the role of the nurse in discharge · pdf filethe role of the nurse in discharge planning and...
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The Role of the Nurse in Discharge Planning and Follow Up for Stroke Patients Imelda Noone, Advanced Nurse Practitioner in Stroke Care [email protected]
28th February,2014
Definition of Stroke
o ‘A focal (or at times global) neurological impairment of sudden onset, and lasting more than 24 hours (or leading to death) and of presumed vascular origin’.
(WHO,2010)
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Copyright ©1996 American Heart Association
Davenport, R.J. et al. Stroke 1996;27:415-420
Delay between stroke onset and complications within first 30 days
SVUH Stroke Service Statistics 2003 - 2013
YEAR TOTAL TPA
F M <65 >80 D/C RHD NRH ENC RIP OPD LOS NURSE LED
CLINIC
TOTAL TAKEN OVER BY GERIATRICIANS
2003 260 - 132 128 31 - 195 28 6 17 37 80 - 96 (42%)
2004 249 - 131 118 25 - 166 26 12 20 32 60 - 86 (38%)
2005 316 - 157 159 23 - 196 41 3 33 43 96 - 94 (32%)
2006 256 -- 144 112 32 101 117 38 4 25 36 76 - 140 (62%)
2007 256 - 133 127 28 116 122 33 4 36 33 94 - 154 (70%)
2008 279 - 153 127 41 147 129 45 10 52 61 89 - 210(89%)
2009 289 8 143 146 46 130 147 34 12 29 44 120 - 219 (90%)
2010 248 13 137 111 39 98 132 27 13 24 33 100 130 199 (95%)
2011 338 21 164 174 45 163 (56%)
164 44 10 22 48 70 103 253(86%)
2012 333 18 168 165 49 141 (50%)
196 41 5 27 43 137 67 231(81%)
2013 337 14 176 161 47 173 (60%)
137 72 6 41 60 86 32 90 247 (85%)
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Discharge planning - begins from admission
o Identification of complexity of needs - all patients admitted to the hospital will be met by the ANP/CNS providing information and education to both the patient and family.
o It is during this time that the patients/families needs and expectations are identified and a management and discharge plan is put in place through the involvement of the Stroke MDT
Pre morbid function
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Nurse-led Ward Rounds o an effective way of instigating a management
plan o engaging nursing staff and ultimately the
whole MDT and patient o plan the aspects of care required leading to
discharge
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Discharge planning at MDT
o Weekly MDT meetings are coordinated by the ANP and a discharge plan is set in place for each patient
o Weekly family MDT meetings are also coordinated by the ANP and allows for clarity between the goals of the MDT, patient and family
o Clinics run weekly allows for review of all patients discharged home post stroke to assess their ongoing needs.
o A Nurse telephone support system is in place for all patients and families easing the transition and discharge process and allowing early identification of problems with direct access to referral to the OPD clinic
o Monthly visits to Nursing Homes to review patients to identify and assess needs and complications.
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A personalised, comprehensive approach to discharge planning o For each patient, information about, and treatment for, stroke and risk factors should be: o given first in the hospital setting o reinforced at every opportunity by all health professionals involved in the care of the patient provided in an appropriate format for the patient. o Patients should have their risk factors reviewed and
monitored regularly in primary care, at a minimum on a yearly basis.
o (RCP,2012)
All patients receiving medication for secondary prevention should:
o be given information about the reason for the medication, how and when to take it and any possible common side effects
o receive verbal and written information about their medicines in a format appropriate to their needs and abilities o have compliance aids such as large-print labels and non-childproof tops provided,
dosette boxes according to their level of manual dexterity, cognitive impairment and personal preference and compatibility with safety in the home environment
o be aware of how to obtain further supplies of medication
o have a regular review of their medication (RCP,2012)
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Discharge Planning and Transfer of Care
Discharge letter should include: o Diagnosis(es) o �ƒ. Investigations and results o �ƒ. Medication and duration of treatment if applicable o �ƒ. Levels of achievement, ability and recovery (BI,AMTS,WEIGHT) o �ƒ. Team care plan o �ƒ. Further investigations needed at primary care level with dates o �ƒ. Further investigations needed at hospital and dates o �ƒ. Further hospital attendance with dates o �ƒ. Transport arrangements o �ƒ. The hospital name, hospital telephone number, ward name or number, ward
telephone number, CNS/ANP number o �ƒ. Consultant’s name and named nurse o �ƒ. The date of admission and discharge.
o What happens to the patients after discharge?
