OPEN-N-Older People in Europe:

New Needs Intensive Erasmus Programme

8
th
June 2012
A stroke is a clinical syndrome characterised by rapidly
developing clinical symptoms and / or signs of focal, and at
times global loss of cerebral function, with symptoms lasting
more than 24 hours or leading to death, with no apparent
cause other than that of vascular origin (WHO, 1978).
Ischaemic Stroke 85% of cases
2.3 million cases of ischaemic stroke in the elderly across
Europe each year (Launer & Hofman, 2000),
1.05 million older people die and 15-30% permanently
disabled (EHN, 2008).
Average cost 16,500 for each case of ischaemic stroke so it
costs the EU 4 billion annually (Truelsen et al , 2005)
Best Practice
Initial Response (Arianna)
Thrombolysis
Country Review
Management (Michelle)
Stroke Units
Country Review
Nursing Care (Tiago)
Nursing Care
Country Review
Rehabilitation (Katerina & Siobhan)
Very Early Mobilisation
Early Supported Discharge
Country Review
Conclusion
Thrombolysis: is the lysis of blood clots by pharmacological
means. It works by stimulating fibrinolsysis by plasminthrough
infusion of tissue plasminogenactivator (t-PA), the protein that
normally activates plasmin. By breaking down the clot, the
decrease process can be arrested, or the complications reduced
(Vatankaha et al, 2005).
Diagnostic test before the therapy: CT, MRI, blood tests,
specialist advice if necessary (cardiological, neurosurgical,
intensivist) (Brunner & Suddarth, 2006)
When thrombolisys can be administrated: the rt-PA therapy
had been licensed for patient up to 75 years in age in many
European country and was recently extended to 80 years. This
age restriction results from the potential higher risk of cerebral
bleeding in the elderly. At any rate age is an independent risk
factor for the stroke and its good or bad prognosis (Ryan &
Harbison, 2011)
When thrombolysis cannot be administrated: in case of
hemorrhagic diathesis, history or suspect of intracranial
hemorrhage, central nervous system disease (neoplasia,
aneurysm..), severe uncontrolled hypertension, ulcer disease of the
gastro-intestinal, platelet count <100.000/mm3 (Regione, 2007).
Treatment: rt-PA 0.9mg/Kg (max 90mg): 10% bolus in 1 minute,
the rest in infusion in 60 min (Parnetti et al, 2006).
Time is brain: Early intensive management of patient suffering a
stroke results in significant and important benefit in terms of
reduced disability and mortality. The European Cooperative Acute
Stroke Study (ECASS) found that the treatment with rt-PA can be
useful within 4.5 hours from the first symptoms of stroke (Torbey et
al, 2008). This treatment window could be expanded with
mechanical thrombectomy(angiography then Mechanical Embolus
Removal in Cerebral Ischemia merci-) up to 8 hours (Layton,
2006).
Greece Ireland Italy Northern
Ireland/UK
Portugal
CT scan
takes 1 hour,
Thrombolysis
within 2 hours
of onset of
stroke
symptoms.
Urgent brain scan
(CT/MRI),
Thrombolysis
within 4.5 hours of
initial symptoms,
Contraindications
CT/MRI brain
scan,
Blood tests,
Thrombolysis
within 3 hours.
Stroke team
called,
CT Scan,
Thrombolysis
within 4.5
hours of initial
symptoms.
Greenway
pre-hospital
assessment,
CT scan,
Thrombolysis
within 3 hours.
STROKE UNITS - A major objective in the treatment of stroke is
represented by the organisation of care for acute patients and the access
to so called stroke units have been recommended by Helsinborg
declaration (1995) for all patients with stroke in Europe.
The first dedicated units for stroke patients were organised in Europe and
the USA in the beginning of the 1960s they had an experimental character
and resembled the organisation of coronary care units. In the 1970s and
80s stroke units were developed in Northern Europe and had mainly a
rehabilitative character, while in the 1990s some intensive units for stroke
care were organised, with controversial efficacy results (Candeliseet al,
2005).
Effective stroke units have 3 essential components
1) Specialist multidisciplinary team,
2) Discrete, defined ward area for caring for patients,
3) Robust government structure with evidence based pathways
& protocols to define care (Ryan & Harbison, 2011).
Stroke Units vs Neurological/Medical wards
The Stroke Unit Trialists Collaboration (2007) meta-analysis have shown that
care in stroke units substantially reduces the risk of both death and permanent
disability by 1/3,
This is supported by evidence published from the Canadian Stroke Network
register in 2010. They found that stroke units benefit the whole stroke population
and increased availability of stroke unit care is associated with a reduction in 6
month stroke mortality at 36% and an increase in discharge home at 28% (Smith
et al, 2010).
Although several studies have now confirmed that all age groups benefit from
stroke unit care.
The degree of early benefit may not be as great in older people as those younger.
