Service Scope:



-731519-397565Self-Assessment Tool - Ontario SPC Core Elements Service Scope:The goal of outpatient management of TIA and non-disabling stroke is rapid assessment and management to reduce the risk of a recurrent, possibly more serious, event. In the province of Ontario, this is achieved by Stroke Prevention Clinics or the equivalent.Stroke Prevention Clinics are defined by a common set of core elements based on the Canadian Stroke Best Practice Recommendations (CSBPR). These core elements are to be reviewed and modified every 2 years to coincide with the release of CSBPR for secondary prevention.The purpose of this assessment tool is to assist SPC sites with the identification of current state of practice as it relates to the core elements. The purpose of the Regional/District Summary is to provide the Core Elements Implementation Working group with examples of barriers and successes within the province in regards to Core Elements implementation and maintenance. These examples as well as any tools shared will be used as implementation resources should there be identified gaps in meeting the core elements in conjunction with the soon-to-be developed implementation toolkit.It is recommended that each SPC utilize this tool to evaluate the current status of core element delivery at their respective SPC. Regional and District Stroke Centres are encouraged to complete the “Self-Assessment Tool - Ontario SPC Core Elements Regional Summary” on behalf of all SPC’s in their region and submit the results to Gwen Stevenson, chair of the Core Elements for Stroke Prevention Clinics in Ontario Implementation Task Group. The results of the regional summaries will guide the development and support the structure of a provincial SPC Core Element Implementation Toolkit. How to use:Users of this assessment tool should:Review each of the core elements relevant to current state of stroke prevention service deliveryComplete an assessment of current state including: services and resources, recommendations in place and levels of access. Evaluate current state under the headings “Fully achieved/Partially achieved/Not achieved” and provide rationale for the plement each of the assessment sections with:If core element fully or partially achieved: Strategies used to attain current state If core element not achieved: Barriers to implementation Tools used to support the achievement of the core element (documentation tool, algorithm etc.). These can be hyperlinked or attached directly into the documentDefinitions:Large Urban Community = population of 100,000 or moreMedium Urban Community = population of 30,000 to 99,999Small Community = population of 1,000 to 29,999Rural Community = geographies outside of other areas identifiedRemote Community = communities without year-round road access, or which rely on a third party (i.e., train, airplane, ferry) for transportation to a larger centreHealth service:STROKE NETWORK REGIONSTROKE PREVENTION CLINICPOPULATION SERVED(check all that apply)DATE OF COMPLETIONClick here to enter text.Click here to enter text.? Large Urban Community? Medium Urban Community? Small Community? Rural Community? Remote CommunityClick here to enter text.Legend: Not AchievedResponsibilities assigned, work in progressPartially AchievedPolicies/procedures/plans/frameworks approved, evidence staff training has been implemented. Education to stakeholders is planned, communication plan complete and implemented. No evaluation complete at this time.Fully AchievedExcellent compliance, meets requirements of criterion in a consistent manner. Requirements are fully implemented. There is a communication plan in effect and being followed, addressing the criterion/process/procedure. Education has been rolled out to all stakeholders. There is good evidence to support effective implementation. Some evidence of evaluation is available with a history of regular reviews or revisions. Adapted from Royal Victoria Regional Health Centre Accreditation Readiness Rating ScaleExample:Title of Core Element:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDEXAMPLE: SPCs will have an established referral system in place which includes the following:? Standard referral formEXAMPLE:The SPC has a standardized referral form that is used by community providers(attachment)XEXAMPLE:The SPC promotes use of the standardized referral form annually at the local CME event which is attended by local family practitioners EXAMPLE:There are hospital specific documents that are required to be completed at this institution which limit the documentation developed by the SPCACTION PLANMRPEXAMPLE:The SPC will coordinate with ambulatory care services within the institution to develop a standardized referral form that