The Role of Stroke Team in

Post Acute Care of Stroke

Yin, Jiu-Haw, MD. Director, Stroke Center

Cheng Hsin General Hospital Taipei, Taiwan

May 29th, 2016

Stroke is a leading cause of

serious, long-term disability, the

effects of which may be

prolonged with physical,

emotional, social, and

financial consequences not only

for those affected but also for

their family and friends.

Global and regional burden of

stroke during 1990-2010

Lancet. 2014 Jan 18;383(9913):245-54

0

50

100

150

200

250

300

1990 2005 2010

Survivor

Mortality

0

50

100

150

200

250

300

1990 2005 2010 an

nu

al r

ate

(per

10

0,0

00

per

son

-ye

ars)

High-income countries Low & middle-income countries

246.32

96.45

221.19

72.33

217.26

60.54

251.93

130.49

277.48 281.12

115.06 104.98

Stroke Care Pathway

EMS

ED

Stroke unit care

REH

Long term care

Stroke Therapy Timeline

Acute Ischemic Stroke

Treatment

IV-tPA – Large & small

vessel occlusions

– Within 3 hours from onset

Intra-arterial – Mechanical

thrombectomy

– Bridging IV/IA

– Large vessel occlusion

Ischemic Stroke

IV-tPA

IA

Characteristics of Different Stroke Teams

Comprehensive Stroke Center

Primary Stroke Center

Acute Stroke Ready Hospital

Academic medical center

Tertiary care facility

Wide range of hospitals;

Standard stroke care;

Stroke unit;

Use TPA

Rural hospitals;

Basic care;

Drip and ship;

Use tele-technologies

Stroke Unit Care vs. General Ward Care

NHLBI –Framingham Heart Study

Survivors of ischemic stroke survivors ≥65 years, the following disabilities were observed at 6 months after stroke:

50% had some hemiparesis

46% had cognitive deficits

35% had depressive symptoms

30% were unable to walk without some assistance

26% were dependent in activities of daily living

26% were institutionalized in a nursing home

19% had aphasia

J Stroke CerebrovascDis. 2003;12:119–126.

10% of stroke survivors recover almost completely

25% recover with minor impairments

40% experience moderate to severe impairments that require special care

10% require care in a nursing home or other long-term facility

15% die shortly after the stroke http://www.ninds.nih.gov/disorders/stroke/stroke_rehabilitation.htm NIH National Institute of Neurologic Disorders and Stroke, updated March 13, 2014

The Continuum of Care

Acute care in hospital

Rehabilitation (subacute inpatient,

homecar, or outpatient)

Community-based system

The Post-Acute Care

Continuun

Acute Care Hospital

Community Follow-up

High

Low

Functional Status

Low High Medical Needs

PAC

• Safe • Efficient • Patient-centered • Effective • Timely • Equitable

急性後期照護團隊 (促進體系垂直整合)

醫院中心

區域醫院

區域醫院

地區醫院

居家

照護機構

照護 團隊

下轉醫院

承作醫院

出院轉銜

下轉評估

出院準備

Stroke Recovery Program

Medical

Rehab

Psycho-social

Commu-nity

Pneumonia/UTI Pain/Spasticity

Bowel/Bladder/Sex Nutrition Cognition

Seizure

Secondary Prevention

Weakness Balance Sensory

Communication Swallowing

Executive function Assistive equipment

Bracing

Depression Anxiety

Emotionalism Fatigue

Insomnia Personality change Family/Caregiver

Return to work Return to driving

Social/Leisure Finance

Inpatient Stroke Team

Stroke physician

Nurses

Physiotherapists (PTs)

Occupational therapists (OTs)

Speech and language therapists (SALTs)

Health care and therapy assistants (trained to support PTs or OTs)

Stroke Physicians

Focus on medical management and oversee patient care from admission through to discharge.

Most advocate for and contribute fully to multidisciplinary team (MDT) or interdisciplinary team (IDT) working.

Stroke Coordinators

Nurses or therapists

Core team members and work with stroke survivors, their families, and the wider stroke team from admission to discharge

Along with physicians and other stroke team members, stroke coordinators provide secondary prevention and behavior change advice aimed at helping stroke survivors reduce the risk of recurrent events.

Main Goals of Successful

Integrative Program

Functional Recovery

Secondary Prevention

Early rehabilitation Post acute care Community

supportive long term care

Risk factors Education Optimization Reinforcement

• All stroke team members can support stroke survivors in practices related to improving independence in ADLs, in increased function and mobility, and in communication.

• Should use an agreed consistent approach for each problem faced by a patient, ensuring that the patient is given the same advice and taught the same technique to ameliorate or overcome it.

Intercollegiate Stroke Working Party, National Clinical Guidelines for Stroke. 4th ed. London: Royal College of Physicians; 2012.

Change in thinking

What am I trained to do (separately) as an OT or nurse?

What does the patient need and how can this be provided collaboratively by the stroke team?

MDT or IDT?

MDT: multidisciplinary team IDT: interdisciplinary team

Teams with an IDT approach were more likely to see delivery of caregiver training as a shared responsibility, more likely to share information on caregiver training in team meetings, and more likely to check with other team members that training had been provided.

Journal of Multidisciplinary Healthcare 2015:8

加強團隊架構 有效整合醫療

個案管理師 中風中心的協調中樞！

中風病人、家屬與照顧者

急診醫學部 神經內、科 影像醫學部 復健醫學部

中風病房、護理師 高壓氧、中醫科 營養室、社福組

中風中心 品質監控

協助與支持

整合流程

實證醫學

Conclusion

Although emerging trends in stroke management have allowed more patients to survive, many are left with varying degrees of disability.

Stroke recovery is complex and dependent on many factors, and is a unique experience for each patient.

It is essential to organize a multidisciplinary team with experience in utilizing techniques to enhance recovery and avoid preventable complications.

Thank You

For Your Attention