Effective new tool to improve Management of Stroke Patients

8th September, 2005

The Stroke Transfer of Care (ToC) document was launched nationally today, following a successful pilot, to improve the delivery and continuity of care for those who have suffered a stroke. The Stroke ToC document was developed by Dr Tony Rudd, Chair of the Intercollegiate Stroke Group and Associate Director of the Royal College of Physicians Clinical Effectiveness and Evaluation Unit, and Dr George Kassianos, a GP from Bracknell, Fellow of the Royal College of General Practitioners and Action for Stroke Group member, to facilitate the smooth transfer of stroke patients from secondary to primary care.

Stroke is a major cause of mortality and morbidity in the UK, affecting over 130,000 people each year. About a third are likely to be left disabled and needing rehabilitation. Much of the responsibility for delivering effective secondary prevention and managing longer term problems associated with stroke falls to the primary care team.

Nevertheless, the 2004 Sentinel Stroke Audit by the RCP revealed that standards for the treatment of stroke in some places remain behind those for other major conditions such as cancer and heart disease.

Continuity of care is crucial to ensure a successful outcome for the stroke patient, and a key part of the management process is the transfer of care from the secondary to primary care environment.

Dr Rudd said: “It is essential that secondary and primary care services work effectively together to achieve the best patient care. One of the most common complaints patients have is that they feel abandoned when they leave hospital. Often this is due to failure to communicate effectively. This new document is a useful tool to ensure that essential information does not get lost when care is transferred after a devastating illness.”

The Stroke ToC document captures in a concise and accessible format the information essential to seamlessly transfer stroke patients to primary care, including key information regarding:

  • Initial diagnosis.
  • Investigations undertaken.
  • Assessments on transfer.
  • Medications (including secondary prevention).
  • Lifestyle advice.
  • Rehabilitation and follow-up appointments. Home care arrangements.

Dr Kassianos commented: “This is a very important tool that ensures the details of excellent and comprehensive care of stroke patients can be recorded and passed on to primary care so that best care can continue.”

Successful pilot

The Stroke ToC document has been successfully piloted in primary and secondary care. A significant proportion of the consultants (78%) would recommend it to their colleagues and nearly all of the GPs (88%) said the document helped them manage their patients more effectively. Also, the document highlights key indicators related to the GMS contract, helping the GP to achieve GMS targets and related financial rewards.

Interestingly, the pilot revealed that almost all of the participating GPs (92%) stated that they did not receive a document similar to the ToC protocol when their patients left hospital.

Dr Michael Power, Consultant Physician in Geriatric Medicine, the Ulster Hospital, Belfast, who participated in the pilot, stated “This document is excellent. It tells GPs exactly what they need to know to confidently continue the management of their stroke patients once they leave hospital. I will definitely recommend the Stroke ToC document to my colleagues.”

The document includes a form to be completed by the hospital consultant, who then provides a copy to the GP as well as the patient. Evidence shows that patient-held records may enhance the patient’s understanding and involvement in their care, and reduce the stress frequently associated with the discharge process.

The Stroke ToC document is supplied with a card for the patient, which provides clear information regarding their medication, lifestyle advice and aftercare arrangements.

Dr Andy Mimnagh, Chairman of the Action for Stroke Group (ASG), said: “The Stroke ToC document is excellent, bridging a real communications gap and meeting the needs both of the patient and the primary care practitioners.”

“I would strongly advise every physician treating stroke patients to use this document. It is a concise and accessible tool that will provide significant practical help for the primary care team in managing stroke patients.”

“This will be of real value to all parties involved in the stroke management process and contribute to raising the standards of care.”

Getting hold of copies

A limited number of free copies are available. Physicians may obtain free copies by emailing their name, work address, and contact telephone number here. Alternatively, they may contact Berit Sund at Avenue HKM on 020 8747 4424.

A downloadable version is also available via the RPC website. The RCP website also contains information on how to order further paper copies.


Avenue HKM