical Care Standard, Quality Statement 2

5). Refer to appendix 8 for the

Statewide ECR flow pathway.

Key principles9

ECR is a highly effective treatment that reduces the occurrence of disability and death after an ischaemic stroke that is caused by a treatable large vessel arterial occlusion.

ECR is a time-critical treatment, and the delays from stroke onset to reperfusion must be minimised to achieve the best patient outcomes.

To enable equitable access to ECR for all Victorians, services must be coordinated, allowing best practice care to be delivered.

Specialised skills are required to perform ECR. Centralising services allows greater procedural volume, and therefore experience, to be achieved.

Statewide data collection for ECR delivery is integral to monitoring service performance and for providing evidence for where improvements could be directed. The data collection should be consistent at all sites so they can be reliably compared.

Rapid decision making regarding thrombolysis and identification of large vessel occlusion is required to detect patients potentially suitable for ECR. Guidelines for ECR eligibility are shown in table 2 Table 2 Guidelines for endovascular clot retrieval (ECR) eligibility

9 p10

* Updated American, Canadian and European guidelines have been released; updated Australian guidelines are in development by the National Stroke Foundation

To ensure rapid decision making, early contact with the VST program will assist in the identification of likely ECR candidates. For VST sites this would include

9

• Calling VST as early as possible, including pre-hospital notification of high-probability ECR patients.

• Arrange rapid brain imaging

• Administer intravenous thrombolysis as appropriate


• Arrange transport via Ambulance Victoria (with Adult Retrieval Victoria support where appropriate), guided by a VST or ECR centre stroke physician

• Explain to the patient/relatives that the interhospital transfer is for the purpose of ECR but that the final decision on suitability for the procedure will be made on arrival at the ECR centre

• Send/transfer the appropriate clinical documentation related to the patient

Safety and Quality

Capacity to evaluate the quality of stroke care delivery is essential for informing clinical practice and improving patient outcomes. As a minimum, all health services should participate in routinely collecting and monitoring a small data set

1.

The Australian Stroke Clinical Registry (AuSCR) http://www.auscr.com.au/ is a collaborative national effort to monitor, promote and improve the quality of acute stroke care. The data collected assists in guiding quality improvement interventions in hospitals, reduce variations in care delivery and ultimately, provide evidence of reduced deaths, disability, and recurrent stroke. Participating health services in the Grampians region include BHS and WHCG. The Australian Commission on Safety and Quality in Health Care has developed a set of indicators to support clinical teams and health services to identify and address areas that require improvement. These indicators include

Proportion of patients admitted to hospital following presentation to the emergency department (ED) with a final diagnosis of stroke who were screened for stroke in the emergency department using a validated stroke screening tool

Proportion of patients with a final diagnosis of ischaemic stroke who were thrombolysed

Proportion of patients with a final diagnosis of acute stroke who have documented treatment in a stroke unit at any time during their hospital stay.

Proportion of patients with a final diagnosis of stroke who start rehabilitation therapy within 48 hours of initial assessment.

Proportion of stroke patients who, before leaving the hospital, have documented evidence of advice on risk factor modification relating to both medications and lifestyle.

Proportion of patients with a final diagnosis of stroke with evidence that a documented plan for their ongoing care in the community was developed with and provided to the patient and/or their carer prior to discharge

5.

Full details of these indicators can be found in the Indicator Specification: Acute Stroke Clinical Care Standard

5.

Follow up/discharge

Patients presenting with stroke or transient ischemic attack (TIA) should not be discharged from the emergency department or urgent care centre without diagnostic evaluations, consultation with a relevant specialist, consideration of functional impairments, initiation or modification of secondary prevention therapy, and a plan for ongoing management. Whether the patient is managed as an inpatient or outpatient is dependent on risk scores and other clinical findings. One score is the the ABCD

2 score which is a risk assessment tool designed to improve the prediction of short-term stroke

risk after a (TIA). The score is optimised to predict the risk of stroke within 2 days after a TIA, but also predicts stroke risk within 90 days. Refer to appendix 9. (Acute Stroke Clinical Care Standard, Quality Statement 7

5)

Rehabilitation

Rehabilitation is a holistic process that should begin the first day after stroke with the aim of maximising the participation of the person with stroke in the community. To achieve this, tailored interventions that focus on impairment, activity and participation levels (based on the World Health Organisation International Classification of Functioning model) should be considered

4.

http://www.auscr.com.au/


Patients managed in acute stroke units that have active rehabilitation programs generally spend less time in bed and more time standing, walking and being active. Studies indicate that commencing rehabilitation early may help recovery

4.

