Document Type: PROTOCOL Title: Cardiac And Stroke Networks In Lancashire And Scope: All Network Organisations in Lancashire and Cumbria Unique Identifier: CORP/PROT/059 Version Number: 1 Status: Ratified Classification: Organisational Author/Originator and Title: Kathy Blacker Associate Programme Director Healthcare Standards Cardiac and Stroke Networks in Lancashire and Cumbria Replaces: New Protocol Description of amendments: Responsibility: Cardiac and Stroke Networks in Lancashire and Cumbria Name of Committee: Divisional/Directorate/ Working Group: Network Board of the Cardiac and Stroke Networks in Lancashire and Cumbria Date of Meeting: 22 nd September 2008 Validated by: Sally Chisholm Programme Director Cardiac and Stroke Networks in Lancashire and Cumbria Risk Assessment: Not Applicable Financial Implications Not Applicable Validation Date: 22 nd September 2008 Ratified by: Clinical Improvement Committee Review Dates: Review dates may alter if any significant changes are made Ratified Date: 05/01/2009 Date of Issue: 05/01/2009 Review Date: 01/12/2010 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Does this document meet with the Race Relation Amendment Act (2000) Religious Discrimination Act, Age Discrimination Act, Disability Discrimination Act and Gender Equality Regulations? Not Applicable
1 PURPOSE. The standards encompass the patient pathway from call for help to post thrombolysis care on an Acute Stroke Unit. Their purpose is to articulate the minimum standards for stroke thrombolysis. 2 SCOPE. All Network Organisations across Lancashire and Cumbria 3 PROTOCOL 3.1 INTRODUCTION These are a set of consensus standards produced by the Cardiac and Stroke Networks in Lancashire and Cumbria. The standards encompass the patient pathway from call for help to post thrombolysis care on an Acute Stroke Unit. Their purpose is to articulate the minimum standards for stroke thrombolysis. Commissioners who wish their acute providers to deliver thrombolysis in acute stroke must ensure that they work with providers to achieve these standards. Thrombolysis in acute stroke across Lancashire and Cumbria should be a Consultant led service. 3.2 ASSESSMENT Symptoms of stroke include numbness, weakness or paralysis, slurred speech, blurred vision, confusion and severe headache. 3.2.1 FAST All first contact staff in organisations receiving calls for help (NHS Direct, 999, Out of Hours Services, Primary Care centres, GPs, Urgent Care/Walk In Centres, Emergency Departments must be FAST trained. Records of FAST training should be held within each department or organisation. A positive FAST test in a patient should initiate a pre alert to the receiving hospital which must have CT scanning facilities. Patients must be transferred either to an Emergency Department or straight to an Acute Stroke Unit. Page 2 of 7
3.2.2 Clinical Assessment The following standards for in-hospital clinical assessment must be achieved: An immediate clinical assessment of the patient must be carried out by an experienced clinician (doctor or nurse). A validated tool such as ROSIER to identify stroke and NIHSS to define the severity of the stroke must be used and the clinician must be familiar with their use. Time of symptom onset should be established. Vital signs must be recorded. These include Blood glucose to exclude hypoglycaemia as a cause of symptoms Glasgow Coma Scale Heart rate, Blood Pressure, Respiratory Rate, Temperature, oxygen saturation (SpO2) Weight Full blood count and clotting profile Assessment documentation must include a checklist to establish inclusion or exclusion for thrombolysis. Consent for scan and thrombolysis should be obtained where possible. 3.3 IMAGING A positive checklist for thrombolysis together with a positive clinical picture should generate a request for non-contrast CT to exclude haemorrhage. This must be performed in the next available slot and definitely within 1 hour, whichever is sooner. Organisations must have a process for accepting referral without delay. Appropriately trained personnel must accompany the patient to scan. CT scanning and immediate reporting must be available 24/7. If CT reporting is outsourced governance arrangements must be adequate to ensure acceptable clinical standards. 3.4 DIAGNOSIS A physician experienced in the management of acute stroke must make the decision to thrombolyse. Experience must include completion of a recognised thrombolysis training programme. Page 3 of 7
