Rural Organisation of Australian Stroke Teams Key messages for Allied Health

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Rural Organisation of Australian Stroke TeamsKey
messages for Allied Health

• Dr Debbie Kesper FAFRM
• Consultant in Rehabilitation Medicine
• Clinical coordinator of ROAST 3
• Allied Health Conference Echuca March 2007

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ROAST is a quality improvement project funded by
the Support Scheme for Rural Specialists.
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• AIM
• To foster the development of well-educated teams
  of health professionals capable of becoming the
  backbone of rural stroke units.
• Continuous Professional Development

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• Background
• Patients suffering a stroke benefit from well
  organized care delivered by motivated and well
  educated teams of health care professionals. We
  know that stroke units act to improve patient
  outcomes.
• 3 reduction in death
• 2 less likely to require institutional care
• 5 less likely to have long-term dependency.

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The recent National Stroke Foundation survey
highlighted the inequity in access to hospitals
providing optimal stroke services with small,
often rural hospitals less likely to offer a
coordinated and integrated stroke service than
metropolitan hospitals.
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Why? It appears that the processes of care and
the structures that support these processes are
different in the more specialized units. These
processes are well articulated in Australia by
the NSF. They are easily monitored using a
limited number of well described KPIs.

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November/December Stroke Types
In total, sixteen (16) forms were received for
stroke patients discharged from the acute unit
during the November/December reporting period.
Patients were aged from 41 to 88 (M 64.06, SD
15.26), and consisted of seven (7) females and
nine (9) males.
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November/December Compliance to NPIs
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Cumulative compliance to NPIs, 2006
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November/December Acute Discharge Destination
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Stroke unit care what is it?
1. Organised multidisciplinary rehabilitation 2.
The hard to define excitement factor 3. Expert
nursing, allied health and medical care
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The black box..
Multidisciplinary team
Organised care
Family carer involvement
Stroke unit care
Aim for functional independence
Discharge planning
Enthusiasm
Specific therapy modalities
Staff education training
Specialist nursing
Medical treatment
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Death or dependency by end of scheduled follow up
Thanks to Prof Peter Langhorne, ESC 2005
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Key Features

• Stroke patients need to be seen early by the team
• Day one

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Key features

• Dysphagia screening and assessment
• Commence therapy early
• Prevent complications by anticipating what might
  happen (pathways?)
• Bladder, bowel, aspiration, etc
• Use of multidisciplinary assessments can work
  well and save time

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Key Features

• early
• mobilisation.transferring. Patient, nurse,
  family involvement in exercise therapy
• Bernhardt J. et al
• Little therapy, little physiotherapy
  rehabilitation within the first 14 days of
  organised stroke care

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Key Features

• Encourage use of hemiparetic upper limb
• -modified constraint therapy
• -mental imagery
• -somatosensory stimulation
• For acute and chronic stroke patients
• Page S. J, Levine P, Leonard AC. Modified
  constraint-induced therapy in acute strokea
  randomised pilot study. Neurorehabil Neural
  Repair 2005 Mar19(1)27-32
• Szaflarski J.P. Page S.J. Kissela B. M. Lee J.H.
  Levine.P. Strakowski. S.M. Cortical
  Reorganisation Following modified
  Constraint-Induced Movement Therapy A Study of 4
  Patients with Chronic Stroke. Arch Phys Med
  Rehabil 2006 Aug87 1052-1057
• Conforto A.B. et al Neurology Dept Sao Paulo
  University Brazil Poster presentation Joint world
  Congress on stroke Sept 2006. Effects of
  somatosensory stimulation on Motor Function in
  Chronic stroke patients

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Key Features

• Neural plasticity occurs in acute stroke patients
  for weeks to months
• - shown by MRI and Pet studies
• Motor activity
• Speech
• Cognitive training
• Askim T. et al Department of public health and
  general practice, Norwegian University of Science
  and technology
• Changes in motor network in stroke patients
  treated in an acute stroke unit combined with
  early supported discharge, evaluated with FMRI
  and functional tests

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Key Features

• Treat depression early
• Identify cognitive deficits especially in
  patients to be discharged directly home from
  acute settings
• Implement a management plan involving the patient
  and significant others
• Patient, family and carer education especially
  about impact of fatigue on performance

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Out Patient Therapy

• Review of goals with patient, family and carers
• Patients who are motivated often achieve goals
  well beyond those expected by therapists
• Home exercise programs promoting bipedal
  movements