Amount and intensity of rehabilitation

4

Rehabilitation should be structured to provide as much practice as possible within the first six months after stroke

For patients undergoing active rehabilitation, as much physical therapy (physiotherapy and occupational therapy) should be provided as possible with a minimum of one hour active practice per day at least five days a week.

Task-specific circuit class training or video self-modelling should be used to increase the amount of practice in rehabilitation.

For patients undergoing active rehabilitation, as much therapy for dysphagia or communication difficulties should be provided as they can tolerate.

Patients should be encouraged by staff members, with the help of their family and/or friends if appropriate; to continue to practice skills they learn in therapy sessions throughout the remainder of the day.

Timing of rehabilitation

4

a) Patients should be mobilised as early and as frequently as possible b) Treatment for aphasia should be offered as early as tolerated c) Upper limb training should commence early. Constraint Induced Movement Therapy (CIMT) is

one approach that may be useful in the first week after stroke (Acute stroke clinical care standard Quality statement 4

5)

Repatriation back to local service

The original local transferring health service has a responsibility to receive the patient back from the specialist service as early as possible. The patient should return to the original service once specialist stroke care has been fully utilised. In some instances, sub-acute rehabilitation services may be accessed prior to transferring back. This will be dependent on the level of sub-acute rehabilitation required and what is available at the original service. An ongoing plan of care should be developed in consultation with the patient and original local service and should accompany the patient. The care plan should incorporate lifestyle modifications, psychosocial needs, any equipment requirements and referral to appropriate services and rehabilitation. (Acute stroke clinical care standard Quality statement 7

5)

Evaluation of Framework

A review of this Framework will be undertaken every two years or when there is a change to best practice acute stroke care. Evaluation of the tools incorporated into the framework will also be undertaken at this time. Participation of Grampians Region health services in the National Stroke Foundation (NSF) clinical and organisational audits, which alternate from acute clinical audit (last undertaken in 2015) and rehabilitation audit (last undertaken in 2016), will provide consistent capturing of the data and enable benchmarking of data and health services. Key performance indicators for stroke include

7

documentation of swallowing ability within 24 hours of arrival at hospital

urgent brain imaging with CT or MRI within 12 hours of arrival at hospital


allied health assessment within two business days of admission including: o physiotherapy o social work o occupational therapy o speech pathology o dietetics

a clinical care plan exists to avoid complications and promote urinary continence

commencement of aspirin for patients with a thrombotic or thromboembolic stroke within 48 hours of admission

the multidisciplinary team meets with the patient and their carer within seven days of admission

timely and informative provision of a discharge summary

commencement of an anti-platelet or anti-thrombotic agent for patients with a thrombotic or thromboembolic stroke at time of separation

a self-management (consumer) care plan. The Grampians Region aspires to the target of 80% of stroke presentations admitted to a stroke unit to be in line with the national target.


Appendix 1 Framework for the management of acute stroke 2016, Grampians Region Working Group

Consultation with:

Michelle Vu – Victorian Stroke Telemedicine service

NAME POSITION ORGANISATION

Meredith Finnigan Director of Nursing Edenhope & District Memorial Hospital

Grant Hocking Regional Clinical Manager Ambulance Victoria - Grampians

Di Dixon Associate Nurse Manager, Urgent care centre Djerriwarrh Health Service – Bacchus Marsh

Judy Wood & Jenny Vague

Nurse Unit Managers (job share), ICU and acute services (Inc stroke unit)

