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Patient and Family Resource Centre


District Stroke Patient and Family Resource Centre

 

 

 

 

 

 

 

Guiding Principles

  • We provide best practice stroke care and seamless transition across the stroke continuum;
  • We provide leadership and support to our community hospital partners in advancing stroke care throughout York Region and beyond;
  • We provide patient and family centered care;
  • We adhere to current Best Practice Recommendations for Stroke developed by the Canadian Stroke Network;
  • We strive to ensure the right patient is in the right bed at the right time;
  • We place an emphasis on stroke prevention across the continuum of care;
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We commit to collaborate on system and regional population issues related to cardiovascular wellness and care.

 

Goals and Objectives Across the Continuum

 

Stroke Prevention Clinic

  • We provide rapid access to assessment and investigation of the underlying cause of Transient Ischemic Attack/Minor Non-Disabling Stroke (TIA/MNDS);
  • We initiate interventions based on current best practices to address risk factors and the underlying cause, working in a timely manner to prevent a full stroke.
  • We provide education on lifestyle and risk management, stroke prevention and warning signs for stroke.
  • We facilitate referral of appropriate patients to local Cardiovascular Rehabilitation services for ongoing secondary prevention and chronic disease management.
  • We facilitate linkage to community programs for secondary prevention and chronic disease management.

Hyper-acute

  • We provide timely access to diagnostic testing – CT completed within 25 minutes;
  • We provide thrombolysis (t-PA) to all eligible patients within 60 minutes of arrival to Mackenzie Health;
  • We refer all patients with TIA/MNDS not requiring admission, to a Stroke Prevention Clinic.

Acute

  • We provide all patients with stroke access to evidence-based stroke care;
  • We provide initial inter-professional assessment of all patients admitted with stroke within 48 hours;
  •  We strive to minimize complications of stroke through the use of validated screening tools: Toronto Bedside Swallowing Screening Test (Tor-BSST); falls risk assessment; Braden Scale Skin Assessment ; PHQ-9 Depression screening; continence assessment;
  • We initiate secondary stroke prevention through education and support with lifestyle changes, risk management and administration of recommended secondary prevention medications;
  • We complete the Alpha FIM®on all patients on day 3 – 5 in order to ensure appropriate sub-acute stroke care;
  • We follow evidence-based clinical pathways;
  • We ensure all stroke patients have access to rehabilitation based on standardized criteria and assessment tools.

Rehabilitation

  • We provide all patients with stroke access to evidence-based stroke care;
  • We provide timely initial interprofessional assessment of all patients admitted with stroke aligned with most recent best practices recommendations;
  • We complete the  Functional Independence Measure (FIM)® on all patients on day 3 – 5 in order to ensure appropriate sub-acute stroke care ;
  • We provide best practice interprofessional rehabilitation, tailored to each patients’ needs and functional goals;
  • We use evidence-based techniques and equipment to ensure optimal therapeutic value and achieve optimal outcomes;
  • We prevent complications of stroke through the use of validated screening tools: Toronto Bedside Swallowing Screening Test (Tor-BSST); falls risk assessment; Braden Scale Skin Assessment ; PHQ-9 Depression Screening; continence assessment;
  • We provide instruction to families and caregivers upon request to promote carry-over of rehabilitation concepts and techniques.
  • We initiate secondary stroke prevention through education and support with lifestyle changes, risk management and administration of recommended secondary medications.

Community Reintegration

  • We provide seamless transition back into the community through a comprehensive discharge plan and follow up discharge phone calls;
  • We refer all eligible patients to a Stroke Prevention Clinic for follow-up and referral to Cardiovascular Rehabilitation, if indicated (see Stroke Prevention Clinic);
  • We provide accessible information to all patients and their family members regarding community resources;
  • We initiate referrals for all patients requiring out-patient rehabilitation and / or other community services;
  • We support and plan community services that address current gaps in stroke care across York Region and Central LHIN.

 

 

Mackenzie Health / 10 Trench St. Richmond Hill, On. L4C 4Z3 / Richmond Hill Line: 905-883-1212 or Vaughan Line: 905-832-4554 / TTY Service: 905-883-2123