Stroke and Rehabilitation

• Provide patient and family centered care that reflects the RVH MY CARE strategic plan
• Provide care that reflects the Canadian Best Practice Recommendations for Stroke Care
• Value roles and perspectives of patients and families in the recovery journey
• Provide compassionate and hopeful care and instill trust for patients and families
• Work together with patients and families and think big to maximize recovery and optimize quality of life following stroke
• Provide leadership and collaborate with our community partners to advance stroke care within the Central East Stroke Region (Simcoe, Muskoka, York, Durham, Haliburton, Kawartha, and Pine Ridge geography which is included within the North Simcoe Muskoka, Central and Central East Local Health Integration Networks)

RVH provides cross continuum stroke services through hyperacute, acute and rehabilitation
(inpatient and out-patient) and stroke prevention services. Across these settings, the overarching goals of the stroke program are to:

• Provide best practice stroke care that is supported by clinical pathways, validated assessments and comprehensive care planning that reflects the Canadian Best Practice Recommendations for Stroke Care
• Conduct timely interprofessional assessment of all patients admitted using validated assessment tools

To own our clinical practice and ensure stroke care expertise within the interprofessional team through annual maintenance of stroke care competencies

• Work together with families and caregivers to address individualized education and information needs;
• Work together with our community partners to achieve smooth transitions across the stroke care continuum, ensuring quality and timely care in the right setting

Our goals are to:

• Provide timely access to appropriate assessment, screening and diagnostic testing that meets

Canadian Best Practice Recommendations for Stroke Care (Hyperacute Standards- Section 3.0)

• Provide thrombolysis (tPA) to eligible patients within 30 minutes of arrival to RVH Emergency Department and refer eligible endovascular treatment patients within 45 minutes of arrival to RVH Emergency Department
• Refer all non-admitted patients with Transient Ischemic Attacks/Nondisabling strokes to the RVH Stroke Prevention Clinic

Our goals are:

• Complete nursing admission assessments, Falls Risk and Pressure Ulcer Risk assessments within 24 hours
• Complete interprofessional team assessments on all patients with stroke within 48 hours of admission using validated assessment tools
• Minimize complications of stroke through the use of evidence based care pathways, validated screening tools and comprehensive care planning
• Initiate referral to vascular surgery for consideration of carotid endarterectomy
• Complete the Alpha Functional Independence Measure (Alpha FIM®) on all patients on day 3 of admission to support triage to the most appropriate care setting within the recommended time frames
• Access stroke prevention services for medical optimization, education, self-management and healthy lifestyle support, risk factor management

Our goals are to:

• Work together with patients and their families
• Provide best practice interprofessional rehabilitation, tailored to individual needs and functional goals;
• Empower patients and families to be active partners in the rehabilitation journey and goal setting process;
• Facilitate seamless transitions to the community through comprehensive discharge planning that includes with patients and their families and community partners
• Ensure effective communication and linkages between the Integrated Stroke Unit, the Rehabilitation Day Program and the North Simcoe Muskoka Home and Community Care Program
• Our discharge planning processes and evaluate the effectiveness of transitions through post discharge phone calls

Our goals are to:

• Provide patient and families with information about NSM Home and Community Care, community rehabilitation and other community resources, facilitate linkages and initiate referrals
• Offer eligible patients timely access to hospital based outpatient inter-professional stroke rehabilitation through the Rehabilitation Day Program
• Work together with community partners to facilitate ongoing self-management, health promotion and successful community reintegration and lifelong recovery for patients and their families
• Think big and work together with our community partners to address current gaps in stroke care within Simcoe County, NSM LHIN and Central East Stroke Region

• Provide early access to multidisciplinary assessment, diagnostic testing, treatment, and referral for patients who have been identified at high risk for stroke
• Provide education on lifestyle and vascular risk management, stroke prevention and warning signs for stroke
• Facilitate linkages to community programs including community exercise programs and cardiovascular rehabilitation for secondary prevention and chronic disease management

Admission criteria for Rehabilitation requirements:

• Be 18 years of age or older
• Have a diagnosis of: stroke, or amputation requiring prosthetic training. Patients with neurodegenerative disease as their admitting diagnosis are not eligible for admission.
• Be referred to the program by a physician, or nurse practitioner. The referral must be complete and may be returned if additional information is required
• Be medically stable and able to tolerate a minimum of three hours of therapeutic activity per day
• Have experienced the neurological event for which he or she is referred within the past 3 months and/or be a new prosthetic limb user
• Require the services of one of the following: Occupational Therapy, Physiotherapy, Speech Language Pathology, Registered Nursing, Social Work
• Not be receiving inpatient hospital care
• Not be a resident of a long term care facility
• Reside within the provider service area for Royal Victoria Regional Health Centre or has received care for the referring diagnosis at RVH
• Demonstrate rehabilitation potential and have functional goals that are attainable in a three month period