meets the requirements for triage of referred SPC patientsSPC ManagerCore Elements:Access to Stroke Prevention Clinics:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC is identified and acknowledged within the local, regional and provincial health system as providing designated stroke prevention services.Click here to enter text.???Click here to enter text.Click here to enter text.The timing of initial assessment in the SPC is based on current recommended timeframes*. Access to the SPC will be expedited based on risk stratification.Click here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 1.0 Patients with stroke or transient ischemic attack who present to an ambulatory setting (such as primary care) or a hospital should undergo clinical evaluation by a healthcare professional with expertise in stroke care to determine risk for recurrent stroke and initiate appropriate investigations and management strategies.VERY HIGH Risk for Recurrent Stroke (Symptom onset within last 48 hours)Patients identified as highest risk should be immediately sent to an emergency department with capacity for advanced stroke care HIGH Risk for Recurrent Stroke (Symptom onset between 48 Hours and 2 weeks, with symptoms of transient, fluctuating or persistent unilateral weakness or speech disturbance/aphasia)These patients should receive a comprehensive clinical evaluation and investigations by a health care professional with stroke expertise as soon as possible ideally initiated within 24 hours of first contact with the health care system MODERATE (INCREASED) Risk for Recurrent Stroke (Symptom onset between 48 hours and 2 weeks with transient, fluctuating or persistent symptoms without unilateral motor weakness or speech disturbance)These patients should receive a comprehensive clinical evaluation and investigations by a health care professional with stroke expertise as soon as possible ideally within 2 weeks of first contact with the health care system. LOWER Risk for Recurrent Stroke (Time lapse since symptom onset greater than 2 weeks)Should be seen by a neurologist or stroke specialist for evaluation, ideally within one month of symptom onset ACTION PLANMRPClick here to enter text.Click here to enter text.Established System for Referral:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDSPCs will have an established referral system in place which includes the following:Standard referral formClick here to enter text.???Click here to enter text.Click here to enter text.Clear process and care pathway for referrals from various sources: ED, primary care, specialists and inpatient unitsClick here to enter text.???Click here to enter text.Click here to enter text.Provision of education and communication to referring providers (including emergency department physicians and primary care providers) regarding:The latest emerging CSBPR for stroke prevention*Their role and the role of the SPC in the care and management of TIA and minor non-disabling stroke patientsClick here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 2.9 - Adherence to individual prevention plansAt each stroke prevention visit with health care team members, assess patients for adherence to individualized secondary prevention plans (pharmacotherapy and lifestyle changes) ACTION PLANMRPClick here to enter text.Click here to enter text.Access to Stroke Specialists:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDPatients referred to the SPC will receive consultation, care coordination and education by physician and nurse stroke specialists.Click here to enter text.???Click here to enter text.Click here to enter text.The SPC will have access to an inter-professional group of internal and external stroke experts including neurology, internal medicine, vascular surgery, rehabilitation medicine, cardiology, neuroradiology, geriatrics, neuropsychiatry, neuropsychology, nursing, rehabilitation therapy (Physiotherapy, Occupational Therapy, Speech Therapy), social work, dietetics, pharmacy, community liaisons/navigator, and administrative support.Click here to enter text.???Click here to enter text.Click here to enter text.ACTION PLANMRPClick here to enter text.Click here to enter text.Access to Telemedicine:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDWhen required, the SPC uses telemedicine technology to increase access to services for patients living in rural and remote settings without local access to stroke specialists.Click here to enter text.???Click here to enter text.Click here to enter text.2017 Telestroke BPG 2.0 - Organization of Telestroke Services for Ongoing Stroke Assessment and Management:Telestroke services should be part of an integrated stroke services delivery plan that addresses hyperacute stroke