Secondary Stroke Prevention: Challenges

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Secondary Stroke Prevention Challenges

• Dr. Tolu Taiwo M.B.,B.S, CCFP, MPH
• 25 November 2008
• Stroke Prevention Clinic
• Wood Buffalo Primary Care Network (WBPCN)
• Fort McMurray, AB
• Ph [phone]/ [phone]
• Fax [phone]
• TTaiwo_at_nlhr.ca

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Conflict of Interest

• Nothing to disclose.

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Objectives

• Describe a rural Secondary Stroke Prevention
  Clinic
• Define the goals of the Wood Buffalo Primary Care
  Network Stroke Prevention Clinic
• Identify challenges faced with setting up and
  running clinic

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Northern Lights Region

• Incidence of Stroke

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Goals of Stroke Prevention Clinic

• To provide co-coordinated and urgent care
• Prompt identification and modification of risk
  factors diabetes mellitus, atrial fibrillation,
  hypertension etc
• Patient and caregiver education on risk factor(s)
  modification
• Ensure accessibility to and co-ordination of
  investigations
• Improve functional outcomes after stroke

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Team members

• RN
• Physician
• Chronic Disease coordinator
• Mental Health Therapist
• Occupational therapist
• Dietician
• Pharmacist

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Referral Criteria

• Individuals 18 years
• Stroke/TIA
• Medium and low risk patients (ABCD2 scores)
• Services unavailable at the PCN SPC
• Swallowing assessment
• Speech rehabilitation
• Physical and Occupational Therapy

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Referral Criteria

• Individuals 18 years
• Stroke/TIA
• Medium and low risk patients (ABCD2 scores)
• Services unavailable at the PCN SPC
• Swallowing assessment
• Speech rehabilitation
• Physical and Occupational Therapy

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• ABCD2 SCORING CHART
• 
  Yes No
• Age ? 60 yrs 1
  0
• BP ? 140/90
  1 0
• Clinical Features
• ????? Unilateral weakness 2 0
• (with or without speech disturbance)
• ????? Speech deficit without weakness 1 0
• Duration
• gt 10 min lt 59 min 1
  0
• ? 60 min
  2 0
• Diabetes 1 0
• Score ? 4 High Risk

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• TIA STROKE RISK ASSESSMENT
• HIGH RISK
• Symptom onset within the last 48 hours with any
  one of the
• following
• Motor deficit lasting more than 5 minutes
• Speech deficit lasting more than 5 minutes
• ABCD2 score gt 4
• Atrial fibrillation with TIA
• MEDIUM RISK
• Symptom onset between 48 hrs and 7 days with any
  one of the following
• Motor deficit lasting more than 5 minutes
• Speech deficit lasting more than 5 minutes
• ABCD2 score gt 4
• LOW RISK
• Symptom onset gt 7 days
• Symptom onset 7 days without the presence of
  high risk symptoms (speech deficit or motor
  deficit or ABCD2 score gt 4 or
• atrial fibrillation with TIA )
• Isolated syncope or dizziness is rarely a TIA
  and may not
• require Stroke Prevention Clinic referral

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• HIGH RISK Complete investigations within 24
  hours
• May require referral to Primary or
  Comprehensive
• Stroke Centre to ensure timely completion of
  investigations
• Stroke Prevention Clinic Referral (seen within 24
  hours)
• MEDIUM RISK Complete investigations within 3
  days Stroke Prevention Clinic Referral (seen
  within 3 days)
• LOW RISK Complete investigations within 2 weeks
• Stroke Prevention Clinic Referral (seen within 2
  weeks)

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Care Map
Referral is received at PCN with necessary labs
and diagnostics and ABCD2 risk assessment if
available
Stroke Nurse Preliminary Assessment
Physician Assessment, Management, Recommendation
PCN Group Education Modules and stroke risk
factors addressed such as hypertension,
cholesterol, diabetes, smoking cessation etc.
Follow up
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Programs and Services available at PCN

• Cardiac Programs Cardiac Rehabilitation, Heart
  Smart etc.
• Weight Management Program Optifast program
• Stanford Chronic Disease Self-Management Program
• Diabetes management Diabetes 101
• Smoking cessation program

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Referral Services (unavailable locally)

• Speech and Language Pathologist
• Neurology
• Neurosurgery
• Vascular surgery
• Trans-esophageal echocardiogram

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Getting Started

• Stroke Prevention Clinic launched in May 2008
• Pilot clinic May 2008
• Information packages sent to local physicians
• Media Blitz
• SPC started in June 2008

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Overview

• Wood Buffalo PCN SPC
• Clinics are held once weekly (on Monday
  afternoons)
• Patients are contacted as soon as referral letter
  is received
• Ph [phone]
• Fax [phone]
• Maximum of 3 patients/clinic day

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• RN Initial assessment
• Physician Further assessment, including
  neurological examination
• Care plan Information binder
• Consultation letter to GP (and referring
  physician)
• Follow-up telephone consultation in-patient
  visit

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Wood Buffalo PCN Stroke Prevention Clinic (SPC)

• From June Nov 2008
• 11 patients 5 males and 6 females
• Age range 48 71 years (average 56.4 years)
• 73 with TIA and 27 with strokes
• Risk factors hypercholesterolemia, diabetes
  mellitus, hypertension, cigarette smoking, atrial
  fibrillation, family history

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Investigations

• Trans-thoracic echocardiogram (available since
  1ST week in Nov. 2008)
• Ambulatory blood pressure monitoring
• Holter monitor
• CT scan
• MRI scan
• Doppler ultrasound
• Anklebrachial index

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REFERRAL ISSUES

• Communication methods
• Telephone
• Fax
• Source of Referral
• Family physicians
• Other health disciplines
• Patients and family members

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PRACTICE ISSUES

• Practice Profile
• EMR and/or paper charts
• Assessment sheets
• Software
• Organization
• Funding
• Support stakeholders NLHR, Wood Buffalo PCN
• Staff

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Challenges

• Psycho-social/financial issues
• Patient adherence
• Attrition/ staff departures
• Incomplete data/ assessment forms ABCD2
• Assessments Cognitive, physical, depression
• Rehabilitation speech, physical and
  occupational therapy
• Evaluation Data collection and analysis

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Challenges continued

• Community-based (not located within hospital)
• Capturing patients Communication with ER and
  in-patient staff attendance at rounds etc

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Unanswered Questions

• Impact of Stroke Prevention Clinic on stroke
  incidence
• (Impact on risk factors weight reduction,
  cholesterol, blood pressure)

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• THANK YOU
• QUESTIONS?