Secondary Stroke Prevention: Challenges

1. 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: (780) 790-6055/ (780)788-1765 Fax: (780)788-1334/ (780)788-1764 TTaiwo@nlhr.ca

2. Conflict of Interest • Nothing to disclose.

3. 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

4. Northern Lights Region Incidence of Stroke

5. 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

6. Team members • RN • Physician • Chronic Disease coordinator • Mental Health Therapist • Occupational therapist • Dietician • Pharmacist

7. 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

8. 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

9. 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 • > 10 min < 59 min 1 0 •  60 min 2 0 • Diabetes 1 0 Score  4 = High Risk

10. 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 > 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 > 4 LOW RISK: • Symptom onset > 7 days • Symptom onset ≤ 7 days without the presence of high risk symptoms (speech deficit or motor deficit or ABCD2 score > 4 or • atrial fibrillation with TIA ) • ** Isolated syncope or dizziness is rarely a TIA and may not • require Stroke Prevention Clinic referral

11. 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)

12. 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

13. 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

14. Referral Services (unavailable locally) • Speech and Language Pathologist • Neurology • Neurosurgery • Vascular surgery • Trans-esophageal echocardiogram

15. 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

16. Overview Wood Buffalo PCN SPC • Clinics are held once weekly (on Monday afternoons) • Patients are contacted as soon as referral letter is received • Ph: (780)788-1765 • Fax: (780)788-1764 • Maximum of 3 patients/clinic day

17. 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

18. 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

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

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

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

22. 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

23. Challenges continued • Community-based (not located within hospital) • ‘Capturing patients’: Communication with ER and in-patient staff; attendance at rounds etc

24. Unanswered Questions • Impact of Stroke Prevention Clinic on stroke incidence • (Impact on risk factors – weight reduction, cholesterol, blood pressure)

25. THANK YOU QUESTIONS?