Wimmera Health Care Group

Roxanne Tucker Clinical Pathways Coordinator Wimmera health Care Group

Sheryl Williams Acute Services Unit Manager East Wimmera Health Service – St Arnaud

Debbie Kakoschke Clinical Support Nurse West Wimmera Health Service

Trish Heinrich Nurse Manager West Wimmera Health Service

Betty Meumann Nurse Manager Acute (until Feb 2016) Stawell Regional Health

Jarrod Hunter Nurse Manager Acute (from Feb 2016) Stawell Regional Health

Lorine Paterson Nurse Manager Acute East Grampians Health Service - Ararat

Vicki Thomas Nurse Manager 4N & stroke unit Ballarat Health Service

Casey Hair Victorian Stroke Telemedicine site coordinator Ballarat Health Services

Thomas Kraemer Neurologist Ballarat Health Services

Scott Silcock Nurse Manager Acute Rural Northwest Health - Warracknabeal

Natalie Ladner Hopetoun Campus Manager Rural Northwest Health - Hopetoun

Sonia Denisenko Manager, Stroke Clinical Network Department of Health and Human Services - Lonsdale St

Pat Standen Emergency & Critical Care Coordinator Department of Health and Human Services - Grampians


Appendix 2

Ambulance Victoria Clinical Practice Guideline (page 1 of 2)


Ambulance Victoria Clinical Practice Guideline (page 2 of 2)


Appendix 3

National Acute Stroke Services Framework 2015 https://www.strokefoundation.com.au/~/media/strokewebsite/resources/treatment/nsf1159_acuteframework2015.ashx?la=en

Recommended stroke services

a) General hospital service Services admitting less than 75 stroke patients generally do not have sufficient demand to justify

specialised inhospital resources such as a stroke unit, clinicians with stroke expertise or advanced neuroimaging, nor do they have essential infrastructure. Given that stroke unit (SU) care should be offered to all people with acute stroke, these services should have formal networks and written agreements in place to transfer stroke patients to a comprehensive or primary stroke service (PSS) (hubs) or support (e.g. via telemedicine) where there is a decision to not transfer the patient (e.g.

due to patient preference or palliation). In regions where a PSS is accessible within reasonable transport time, ambulance services should bypass basic services and deliver suspected stroke

patients to the primary or comprehensive stroke service.

b) Primary stroke service (PSS) All services with 75 stroke patients per year should be a primary stroke service. Primary stroke services have a dedicated stroke unit with clinicians who have stroke expertise; written stroke protocols for emergency services, acute care and rehabilitation; CT/ CT angiography

capability; ability to offer thrombolytic therapy at least during normal business hours and preferably 24/7 (either via onsite specialist or supported by telehealth); protocols to transfer appropriate patients to a comprehensive stroke service as needed (e.g. for neurointerventional or neurosurgical services); timely neurovascular imaging and timely access to expert interpretation; telemedicine services and coordinated processes for patient transition to ongoing rehabilitation and secondary prevention services. Depending on local factors (previous and existing services, geography etc)

these services may have some of the additional elements of comprehensive stroke services and or responsibility for regional coordination of stroke services.

c) Comprehensive stroke service (CSS) Comprehensive stroke services have highly specialised resources and personnel available (24 hours a day, 365 days a year). These services are located in large, tertiary referral services which see high volumes of stroke patients (usually over 350 annual admissions) including the most complex

presentations. These services have a dedicated stroke unit, established well organised systems to link emergency services, hyperacute care, coordinated processes for ongoing inpatient rehabilitation, secondary prevention (e.g. clinic or follow up service), and community reintegration (e.g. early supported discharge). Such services have timely neurovascular imaging and expert interpretation (including advanced imaging capability) and offer thrombolysis, endovascular therapy and neurosurgery (24/7), along with links to other specialist services such as cardiology and palliative care. These services have a leadership role in establishing partnerships with other local hospitals for

supporting stroke care services (e.g. formal networks, specialist education and clinical advice including outreach visits or telemedicine links) and leading clinical research. CSS are located to allow the greatest equity of access to highly specialised interventions. CSS have a minimum of eight dedicated stroke beds in their stroke unit for centres admitting 350 stroke

patients annually increasing to a minimum of 12 dedicated stroke beds for services that see >600

stroke admissions. Recommended bed numbers are for acute stroke units only (not combined acute/ rehabilitation units) with the actual capacity of a CSS stroke unit dependent on local factors including referral patterns, case mix and efficient access to further rehabilitation services. Depending on local factors (previous and existing services, geography etc) these services will commonly have responsibility for regional coordination of stroke services.

