Abstract

Abstract Background A Multi-Disciplinary Team (MDT) approach is instrumental to post-stroke management in the Hyper Acute Stroke Unit (HASU). There is strong evidence highlighting the importance of patients’ social needs post-stroke (UK National Clinical Guideline for Stroke, 2016) and the need for a clear plan and resource combining both health and social care. This is outlined in the National Stroke Strategy (2020-2025). Stroke care involves a cohesive multi-disciplinary approach. In 2021, members of the MDT in HASU identified a service gap and implemented a unified tool. The aim of this project was to develop a user-friendly resource “Stroke Passport” to ensure the patient was central to their own stroke journey. Methods National and international guidelines were reviewed and benchmarking of other acute services was completed. The Stroke Passport was specialised to the HASU to include key stakeholders including stroke Consultant, stroke MDT and stroke Nursing Staff. Key stakeholders contributed to the development and adjustments were made after feedback. A sample of stroke patients piloted the passport (n=10). Education was provided for staff and patients through information sessions. Results This project resulted in the development of a resource that captured the following key areas:(i)Causes of Stroke (ii) Risk Factors (iii) Stroke Team (iv) Rehabilitation Goals (v) Useful Contacts (vi) and Medication List (vii). Qualitative feedback from the pilot study included: consistent awareness into stroke type, rehabilitation goals and discharge plan. The passport was successfully implemented to meet the organisational demands of the service while including the patient’s voice and is now embedded into standard practice in the HASU. Conclusion The development and implementation of a Stroke Passport ensured inclusion of the patient central to rehabilitation goal setting and discharge planning. The project supports an integrated approach to care and allows for patient centred care from admission to safe discharge.

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