Your stroke rotation is a team environment where one engages with many colleagues across medical specialties, allied health teams, and nursing. The Neurovascular Unit brings together neurology & in-patient medical care in a unique way.
Daily we meet with our allied health colleagues on The Stroke Unit, for "Bullet Rounds" at 9:45AM.
The focus of Allied Health "bullet rounds" is the following:
Discuss disposition issues for each stroke in-patient
Discuss outstanding tests, plans, consults, that are holding up discharge planning/disposition
Discuss the patient's disposition trajectory: home, home with out-patient rehab, or inter-facility transfer with in-patient rehab
for any kind of rehab an "E-Stroke" form needs to completed by the MD and each Allied Health; ask your friendly neighborhood allied health team member to show you this resource; our Allied Health Team can log you in to complete the MD portion.
Discuss transfers in / out of the stroke unit; for example tPA and EVT patients who are in the ICU, and readiness for transition out of the stroke unit.
STROKE ROTATION ORIENTATION
Please Checkout Pharmacy Services for additional Important Information from Our Pharmacy Team, regarding the general care of stroke patients and How-To perform Medication Transfer Reconciliation on admitted or transferred patients!
See ward patient under the stroke service first before the day gets busy
Phone-in consults to other services early in the day
On admission use Templates/Work-flows to help standardize the admission process and pending investigations; allow your admission note to transition seamlessly to a progress note, and ultimately a discharge note
Keep the sign-out list updated
Provide daily handover to at 5PM On-call Stroke Neuro resident and Receive daily handover
Key points to consider to made for a great stroke rotation
excellence in patient care
efficient and concise handover
disposition and discharge planning
See the in-patients first (i.e. patients admitted under the stroke service on B4 or bed-spaced to other wards)
Designate MD Roles in the Morning - MD1, MD2
Daily check of Medication Reconsiliation on Sunnycare
Provide handover: On-call Stroke Neuro resident
Daily at 5PM - Sr/designate to handover to On-call Stroke Neuro resident
Daily at 8AM - Sr/designate to receive Handover from On-call Stroke Neuro resident
Update the Sign-out List daily
Flow of Stroke Patients (during the acute Code Stroke) phase:
Flow diagram of patients during a Code Stroke activation. This is meant as a general guide/outline of our current processes. Please note that each individual case needs consideration.
First questions to ask during code stroke
Last seen well?
Did you bypass a hospital? (repatriation implication)
acute medical history, clinical course on scene, glucose, BP; any deterioration on transport
TPA contraindications - antiplatelets, anticoagulants, recent surgery, recent trauma, recent stroke/TIA, malignancy, etc...
If the patient looks unstable ask for help early - ED/Emerg MD or Critical Care consult - ED first to stabilize the patient/airway management
Stroke patients are admitted to the hospital from the following routes:
Direct presentation to ED (i.e. hospital catchment - pt walks in/EMS brings patient to the base institution)
"Walk-in Protocol" - our hospital partners will send strokes directly from their ED to our hospital for assessment - these are then activated as a code stroke on arrival - referring hospitals include:
North York General Hospital
Scarborough Hospitals (Birchmount, General)
If these patients are not treated with TPA/EVT, and/or if they need admission to hospital, they are repatriated from the ED to their home hospital.
from CVH - a TPA centre, we have a Drip-and-Ship model, where TPA is given at MH and CVH and patients (who are candidates meeting specific criteria) come to hospital for (consideration/treatment) EVT
CritiCall life-or-limb protocol for EVT from other hospitals
Transfer from ICU to the Stroke Unit - post-TPA or TPA/EVT after 24H of observation if there are not active medical issues.
Stroke patients are discharged from our Stroke unit to the following disposition possibilities:
Home (with CCAC, Private Support, Family)/Home with out-patient rehabilitation
Repatriation to home/bypassed hospitals
Other health facility: PCU, Long-term Care (LTC)