care, acute stroke care, stroke prevention, rehabilitation, home-based, and ambulatory care to support optimal patient recovery and family support regardless of geographic location.ACTION PLANMRPClick here to enter text.Click here to enter text.Access to Diagnostic Imaging:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDNOT ACHIEVEDThe SPC has timely access to brain and vascular imaging (CT/MRI, CTA, carotid ultrasound), cardiac diagnostics (ECG, Holter, prolonged cardiac monitoring, ECHO) and laboratory services for their patients.The SPC ensures rapid access to imaging for patients who present to the emergency department based on recommended target times*. For patients referred to the stroke prevention clinic without completed imaging, the SPC ensures access to testing based on recommended target times* when indicatedClick here to enter text.???Click here to enter text.Click here to enter text.The SPC ensures agreements are in place for timely access to internal diagnostic services for all SPC patients*Click here to enter text.???Click here to enter text.Click here to enter text.If diagnostic services are not available on site, agreements are in place for timely access to diagnostic services within the region, or next closest facility providing such services within target wait times*Click here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 1.2 - Diagnostic investigations/1.2.1 Initial assessment:Patients presenting with suspected acute or recent transient ischemic attack or non-disabling ischemic stroke should undergo an initial assessment that includes brain imaging, non-invasive vascular imaging (including carotid imaging), 12-lead ECG, and laboratory investigations.Brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed within time frames based on triage category. VERY HIGH risk for Recurrent StrokeUrgent brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed as soon as possible within 24 hours An electrocardiogram should be completed without delay HIGH Risk for Recurrent Stroke These patients should receive a comprehensive clinical evaluation and investigations by a health care professional with stroke expertise as soon as possible ideally initiated within 24 hours of first contact with the health care system MODERATE (INCREASED) Risk for Recurrent Stroke These patients should receive a comprehensive clinical evaluation and investigations by a health care professional with stroke expertise as soon as possible ideally within 2 weeks of first contact with the health care system. For patients being investigated for an acute embolic ischemic stroke or transient ischemic attack, ECG monitoring for more than 24 hours is recommended as part of the initial stroke work-up to detect paroxysmal atrial fibrillation in patients who would be potential candidates for anticoagulant therapy.ACTION PLANMRPClick here to enter text.Click here to enter text.Diagnosis & Determination of Etiology:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC physician is responsible for the diagnosis of stroke type (TIA, ischemic, hemorrhagic) or other and for the determination of underlying etiology Ischemic: large-artery atherosclerosiscardio-embolismsmall-vessel occlusionstroke of other determined etiologystroke of undetermined etiologyHemorrhagic:HypertensionAmyloid AngiopathyOtherClick here to enter text.???Click here to enter text.Click here to enter text.The SPC physician is responsible for the communication of the above to care providers and patient.Click here to enter text.???Click here to enter text.Click here to enter text.ACTION PLANMRPClick here to enter text.Click here to enter text.Vascular Risk Factor Assessment, Screening & Management :CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC assesses, screens and initiates management of vascular risk factors in accordance with the current CSBPR*:Atrial fibrillationClick here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 7.1 - Detection of Atrial FibrillationPatients with suspected transient ischemic attack or ischemic stroke should have a 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation or flutter or evidence of structural heart disease For patients being investigated for an acute embolic ischemic stroke or transient ischemic attack, ECG monitoring at least 24 hours is recommended as part of the initial stroke work-up to detect paroxysmal atrial fibrillation in patients who would be potential candidates for anticoagulant therapyFor patients being investigated for an acute embolic ischemic stroke or transient ischemic attack of undetermined source whose initial short-term ECG monitoring does not reveal atrial fibrillation but a cardioembolic mechanism is suspected, prolonged ECG monitoring for at least 