Stroke AVC Guidelines for multidisciplinary allied health professional care

Allied Health Professional Care Pathway


Case Example

• Betty is a 40-year-old woman, married with no children; she lives with her husband in a first floor flat.

She works as a personal secretary in a large company.

• Betty collapsed and was admitted to the A&E department with the signs and symptoms of a stroke.

Diagnostic and assessment

• Diagnostic Radiographer – fast-tracked CT brain scan and was responsible for taking, evaluating and reporting on the scan which showed the location of the stroke and any other problems it may have caused.

• Speech and Language Therapist – on admission conducted a dysphagia screen.

• Occupational Therapist –initial interview to determine previous level of function, roles, tasks required within roles and home/community environment.
A neurophysical assessment, cognitive and perceptual screen and a functional assessment were undertaken.

Intervention

Dietitian – assessed nutritional status and requirements and risk of refeeding syndrome. A feeding regimen was planned in liaison with nursing and medical staff. The feeding process was monitored daily initially until blood results were stable.

• Physiotherapist – acute rehabilitation work with 2 physiotherapists to facilitate balance and normal movement including safe transfers and walking.

• Speech and Language Therapist – a comprehensive swallow assessment was conducted within 72 hours of admission and a communication assessment within 7 days of admission. Recommendations were made for alternative feeding, supplementary feeding and supervision. The nature of the swallowing problem was discussed with Betty and her husband and swallowing therapy exercises were advised.

• Diagnostic Radiographer – instrumental assessments with videofluoroscopy provided further information on overall swallow physiology.

• Orthoptist – a subtle 4th cranial nerve palsy caused vertical double vision on downgaze. This was originally missed by the neurology registrar, but detected by orthoptic stroke service. Temporary prisms were fitted on Betty’s glasses and she was advised how to use head movements (rather than eye movements) to look down, and to use separate reading glasses rather than bifocals, which helped eliminate double vision for everyday tasks. Regular follow-ups were required to change prisms during recovery.

• Occupational Therapist – worked with Betty to assist her in achieving occupational goals relating to identified self-care, leisure and work activities.
• Physiotherapist - assessed within 72 hours of her admission and short and long term goals were set with Betty and her husband.

Follow up and rehabilitation

• Diagnostic Radiographer – a follow-up CT brain scan to monitor progress. Images were taken, evaluated and reported.

• Dietitian – information regarding the long-term management and feeding process was supplied.

• Physiotherapist – 30 rehabilitation sessions over 6 weeks were undertaken at the community stroke unit.

• Orthotist – due to her loss of ability to dorsiflex her ankle Betty required an ankle foot orthosis; this gave her ankle dorsiflexion and prevented her from tripping up. In addition, she required a knee brace to prevent hyperextension of the knee.

Ongoing involvement

• Speech and Language Therapist – Betty continued to require therapy exercises for swallowing and communication difficulties and for vocational support for her return to work, social and leisure pursuits.

• Occupational Therapist – Betty required help with her home environment, including self care and meal preparation. She also needed support with her shopping and with her return to work. This included in-depth task analysis of activities required within her working life, analysis of her current skills and deficits which would impact on her roles, a visit to her work place to assess her work environment and liaison with her employers.

No Allied Health Professional Care Pathway

• Diagnostic Radiographer – without the imaging, exact diagnosis and progress of the condition were unknown and therefore management was compromised.

• Occupational Therapist - no assessment was conducted therefore cognitive and perceptual deficits were not identified. Behavioural, psychosocial and confusion issues were wrongly assumed. No rehabilitation which led to a loss of independence, inability to perform her own self-care tasks, transfers etc. Discharged with full care package and husband also had to stop work to look after Betty. Unable to leave her home which led to isolation and a lack of integration back into society. As a result there was a loss of roles and their marriage broke down. Disability benefit for life was required.

• Speech and Language Therapist - swallowing problems led to malnutrition which resulted in complications including chest infections, urinary tract infections, breakdown in skin integrity and subsequent sores and ulcers which led to delays in discharge. Communication issues reduced efficacy of rehabilitation and decision making with the family; reduction in mood and depression and behavioural problems such as aggression as a result of not being able to communicate.

• Dietitian - Betty required ongoing feeding at home and was assessed by the multidisciplinary team as a candidate for nasogastric feeding.
Arrangements were organised for home feeding.

• Physiotherapist - development of further musculoskeletal problems e.g. contractures with the need for surgery.

• Orthoptist - diplopia was not diagnosed and therefore Betty was uncertain with stairs and kerbs which led to several falls. Discharged home with double vision on downgaze. Unable to read or do close work comfortably.

• Orthotist - Betty tripped and had a fall breaking her ankle.

• Betty became housebound and needed 24 hour care, a wheelchair and hoist. Avoided going out, suffered loss of confidence and depression and was unable to return to work.

rfahp@ahpf.org.uk