https://www.strokefoundation.com.au/~/media/strokewebsite/resources/treatment/nsf1159_acuteframework2015.ashx?la=en

https://www.strokefoundation.com.au/~/media/strokewebsite/resources/treatment/nsf1159_acuteframework2015.ashx?la=en


Appendix 4

Australasian Triage Scale 6

The philosophy underpinning the use of the Australasian Triage Scale (ATS) is based on the values of justice and efficiency in health service delivery. The ATS has been designed to provide a timely assessment and medical intervention for all people who present to an emergency/urgent care service. The application of the ATS is underpinned by the formulation of a chief complaint, which is identified from a brief history of the presenting signs and symptoms of an illness or injury. Triage decisions using the scale are made on the basis of observation of general appearance focused clinical history and physiological data. The collection of physiological parameters at triage requires the clinician differentiate predictors of poor outcome from other data collected. The aim is to identify patients who have evidence of, or are at high risk of, physical instability. The primary survey approach is recommended to identify and correct life-threatening conditions at triage. The time to treatment criteria attached to the ATS categories describe the ideal maximum time a patient can safely wait for medical assessment and treatment.

ATS category Treatment acuity Maximum waiting time

Category 1 Immediately life threatening Immediate

Category 2 Imminently life threatening <10 minutes

Category 3 Potentially life threatening or important time critical treatment or

severe pain

<30 minutes

Category 4 Potentially life-serious or situational urgency or significant complexity

<60 minutes

Category 5 Less-urgent <120 minutes

The ATS has been endorsed by the Australasian College for Emergency Medicine, further information can be found at https://www.acem.org.au/getattachment/693998d7-94be-4ca7-a0e7-3d74cc9b733f/Policy-on-the-

Australasian-Triage-Scale.aspx

https://www.acem.org.au/getattachment/693998d7-94be-4ca7-a0e7-3d74cc9b733f/Policy-on-the-Australasian-Triage-Scale.aspx

https://www.acem.org.au/getattachment/693998d7-94be-4ca7-a0e7-3d74cc9b733f/Policy-on-the-Australasian-Triage-Scale.aspx


Appendix 5

Recognition of Stroke in the Emergency Room (ROSIER)

Assessment Date: ___________________ Time: ___________________

Symptom onset Date: ___________________ Time: ___________________

GCS E=___ M=___ V=___ BP= ____ / ____ *BG= __________

*If BG < 3.5 mmol/L, treat urgently and reassess once blood glucose normal

Has there been loss of consciousness or syncope? Y (-

Has there been seizure activity? Y (-

Is there a NEW ACUTE onset (or on awakening from sleep)

Total Score ________ (-2 to +5)

Provisional diagnosis

-stroke (specify) __________________________

Note: Stroke is unlikely, but not completely excluded if total scores are ≤0. Stroke likely if total score > 0

Accessible at - https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp116_app_g_rosier_scale.pdf

https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp116_app_g_rosier_scale.pdf


Appendix 6

Emergency Department check list

Ref - Emergency Department Stroke & Transient Ischaemic Attack Care Bundle – Poster

Accessible at - http://www.nhmrc.gov.au/guidelines/publications/cp116

http://www.nhmrc.gov.au/guidelines/publications/cp116


Appendix 7

Brain imaging for suspected stroke

Reference: Endovascular clot retrieval for acute stroke: Statewide service protocol for Victoria https://www2.health.vic.gov.au/about/publications/policiesandguidelines/endovascular-clot-retrieval-for-acute-stroke-statewide-service-protocol

https://www2.health.vic.gov.au/about/publications/policiesandguidelines/endovascular-clot-retrieval-for-acute-stroke-statewide-service-protocol



Appendix 8


Appendix 9

ABCD2 Tool 5

The ABCD2 score is a risk assessment tool designed to improve the prediction of short-term stroke risk

after a transient ischemic attack (TIA). The score is optimised to predict the risk of stroke within 2 days after a TIA, but also predicts stroke risk within 90 days. The ABCD

2 score is calculated by summing up points for five independent factors.

