VOL: 97, ISSUE: 01, PAGE NO: 39
Anna Lynham, BA, RGN, is stroke research nurse, Leicester Royal Infirmary
Cheryl Utecht, BA, RGN, is stroke liaison nurse, Leicester Royal InfirmaryStroke is the most common cause of adult disability and the third biggest killer in the UK. The last decade has seen many significant changes in our understanding of the disease and in service provision but the results of the National Sentinel Audit of Stroke demonstrate that, although the provision of stroke services has improved, overall standards remain low (Alberti, 2000).
Stroke is the most common cause of adult disability and the third biggest killer in the UK. The last decade has seen many significant changes in our understanding of the disease and in service provision but the results of the National Sentinel Audit of Stroke demonstrate that, although the provision of stroke services has improved, overall standards remain low (Alberti, 2000).
Leicester Royal Infirmary's stroke team consists of: a consultant; stroke services coordinator; liaison nurse; ward nursing staff; physiotherapists; occupational therapists; speech and language therapists and a stroke research nurse. The team has developed several forward-thinking initiatives to improve and enhance the care of stroke patients admitted to the hospital.
Of the 600 stroke patients admitted to A&E, two-thirds are reviewed by a senior nurse from the stroke team within 72 hours of admission. The hospital has a six-bed acute stroke unit, based on a neurology ward. Criteria for admission to the stroke unit are that the patient must have been independent before the stroke, and must have good potential for rehabilitation. The average length of stay on the unit is seven days.
The stroke unit nurses have led some important initiatives in patient care. Several protocols have been put into action, including an aspirin protocol which starts after the patient's computerised tomography scan. An initial physiotherapy assessment and a swallowing assessment are begun on the day the patient is admitted to the unit.
The team has also developed a seven-day stroke care pathway to ensure standardised care throughout the stroke unit. The completed care pathways are used as an audit tool. Collaborative documentation is also started on the acute stroke unit, and this follows the patient through to the rehabilitation unit.
All members of the multidisciplinary team, including the medical staff, document patient progress daily using the same paperwork. The aim is for this paperwork to become district-wide. It is also in use at the other two major Leicester hospitals.
The rehabilitation unit has 18 beds, with full access to physiotherapy, occupational therapy and speech and language services. Care is multidisciplinary, with an emphasis on goal planning and promoting independence through dynamic, evidence-based interventions.
The team was concerned that many suitable stroke patients were not admitted to the stroke unit, as only six acute beds were available. These patients were frequently sent to general medical wards, where they did not always receive optimal care. A roving stroke team, consisting of a senior stroke nurse, a physiotherapist and an occupational therapist, was established to visit all the medical wards and assess stroke patients. The patients are reviewed for their rehabilitation potential, while ward staff are encouraged to put antiembolic stockings on the patients, and to refer them for a safe-swallowing assessment.
All patients are discussed at a weekly multidisciplinary case conference, headed by the stroke consultant. Each patient's appropriate rehabilitation placement is decided at these meetings. Some of the patients will be transferred to the rehabilitation unit, while others will be referred for rehabilitation in the community hospitals.
The team also noticed that many people were being diagnosed as having had a transient ischaemic attack (TIA) by A&E staff, and referred back to their GPs. It was decided to set up a rapid access TIA clinic, to which patients could be referred directly from A&E. The TIA patients are all seen within four weeks of referral by the stroke consultant.
The stroke services coordinator at Leicester Royal Infirmary stroke service is an RGN who liaises between the consultant and nursing staff regarding development issues. The coordinator is also concerned with the clinical audit of stroke services and maintaining documentation standards.
A stroke support nurse is available who can offer help and advice to patients and their families and telephone support following discharge. The support nurse is also actively involved with general advice on the wards and in the clinics.
There is also a stroke services research nurse on the team who is involved in coordinating a number of clinical trials, including neuroprotectant drugs and thrombolysis treatment.
All the team nurses provide health education sessions in the community, to raise awareness of stroke, to promote a healthy lifestyle and reduce individual risk factors. Leicester has a high ethnic minority population, whose risk of stroke is higher than that of the indigenous population, and the sessions have been tailored towards differing communities' needs. Promoting public awareness has involved nurses attending religious festivals, carnivals and local neighbourhood centres, and communicating with local media.
Stroke health education is also undertaken on the rehabilitation unit, on a weekly basis. Patients and their relatives are invited to attend 'drop-in' sessions to get advice regarding healthy lifestyle, as well as information from physiotherapists, occupational therapists, and speech and language therapists.
The stroke team believes that it is providing a broad base of services while simultaneously highlighting stroke as a priority. The emphasis is on raising the profile of this disease, both in the hospital and in the community.
The team feels this approach is imperative if all the targets in the recently published National Clinical Guidelines for Stroke are to be met (Royal College of Physicians, 2000).