Driving After Stroke: Decision Making Approaches in Northwestern Ontario

Transcription

1 Driving After Stroke: Decision Making Approaches in Northwestern Ontario January 24, 2017 Sharon Jaspers NP, TBRHSC Stroke Prevention Clinic

2 Driving and Stroke Post Stroke 2 Possible Approaches Voluntary Suspension Formal Report to MTO 4 6 weeks Medical Condition Report MTO Determines Suspension Medical Review Process (6 wks)

3 Type of Driving Suspension Dependant on Various Factors TIA vs Stroke (need imaging) Location of stroke (cerebellar vs parietal) Cognitive assessment Impact of deficits Insight of stroke deficits Other co morbidities ie diabetes, previous stroke, visual impairments If visual field loss hemianopsia MTO reporting mandatory Require 120 degree visual field in order to have Drivers license (DL)

4 Hemianopsia

5 Voluntary Suspension Honour system Ensure discussion is documented see next slide TBRHSC EMR notes, care activity or other reports Ensure family members/care partners are involved and aware of the discussion Reinstated after assessment, usually for 4 6 weeks post TIA/Stroke, by stroke team ( often at Stroke Prevention Clinic appointment by MD or NP) May need pre-driving screen referral to support return to driving available at SJCG outpatient neurology clinic or Neuro Day Program or Dryden Family Health Team OT referral Legalities????

6 Electronic Medical Record TBRHSC Stroke Unit Admission or Stroke Prevention Clinic Visit information can be found in: Notes: Stroke Nurse (likely nearing end of Admission) Other Reports: Nurse Practitioner or Neurologist Consults Care Activity: OT Progress Record

7 Legalities Ministry of Transportation: Report any patient, age 16 or over who may be suffering from a medical/visual condition that may impair driving ability (Highway Traffic Act s 203 & 204) Report even if do not have DL, in case in process of obtaining DL Canadian Medical Association: Physicians who have determined that a patient is unfit to drive should inform the patient that: A report will be made to the motor vehicle licensing authority Motor vehicle licensing authority has processes for appeal and reinstatment. Such patients should be cautioned not to drive until the licensing authority has made and communicated its final decision. (CMA,Determining medicial fitness to operate motor vehicles, 2006)

8 Canadian Stroke Best Practice Guidelines 2015 Stroke Rehabilitation Writing Group: Patients should be told to stop driving for at least one month after stroke, in accordance with the Canadian Council of Motor Administration (CCMTA) Medical Standards for Drivers

9 Driving is not a right, but a privilege Medical Condition Report Can be submitted electronically B=PROFILE&ENV=WWE&NO=023-SR-LC-097 Or faxed Physician to complete ( and NP??)

10 Stroke/TIA or head injury with Significant deficits Pt will receive decision by regular mail in 6 wks. Formal Notice of Suspension will advise what type

11 Notification/Response by MTO Pt will received decision/response by MTO in 6 weeks. Incoming medical reports are prioritized according to the risk to road safety and by date received. Correspondence from MTO is by snail mail. They may receive Formal Notice of Suspension letter If DL suspended, they will also receive a letter advising of what type of medical information is required to have the case considered for reinstatement. MTO makes final decision. Physician/NP provides information, but MTO is the final decision

12 How to get DL reinstated The Medical Review process may require completion of various MTO forms by MD or NP, such as Cerebrovascular Diseases or Truamatic Brain Injury/Tumour or other Neurological Diseases Medical Assessment Vision Assessment visual deficit, may require binocular visual field test report by optometrist/opthalmalogist Independent Driving Assessment Pre-driving Screen or Functional Driving Assessment and/or Road Test If DL has been suspended, need 24 hour temporary DL, which requires the Cerebrovascular Diseases. MTO form. If

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15 Process for Reinstatement of DL Once Medical Review completed, takes another 6 weeks to have a response for decision by MTO Often tell patients that for DL to be reinstated, it may take 4 6 months. Also discuss that longer time, does increase success with functional driving assessments Encourage significant others to be present when discussing return to driving process Medical Review results can be challenged at MTO Review Board

16 Cases 65 female, cerebellar infarct Mild ataxia Referred to NDP SJCG Voluntary suspension x 4 weeks MOCA normal Pre-driving screen passed at NDP Follow up assessment at SPC, advised can return to driving 74 male, left occipital infarct R homonymous hemianopsia Reported to MTO *** DL was suspended by MTO *** Required vision waiver to regain DL Required binocular visual field test by optometrist/opthalmal Required 24 hr temp DL Required completion of Cerebro vas.. form, submit to MTO *** Required Medical submitted to MTO *** Referred to Driving Clinic Passed Driving Clinic, MTO notified patient *** *** denotes up to 6 week wait

17 80 male, L parietal infarct Perceptual concerns Hearing deficits language barrier, limited education Poor insight in deficits MTO notified Finances a concern Cases Referred for pre driving screen and did not pass recommended road test as difficult assessment Referred for Driving Clinic Required 24 hr Temp DL and MTO form cerebro.. Did not pass road test, unsafe++ Family very upset (wife non driver) Pt wished to repeat, and retried, but failed significantly Family very upset, want retry (sons made appts to discuss) 60 female, truck driver G and A license R Basal ganglia stroke, left hemiparesis MTO notified Sent to incorrect address, patient had not renewed DL Referred to Driving Clinic Required 24 hr Temp DL and MTO form cerebro, patient wishes to only focus on G license Passed road test but recommended adaptive aids

18 Questions: Sharon Jaspers NP, TBRHSC Stroke Prevention Clinic