2 weeks is recommended to improve detection of paroxysmal atrial fibrillation in selected patients are not already receiving anticoagulant therapy but would be potential anticoagulant candidates.2017 Stroke Prevention BPG 7.2 - Prevention of recurrent stroke in patients with nonvalvular atrial fibrillationPatients with transient ischemic attack or ischemic stroke and nonvalvular atrial fibrillation should receive oral anticoagulation. In most patients requiring anticoagulants for atrial fibrillation, direct non-vitamin K oral anticoagulants (DOAC) should be prescribed in preference over warfarin For patients with ischemic stroke or transient ischemic attack and atrial fibrillation who are unable to take oral anticoagulant therapy (DOAC or warfarin), aspirin alone is recommended.For patients in whom long-term anticoagulant therapy is contraindicated, a left atrial appendage closure procedure may be considered [Evidence Level B].Blood pressureClick here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 3.0Hypertension is the single most important modifiable risk factor for stroke. Blood pressure should be assessed and managed in all persons at risk for stroke.2017 Stroke Prevention BPG 3.1 - Blood pressure assessmentAll persons at risk of stroke should have their blood pressure measured routinely, no less than once annually and more frequently based on individual clinical circumstances.Proper standardized techniques should be followed for initial and subsequent blood pressure measurement including office, home, and community testing as outlined by the Hypertension Canada Guidelines. Patients found to have elevated blood pressure (systolic greater than 130mmHg and/or diastolic greater than 85 mmHg) should undergo thorough assessment for the diagnosis of hypertension. Patients with refractory hypertension should have comprehensive investigations for secondary causes of hypertensionPatients with hypertension or at risk for hypertension should receive aggressive risk factor modification, lifestyle counseling and lifestyle modification interventions 2017 Stroke Prevention BPG 3.2 - Blood pressure managementFor patients who have had a stroke or transient ischemic attack, blood pressure lowering treatment is recommended to achieve a target of consistently lower than 140/90mm Hg.For patients who have had a small subcortical stroke, blood pressure lowering treatment to achieve a systolic target of consistently lower than 130mm Hg is reasonable.In patients with diabetes, blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke to attain systolic blood pressure targets consistently lower than 130mm Hg and diastolic blood pressure targets consistently lower than 80mm Hg.Patients who are not started on hypertensive therapy in acute care should have arrangements made for follow-up with primary care or stroke prevention service for ongoing evaluation and management Note: Blood pressure management is the responsibility of all health care team members, and initially stroke patients require frequent monitoring until they achieve target blood pressure levels and optimal therapy has been established.LipidsClick here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 4.0Patients who have had an ischemic stroke or transient ischemic attack should have their serum lipid levels assessed and aggressively managed.2017 Stroke Prevention BPG 4.1 - Lipid assessmentLipid levels, including total cholesterol, total triglycerides, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol, should be measured on all patients presenting with stroke or transient ischemic attack.2017 Stroke Prevention BPG 4.2 - Lipid managementPatients with ischemic stroke or transient ischemic attack should be managed with aggressive therapeutic lifestyle changes to lower lipid levels, including dietary modification, as part of a comprehensive approach to lower risk of first or recurrent stroke unless contra-indicated.A statin should be prescribed for secondary prevention in patients who have had an ischemic stroke or transient ischemic attack in order to achieve a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol, from baseline For individuals with stroke and acute coronary syndrome or established coronary disease, treatment to more aggressive targets (LDL-C <1.8 mmol/L or >50% reduction) should be considered.DiabetesClick here to enter text.???Click here to enter text.Click here to enter text.2017 Stroke Prevention BPG 5.0 Patients with diabetes who have had an ischemic stroke or transient ischemic attack should have their diabetes assessed and optimally managed.2017 Stroke Prevention BPG 5.1 - Diabetes screening and assessmentPatients with ischemic stroke or transient ischemic attack should be screened for diabetes