The clinician must have seen the scan as well as the patient in order to make the decision to thrombolyse. This may require facilitation through the use of remote technologies such as image transfer and telemedicine. Cross-organisational working will be necessary in order to deliver equitable 24/7 thrombolysis availability across Lancashire and Cumbria. In order to protect patients, clinicians and organisations the governance arrangements for clinical responsibility, decision-making and follow up support must be resolved before clinicians can work across organisations. 3.5 Thrombolysis Delivery Thrombolysis therapy should be only delivered in centres with facilities that enable it to be used in full accordance with the drug s marketing authorisation. Within Lancashire and Cumbria this means that an organisation must ensure that Staff are trained and competent in delivering thrombolysis and in monitoring for post-thrombolysis complications. Nursing staff are trained and competent in acute stroke and thrombolysis care, have Levels 1 and 2 critical care skills and are available 24/7. There is access to re-imaging and reporting. Thrombolysis may be administered in Emergency departments that meet the above standards. Patients must be admitted to an Acute Stroke Unit as defined in NICE guidance (a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patents. Regular multidisciplinary team meetings occur for goal setting.). There are protocols in place for the delivery and management of thrombolysis, including post-thrombolysis complications. This will include protocols for prompt critical care referral in the event of patient deterioration. Processes are established to ensure audit and clinical review of thrombolysis delivery throughout the Network. 3.6 Monitoring Following thrombolysis patients must be nursed on an Acute Stroke Unit by appropriately trained nursing staff according to dependency at a ratio of a minimum of 1:2 for the first 24 hours. Page 4 of 7
Patients will require monitoring for neurological changes and signs of bleeding. Patients must receive continuous ECG monitoring for first 24 hours, with vital signs including Glasgow Coma Scale, Early Warning Scores and SpO2 recorded as a minimum of ¼ hourly for 2 hours, ½ hourly for 2 hours, hourly for remaining 24 hours. Patients should have a repeat CT or MRI scan at 24 hours after thrombolysis to rule out asymptomatic hemorrhagic transformation prior to initiating antithrombotic therapy. Staff must be trained in the use of protocols for the delivery and management of thrombolysis, including post-thrombolysis complications. If the patient requires transporting for an investigation transport monitoring must be used and trained personnel must accompany the patient. Please Note Level 1 and 2 refers to the level of dependency of the patient and is taken from Comprehensive Critical Care (DoH 2001) The definitions are as follows. Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team. Level 2 Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those 'stepping down' from higher levels of care. 4 ATTACHMENTS. Appendix 1 References 5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION. Database for Policies, Procedures, Protocols and Guidelines Archive/Policy Co-ordinators office Held By: Directorate/Department/Author Held in format: Electronic and/or hard copy 6 LOCATIONS THIS DOCUMENT ISSUED TO. Copy No Location Date Issued 1 Intranet 05/01/2009 2 All Network Trust s Governance Leads Page 5 of 7
7 OTHER RELEVANT /ASSOCIATED DOCUMENTS. Unique Identifier Title None 8 AUTHOR//DIVISIONAL/DIRECTORATE MANAGER APPROVAL. Issued By Kathy Blacker Checked By Dr M O Donnell Job Title Associate Programme Director Job Title Consultant Clinical Lead Signature Signature Date January 2009 Date January 2009 Page 6 of 7
Appendix 1 References: http://www.emedicine.com/neuro/topic370.htm Implementing the National Stroke Strategy an Imaging Guide DH May 2008 National Stroke Strategy DH December 2007 National Clinical Guidelines for Stroke RCP July 2008 NICE Clinical Guideline 68 July 2008 Blackpool Fylde and Wyre Hospitals NHS Foundation Trust I.D. No: CORP/PROT/059 Page 7 of 7