RISK FACTOR CATEGORY SCORE

A Age > 60 years 1 point

B Blood pressure > 140/90mmHg 1 point

C Clinical features Unilateral weakness 2 point

Speech impairment without weakness 1 point

D Duration > 60 minutes 2 points

10 to 59 minutes 1 point

D Diabetes 1 point

Tool interpretation:

> 4 = HIGH risk

4 = LOW risk

Maximum score = 7


Abbreviations & Acronyms AAV Air Ambulance Victoria ARV Adult Retrieval Victoria AV Ambulance Victoria ATS Australasian Triage Scale ABCD Age, Blood pressure, Clinical features, Duration & Diabetes BHS Ballarat Health Service CPSS Cincinnati Prehospital Stroke Scale CT Computerised Tomography ED Emergency Department EDMH Edenhope & District Memorial Hospital EGHS East Grampians Health Service EWHS East Wimmera Health Service ECG Electrocardiography FAST Face Arm Speech Time test GP General Practitioner GCS Glasgow Coma Scale LAPSS Los Angeles Prehospital Stroke Screen MASS Melbourne Ambulance Stroke Screen MRI Magnetic Resonance Imaging NIHSS National Institute of Health Stroke Scale NSF National Stroke Foundation NICS National Institute for Clinical Studies rt-PA Intravenous Recombinant Tissue Plasminogen Activator ROSIER Recognition of Stroke in the Emergency Room SRH Stawell Regional Health TIA Transient Ischaemic Attack UCC Urgent Care Centre VCSN Victorian Clinical Stroke Network VEMD Victorian Emergency Minimum Dataset VAED Victorian Admitted Episode Dataset WWHS West Wimmera Health Service WHCG Wimmera Health Care Group


References 1 National Stroke Foundation, National Acute Stroke Services Framework 2015. https://strokefoundation.com.au/what-we-do/treatment-programs/clinical-guidelines/national-stroke-services-frameworks 2National Stroke Foundation, National Stroke Audit - Acute Service Report 2015. Melbourne, Australia https://strokefoundation.com.au/what-we-do/treatment-programs/stroke-data-collection 3 Stroke and its management in Australia: an update 2013. Australian Institute of health and Welfare. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129543611 4. National Stroke Foundation Clinical Guidelines for Stroke Management 2010 Melbourne Australia. http://strokefoundation.com.au/health-professionals/tools-and-resources/clinical-guidelines-for-stroke-prevention-and-management/ 5 Australian Commission on Safety and Quality in Health Care (ACSQHC) Acute Stroke Clinical Care Standard Sydney ACSQHC 2015.

http://www.safetyandquality.gov.au/our-work/clinical-care-

standards/acute-stroke-clinical-care-standard/ 6. Grampians region health status profile 2012 https://www2.health.vic.gov.au/getfile/?sc_itemid=%7bBFD51CA1-501A-4A9A-8D8B-8884925A0FC5%7d&title=2012%20Regional%20Health%20Status%20Profile%20Grampians%20Region 7 Victorian Government Department of Human Services Stroke care strategy for Victoria 2007 http://docs.health.vic.gov.au/docs/doc/Stroke-Care-Strategy-for-Victoria 8 Australian Government, Department of Health and Ageing Emergency Triage Education Kit: Triage Workbook. http://www.health.gov.au/internet/main/publishing.nsf/Content/casemix-ED-Triage+Review+Fact+Sheet+Documents 9. Endovascular clot retrieval for acute stroke: Statewide service protocol for Victoria https://www2.health.vic.gov.au/about/publications/policiesandguidelines/endovascular-clot-retrieval-for-acute-stroke-statewide-service-protocol

