Revised Case Study 2: 28 year old repeat admission

CASE STUDY: On 9/17/2013; 28 y/o female Syliva admitted through the ED for right sided numbness; headache, double vision and mild expressive aphasia. ( works at Tim Hortons) Symptoms had started 16 hours ago while at a party. No past medical history; no past medications.

• Person who brought her in says she lives alone
• Indicated not wanting to be admitted
• She does not drive

Transition Plan:
Will be transferred and admitted to stroke unit.

( we will multiple choice the questions below)

• What patient education would be best suited at this transition point?
• How do we know what the patient is ready for?
• How do we determine what the patient educational needs or desire to know is at this point?

After healthcare professional educates patient on the value of being admitted to stroke unit, patient agrees and enters stroke unit.

• What would successful patient information  between departments look like in this situation?

Patient arrived too late for acute stroke intervention, will be transferred to stroke unit.                     

Patient concerns: - what happened? It will be difficult for a 28 year old to accept they had a stroke. Patient needs:    

·         Teaching on mechanism of stroke and recovery

·         Signs and symptoms of stroke

·         Supporting return-to-work concerns

Healthcare team focus:

·         Transfer to stroke unit for rehabilitation

Hospital course: Admitted to stroke unit; consult with Neurology; NIHSS upon admission was 2; CT Head was negative for acute process, MRI of brain showed acute left pontine infarct. MRA was negative with patent carotid and vertebral arteries. Hypercoagulable workup was negative. 2D echo was negative and TEE completed.

                Stroke Team focus:

·         Complete diagnostic testing and determine stroke etiology

·         Provide appropriate treatment for patient

·         Start Rehab

·         Discharge planning

Patient’s concerns:

·         When will I get better?

·         Patient will need teaching on stroke recovery, timelines, activities to promote…

·         Describe the roles of the different therapists and other team member; inform patient of community services available to assist her once she is discharged

·         Will I be able to work?

·         Referral to Glenrose or other out-patient stroke assessment services for neuropsychology testing and Return-to-Work assessment

·         Contact employer for a discussion on modified RTW duties

·         Will I be able to function at home on my own?

·         Propose a home assessment

·         Refer to Homecare

·         Assist patient to write a list of support people to contact

·         Refer to out-patient therapy programs

·         Can I still drive?

·         Refer to Drive-Able or other driver assessment programs

·         Help patient plan alternative transportation modes

·         Discuss the impact on insurance, etc. if patient drives with a disability and is involved in an accident              

Disposition: Patient discharge home on day 5, ambulating with a mild gait disturbance; and mild dysarthria. Acute rehabilitation was recommended but patient refused. Stroke instructions were provided. Follow up appointment was made with primary care physician; TEE results were pending. Medications: Aspirin. Discharge summary suggested follow up with Cardiology for loop recorder.

                Stroke Team:

·         Provide discharge teaching – S&S of stroke, medications, importance of follow-up

·         Ensure follow-up appointments and appropriate referrals are made, and patient has contact information for each location:

·         Stroke Prevention Clinic

·         Driving assessment/RTW assessment

·         Homecare

·         Cardiology follow-up

·         Family physician

·         Arrange home assessment to determine whether patient would benefit from equipment and ADL aids.

Patient concerns:

·         When can I drive?

·         Ensure patient has contact information for driver assessment

·         When can I return to work?

·         Ensure referral is sent and patient has contact information

·         Who can I call if I have problems or concerns?

·         Stroke Navigator/Stroke Lead; Stroke Program Edmonton Zone

Patient was readmitted on 10/31/2013 for new left sided numbness, and a chronic headache x 1 month. She had stopped taking her ASA – she states ran out. Cardiac monitor showed one episode of atrial fibrillation. MRI this admission now shows tiny multiple right subacute infarcts in the left and right internal capsule. POOR TRANSITIONAL CARE: Her failed follow up; No support at home; poor understanding of condition and social situation. TEE results had no follow up; Discharge recommendations for Loop recorder were not completed. Follow up with Cardiology was not completed.

Despite our best efforts, this patient was readmitted for the same problem. What Factors Contributing to Readmission?

·         Poor health literacy

·         Poor understanding of diagnosis

·         Inability to identify signs of stroke

·         Non-compliance or poor management of personal risk factors

·         Non-compliance with Medication regime

·         No Follow- up care

·         Confusion: due to TOO MANY TRANSITIONS with multiple health care providers

What other ways can we support this patient to improve outcomes and reduce risk of recurrent events?

·         Post-stroke support group e.g. Stroke Recovery Association

·         CDM courses on risk factor management

·         Stroke learning activities e.g. Living with Stroke