However even those over 80 years have consistently been found to derive benefit
from active investigation and management of stroke,
It is arguable given that their expected outcomes may actually be poorer than for
younger subjects that such active management is in fact proportionally more
important in older stroke patients (Ryan & Harbison, 2011)
Mobile Stroke Units only 2-5% of patients who have a stroke receive
thrombolytic treatment mainly because of delay in reaching the hospital,
Evidence suggests that mobile stroke units in the form of specialised ambulance
equipped with a CT scanner, point of care laboratory and telemedicine connection
substantially reduced median time from alarm to therapy decision. The MSU
strategy offers a potential solution to the medical problem of the arrival of most
stroke patients at the hospital too late for treatment (Walter et al, 2012).
Author Study Design Findings
Krespi et al (2003) Stroke Unit vs Neurology Ward
Before and after study
Shorter length of stay
Fjaertoft et al (2004) Stroke Unit vs Neurology Ward
RCT
Reduce stay in hospital
Evans et al (2001) Stroke Unit vs Neurology Ward
Three groups
Better functional status at 3, 6 and
12 months
Reduction in complications
Diez-Tejedor and Fuentes (2001) Stroke Unit vs Neurology Ward
Prospective
Better functional status at discharge
Fuentes et al (2006) Stroke Unit vs Neurology Ward
Historical controls
Neurological setting
Reduction in complications
Reduction in long stay
hospitalisation
Reduction in health costs
Cadilhac and Ibrahim (2004) Stroke Unit vs Neurology Ward
Prospective single blind
Higher rates of adherence to key
processes of care in SU than in
other models
Walter et al (2012) Mobile Stroke Unit
RCT
Reduces time from alarm to
therapeutic decision.
Greece Ireland Italy Northern
Ireland/UK
Portugal
Few stroke
units
Mainly cared
for in
pathological
ward
Few stroke
units
Mainly cared
for in
neurological
/medical ward
Stroke Units
mainly in the
central hospital
Regional
hospitals
medical or
neurological
ward
Mainly stroke
Units
Few in
medical wards
Mainly stroke
units
Acute Phase
preserving one's life;
prevent complications;
meet human needs changed;
After patient stabilization :
develop greater functional independence of the person and
the family (AHA, 2009).
NURSING DIAGNOSIS
Ineffective Breathing
provide frequent alternations of position;
teaching /instructing/ train /techniques encourage
coughing;
thin secretions with nebulizer;
aspiration of secretions (Good et al, 1996).
Communication compromised
Manage / Optimizing Communications
Speak slowly, articulating his words in a tone of normal
voice (Waddington, 2009)
Staying within the range of focus as the person;
Use simple words and phrases and short;
Writing, reading, mime, pictures or gestures;
Speech Therapy
Intestinal Elimination and impaired bladder
Impaired bladder
To evaluate the ability of the person to control urination;
Teach / Instruct / Train the implementation of pelvic muscle
exercises;
Advise urinary elimination before sleep;
Teach / Instruct / Train autonomy bladder;
Permanent urinary catheter - Last Appeal (Nazarko, 2003)
Intestinal Elimination
Advise / educate about regular bowel habits;
Planning high-fiber diet and strengthening water
Teach / Instruct / Train technique training intestinal (Booth,
2009).
Compromised swallowing reflex
Search swallowing reflex daily oral administration
through the small amounts of water;
Inspect the oral cavity after the meal;
Planning for proper diet (Lees et al, 2006)
Provide adaptive equipment;
Inform about adaptive equipment;
Encouraging self-feeding;
Teaching about adaptive strategies for food
Greece Ireland Italy Northern
Ireland/UK
Portugal
IV
fluids/access
Medication,
ECG,
Observing the
patient,
Personal care
Consulting
the patient
Vital signs
O2 therapy
IV
fluids/access
Drugs,
Nutrition
Hydration
Continence
Hygiene
Mobilisation
Vital signs,
O2 therapy,
IV
fluids/access,
Medication,
Mobilisation,
Personal
Care
IV fluids/access
ECG
Routine bloods
O2 therapy
Vital signs
Repositioning
Early
mobilisation
Personal Care
Vital signs,
Oxygen
therapy,
Airway patent,
GCS,
IV
access/fluids,
Drugs,
Feeding,
Drinking,
Hygiene,
Movement,
Early mobilisation reduces complications such as infection,
venous thromboembolism, orthostatic hypotension, hypoxia,
subluxation of joints and infection (NICE, 2009)
Very Early Mobilisation (VEM) involves getting up out of bed
within 24 hours of the onset of a stroke,
Best Practice evidence
Asimple, easy-to-deliver intervention, requiring little or no
equipment that is potentially deliverable to 85% of the acute
stroke population,
May reduce death and dependency & the need for
institutionalisation (Teasell et al, 2011)
May help reduce the significant personal and community
burden of stroke (Bernhardt, 2008),
Caution
Insufficient evidence to support or refute the efficacy of
routine very early mobilisation after stroke (Cochrane
Systematic Review, 2009)
More researchneeded e.g. a large high-quality clinical trial
Early Supported Discharged (ESD) is about helping
