1. Education Workshop (click to go to the desired section)  Introduction to Workshop/Instructions Introduction to Workshop/Instructions  Evidence-Based Care Program Evidence-Based Care Program  Stroke Pathway Workshop Stroke Pathway Workshop Stroke

2. Introduction  This interactive workshop is designed to go along with a copy of the pathway. Keep the pathway handy as you go through the workshop to engage in the required activities.  This is a web-based workshop, and thus has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic.underlined like this  At the bottom of each page are navigational buttons to help you move through the workshop.  You can go through as much or as little of the workshop as you like at a time.  If you have any questions about how to use this workshop or the individual pathways, feel free to ask your Site Champion. Back to Start of Workshop NextBack

3. These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop clinical pathways and other evidence-based care tools based on clinical practice guidelines, that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, and the Community Care Access Centre). It is hoped that these pathways will improve: Coordination of care through more communication across professions; Continuity of care, through increased linkages among hospitals and the CCAC; Clinical outcomes, through increased usage of best practices; and Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop NextBack

4. Stroke Pathway Package  This pathway is for patients who have an ischemic stroke that are over 18 years of age.  The pathway consists of 6 parts: Clinical Practice Guideline Pre-Printed Orders Patient Pathway Clinical Pathways Acute Stage-Medical Phase Rehabilitation Phase Caregiver ’ s Handbook Caregiver Checklist Teaching Checklists Back to Start of Workshop Back to beginning of Section NextBack

5. Clinical Practice Guideline  This pathway package is based on the Heart and Stroke Foundation ’ s “ Best Practice Guidelines for Stroke ”  This guideline summarizes the evidence used in the development of this pathway.  It can be found on the GBHN website at www.gbhn.ca www.gbhn.ca Back to Start of Workshop Back to beginning of section NextBack

6. Pre-Printed Orders  There are three sets of pre-printed orders for this pathway package: Thrombolytic Patients - Emergency - 0-3 hours Non-Thrombolytic Patients Ischemic/Hemorrhagic Stroke – Rehabilitation Stage  These orders can be found in the ER and on the unit. Back to Start of Workshop Back to beginning of section NextBack

7. Clinical Pathways: 0-3 hrs  The first page of the pathway is the Emergency phase – 0-3 hours.  At the right hand side of the sheet is a place to enter the date. There are also columns to indicate the time you are caring for the patient (i.e. the shift you are working).  The rest of the page has the tasks that should be completed during that time period. Staff initial to the right of a task that is complete in the column in which they are working.  The Canadian Neurological Scale-Stroke Assessment is to be used and is included in the package as well as the guidelines for use.  The Modified Rankin Scale is to be completed as an assessment of the patients abilities prior to the stroke Back to Start of Workshop Back to beginning of section NextBack

8. Clinical Pathway: 3-24 hrs, Day2, Day 3  One of the performance indicators we are looking to achieve is #1 Completion of the Dysphasia Screening Tool (Tool and guidelines for use included). This indicator is to be inputted as “ met ”, “ not met ” or “ N/A ” not applicable.  Then, using the column for your shift, tasks are initialed as they are completed, or enter N/A and initial if they are not applicable to the patient. For example, if it is the night shift and you are not doing any patient teaching, indicate N/A and initial in the section for Psychosocial/Education under “ Introduce Patient Pathway ”.  The same follows for the next two pages Acute Day 2 and Acute day 3, up to 72 hours post admission.  The Braden Risk Assessment is to be completed Day 2 to ensure to maintain skin integrity Back to Start of Workshop Back to beginning of section NextBack

9. The first page has room for up to 3 days to chart on. Indicate the date and timeframe you are working, and then like the previous page, initial tasks as they are completed or indicate N/A and initial for tasks that are not applicable to that patient. The performance indicators #2 Interdisciplinary consults completed #3 Triage (Transition Plan) completed – need to be inputted as “met” or “not met” The next page is the “Acute – Progressive Phase” (Beyond day 6), used for patients who remain in hospital for more than 6 days. Back to Start of Workshop Back to beginning of section NextBack Clinical Pathway: Day4-6

