Addressing modifiable risk factors after mild stroke or transient ischaemic attack

Patients are often discharged without a care plan from the acute stroke unit following a non-disabling stroke or transient ischaemic attack (TIA).

Given inactivity is one of the main risk factors for cardiovascular disease, it is important to support patients in accessing exercise and lifestyle programs, and a care plan helps to address this, and in doing so, potentially reduce secondary risk factors for stroke.

To address this issue, communication materials were developed alongside other initiatives, to support an increased incidence of exercise.

Aim

By December 2018: 100% of patients following a mild stroke or transient ischaemic attack, will be offered an exercise or lifestyle program within six weeks of discharge.

Benefits

• To enable staff to meet the Clinical Guidelines for Stroke Management 2017 which state, ‘secondary prevention strategies should be considered for all people with stroke or TIA who are not receiving palliative care’.¹
• Development of a resource package on community exercise programs to provide information to patients and reduce time constraints on therapists.
• Enable staff to provide a comprehensive discharge plan to meet patient goals.
• To reduce the burden on the healthcare system by aiming to prevent secondary strokes through lowering a patient’s modifiable risk factors.
• To provide education to patients about the risk factors for stroke and preventative strategies.
• To increase a patient’s health literacy through education.

Background

• One in four patients with a stroke will have another stroke within their lifetime.²
• Around 33% of patients discharged from acute stroke unit are discharged with a mild stroke or TIA (Modified Rankin Scale, mRS 0-1)
• Secondary prevention for patients with cardiovascular disease is a primary goal of healthcare.³
• All patients should receive a comprehensive discharge care plan that includes relevant community services and self-management strategies.⁴
• Being physically active is an important factor in preventing and managing stroke and other cardiovascular diseases.⁴
• An emerging body of evidence supports exercise and lifestyle modification programs to reduce the risk of cardiovascular disease and recurrent stroke. Knowledge of available services to refer patients towards is limited.
• The Clinical Guidelines for Stroke Management 2017 support that this segment of the patient population be advised and supported to meet national physical activity guidelines.¹

Implementation

Implementation consisted of a range of initiatives.

• Patients continued to be offered participation in the Get Healthy NSW program, with patient uptake being reviewed in relation to the current referral process.⁵
• Launch of a piloted cardiac rehabilitation style exercise program for stroke patients, run in two stages across 2018.
• Evaluation of a cardiac rehab style exercise and education program that ran for six weeks. Given two staff members are required to be present for each exercise class, the development of a revised more sustainable program is being explored.
• Provision of TIA patient information leaflets or ‘TIA packs’ were provided from the National Stroke Foundation.
• Distribution of handouts which list local exercise groups in the community.

Status

Implementation – The initiative is ready for implementation, is currently being implemented, piloted or tested.

Dates

• Start date – June 2018
• Evaluation – February 2019

Implementation sites

St George Hospital - 6 South, physiotherapy and neurology departments, with support from nursing and dietetics departments.

Partnerships

Clinical Excellence Commission Clinical Leadership Program

Results

This project highlights the need for physiotherapists to question patients about their level and intensity of physical activity, and to give recommendations and strategies in support of a more active and healthy lifestyle. This helps to empower physiotherapists to provide such detailed advice.

Data shows that:

• 91% of eligible patients received a TIA pack
• 67% of eligible patients received a handout listing available exercise classes in the community
• 31% of eligible patients accepted a referral to participate in Get Healthy NSW.

Other insights

• The handouts and TIA packs prompted patients to ask questions and seek further advice. Further evaluation will assess the number of patients that commenced an exercise program or changed their lifestyle based on these information packs.
• Two of the cardiac rehab style exercise and education program groups were trialled with positive patient feedback received, and patients attending 80% of their group sessions.
• Results also showed improvements in the ‘6 minute walk test’ by patients, with patients improving their original score by 10 to 25% by the end of the six week program.

Lessons learnt

• People are often highly motivated to improve their health after mild stroke or TIA.
• Patients have a desire to learn more about their health and want to reduce risk factors for secondary stroke or cardiac disease. The provision TIA packs, exercise programs in the area and strategies to prevent further health problems was well received.
• Participating in a safe environment at the hospital, and alongside participants with similar experiences, increased motivation and compliance for exercise.
• Widespread awareness about such resources helped to enable staff to refer patients on to such programs after discharge from an inpatient admission.
• By making handouts easily accessible, it increased the number of TIA packs given to patients.
• Collating a one-page list of available exercise services in the community helped to ensure that the information is quick and easy to provide to patients.
• Implementation of a new service model is time consuming and requires a team based approach, as well as redistribution of staffing to ensure the program’s success.

Specific challenges related to implementing the new model include the:

• amount of time taken from an already busy caseload
• requirements of setting up clinic times for assessment and referral
• provision of an ongoing program that patients could join at any time.
• awareness that some patients would likely be better catered for in a cardiac rehabilitation class as a result of more complex cardiac conditions.
• understanding that a range of patient factors impact on the willingness and ability to participate in an exercise program, such as transport, work and family commitments, cost, motivation, health, fear of gyms and not knowing what to do.

References

1. National Stroke Association. Preventing another stroke (cited Oct 2018).
2. National Heart Foundation of Australia. Secondary prevention of cardiovascular disease. National Heart Foundation of Australia: 2010.
3. National Stroke Foundation. Clinical Guidelines for Stroke Management 2017. (Cited Oct 2018).
4. NSW Health. Get healthy: information and coaching service

Further reading

• Sweetapple A, Mason G, Janssen H. Service change and supporting lifestyle and activity modification after TIA (and mild stroke). (Cited 2018 July 6)
• Deijle IA, Van Schaik SM, Van Wegen EEH, et al. Lifestyle interventions to prevent cardiovascular events after stroke and Transient Ischemic Attack: systematic review and meta-analysis. Stroke. 2017; 48: 174-179.
• Mackay-Lyons M, Gubitz G, Giacomantonio N, et al. Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (Prevent trial): a multi-centred, randomised control trial. Neurology. 2010: 10(122): 2-9.
• Prior PL, Hachinski V, Unsworth K, et al. Comprehensive Cardiac Rehabilitation for secondary prevention after transient ischemic attack or mild stroke. Stroke. 2011; 42:3307-3213.

Contact