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.1 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.1
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.