10. Clinical Pathway: Acute Progressive Phase (beyond day 6)  The patient remains in this phase until the Patient Outcomes have been met and the patient has met all the discharge criteria listed below. When this is achieved the patient is ready for discharge.  PATIENT USING APPROPRIATE ASSISTIVE DEVICE FOR MOBILITY CAREGIVER IN RECEIPT OF INFORMATION AND DEMONSTRATVES UNDERSTANDING OF CARE MANAGEMENT OF STROKE PATIENT AT HOME AS PER TEACHING/EDUCATION CHECKLIST SKIN INTEGRITY INTACT BOWEL AND BLADDER ROUTINE ESTABLISHED  If one week passes, and the outcomes have not been met, you move to the next phase, the Transition Management/Maintenance Phase.. Back to Start of Workshop Back to beginning of section NextBack

11. Clinical Pathway: Transition Management Maintenance Phase  At this point you will notice you only need to document if outcomes have been met.  The reason for this is that the tasks remain the same from the previous phase, and the patient may remain in hospital for some time before meeting the outcomes.  For this reason, the pathway is used as a cue sheet only, and you can document on your progress notes, rather than having to initial each task every day Back to Start of Workshop Back to beginning of section NextBack

12. Clinical Pathway: Transition Management Maintenance Phase  When the patient has met all the outcomes in the Transition Management Phase, and all the discharge criteria have been met, the patient is ready for discharge.  At any point along this pathway, the patient may be referred to the Rehabilitation unit, or to another hospital. If they are, the pathway for this phase is complete. The following materials should go with the patient to the rehab unit: Discharge Criteria (copy, original stays on the chart) MAR sheet (copy, original stays on chart) Anticoagulant record (copy, original stays on chart) Teaching and caregiver checklists (copy, original stays on chart) Back to Start of Workshop Back to beginning of section NextBack

13. Clinical Pathway: Discharge Criteria  When all the indicators,outcomes, and all the discharge criteria have been met, the patient is ready for discharge regardless of where they are at in the pathway. Performance Indicators on Discharge Criteria  #4 Driving status reviewed  #5 Secondary prevention risk factors addressed Back to Start of Workshop Back to beginning of section NextBack

14. Patient Materials  This package has a patient pathway for the Acute-Medical phase, and another one for the rehabilitation stage. It explains to the patient what is happening to them while in hospital. It should be given to the patient or caregiver at admission.  There are also accompanying education materials that should be used for education of the patient and the caregivers. Heart and Stroke Foundation Booklet “ Let ’ s Talk about Stroke ” Community Resources “ Caregiver Handbook ” Back to Start of Workshop Back to beginning of section NextBack

15. Patient Materials  Along with the patient materials are two teaching checklists:  The Teaching Checklist is for patients  The Caregiver Checklist is for caregivers  Both should be used as a guideline for teaching the patient and/or caregiver. They are put on the chart and staff can document as topics are covered and understood by the patient and/or caregiver.  By the time the patient is discharged from hospital, all the topics on both checklists should be completed. Back to Start of Workshop Back to beginning of section NextBack

16. Rehabilitation Stage Pathway  If a patient is referred to the rehabilitation unit, the rehabilitation stage of the pathway begins.  It is used for both ischemic and hemorrhagic stroke patients, unlike the previous pathways that were only used for ischemic patients.  The first phase is for the assessment in the first week.  You will notice the top row is the performance indicator for this stage. This needs to be entered as met or not met.  The rest of the page includes the goals for the first week in the rehab unit. As each goal is met, indicate the date it was met and initial.  At the end of the first week, the pathway moves on to the Team Assessment Phase - Progress Summary Back to Start of Workshop Back to beginning of section NextBack

17. Rehabilitation Stage Pathway  This part of the pathway replaces your team assessment documentation. In the weekly progress meeting, this part of the pathway is filled in.  On the right hand side, enter the date of the meeting, and then each of the categories has tasks or goals that need to be entered. For example, under Continence, enter whether the patient is continent by entering C in the box to the right of it.  Each week, in the progress meeting, the discharge criteria should be consulted to see what has been met. When they have all been met, the patient can be discharged from the unit. Back to Start of Workshop Back to beginning of section NextBack

18. End of Stroke Education This is the end of the general information for the Stroke pathway. To get further information by trying the pathway on a sample patient, move to the Simulation portion of the workshop.Simulation Test your knowledge of the Stroke pathway by doing the Stroke quiz.Stroke quiz. Back to Start of Workshop NextBack Back to beginning of section