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Nurse- led stroke follow-up clinic
o Secondary Prevention o (B/P, weight, diet, information re-smoking etc) o Physical/ medical status o (medications, complications, pressure areas, continence etc) o Functional Ability (Barthel, mRS,MMSE,ACE-R,MoCA) o Social /environmental issues o ( equipment, benefits, support) o Mood (HADS) o Carer/family issues (CSI)
o Nurse Prescribing
Secondary Prevention Guidelines
o BP aim clinic BP < 130/80 >50s CCB/diuretic +/-ACE,ARB o APT ASA 75mg +MR dipyridamole 200 bd o Statin aim reduce total C < 4, LDL.C < 2 o Afib warfarin INR 2-3, must be in TR >70% NOAC o Exercise moderate intensity 30min/day x5/wk o Diet fruit/oily fish o Alcohol 2u/day(women),3u/day(men) o Smoking cessation
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Secondary Prevention Cautions o Target BP in very old, frail, fallers should be higher
(HYVET 150/80) o bilateral critical carotid artery stenosis o ASA/clopidogrel not for longer than 3/12 o Statins myopathy,ICH risk o Monitor renal fn in NOACs caution GFR <30 o ?PAF in ischaemic stroke >one vascular territory,
normal carotids o 7d >48h>24h holter
Follow Up of Patients in Nursing Homes o Simple scores (BI, Weight, cognitive fn measures) helpful in
assessing disabled patients’ recovery after discharge from hospital with stroke
o Falls, pain, spasticity, incontinence, dysphagia and mood/cognitive problems may become more evident after discharge
o Clear guidelines on secondary prevention but benefit v risk in very old frail patients is less clear
o Point of education
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Lifestyle o Stop smoking (? 35% relative risk reduction*) - individualised approach(± pharmacological agents, psychological support)
o Regular exercise –(24% relative risk reduction*) - to slight breathlessness, 20-30 min daily
o Moderate alcohol intake – (? 20% relative risk reduction*) - ≤ 3 units per day for men and ≤ 2 units per day for women
o Healthy diet - ≥ ‘ 5 a day’ fruit and veg, 2 fish portions per week( one oily), low fat dairy products, reduce meat intake
o Target weight - advice, support and exercise
o Restricted salt intake - avoid adding to food, minimise in cooking, choose lower sodium/ salt foods
Stroke Service 1998 and 2012
1998 2012 No. 183 333
< 65 22% 15%
Mortality 26% 13%
Home 42% 59%
Residential Care
17% 9%
Off site rehab 12% 14%
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National Clinical Programme Irish stroke thrombolysis rates, change over time
0
2
4
6
8
10
12 P<0.001
Goal rate, end 2012
Discharges
Percentage Patients (ICD I60-I64) Discharged Directly Home
49.4%51.1%
0
10
20
30
40
50
60
2005 2006 2007 2008 2009 2010 2011 2012
Year
%
NSP
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Nursing Home Discharges (Disability)
Percentage Patients (ICD I60-I64) Discharged to Nursing Home
14.5
17.3%
0
5
10
15
20
25
2005 2006 2007 2008 2009 2010 2011 2012
Year
%
NSP
Mortality
Percentage Patients (ICD I60-I64) Died
16.2%14.8%
0
5
10
15
20
25
2005' 2006' 2007' 2008' 2009' 2010' 2011' 2012'
Year
%
NSP
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National Stroke Programme o Funding for TIA, Early Supported Discharge and
Rehab. services o Posts-57 posts (nursing & AHP)
n 17 of the 21 CNS posts filled o 2 posts candidates awaiting start dates (CUH & Loughlinstown) o 1 post in recruitment (Drogheda) o 1 post awaiting management approval (Kerry)
o Stroke Register-in 28 hospitals o Care Pathways & Care Bundles-on www.hse.ie o Atrial Fibrillation Screening Pilot in Primary Care-in
progress o Telemedicine Rapid Access for Stroke and
Neurological Assessment (TRASNA)-in progress