with either a fasting plasma glucose, or 2-hour plasma glucose, or glycated hemoglobin (A1C), or 75 g oral glucose tolerance test in either inpatient or outpatient setting. For patients with diabetes and either ischemic stroke or transient ischemic attack, glycated hemoglobin (A1C) should be measured as part of a comprehensive stroke assessment.2017 Stroke Prevention BPG 5.2 - Diabetes managementGlycemic targets should be individualized; however, lowering A1C values to <7% in both type 1 and type 2 diabetes and stroke or transient ischemic attack, provides strong benefits for the prevention of microvascular complications.To achieve a target of A1C <7.0%, most patients with type 1 or type 2 diabetes should aim for a fasting plasma glucose or preprandial plasma glucose target of 4.0 to 7.0 mmol/L . The 2-hour postprandial plasma glucose target is 5.0 to 10.0 mmol/L. If A1C targets cannot be achieved with a postprandial target of 5.0 to 10.0 mmol/L, further postprandial blood glucose lowering, to 5.0 to 8.0 mmol/L, should be considered.Lifestyle:DietClick here to enter text.???2017 Stroke Prevention BPG 2.1 - Healthy balanced dietCounsel and educate individuals with transient ischemic attack or stroke to eat a healthy balanced diet that includes: A variety of natural and whole foods at each meal.Fewer highly processed foods which include highly refined foods, confectionaries, sugary drinks, and processed meats.A diet high in vegetables and fruit; encourage patients to choose fresh or frozen unsweetened fruit, or fruit canned in water without added/free sugars or artificial/noncaloric sweeteners; fresh or frozen vegetables without added sauce, or canned vegetables with no added salt. Lean meats, whole grains and protein from plant sources which are low in saturated and trans fats, low in cholesterol (<200 mg daily for patients at increased vascular risk) and low in sodium. Counsel and educate individuals with transient ischemic attack or stroke to follow a Mediterranean-type diet, which is high in vegetables, fruit, whole grains, fish, nuts and olive oil and low in red meat. Counsel and educate individuals with transient ischemic attack or stroke to have a total intake of free sugars that does not exceed 10% of total daily calorie (energy) intake Lifestyle:Sodium2017 Stroke Prevention BPG 2.2 - Sodium intakeCounsel and educate individuals with transient ischemic attack or stroke to have a daily sodium intake from all sources to no more than 2000 mg per day.Lifestyle:Exercise2017 Stroke Prevention BPG 2.3 - ExerciseCounsel and educate individuals with transient ischemic attack or stroke to reduce sedentary behaviors and to work towards increased activity goals as tolerated throughout their stroke recovery. Counsel and educate individuals with transient ischemic attack or stroke to participate in dynamic exercise of moderate intensity (such as brisk walking, jogging, swimming, cycling) 4 to 7 days per week, to accumulate at least 150 minutes in episodes of 10 minutes or more, in addition to routine activities of daily living. Most people who have had a stroke or transient ischemic attack should be encouraged to start a regular exercise program.Lifestyle:Weight2017 Stroke Prevention BPG 2.4 - WeightCounsel and educate individuals with transient ischemic attack or stroke to achieve a body mass index (BMI) of 18.5 to 24.9 kg/m2; or a waist circumference of <88 centimeters for women and <102 centimeters for men. Counsel and educate individuals with transient ischemic attack or stroke who are overweight to set healthy weight loss goals and develop individualized plans to achieve goals.Lifestyle:Alcohol consumption2017 Stroke Prevention BPG 2.5 - Alcohol consumptionCounsel and educate individuals with transient ischemic attack or stroke to avoid heavy alcohol use as excessive alcohol intake increases the risk of ischemic stroke and intracranial hemorrhage. Counsel and educate individuals with transient ischemic attack or stroke to follow Canada’s Low-Risk Alcohol Drinking Guidelines (2011):28 for women, no more than 10 drinks per week, with no more than 2 drinks per day most days and no more than 3 drinks on any single occasion; for men, no more than 15 drinks per week, with no more than 3 drinks per day most days and no more than 4 drinks on any single occasion.Lifestyle:Birth control/hormone replacement therapy2017 Stroke Prevention BPG 2.6 - Oral contraceptives and hormone replacement therapyEstrogen-containing oral contraceptives or hormone replacement therapy should be discouraged or discontinued in female patients with transient ischemic attack or ischemic stroke.Lifestyle:Recreational drug use2017 Stroke Prevention BPG 2.7 - Recreational drug useIndividuals with stroke and known