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Out Patient Therapy

• Identification of spasticity using
  screening/assessment tools
• Daily regimes that reduce the negative impact of
  spasticity
• Need to seek early assistance for intervention
• Consequences of not adhering to a spasticity
  management regime

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Outpatient therapy

• Assess for cognitive deficits
• Education of patients and family about
  compensatory strategies
• Use of novel training of cognitive domains
• - computer programs
• - repetitive tasks

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Outpatient Therapy

• When to stop therapy ?
• Neuroplasticity can occur for months
• There are subgroups of stroke patients that
  continue to improve
• Reassessment important to identify those patients
• Use goal directed therapy

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The TEAM message

• All team members need to reinforce each others
  area of expertise
• Multi-skilling may be the way for rural teams
  to provide care to their patients
• Strive for best practice- lead by example
• Keep educating yourself and review your clinical
  practice regularly

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Lifestyle interventions

• Smoking cessation
• Weight reduction
• Dietary manipulation
• Increased physical activity
• Reduction in alcohol intake
• Optimal management of diabetes

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Stroke prevention strategies

• Carotid endarterectomy
• Warfarin for AF and high risk cardiac sources
• Anti-platelet agents
• Risk factor management
• BP lowering
• Lipid lowering
• Education of patient and family

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Education of patient and family

• Stroke symptoms and signs
• Risk factors and their management
• More success with reaching targets
• Emergency action plan
• Call an ambulance
• IV alteplase and stroke unit care

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Education of patient and family

• What to expect when goes home
• Outpatient rehabilitation
• Complications post hospital
• Fatigue
• Depression
• Spasticity

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Resources

• Clinical champions, within the team and outside
  of the team
• National stroke foundation acute and subacute
  guidelines
• DHS stroke strategy
• Networking with peers, professional body, ROAST
• Dont reinvent the wheel
• Change takes time

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References

• Askim T. et al Department of public health and
  general practice, Norwegian University of Science
  and Technology. Poster Joint World Congress in
  Stroke Sept 2006
• Changes in motor network in stroke patients
  treated in an acute stroke unit combined with
  early supported discharge, evaluated with FMRI
  and functional tests
• Brainin, M. Stroke Services. Cerebrovasc Dis
  2003 15(suppl 2)63-69
• Bernhardt J. Chan J, Nicola I, Collier JM. Little
  therapy, little physiotherapy rehabilitation
  within the first 14 days of organised stroke
  care. J Rehabil Med 2007 Jan 39(1) 43-8
• Conforto A.B. et al Neurology Dept Sao Paulo
  University Brazil Poster presentation Joint world
  Congress on stroke Sept 2006. Effects of
  somatosensory stimulation on Motor Function in
  Chronic stroke patients
• Dunsky A. Dickstein R. Ariav C. Deutsch J.
  Marcovitz E. Motor Imagery practice in gait
  rehabilititation of chronic post-stroke
  hemiparesisfour case studies International
  Journal of Rehabilitation Research 29356 2006
• Guendisch G.M. et al FRMI Research group,
  Innsbruck Medical University, Innsbruck Austria.
  FMRI of the Human Sensorimotor Cortex before and
  after subsensory whole hand afferent electrical
  stimulation
• Page SJ, Levine P, Leonard AC. Modified
  constraint-induced therapy in acute strokea
  randomised pilot study. Neurorehabil Neural
  Repair 2005 Mar19(1)27-32
• Paul, Seana L et al. Prevalence of Depression
  and Use of Antidepressant Medication at 5-years
  Post Stroke in the North East Melbourne Stroke
  Incidence Study. Stroke 2006 372854-2855
• Read S.J. Levy J. Differences in stroke care
  practices between regional and metropolitan
  hospitals
• Internal Medicine Journal 2005 35 447-450
• Szaflarski J.P. Page S.J. Kissela B. M. Lee J.H.
  Levine.P. Strakowski. S.M. Cortical
  Reorganisation Following modified
  Constraint-Induced Movement Therapy A Study of 4
  Patients with Chronic Stroke. Arch Phys Med
  Rehabil 2006 Aug87 1052-1057
• Srikanth, Velandai K et al. Long term Cognitive
  transitions, rates of cognitive change, and
  predictors of Incident Dementia in a population
  based first ever stroke cohort. Stroke 2006
  372479-2483