26IMPACT OF COMPREHENSIVE GERIATRIC ASSESSMENT AND EARLY COMMUNICATION IN MORE DEBILITATED PATIENTS FOLLOWING STROKE

Abstract

Introduction: Patients with severe strokes commonly have prolonged admissions for multifactorial reasons. With the aim of improving care and reducing length of stay, patients with more severe strokes were highlighted for prompt comprehensive geriatric assessment (CGA) with communication between patients and relatives to set realistic expectations at an earlier stage. Method: Sheffield Teaching Hospitals has separate Hyper-acute stroke units (HASU) and Acute stroke units (ASU). Neurologists and geriatricians operate a weekly 'consultant of the week' rota on HASU. On ASU, patients are under the care of geriatricians only. Patients with admission National Institute of Health Stroke Scale (NIHSS) score of 15 or more, Total-Anterior Circulation Strokes (TACS) or pre-morbid-Modified Rankin Scale of 4 or more were highlighted by a stroke pathway coordinator for geriatric consultant review, and early communication with families on HASU and ASU from July 2017 onwards. Medical notes and computer systems were retrospectively audited. Results: A total of 23 patients were audited, mean age 78. Stroke severity; 15 TACS, 8 Partial-Anterior Circulation Strokes. Mean admission NIHSS was 19. Of the 23 patients on HASU, 6 patients had geriatric consultant review when under neurology consultant care. A further 8 were admitted during geriatric consultants 'HASU week'. Of these 14 patients who underwent CGA on HASU, 9 patients had change in management following review including managing complications of stroke, discharge destination and palliation. On HASU, 82% of patients had family discussion. 17 patients were moved from HASU to ASU. Of these patients, 88% of patients had early family discussions with medical staff. Mean time from arrival on ASU to medical meeting was 8.7 days. 6 patients were palliated on ASU at first family meeting. 7 patients were planned for Per-oral Image Guided Gastrostomy (PIGG) insertion. Mean time to PIGG insertion from request was 10days. Mean time from stroke to PIGG was 32.5 days, compared with 62 days on previous audit. Mean length of stay for stroke patients discharged into a 24 hour care facility was 106 days in 2017. This has reduced to 64 days in 2018. Conclusion: Early CGA and prompt communication with relatives in patients with more severe acute stroke changed management in several HASU patients, reduced length of time from stroke to PIGG insertion, and reduced length of stay for patients requiring 24 hour care.