Andy Case Scenario

Case Scenario- rural Andy, a 63 year truck driver, was just returning to the worksite after a delivery in the country. As he approached the traffic lights leading into town, he suddenly felt dizzy and then lost his vision.

1st Medical visit Transition

 Although in a panic, he was able to radio for help and a co-worker brought him to the local Healthcare Centre. On arrival at the HCC, his vision was improving, so the ER physician did not feel admission was warranted. Arrangements were made for Andy to be seen as an outpatient at a tertiary Stroke Prevention Clinic the following day. Andy’s wife was there to drive him home, but looked alarmed when he was being discharged.

Questions / Learning 

What teaching/ information should be provided before Andy and his wife leave the Emergency Department? (Identify 5 topics and use Patient Education across the Continuum chart) a. Current diagnosis (TIA/Minor Stroke) b. Signs of stroke and what to do-call 911 c. Diagnostic tests for cause of stroke and TIA d. Information about driving after stroke or TIA e. Importance of follow up with stroke specialist f. Importance of follow up with Primary Care Physician g. Potential causes of event and risk of recurrence h. Accessing resources and stroke support following discharge

Transition Scenario

Questions / Learning 

 As a HC Provider in ED, what forms or protocols are available to you to support Andy’s transition to the next level of care? (Identify 2) a. TIA/ Minor Stroke Order Set b. Stroke Prevention clinic referral form, completed and faxed c. TIA Discharge Information Sheet/ Checklist

Transition Scenario

Questions / Learning  ( Caregiver Assessment)

 Prior to Andy and his wife leaving the ED, what caregiver assessment should be completed? a. Confirm wife’s ability to drive patient to appointment b. Determine understanding of plan of care c. Provide opportunity to express concerns, get clarity

Caregiver Dialog Link

2nd  Medical visit Transition

 Andy was seen at the SPC where he had a head CT and CT Angiogram and was found to have had a small ischemic stroke. A repeat visual exam at the SPC confirmed a persistent loss of peripheral vision and a mild balance problem. Andy was advised not to drive due to the visual deficits, and could therefore not return to work. He was given a prescription for Aspirin 81 mg and Crestor 10 mg daily and was advised to buy a Blood Pressure monitor and check his BP daily. He was also advised that he would be scheduled for a Holter Monitor test and should have some rehab therapy to assist with recovery. Andy and his wife are concerned about him not being able to drive.

Questions / Learning 

What teaching information should be provided to Andy and his wife at this stage? a. Re-enforce information given in ED b. Confirm diagnosis c. Review importance of calling 911 if new signs of stroke d. Review risk factors for stroke and confirm which apply to Andy e. Medication teaching and management f. Expectations for recovery g. Expectations for return to work h. Criteria for driving again i. Review purpose of further testing

Questions / Learning 

As a Healthcare provider, what tools and processes support Andy’s transition back to the community? a. Early completion of stroke specialists letter back to PCN physician b. Written information regarding follow up appointments c. Advise who will take over care d. Refer to local rehab department e. Advise re local stroke support groups

3rd Medical visit Transition

 Andy was seen by his family physician within 1 week of the SPC consult. His doctor reviewed recent fasting bloodwork and his blood pressure readings since the SPC clinic visit. Andy was known to have mild hypertension for a number of years, but was reluctant to take medications. Most of the recorded BP readings this week were greater than 155 systolic and greater than 100 diastolic. Andy was advised that he needed to be on medication to control this risk for stroke. As well, his fasting lipids were elevated. His Holter monitor results were not available at this appointment. Andy told his physician that he had an appointment with the OT at the Healthcare Centre that same afternoon.

Questions / Learning 

What teaching information should be reviewed at this time? a. Provide information regarding hypertension and management b. Review information regarding lipid management c. Provide information regarding CDM education and self-management programs in community d. Discuss goal setting as a strategy to make changes in lifestyle e. Support patient centered goal setting f. Discuss follow-up g. Complete depression screen as necessary Define Collaborative Care Planning and goal setting:¬¬________

4th Medical visit Transition

 Andy was assessed by an Occupational Therapist with training in visual rehabilitation. During therapy, she was able to determine the impact of Andy’s visual deficits on his finances, emotions and relationships. She was also able to identify potential safety concerns that would have to be addressed as he returned to a new normal in life.

Questions / Learning 

Define the term “Community Re-integration”:_______________ What actions can this OT take to support Andy’s return to meaningful activities of daily living? a. Screen for other deficits that may not have been initially identified ie cognitive assessments b. Do a home visit to assess for potential safety concerns c. Provide information regarding alternate transportation options d. Re-enforce information regarding local community services e. Assess for potential to return to work