Transcript The Role of the ANP in the Management of Stroke Patients

Carepathways in
Stroke care
Imelda Noone,MSc,RGN,RM.
ANP in Stroke Care
St. Vincent’s University Hospital,
Elm Park,
Dublin 4.
[email protected]
Background
10,000 Strokes in Ireland per year
ECA pop. 333,500
> 65 yrs 36,928
475 beds in SVUH (5%)
255 - 316 Strokes annually
Stroke Team (Keating,D et al, IMJ,85,4,1992)
Ireland 2006
UK 2002
UK 2004
UK 2006
3%
73%
79%
91%
Rapid transfer to 3%
hospital
NA
4%
12%
Routine
Thrombolysis
0%
NA
NA
18%
Neurovascular
clinic
6%
NA
65%
78%
Mobile stroke
team
14%
NA
23%
29%
Early support
DC team
0%
NA
14%
22%
CNS Stroke
14% (5)
30%
35%
42%
Consultant with
responsibility for
stroke
32%
80%
90%
98%
Stroke unit
St.Vincent’s University Hospital
SVUH STROKE SERVICE
STATISTICS 2004 - 2008
YEAR TOTAL <65
>80 RHD NRH ENC TIA
2004
260
31
-
28
6
17
60
2005
249
25
-
26
12
20
71
2006
316
23
101
41
3
33
62
2007
256
32
143
38
4
25
61
2008
276
39
147
45
10
52 86
TOTAL
1357
150
391
178
35
147 340
Members of the MDT
ANP (1)
Clinical Nurse
Specialist in Stroke
Care (1)
Registrar (1)
SHO (1)
Physiotherapist (1.5)
Occupational
Therapist (1.5)
Speech and language
therapist (2)
Geriatrician with an
interest in Stroke
Consultant
Neurologist
 Consultant
Physician in
Rehabilitation
 Psychiatrist
Dietician (0.5)
Social Worker(0.5)
Core Concepts of :
CNS
(Post reg. education relevant
to specialist practice)
Clinical Focus
Patient Advocate
Education and Training
Audit and Research
Consultant
ANP
(Masters Degree)
Autonomy in Clinical Practice
Pioneering Professional and
Clinical Leadership
Expert Practitioners
Researcher
Approval of Job des/ site prep
Acceditation
Autonomy in Clinical
Practice
Advanced levels of decision making
Comprehensive health assessment
Clinical diagnosis
Overlap with other healthcare
professionals
Comprehensive History
Date and time of history
Identifying Data – age, gender, marital status,
occupation
Past Medical History
Current Medications & Known Drug / Food
Allergies
Current Health Status – smoking, alcohol, drugs,
exercise, and immunizations.
Family History
Professional and Clinical
Leadership
Initiate and implement changes
Provide additional services to many
communities in collaboration with other
healthcare professionals
Participate in educating nursing staff
and other healthcare professionals
Who should be admitted
ABCD
Points
Age
Blood Pressure
> 60 YEARS
1
Systolic >140
+/ Diastolic > 90
1
Clinical Features
Unilateral weakness
2
Speech disturbance alone 1
Other
0
Duration of symptom > 60 minutes
2
10-59 minute
1
< 10 minutes
0
Diabetes
present
1
A score of > 5 is highly predictive of 7 day risk of
stroke and these patients should e admitted for
Stroke Risk after TIA
ABCD score
2 days:
7 days:
30 days:
1-4
2%
3%
8%
5
8%
10%
15%
6
14%
26%
30%
Neurovascular Clinic
Weekly in OPD
G.P'S
Referrals from
A/E
Other Consultants
Patients
contacted
Tests ordered
Collects
results
Health
Promotion
Secondary
prevention
TIA Booklet
Complications of stroke
Deep Vein thrombosis/ PE
Pneumonia
Pressure sores
Urinary tract infection
Urinary/ faecal incontinence
Contractures
Shoulder pain
Depression
Seizures
Changes in the mean barthel
on admission and discharge
in both groups
20
15
14.9
10
11.5
5
0
9.8
BI dc
6.5
BI adm
> 80
< 80
BI adm
BI dc
Outcome Measures
Functional Ability
• Pre- stroke function - OHS
• BI
Cognition
• AMTS / MMSE
Clinical Outcomes
• Mortality
Fiscal Outcomes
• L.O.S
Comparison of outcomes data
(1997 & 2008)
1997
n = 183 (50 weeks)
Mean age 72
<65 yrs 22%
CT 94.5%
Mean L.O.S 35 days
Mortality 25.7%
Discharge destination:
Institutional care 16.9%
rehabilitation 11.5%
Community 41.5%
2008
n = 240 (50 weeks)
Mean age 75.5
< 65yrs 11%
CT Brain 100%
Mean L.O.S. 28 days
Mortality 14%
Discharge destination:
Institutional care 5.4%
rehabilitation 13.3%
Community 62%
Research
The application of evidence based
practice, audit and research will inform
and evaluate practice and thus
contribute to the professional body of
nursing knowledge both nationally and
internationally.
( NCNM, 2008)
Research projects
“Screening for Visual Impairment in Elderly
Rehab Patients”
2. “The implementation of a falls risk
assessment tool”
3. The Use of Cotsides in an Irish Hospital
4. The outcome of Stroke in the very old.
5. F.U of stroke survivors in ENC
6. Factors associated with delay in acute
stroke management
7. Preventing complications post stroke
8. Management of urinary incontinence
1.
Falls Reduction OLW
(n =400)
Assessment
for Cotsides
Factors Associated with Delays in Acute Stroke
Management.
100 patients
51% female, mean age 76yrs
(95%, CI, 74 to 78)
Mean time from onset of symptoms to
arrival in A&E =10hrs
A&E to CT = 12 hrs
CT to APT = 15 hrs
Repeat in July 2009
Nurse- led stroke follow-up clinic
Secondary Prevention
(B/P, weight, diet, information re-smoking etc)
Physical/ medical status
(medications, complications, pressure areas,
continence etc)
Functional Ability (Barthel, O.H.S,MMSE)
Social /environmental issues
( equipment, benefits, support)
Mood (HADS)
Carer/family issues (CSI)
Nurse Prescribing
% of aspects of hospital
costs on stroke care
Overheads
14%
Other
5%
Nursing
81%
Doctoring
19%
Therapy
31%
Drugs
10%
Investigations
40%
Conclusion
Significant developments in the
specialist role
The role of the nurse has been key in
leading the care pathway
The flexibility of the specialist role has
ensured that stroke patients and carers
are assessed promptly and transferred
to the most appropriate settings
St.Vincent’s University Hospital 2009
Thank you