Definition of STROKE UNIT

This is a geographic area within the hospital designated for stroke and stroke-like patients who are in need of rehabilitation services and skilled professional care (by personnel* with special interest on stroke) that such a unit can provide.

* Personnel with special interest on stroke are MD or other paramedical people who:

• has undergone continuing education on stroke and other related activities or subspecialties on stroke,
• has been attending at least one national or international meeting on stroke in a year,
• has undergone stroke fellowship or preceptorship training on stroke,
• is a member/officer or has been a member or officer of a national or international organization devoted to stroke.

Location

The SU of the Department of Neurology and Psychiatry, Section of Neurology is located at the San Vicente Ferrer Ward of the University of Santo Tomas Hospital. It is an “open ward” with 5 bed facility equipped with the following: cardiac monitor, pulse oximeter and other neurodiagnostic tests available for 24 hours.

Staff

The Stroke unit will be manned by the following:

1. Neurologists
2. Stroke Fellow
3. Neurology resident
4. Nursing staff

A Stroke Team will be formed and will consist of the following:

1. Neurologists
2. Stroke fellow
3. Neurology resident
4. Rehab medicine specialist/physiatrist
5. Emergency Room physician
6. Neurosurgeon
7. Radiologist (neuroradiologist-CT, MRI, angio)
8. Nutritionist
9. Social worker

Admissions and Discharges

• Criteria for admission at the SU:

Inclusion Criteria:

• Acute stroke (within 7 days)
• Awake, somnolent, Rankin scale 4 and below.
• Fluctuating or progressing symptoms
• TIA with high stroke risk (NVAF, carotid stenosis)
• Unstable parameters
• Patients for thrombolysis or anticoagulation
• New investigational treatment / procedures

Exclusion criteria:

• febrile patients transferred from other wards or other hospitals
• GCS 9 and below

• Patients admitted at the SU should have a neurologist as attending physician or as co-attending physician. If there is no attending neurologist, the neurologist of the month will be designated as such.
• The Stroke fellow and / or Neurology resident assigned at the SU will be responsible for the care of the patients.
• All admissions to stroke unit will make use of the stroke admission form. Other orders should be written on the physician’s order sheet.
• The Stroke unit nurses will be responsible for the monitoring of patients.
• The staff of the SU (or Stroke Team) with the attending neurologist or attending non-neurologist, if available will hold a weekly Multidisciplinary Team meeting and come up with a comprehensive recommendation on patients admitted at the SU. The attending neurologist will be provided with the recommendations from the Stroke Team.
• In cases where a patient would deteriorate, immediate transfer to the appropriate intensive care should be facilitated and done.

The Head of the SU

A neurologist will be the head of the SU. He is expected to perform the following duties:

• Manage and supervise the everyday activities of the unit.
• Supervise the training of residents and fellows assigned in the unit.
• Carry out weekly Multidiciplinary Team conference with the SU staff or the stroke team.
• Maintain a Stroke registry.
• Together with the stroke team, provide the attending physician/neurologist with a comprehensive evaluation and recommendations of their patient as to: neuro status, impairment, disability, and handicap status.
• Provide a periodic report of the activities and census of the unit.
• Formulate strategies to make the hospital staff and the public to be aware of the existence of the stroke unit in our hospital.
• Prepare necessary papers such as Daily Coordinated Pathway, educational brochures for patients, relatives and other caregivers.

GENERAL NEUROLOGY WARD

All stroke patients admitted in the general ward are evaluated by the Stroke Service and enrolled in the stroke registry. Relevant suggestions made by the stroke service during the weekly stroke meetings are relayed to the corresponding attending physician.

OUT PATIENT STROKE CLINIC

Follow-up of stroke patients is conducted by the stroke fellow every Monday 10-12AM at the Out-patient Department of the University of Santo Tomas Hospital

DIAGNOSTIC EXAMINATIONS

Transcranial Doppler

The acquisition of a transcranial Doppler machine has allowed more complete and objective evaluation of risk factors/complications among stroke patients. Although not yet in formal operation, the examination has been offered to 10 patients over the period of 2 weeks, with cases ranging from subarachnoid hemorrhage, vertebrobasilar insufficiency, and cerebral infarction.

COOPERATING DISCIPLINES

The following are the various disciplines involved:

• Neurosurgery
• Neuro-radiologist/Interventionist
• Psychiatry
• Rehabilitation Medicine
• Speech pathology & Occupational Therapy
• Nursing
• Dietary Service
• Social Worker

Representatives from each discipline are represented during the Stroke Meetings that are held every Wednesdays at 8AM. During this time, all stroke cases seen by the Stroke Service within the past 7 days are discussed. The Stroke Fellow presents relevant articles regarding the various cases. Strategies to optimize treatment for each patient are then tackled.

Because of cooperation with various disciplines, treatment options that are in accordance with international standards can now be routinely provided to acute stroke patients. In December 2005, intravenous thrombolysis was administered to a stroke patient for the first time at the University of Santo Tomas Hospital. In the same month, 2 cases of subarachnoid hemorrhage secondary to a ruptured aneurysm underwent coiling, instead of the traditional surgical approach. The capability of the hospital to provide intra-arterial thrombolysis is now being explored.