people with stroke leave hospital as soon as possible and be
cared for at home,
Best Practice evidence
Reduced risk of death and dependency and have
fewer adverse outcomes,
Shorter hospital stay (Rudd et al, 1997),
Significantly improves patients scores on the extended
activities of daily living scale,
Improves patient satisfaction with stroke services
(Langhorne, 2005)
Cautions
Need well organised discharge teams,
Only suitable for patients with less severe strokes,
No statistically significant differences in carers
subjective health status, mood or satisfaction with
services (Cochrane Systematic Review, 2009)
Greece Ireland Italy Northern
Ireland/UK
Portugal
MDT

Rehabilitation
hospitals
(private)
Mobilisation
Early
mobilisation
Rehabilitation
units,
Clinical Nurse
Specialists
MDT within 72
hours
National
Rehabilitation
Centre
MDT
Early
mobilisation
Ward rehab
starts ASAP,
Residential
rehabilitation
Rehab at
home with
domiciliary
service
MDT approach
Early
mobilisation
Rehabilitation
wards
Early supported
discharge
Continued
care units,
MDT
Rehab
between 24-
48 hours
Stroke Care
Thrombolysis - early intensive management with
4.5 hours from the first symptoms of stroke,
mechanical thrombectomycould extend this time to
8 hours
Stroke Units - stroke units substantially reduces the
risk of both death and permanent disability by 1/3,
mobile stroke units reduced median time from alarm
to therapy decision,
Nursing Care an intensive range of nursing
interventions improves patients functional outcomes
Rehabilitation very early mobilisation is a simple
easy intervention but more researchis needed
around very early mobilisation,
Evidence based practice
Even though empirical research is critical to provide the support for nursing
practice, other forms of evidence can be equally important in nursing, for
example clinical pathways, protocols, practice guidelines and review articles.
Also extremely important is patient involvement,
Nursing practice has always emphasised the involvement of the patient in their
care, yet rarely is their preferences included,
For EBP to be effective application to the individual patient occurs by
combining all of this evidence
empirical studies,
non-empirical studies,
published evidence,
clinical expertise
patient preference, values, uniqueness (Keele, 2011)
Questions ?
Fjaertoft, H., Inderdavik, R.J ., & Lydersen, S. (2004) Acute stroke unit care combined with early
supported discharge. Long-term effects on quality of life. A randomised controlled trial. Clinical
Rehabilitation, 18:580,
Walter, S., Kostopoulos, P., Haass, A. et al (2012) Diagnosis and treatment of patients with
stroke in a mobile stroke unit versus in hospital: a randomised controlled trial,
Candelise, L., Micieli, G., Sterzi, R & Morabito, A. (2005) Stroke units and general wards in
seven Italian regions: the PROSIT study. Neurological Science, 26:81-88.
Stroke Units Trialists Collaboration (2007) Organised inpatient (stroke unit care) for stroke.
Cochrane Database System Review, 4; CD000197.
Krespi, Y., Gurol, M.E., Coban, O., Tuncay, R., Bahar, S. (2003) Stroke unit versus neurology
ward a before and after study. J ournal of Neurology, 230:1363-9.
Evans, A., Perez, I., Harraf, F. et al (2001) Can differences in management processes explain
different outcomes between stroke unit and stroke team care? Lancet, 358:1586-92.
Diez-Tejedor, E., Fuentes, B. (2001) Acute care in stroke: do stroke units make the difference?
Cerebrovascular Disease, 11 (Suppl 1.) 31-9.
Fuentes, B., Diez-Tejedor, E., Ortega-Casarrubios, M.A. et al (2006) Consistency of the
benefits of stroke units over years of operation: an 8 year effectiveness analysis.
Cerebrovascular Disease, 2,173-9.
Cadilhac, D.A., Ibrahim, J . (2004) for the SCOES Study Group: Multicentre comparison of
processes of care between stroke units and conventional care wards in Australia, 35: 1035-40.
Bernhardt J . Very early mobilization following acute stroke: Controversies, the unknowns, and
a way forward. Ann Indian AcadNeurol 2008;11:88-98
Bernhardt J , Thuy MNT, Collier J M, Legg LA. Very early versus delayed mobilisation after
stroke. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006187. DOI:
10.1002/14651858.CD006187.pub2
Brunner Suddarth Infermieristica Medico Chirurgica Casa Editrice Ambrosiana 2006 (Cap.
62)
European cardiovascular disease statistics 2008. European Heart Network, Brussels.
Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute
stroke patients (Cochrane review). In: Cochrane Library, issue 2 [database online]. Oxford, UK:
Cochrane Library; 2009
Langhorne, P (2005). Early Supported Discharge Trialists. Services for reducing duration of
hospital care for acute stroke patients. The Cochrane Database of Systematic Reviews, Issue 2.
Layton, K., White, J .B., Cloft, H.J , Kallmes, D. F., Manno, E.M., (2006) Expanding the
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Parnetti, L., Silvestrelli, G., Lanari, A., Tambasco, N., Capocchi, G, Agnelli, G., (2006) Efficacy
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