https://strokefoundation.com.au/what-we-do/treatment-programs/clinical-guidelines/national-stroke-services-frameworks

https://strokefoundation.com.au/what-we-do/treatment-programs/clinical-guidelines/national-stroke-services-frameworks

https://strokefoundation.com.au/what-we-do/treatment-programs/stroke-data-collection

http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129543611

http://strokefoundation.com.au/health-professionals/tools-and-resources/clinical-guidelines-for-stroke-prevention-and-management/

http://strokefoundation.com.au/health-professionals/tools-and-resources/clinical-guidelines-for-stroke-prevention-and-management/

http://www.safetyandquality.gov.au/our-work/clinical-care-standards/acute-stroke-clinical-care-standard/

http://www.safetyandquality.gov.au/our-work/clinical-care-standards/acute-stroke-clinical-care-standard/

https://www2.health.vic.gov.au/getfile/?sc_itemid=%7bBFD51CA1-501A-4A9A-8D8B-8884925A0FC5%7d&title=2012%20Regional%20Health%20Status%20Profile%20Grampians%20Region



http://docs.health.vic.gov.au/docs/doc/Stroke-Care-Strategy-for-Victoria

http://www.health.gov.au/internet/main/publishing.nsf/Content/casemix-ED-Triage+Review+Fact+Sheet+Documents

http://www.health.gov.au/internet/main/publishing.nsf/Content/casemix-ED-Triage+Review+Fact+Sheet+Documents




Framework for the management of acute stroke 2016 Attachment

Grampians Region: Acute stroke interhospital transfer

guideline

This Grampians Region: Acute stroke interhospital transfer guideline has been developed as part of the Framework for the management of acute stroke 2016. This guideline is available as a template for small health services to use in conjunction with local procedures. The interhospital transfer guideline incorporates a flowchart for the management of the interhospital transfer of suspected acute stroke and is designed for self presenting patients to a General hospital service (GHS).


Grampians Region: Acute stroke interhospital transfer guideline This protocol should be read in conjunction with other relevant documents including:

Framework for the management of acute stroke 2016: Grampians Region

Local interhospital transfer policies

Endovascular clot retrieval for acute stroke: Statewide service protocol for Victoria https://www2.health.vic.gov.au/about/publications/policiesandguidelines/endovascular-clot-retrieval-for-acute-stroke-statewide-service-protocol

Subject Acute or suspected acute stroke interhospital transfer from a General hospital service (GHS) to a Primary stroke service (PSS), either Ballarat Health Services or Wimmera Health Care Group, within the Grampians Region.

Outcome Acute or suspected acute stroke patients presenting to <<enter health service name>> are safely transferred to an alternative health service which provides acute stroke unit care and access to evidenced based care such as thrombolysis as necessary.

Purpose This guideline supports, and should be used in conjunction with the, Framework for the management of acute stroke 2016 Grampians Region The National Stroke Foundation Clinical Guidelines for Stroke Management (2010) and Acute Stroke Services Framework 2015 note that for a GHS – transfer protocols should be developed and used to guide transfers to the nearest stroke unit hospital, with access to thrombolysis and Endovascular clot retrieval where appropriate, for suspected stroke presentations. Health services within the Grampians Region with the capacity (PSS) for acute stroke unit care are Ballarat Health Services (BHS) and Wimmera Health Care Group (WHCG).

Guideline Decision to transfer The General Practitioner (GP) or Registered Nurse (RN) will make the decision regarding where, when and how (in consultation with Ambulance Victoria) to transfer the patient currently in their care. This decision will be based on:

Clinical assessment and condition of the patient

Availability of expertise and resources of both the transferring and receiving health service

Consideration of the risk involved in transferring the patient

Consideration of the patient and/or families wishes

Consideration should be given to the urgency and availability of a CT brain and angiography to differentiate between a haemorrhagic or ischaemic stroke and determine the appropriate treatment plan.

