Clinical Guidelines for Acute Stroke Management - Living on the EDge

8. Discharge Planning, Transfer of
Care and Integrated Community Care
d) Eligible patients should undergo carotid
endarterectomy as soon as possible after the
event (ideally within 2 weeks). (Grade A; Level I 431 )
e) Carotid endarterectomy should only be per<strong>for</strong>med
by a specialist surgeon at centres where outcomes
of carotid surgery are routinely audited. (Grade B;
Level I 429 )
f) Carotid endarterectomy is not recommended <strong>for</strong>
those with in<strong>for</strong>mation, reminders, self-monitoring,
rein<strong>for</strong>cement, counselling, family therapy;
(Grade B; Level I 446-448 )
> reduction in the number of daily doses;
(Grade B; Level I 446, 447 )
> multi-compartment medication compliance device;
(Grade C; Level I 449, 450 )
8.1: Inpatient rehabilitation
If ongoing inpatient rehabilitation is needed, care
should be provided in either a stroke rehabilitation unit
or a general rehabilitation unit. (Grade A, Level I 6, 19 )
8.2: Pre-discharge needs assessment
a) Be<strong>for</strong>e discharge, people with stroke and their
carers should have the opportunity to identify and
discuss their post-discharge needs (e.g. physical,
emotional, social and financial) with relevant
members of the interdisciplinary team. (✓)
b) Be<strong>for</strong>e discharge all patients should be assessed
to determine the need <strong>for</strong> a home visit prior to
discharge from hospital. (✓)
c) If needed, a home assessment should be carried
out to ensure safety and community access.
(Grade C; Level I 453 )
8.3: Carer training
Relevant members of the interdisciplinary team should
provide specific training <strong>for</strong> carers be<strong>for</strong>e the person’s
discharge home. This should include training, as
necessary, in:
> personal care techniques, communication
strategies, physical handling techniques, ongoing
prevention and other specific stroke-related
problems; (Grade B; Level II 56 )
> safe swallowing and appropriate dietary
modifications. (✓)
8.4: Care plans
a) People with stroke, their carers, the general
practitioner, and community care providers should
be involved with the interdisciplinary team in the
development of a care plan. (✓)
b) Care plans should be used and outline care in the
community after discharge, including the
development of self-management strategies,
provision of equipment and support services, and
outpatient appointments. (✓)
8.5: Discharge planner
a) A discharge planner may be used to coordinate a
comprehensive discharge program <strong>for</strong> people with
acute stroke. (Grade D; Level III-3 457 )
Key Messages
xi