recreational drug use that may increase the risk of stroke should be counseled to discontinue use if not prescribed for medical indications and should be provided with appropriate support and referrals to services and resources for drug addiction and rehabilitation Lifestyle:Smoking Cessation2017 Stroke Prevention BPG 2.8 - Smoking cessation (tobacco and other inhaled substances)In all health care settings along the stroke continuum, patient smoking status should be identified, assessed and documented.Provide unambiguous, nonjudgmental, and patient-specific advice regarding the importance of cessation to all smokers and others who reside with the patient.Offer assistance with the initiation of a smoking cessation attempt – either directly or through referral to appropriate resources.People who are not ready to quit should be offered a motivational intervention to help enhance their readiness to quit.A combination of pharmacological therapy and behavioral therapy should be considered in all smoking cessation programs and interventions. The three classes of pharmacological agents that should be considered as first-line therapy for smoking cessation are nicotine replacement therapy, varenicline, and bupropion. For stroke patients in hospital who are current smokers, protocols should be in place to manage nicotine withdrawal during hospitalization. Interdisciplinary team members should counsel patients, family members, and caregivers about the harmful effects of exposure to environmental (second-hand) smoke.Lifestyle:Medication adherence2017 Stroke Prevention BPG 2.9 - Adherence to individual prevention plansAt each stroke prevention visit with health care team members, assess patients for adherence to individualized secondary prevention plans (pharmacotherapy and lifestyle changes). Note: Adherence topics include medication compliance; diet management, rehabilitation therapy and/or exercise participation, and other areas specific to each patient.The SPC has a responsibility to initiate timely linkages and referrals to internal and external behavioral management programs and services to address risk factors and patient/caregiver needs, including referrals to tobacco cessation programs, diabetes education centre, outpatient dietitian, etc. as required*.2017 Stroke Prevention BPG 2.0 - Risk factor assessmentPersons at risk of stroke and patients who have had a stroke should be assessed for vascular disease risk factors, lifestyle management issues (diet, sodium intake, exercise, weight, alcohol intake, smoking), as well as use of oral contraceptives or hormone replacement therapy.Persons at risk of stroke should receive individualized information and counseling about possible strategies to modify their lifestyle and risk factors. Referrals to appropriate specialists should be made where required. The SPC has a responsibility to initiate medical management strategies for secondary stroke prevention in line with current CSBPR*. 2017 Stroke Prevention BPG 6.1 All patients with ischemic stroke or transient ischemic attack should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for anticoagulation.Acetylsalicylic acid (80–325 mg daily), combined acetylsalicylic acid (25 mg) and extended-release dipyridamole (25 mg/200 mg twice daily), or clopidogrel (75 mg daily) are all appropriate options and selection should depend on the clinical circumstances.2017 Stroke Prevention BPG 7.2 - Prevention of recurrent stroke in patients with nonvalvular atrial fibrillationPatients with transient ischemic attack or ischemic stroke and nonvalvular atrial fibrillation should receive oral anticoagulation. 2017 Stroke Prevention BPG 3.2 - Blood pressure managementFor patients who have had a stroke or transient ischemic attack, blood pressure lowering treatment is recommended to achieve a target of consistently lower than 140/90mm Hg.For patients who have had a small subcortical stroke, blood pressure lowering treatment to achieve a systolic target of consistently lower than 130mm Hg is reasonable.In patients with diabetes, blood pressure lowering treatment is recommended for the prevention of first or recurrent stroke to attain systolic blood pressure targets consistently lower than 130mm Hg and diastolic blood pressure targets consistently lower than 80mm Hg.Patients who are not started on hypertensive therapy in acute care should have arrangements made for follow-up with primary care or stroke prevention service for ongoing evaluation and management Note: Blood pressure management is the responsibility of all health care team members, and initially stroke patients require frequent monitoring until they achieve target blood pressure levels and optimal therapy has been established.2017 Stroke Prevention BPG 