Potential thrombolysis or endovascular clot retrieval patient – emergency transfer The <<enter health service name>> does not offer a thrombolysis service to patients with acute ischaemic stroke. Thrombolysis should be administered as early as possible, up to 4.5 hours post stroke onset, in carefully screened patients with acute ischaemic stroke. Initial clinical assessment at the GHS service should include:

The patient was last seen well < 3 hours previously. (to allow for transfer time)

Patient over the age of 18 years.

A measurable or clinically significant deficit using the Recognition of Stroke in the Emergency Room (ROSIER) scale. See Appendix 1 for an example of ROSIER tool.

No absolute contraindications to thrombolysis – see https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management-2010 for thrombolysis inclusion/exclusion criteria.



https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management-2010

https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management-2010


Stroke Unit Care patient (not eligible for thrombolysis or endovascular clot retrieval) – urgent transfer If the patient is not eligible for thrombolysis or endovascular clot retrieval they should be admitted directly to a stroke unit. Patients who receive care in a stroke unit are more likely to survive their stroke, return home and become independent in looking after themselves. Patients requiring transfer for stroke unit care should be transferred as early as possible but ideally during normal business hours to ensure minimum disruption for the patient. If transfer is delayed, an interim care plan (case specific) for the patient should be obtained from the receiving stroke unit. This interim care plan may include items such as nil orally, close monitoring of vital signs, intra venous hydration and monitoring of any seizure activity.

Transfer coordination If transferring to Ballarat Health Services:

Contact the switchboard on 5320 4000 o During business hours (8am – 5pm Monday to Friday) for medical referral ask for

Neurology Unit Registrar pager – 4663 o Out of hours and weekends for medical referral ask for Medical Registrar on call pager –

4633

Once patient has been accepted for transfer by medical staff at BHS, the transferring hospital needs to contact the Patient Flow Coordinator at BHS on 0403 394 471 to arrange a bed and day and time of transfer.

Ballarat Health Services has thrombolysis therapy available 24 hours per day, 7 days a week and availability of telehealth consultation through the Victorian Stroke Telemedicine program If transferring to Wimmera Health Care Group – Horsham

Contact the switchboard on 5381 9111 and ask for the Emergency Department Registrar 24 hours a day, 7 days a week

Wimmera Health Care Group has thrombolysis therapy available 24 hours per day, 7 days a week and availability of telehealth consultation through the Victorian Stroke Telemedicine program

Contacting Ambulance Victoria AV can assist with organisation of urgent secondary transfer of stroke patients to a centre with a stroke unit, thrombolysis and/or endovascular clot retrieval where appropriate. This may involve the AV clinician, Air Ambulance Victoria (AAV) and/or Adult Retrieval Victoria (ARV). Discussions with the AV clinician should occur as early as possible to ensure appropriate consultation and prompt coordination of resources. To consult with an AV clinician call 1300 113 312. If the patient is time critical, consultation with ARV may also aid in patient care guidance and early transfer. For emergency transfer of potential thrombolysis and/or ECR patient phone 000 and complete the required information. If there are any difficulties in organising the transfer –

request to speak to the AV clinician or contact them directly on 1300 113 312

or alternatively request to speak to the AV Regional duty manager.


The following information will be required on contact with the Primary Stroke Service (PSS) or Comprehensive Stroke Service (CSS)

ISBAR Details Description Yes No N/A

Identity Person providing information Person receiving information

Introduce yourself and confirm who you are talking to

Patient Name

Patient DOB

Situation Give clear concise overview of relevant issues

If Urgent - state this at the beginning using triage category if appropriate

Onset of stroke symptoms

Background Tell the story

Patients past history FAST or ROSIER scale

Assessment What is going on

Vital signs Heart rate -

Blood pressure -

Blood glucose -

Oxygen saturation -

Oxygen administration -

Glasgow Coma Scale -

CT scan results (if service available)

12 lead ECG results Look for atrial fibrillation

IV cannula insitu Size

Position

Pathology taken (if service available)

