Patient Pathway Stroke Discharge Issues 19 th September 2007 Thérèse Jackson Consultant OT in Stroke NHS Grampian

GP identifies patient at risk of stroke BP maintained below 140/85 Risk factors identified and managed Health promotion Advised on lifestyle modification smoking/diet/exercise Primary prophylaxis TIA suspected Refer to neurovascular clinic (or specialist team) for investigation. Or DOME OP or day hospital, General Medicine O/P clinic GP notified of recommendations Secondary prophylaxis Suspected stroke Moray Diagnosis of stroke Emergency medical treatment Manage complications CT scan & other investigations Aberdeen A&E/AMAU/DOME Dr Gray’s (?Stroke beds) Outlying wards Home Community Rehab Social services Alternative care ASU Woodend Wards 6 & 12 Stroke Rehab CHSS Stroke nurses Follow up clinic Outlying wards DOME Intermediate care Community Hospitals

BP maintained below 140/85 Risk Factors identified and managed Primary prophylaxis GP identifies patient at risk of stroke Health Promotion Advised on lifestyle modification - smoking/diet/ exercise TIA suspected Refer to neurovascular clinic, stroke prevention clinic or specialist team for investigation. DOME O/P clinic or Day Hospital Gen med. O/P clinic GP notified of treatment Secondary prophylaxis

Suspected stroke Moray – Dr Grays Diagnosis of stroke Emergency medical treatment Manage complications CT Scan/investigations Aberdeen A&E/AMAU/DOME Dr Gray’s ?Stroke beds Outlying Wards Community hospitals Home Community Rehab Social Services Alternative care ASU Woodend Wards 6 and 12 (Stroke Rehab) CHSS Stroke nurses Follow up Clinic ARI Wards (MST) DOME Intermediate care

Stroke Rehabilitation in Grampian Referral Community Hospitals No designated stroke beds Dr Grays (8 designated stroke beds) Acute / rehab Wd 11 ASU Specialist MDT Mobile stroke Team (outlying ARI wards) Rehabilitation -Wd`s 6 &12 Woodend ( Fraserburgh Hospital Stroke Unit) -FTST - DOME/DH -Community hospital rehab beds Community Therapy Aberdeenshire N, S and Central community therapy services Aberdeen City CHP Community Therapy Services Horizons Rehabilitation Services Deeside Community Therapy Team Kincardine Community Hospital Spynie rehab team (Moray) Buckie Community Therapy Team