4.2 - Lipid managementA statin should be prescribed for secondary prevention in patients who have had an ischemic stroke or transient ischemic attack in order to achieve a target LDL cholesterol consistently less than 2.0 mmol/L or >50% reduction of LDL cholesterol, from baseline For individuals with stroke and acute coronary syndrome or established coronary disease, treatment to more aggressive targets (LDL-C <1.8 mmol/L or >50% reduction) should be considered.2017 Stroke Prevention BPG 2.8 - Smoking cessation (tobacco and other inhaled substances)A combination of pharmacological therapy and behavioral therapy should be considered in all smoking cessation programs and interventions. The three classes of pharmacological agents that should be considered as first-line therapy for smoking cessation are nicotine replacement therapy, varenicline, and bupropion. ACTION PLANMRPCarotid Stenosis Management:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC expedites assessment and facilitates rapid access to interventional and surgical services for patients with symptomatic carotid stenosis. Clear pathways are in place to expedite interventions in line with current CSBPR*.2017 Stroke Prevention BPG 8.1 - Symptomatic Carotid StenosisPatients with recent transient ischemic attack or non-disabling stroke and ipsilateral 50 to 99 percent symptomatic carotid stenosis should have an evaluation by a clinician with stroke expertise and selected patients should be offered carotid endarterectomy (revascularization) as soon as possible.In individuals with nondisabling stroke or transient ischemic attack and 70–99% symptomatic carotid stenosis, carotid endarterectomy should be performed, on an urgent basis.Ideally carotid endarterectomy should be performed within the first days following nondisabling stroke or transient ischemic attack and within 14 days of ischemic event onset for patients who are not clinically stable in the first few days.Carotid endarterectomy should be performed by a surgeon/center that routinely audits their performance results, especially perioperative stroke and death rates. Carotid endarterectomy is generally more appropriate than carotid stenting for patients over age 70 years who are otherwise fit for surgery as current evidence indicates stenting carries a higher peri-procedural risk of stroke and death in older patients. Carotid stenting may be considered for patients who are not operative candidates for technical, anatomic, or medical reasons.Carotid stenting should be performed by an interventionist/center with expertise that routinely audits their performance results, especially perioperative stroke and death rates. ACTION PLANMRPPatient and Family Education:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC will provide:Personalized information to support patient/family transition after their initial SPC appointment including diagnosis, medication changes, tests and referrals, follow-up plan, etc.SPC assesses patient and family knowledge, self-management capability, and learning needs for skills and coping mechanisms (for example, using HSF Post-Stroke Checklist)Multi-modal education on stroke, TIA, when to seek medical attention, risk factors, post-stroke depression, medications, community resources, etc.Aphasia friendly material and multilingual materialAccess to staff with training in supported conversationTranslation services available for patients during SPC visits if requiredACTION PLANMRPSPC Staff Education:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDSPC Staff have the responsibility to obtain appropriate training and education to remain current with updates to the CSBPR and new developments in their specialized disciplineACTION PLANMRPRehabilitation and Community re-integration:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC has the responsibility to ensure timely and appropriate referral to in-home and outpatient therapy to address specific rehabilitation needs as required.2016 Rehab BPG 1.0v All patients who present with acute stroke or TIA who are not admitted to hospital should be screened for the need to undergo a comprehensive rehabilitation assessment to determine the scope of deficits from index stroke event and any potential rehabilitation requirements.The SPC physician and/or Nurse Practitioner have the responsibility to review each patient's driving status (e.g. driver/non-driver, holds drivers' license) at the SPC appointment. National guidelines and reporting requirements are to be followed when indicated. This includes;Advising patients not to drive Physician reporting to the Ministry of Transportation2016 Rehab BPG 11A. Return to DrivingPatients should be told to stop driving for at least one month after stroke, in