U & E

FBE

Clotting profile

Current medications Allergies

Particularly anti platelet or anti coagulants

Patient Nil by mouth

Request What action(s) are you asking for

What do you want to happen next

Treatment plan

Telephone orders (if required)

ETA of transport (if relevant)

Is there anything you can do while waiting for assistance/transfer

Plans for patient returning to referring General Health Service(GHS) following stroke unit care The original transferring GHS has a responsibility to receive the patient back from the PSS or CSS as early as possible. The stroke survivor should return to the referring GHS once specialist stroke unit care has been fully utilised. In some instances, sub acute rehabilitation services will be available at the PSS or CSS and may be accessed prior to transferring back to the GHS. This will be dependent on the level of sub acute rehabilitation available at the GHS. An ongoing plan of care should be developed in consultation with the referring GHS and should accompany the patient. Consideration should be given to:

Patient care needs

Patient (and carer) wishes

Resources available to meet the patient care needs

Bed capacity at both the GHS and the PSS


Flowchart for the management of interhospital transfer of suspected acute stroke patient self presenting to a General hospital service

Patient self presents with a suspected acute stroke

Assess using FAST

• Face – Check their face, has their mouth drooped? Ask person to smile

• Arms – Ask person to raise both arms, can they lift both arms?

• Speech – Is their speech slurred, do they understand you? Ask person to repeat a phrase

• Time – Time is critical, every second counts

ATS category 2

NO


outside of thrombolysis or

endovascular clot retrieval

time frame or indeterminable

Consult with PSS or CSS by

phone or v/c to determine

urgency of transfer

Grampians PSS -

Ballarat Health Services

5320 4000 ask for Neuro Reg

during hours or Med Reg

afterhours

Wimmera Health Care Group

5381 9111 ask for ED Reg

Transfer as soon as

possible based on clinical

condition and the advice

from the consult

For emergency transfer via Ambulance Victoria phone 000

Consult via Adult Retrieval Victoria – 1300 36 86 61


within the 4.5 hour time frame

for thrombolysis and is a

potential candidate for

thrombolysis and/or

endovascular clot retrieval

Urgent CT brain and

angiogram available

onsite

YES

Arrange for emergency transfer via

Ambulance Victoria

and

Undertake urgent CT brain and

angiogram

Discuss results with CSS via VST

Other considerations

Vital signs (including GCS)

Oxygen saturation (maintain >95%)

Blood glucose

12 lead ECG (look for AF)

IV cannula

Pathology (U&E, FBE, clotting profile)

Nil orally

Legend

PSS – Primary Stroke Service

CSS – Comprehensive Stroke Service

VST – Victorian Stroke Telemedicine

Reference – Grampians Region acute

stroke working group May 2016


Appendix 1

Recognition of Stroke in the Emergency Room (ROSIER)

Assessment Date: ___________________ Time: ___________________

Symptom onset Date: ___________________ Time: ___________________

GCS E=___ M=___ V=___ BP= ____ / ____ *BG= __________

*If BG < 3.5 mmol/L, treat urgently and reassess once blood glucose normal

Has there been loss of consciousness or syncope? Y (-1) N (0)

Has there been seizure activity? Y (-1) N (0)

Is there a NEW ACUTE onset (or on awakening from sleep)

I. Asymmetric facial weakness Y (+1) N (0)

II. Asymmetric arm weakness Y (+1) N (0)

III. Asymmetric leg weakness Y (+1) N (0)

IV. Speech disturbance Y (+1) N (0)

V. Visual field defect Y (+1) N (0)

Total Score ________ (-2 to +5)

Provisional diagnosis

Stroke Non-stroke (specify) __________________________

Note: Stroke is unlikely, but not completely excluded if total scores are ≤ 0. Stroke likely if total score > 0

Reference: National Institute of Clinical Studies. Emergency department stroke and transient ischaemic attack care bundle: information and implementation package. Melbourne: National health and medical research Council; 2009 http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp116_complete.pdf

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp116_complete.pdf