19. Simulation Try it! Let ’ s assume Nancy arrives in hospital after having a stroke. Take a look at the clinical pathway. The first page is a master signature sheet. Sign it, and then for the remainder of the pathway you can just initial as tasks are complete (if you have a Master Signature Sheet for your facility, this will not be on your pathway page). There are also some basic instructions on the first page on how to use the pathway. Each page will need a patient ID sticker. Flip to the first page of the pathway, “ Emergency Phase ” : On the first page of each pathway will be a section for comorbid conditions. Please list any conditions the patient has that may affect the care you are giving. This will help health records in coding Nancy appropriately. Back to Start of Workshop Back to beginning of section NextBack

20. Simulation Cont ’ d This page is used for the first three hours Nancy is in hospital. You will see a column on the right hand side – write in today ’ s date at the top (in some sites, this will be filled in for you). Below the date, write in the hours you will be caring for Nancy. You will then use this column to initial as each task on that page is completed. (see a sample page completed). You can use your corporate progress notes if you require further documentation(see a sample page completed). The rest of the page, and going on to the back of the page, lists the tasks that should be completed during these two hours. For example, under assessments, a chest assessment should be done. Initial in the column to the right that corresponds to your shift as each task is completed. Some tasks are not appropriate for all patients or all time frames. In these cases, you can indicate an N/A and initial to show this. (see a sample page completed)(see a sample page completed) Flip to the next page of the pathway, which is used for the remainder of the admission day, until the end of the night shift. It works the same as the first page, except is in effect longer. Be sure to indicate the time you are caring for Nancy at the top of each column. Back to Start of Workshop NextBack Back to beginning of section

21. Simulation Cont ’ d The sections are tasks that are to be completed for that day. Again, some tasks are not applicable to each patient, or to each shift. For example, if it is night shift, you will most likely not be teaching Nancy, so under “ Psychosocial Support/Education ”, you can indicate “ N/A ” and initial “ Review Patient Pathway ” and “ Start Teaching Checklist ”. (see a sample page completed) (see a sample page completed) Take a look at the indicator, at the top of the page. Performance indicators are goals we are looking to achieve in this time period. Let ’ s assume that the dysphagia tool did not get completed indicate as not met and initial Back to Start of Workshop NextBack Back to beginning of section

22. Simulation Cont ’ d On each day of all pathways, you will notice a referral to a Teaching Checklist and a Patient Pathway. Find this on the pathway. The Teaching Checklist should be on the chart and be filled in as topics are covered with Nancy. This way the next nurse on shift will know what has been covered and can continue down the list. The Patient Pathway should also be given to Nancy.Teaching Checklist Patient Pathway The Heart and Stroke Materials can be referenced to aid you in teaching. Also, the Patient Pathway should be referred to on a daily basis to help Nancy understand the plan of care. The Caregiver Checklist and Caregiver Handbook are used to help with teaching Nancy ’ s husband, who will be caring for her when she goes home.Caregiver Checklist Caregiver Handbook Back to Start of Workshop NextBack Back to beginning of section

23. Simulation Cont ’ d At the end of each day, in the Discharge Planning section (last section of each page), you will notice it says “ Assess Discharge Criteria Daily ”. This means you will need to flip to the Discharge Criteria, on a daily basis, and check if any of these goals have been met. If they have, initial and date them. Once all of these criteria have been met, Nancy is ready to go home. (see sample page completed)(see sample page completed) Let ’ s assume it is Day 4 of the pathway, and Nancy has achieved all the patient outcomes and the Discharge Criteria are completed. As soon as these criteria have been met, she can go home. Back to Start of Workshop NextBack Back to beginning of section

24. Simulation Cont ’ d If Nancy is transferred to another hospital or into CCAC care, there are instructions for this first page of the pathway. Make sure the proper materials get forwarded to the receiving hospital or the CCAC, so they can continue using the pathway. If Nancy has not met the Discharge Criteria, she now moves into the second stage of the pathway – the Acute Medical Stage. The Acute-Medical Day 4-6 of the pathway works much like Day 2 and 3. There are performance indicators that need to be inputted Indicating if they were “ Met ” or “ Not Met ” or “ N/A ”. Below that are the tasks that need to be completed for the time period.Acute-Medical Day 4-6 You will notice that the first three days are on the first page. If the patient needs to stay beyond this, you move to the Acute Progressive Stage. You then remain in the Acute Progressive Stage for up to a week. Each day, the discharge criteria should be checked. Once the discharge criteria have been met, Nancy is ready for discharge. Back to Start of Workshop NextBack Back to beginning section

