Management of patients with stroke
Rehabilitation, prevention and management of complications, and discharge
planning
Section
7: Patient issues
This section of the guideline is intended
to highlight the main issues that healthcare professionals should discuss
with patients and carers. It is based on the best available evidence of what
is effective and has been adapted with permission from Chest, Heart & Stroke
Scotland (CHSS) literature. Please refer to the other SIGN Stroke guidelines
for full background.5,
7
7.1 Diagnosis and assessment - identifying the
problems and assessing what the patient needs
Everyone should be made aware of the symptoms of a stroke; particularly
those in high-risk groups - for example, with a family history of stroke,
coronary heart disease or high blood pressure
Patients with persisting symptoms should be admitted as an emergency to
hospital. They should receive immediate medical assessment, with all relevant
investigations, including CT scan, carried out within 48 hours
Patients should be assessed for their nursing and other care needs, and
have an immediate swallowing assessment. Patients and their carers need
to be fully informed of the purpose and results of all investigations, and
as far as possible of the likely outcomes
An alternative to hospital admission for patients with minor symptoms
(or those with symptoms that have completely resolved) is a neurovascular
clinic review, ideally within a week (even if already seen in the Emergency
Room). They should receive a full medical assessment and investigations,
including a CT scan and (if appropriate) carotid doppler ultrasound and
echocardiography
Ideally, this should be a “one-stop” service. Patients should
be given a full explanation of the purpose and results of all investigations,
and of action to reduce the risk of future strokes.Appropriate dietary and
therapy advice should also be provided.
7.2 Acute care and rehabilitation - hospital-based
services
Patients should ideally be cared for in a dedicated Stroke Unit. This
should be staffed by medical, nursing and therapy staff with specialist
interest and expertise in stroke care, operating as a multidisciplinary
team. The stroke service should provide both acute care and specialist stroke
rehabilitation
In rural areas with small hospitals and dispersed populations, this may
not be possible. In these circumstances, patients should still be treated
using agreed protocols for stroke care, and rehabilitation should make use
of generic rehabilitation facilities
Care should be provided by staff with specialist knowledge and skills
in stroke. There should be particular attention to potential problems such
as swallowing and eating, communication, fluid balance and hydration, nutrition,
mobility, everyday activities, continence, associated cardiovascular problems,
infections, prevention of pressure sores and skin care problems. Patients
may also have vision or cognitive problems. Staff should be aware of all
of these issues and ensure that patients’ dignity is respected at
all times
Patients are likely to be affected by emotional problems including anxiety
and are at significant risk of depression, which can be treated
Patients should be encouraged to move, walk and communicate as soon as
possible
The patient should be actively involved in setting and meeting rehabilitation
goals. Patients and their carers need to be kept fully informed of the aim
of rehabilitation and the probable course of recovery, and of action taken
to reduce the risk of future strokes. Appropriate secondary prevention measures
should be initiated as soon as possible
Information provided in booklet, video and audiotape form is particularly
useful for both patients and carers. Publications such as those provided
by CHSS should be made available, together with information about the CHSS
Advice Line. The charity can also organise visits by trained volunteers
to hospital stroke patients, which can be particularly helpful for those
with limited family support.
7.3 Discharge planning - returning home from
hospital
Discharge planning should begin well in advance, and be based on the individual
needs and circumstances of the patient. Patients and carers need to be kept
fully informed, and consulted at each stage in the process
There needs to be full consultation and joint working with local authority
and primary care services to ensure that the full community care package
is available to patients and carers immediately on discharge. This includes
all necessary assessments for OT aids, adaptations and equipment
Initial appointments, for example with therapists, should be arranged
before discharge. There must also be close co-ordination with the patient’s
GP
Patients and carers who could potentially benefit should be made fully
aware of the services provided by voluntary agencies such as CHSS, and appropriate
referral procedures put in place
Follow-up after hospital discharge is vital for both patients and carers.
There should be a named telephone contact to deal with any immediate problems
following discharge
Ideally, a family support worker or CHSS stroke nurse should make contact
with the patient and carer prior to discharge and follow-up regularly over
the following six to twelve months, through home visits and telephone contact
GPs need to be kept fully informed and undertake responsibility for monitoring
patients’ progress at home. In particular, GPs should ensure suitable
secondary prevention measures are taken, including smoking cessation, and
management of risk factors such as hypertension, diabetes and atrial fibrillation
(please refer to the SIGN guideline on secondary prevention5).
Problems associated with stroke, such as cognitive and behavioural problems,
and depression, should also be monitored.
7.4 Community
support - long term care and support
at home
The Primary Care team should ensure that patients and carers are given
information on statutory benefits such as Disability Living Allowance and
Attendance Allowance, for which they may qualify, if not addressed by hospital
services. They should be referred to the National Benefits Agency Enquiry
Line, local Benefits Agency, Citizens’ Advice Bureau, Welfare Rights
Office, or any other agency that might be able to help
Patients who drive should be advised on when it is appropriate to return
to driving
SLTs and GPs should make patients with communication problems aware of
the CHSS Volunteer Stroke Service, and where appropriate, discuss referral
with the patient
CHSS also provides a network of local stroke clubs, run on a voluntary
basis and offering social support, activities and companionship. Patients
and families should be made aware of these clubs and the means of accessing
the services they offer
In some parts of the country, there are also separate groups for younger
stroke patients operated by both CHSS and Different Strokes. Patients under
65 should be given information on these groups if their services are available
locally
At every stage in the process, from admission to long term support in
the community, patients and carers need to be provided with the fullest
possible information, and encouraged to take the maximum responsibility
for their own recovery.
7.5 Sources
of further information/support
The following organisations provide support and information for stroke patients
and their carers:
Fife Assessment Centre for Communication through Technology (FACCT)
ASDARC, Woodend Road, Cardenden, Fife KY5 0NE
Tel: 01592 414 730 Fax: 01592 414 737
Email: facct@itasdarc.demon.co.uk
KEYCOMM
Lothian Communication Technology Service, St. Giles Centre, 40 Broomhouse Crescent,
Edinburgh, EH11 3UB
Tel: 0131 443 6775 Fax: 0131 443 5121
Email: djans@keycomm.demon.co.uk
Momentum (formerly Rehab Scotland) (Provide rehabilitation
and training services, empowering people with disabilities to gain greater
independence and access to employment)
Head Office, 1650 London Road, Glasgow, G31 4QF.
Tel: 0141-554-8822
Email: headoffice@rehab-scotland.co.uk
Web: www.rehab.ie/scotland/index.htm
Moving Into Work (Employment consultancy and support for
people after acquired brain injury):
Norton Park, 57 Albion Road, Edinburgh EH7 5QY
Braid House, Labrador Avenue, Howden, Livingston EH54 6AU
Princess Royal Trust for Carers (Glasgow Office) Campbell
House, 215 West Campbell Street, Glasgow G2 4TT
Tel: 0141 221 5066 Fax: 0141 221 4623
Email: infoscotland@carers.org
Web: www.carers.org
Scottish Centre of Technology for the Communication Impaired
SCTCI, WESTMARC, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF
Tel: 0141 201 2619 Fax: 0141 201 2618
Email: sctci@sgh.scot.nhs.uk
Speakability (Information for people with aphasia, their
families and healthcare professionals)
1 Royal Street London, SE1 7LL
Helpline: 080 8808 9572 Tel: 020 7261 9522 Fax: 020 7928 9542
In England and Wales: The Stroke Association
Stroke House, Whitecross Street, London EC1Y 8JJ
Tel: 020 7566 0300 Fax: 020 7490 2686
Web: www.stroke.org.uk
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