accordance with the Canadian Council of Motor transport Administrators (CCMTA) Medical Standards for Drivers.Patients who have experienced one or multiple TIAs should be instructed not to resume driving until a comprehensive neurological assessment (including sensorimotor function and cognitive ability) shows no residual loss of functional ability, discloses no obvious risk of sudden re-occurrence, and any underlying cause has been addressed with appropriate treatment, in accordance with the Canadian Council of Motor Transport Administrators (CCMTA) Medical Standards for Drivers.The SPC has the responsibility to initiate timely and appropriate referrals for driving evaluation (e.g. to occupational therapy) for patients with stroke deficits that may affect driving safety when the patient has a goal of return to driving.2016 Rehab BPG 11A. Return to DrivingPatients can be referred to training programs, such as simulator based training, to help prepare for a road test or the resumption of driving.ACTION PLANMRPCognition, Depression and Post-Stroke Fatigue Assessment, Screening & Management:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC assesses screens and establishes a plan to manage cognition, depression and post-stroke fatigue for selected patients when appropriate in accordance with the current CSBPR*.2016 Rehab BPG 1.0vi: Priority screening, including evaluation of safety (cognition, fitness to drive), swallowing, communication and mobility, should be completed by a clinician with expertise in stroke rehabilitation before the patients leave the emergency department or primary care setting.Additional screening should be conducted within 2 weeks of stroke onset, including impairment, functional activity limitations, role participation restrictions, environmental factors and screening for onset of depression.The SPC facilitates timely linkages and referrals to internal and/or external programs and services to address cognition, depression and post-stroke fatigue for selected patients when appropriate*.2015 Mood and Cognition BPG 1.0 and 1.1 – Post Stroke DepressionAll patients with stroke should be considered to be at high risk for PSD, which can occur at any stage of recoveryAll patients with stroke should be screened for depressive symptoms, given the high prevalence of depression poststroke, the need for screening to detect depression, and the strong evidence for treating symptomatic depression poststroke .2015 Mood and Cognition BPG 2.0 and 2.1 – Vascular Cognitive ImpairmentAll patients with clinically evident stroke or TIA should be considered at risk for VCI Patients with stroke and TIA should be considered for screening for VCI.2015 Mood and Cognition BPG 3.0 and 3.1 – Post Stroke FatiguePSF is a common condition and can be experienced after TIA and stroke at any point during the recovery process. PSF is often under-recognized; thus, healthcare professionals should anticipate the possibility of PSF, and prepare patients and families to mitigate fatigue through assessment, education, and interventions at any point during the stroke recovery continuum.Stroke and TIA survivors should be routinely asked about PSF during healthcare visits (e.g. primary care, home care, and outpatient) following return to the community and at transition points.Prior to discharge from hospital ward, stroke unit, or the emergency department, the stroke survivors, their families, and informal caregivers should be provided with basic information regarding the frequency and experience of PSF ACTION PLANMRPQuality Assurance:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC has mechanisms in place to monitor and measure outcomes for stroke prevention and engages in ongoing quality assurance and process improvement.ACTION PLANMRPCommunication to External Care Providers:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC has the responsibility to ensure that the plan of care for ongoing management is communicated to the primary care provider, referring physician and other care providers as appropriate.ACTION PLANMRPFollow-Up Care:CORE ELEMENTCURRENT STATESTATUSSTRATEGIES USED TO ACHIEVE TARGETBARRIERS TO ACHIEVING TARGETNOT ACHIEVEDPARTIALLY ACHIEVEDFULLY ACHIEVEDThe SPC has the responsibility to ensure that follow-up care is in place after the initial SPC visit. This may occur in the SPC, primary care or other care settings as appropriate.ACTION PLANMRPThis document has been prepared by Aline Bourgoin (Champlain Regional Stroke Network/The Ottawa Hospital) and Lisa Fronzi (Hamilton Health Sciences Centre) on behalf of Core Elements for Stroke Prevention Clinics in Ontario Implementation Task Group (November 2017) ................
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