25. Transition Management/Maintenance Phase If Nancy has not met the discharge criteria by 12 days, you then move into the Transition Management/Maintenance Phase. At this point, the tasks remain the same, but we have removed the columns to the right so you don ’ t have to tick them off each day as completed, since they are the same now until discharge or transfer into rehab. Nancy remains in this phase until discharge criteria have been met, or until transfer to rehab. If Nancy is transferred to the Rehabilitation Unit in Owen Sound, the Rehab stage of the pathway begins. Back to Start of Workshop NextBack Back to beginning of section

26. Rehab Simulation The Rehabilitation Stage begins with a one page (double sided) Assessment Phase. This phase lasts up to one week, and as each goal is met (they are listed in the categories down the page), you initial the date it was met.Rehabilitation Stage You will notice a performance indicator at the top of the page #1 Goals were established – when Nancy ’ s goals are established, this needs to be inputted as “ Met ”, “ Not Met ” or “ N/A ” Back to Start of Workshop NextBack Back to beginning of section

27. RehabTeam Assessment Phase  After the first week, Nancy moves into the Team Assessment Phase, similar to your weekly team assessments.  Each week, during your meeting, you will refer to this sheet and determine Nancy ’ s progress in each of the categories. For example, under Continence, you will fill out whether Nancy is Continent or Incontinent by indicating “ C ” or “ I ” in the box to the right corresponding to the week.  There are also two performance indicators for this phase, that need to be inputted as “ Met ” or “ Not Met ”, similar to the first phase. #2 Screened for mood disorders #3 Speech/Language intervention completed Monday to Friday for aphasia Back to Start of Workshop NextBack Back to beginning of section

28. Rehab continued …  The teaching checklist should have followed Nancy from her acute hospital stay. This should be referred to during your patient teaching to ensure all topics are covered before she is discharged. In addition, the caregiver checklist can be used to help with teaching Nancy ’ s husband, as he is the one that will be caring for her when she gets home.teaching checklist caregiver checklist  There is a new patient pathway for this part of her hospital stay, that should be given to Nancy and referred to during teaching and discharge planning.patient pathway Back to Start of Workshop NextBack Back to beginning of section

29. Rehabilitation Stage  Each week, the Discharge Criteria need to be looked at to determine how many have been met. Nancy should be ready for discharge when all of the indicators and discharge criteria have been met. You will notice two more performance indicators on this page that need to be inputted. #4 Secondary prevention risk factors addressed #5 Driving status reviewed  If Nancy is transferred to another hospital or to the CCAC, please note there are some parts of the pathway that need to be sent with her. These are listed on the first page of the pathway. Back to Start of Workshop NextBack Back to beginning of section

30. Stroke Quiz 1.What are the three stages of this pathway? 2.What are the three order sets included in this package? 3. What is the caregiver checklist used for? 4. What teaching materials are included in the package? Back to Start of Workshop Back Answers

31. Answers: Stroke Quiz 1.What are the 2 phases of this pathway? The Acute-Medical Phase is used from 0-3 hours through to the Transition Management Phase if needed and the Rehabilitation Stage is used for when the patient is in the Rehabilitation unit in Owen Sound. 2.What are the three order sets included in this package? The Thrombolytic Orders for those patients who are administered a thrombolytic, the Non-Thrombolytic for those who were not, and the Rehabilitation orders for those patients admitted to the Rehabilitation Unit in Owen Sound. 3.What is the caregiver checklist used for? This is put on the chart and used to make sure all the topics for caregiver teaching are covered. Each nurse/allied health provider documents as topics are covered. 4.What teaching materials are included in the package? The Heart and Stroke Foundation Booklet “Let’s Talk about Stroke” must be ordered from the District Stroke Centre@ 519-376-2121 ext #2920. The Caregiver Handbook, Community Resources and Risk Factors Checklist can be printed from the GBHN website. If you have any questions, contact the Evidence-Based Care Program or ask your Site Champion. Back to Start of Workshop Back