IMPLEMENTATION OF THE ALPHAFIM® INSTRUMENT FOR STROKE PATIENTS IN ONTARIO FREQUENTLY ASKED QUESTIONS FOR CLINICIANS
The AlphaFIM® Instrument should be completed on all NEW Ischemic and Hemorrhagic strokes on or by Day 3 (target is Day 3) following admission to acute care (including repatriated patients) in Ontario. Completion of the AlphaFIM® Instrument is recommended in the Quality Based Procedures (QBP): Clinical Handbook for Stroke (2015) to inform discharge planning and align services to patient needs. 1. SHOULD I COMPLETE THE ALPHAFIM® INSTRUMENT ON ______ (TYPE OF PATIENT OR DIAGNOSIS)? A patient who was admitted to the hospital for a condition other than stroke? A palliative patient or a patient who clearly shows signs that they will soon become palliative? A patient for whom palliative care is documented as a known component of their care before they arrive at the hospital? A non-responsive patient? A patient diagnosed with TIA? (Note diagnosed with TIA ICD G45 and H34.0 (Transient Retinal Artery Occlusion)) A patient with Query Stroke or Weakness Not Yet Diagnosed with stroke-like symptoms? A patient with a subdural hematoma? A patient with a subarachnoid hemorrhage? (ICD 160 including NEW 160.8) Meningeal haemorrhage Rupture of cerebral arteriovenous malformation NEW A patient with non-pyogenic thrombosis of intracranial venous system? (ICD 167.6) Nonpyogenic thrombosis of: Cerebral vein Intracranial venous sinus A patient with intracerebral haemorrhage (ICD 161) A patient with a traumatic intracerebral hemorrhage or a patient with a traumatic brain hemorrhage that presents like stroke? A patient who falls and develops a brain hemorrhage? A patient with an intracerebral hemorrhage that is secondary to brain surgery (e.g. tumours, aneurysm rupture)? A stroke patient who is confused? A patient with central retinal artery occlusion (ICD H.34.1) Updated July 7, 2016
No (exception in-hospital strokes, see 2.I) Yes, the AlphaFIM® instrument can be scored without direct patient contact using chart abstraction. No Yes No Yes, may be diagnosed as stroke later (use your clinical judgement) No Yes
Yes
Yes No, if the hemorrhage is traumatic there would have been an incident traumatic in nature and this is not a stroke. No, regardless of where they fell No Yes, the AlphaFIM® instrument is a measure of burden of care at time of assessment. Yes 1
IMPLEMENTATION OF THE ALPHAFIM® INSTRUMENT FOR STROKE PATIENTS IN ONTARIO FREQUENTLY ASKED QUESTIONS FOR CLINICIANS
2. I KNOW I HAVE TO COMPLETE THE ALPHAFIM ON DAY 3, BUT WHEN IS DAY 3? The AlphaFIM assessment is to be completed on Day 3 after the physician orders admission to the acute care hospital setting, regardless of where the patient is physically located (e.g. Emergency Department, Intensive Care Unit, Stroke Unit). Day 1 is not the time/date of arrival in the Emergency Department or the time/date of symptom onset. This following table should help clarify Day 3: Patient was admitted on Monday, April 7th Day 1 Monday, April 7 Day 2 Tuesday, April 8 Day 3 Wednesday, April 9 I.
When is Day 1 for in-hospital strokes? What about strokes during a procedure? For in-hospital or in-house strokes, Day 3 should be considered from the time of stroke or symptom onset rather than from admission. If it is suspected that the stroke occurred during a procedure, Day 1 is the day that stroke-like symptoms are first documented or observed.
3. CONFIRMATION OF STROKE BY IMAGING AND/OR PHYSICIAN I. It is Day 3 and the CT Scan or MRI is not completed but the patient has stroke-like symptoms. Should I complete the AlphaFIM assessment? Yes, if you suspect a stroke, complete the AlphaFIM assessment. The patient’s diagnosis is likely Query Stroke already, which requires an AlphaFIM assessment be completed. II.
What if the CT scan is negative but the patient has stroke-like symptoms? Whether or not AlphaFIM assessment completion is required depends on the clinical diagnosis of stroke. If the physician has not ruled out a stroke, complete the AlphaFIM assessment.
4. RE-ASSESSING STROKE PATIENTS USING THE ALPHAFIM INSTRUMENT - SHOULD I RE-DO AN ALPHAFIM ASSESSMENT AT ANY TIME? There are some instances where the AlphaFIM assessment can be re-done, for example if there has been a significant change in function. If you do a second AlphaFIM assessment, be sure not to overwrite or erase the original score in the patient’s chart and note that the assessment is being re-done. 5. DELAYED APPLICATION TO REHABILITATION In some cases, a patient may stay in acute care for a long period of time and may have made significant functional gains since the first AlphaFIM® assessment that was completed on Day 3. A rehabilitation facility may request a more up-to-date AlphaFIM® score for the patient’s rehab application. The rule of thumb is: Updated July 7, 2016
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IMPLEMENTATION OF THE ALPHAFIM® INSTRUMENT FOR STROKE PATIENTS IN ONTARIO FREQUENTLY ASKED QUESTIONS FOR CLINICIANS
I.
The Day 3 AlphaFIM® score can be used for referral to rehabilitation within the week (seven days) following the assessment date. Re-do the AlphaFIM® assessment if there has been a significant change in function of the patient or if the referral to rehabilitation is more than one week after the initial assessment. **Use your clinical judgement; the AlphaFIM® instrument is a measure of burden of care and the score is used for determining the appropriate level of rehabilitation or care for your patient. What’s the point of doing the AlphaFIM® assessment on Day 3 if I know I will have to re-do it before the rehab application? The first AlphaFIM® score (target Day 3) will be collected by the Canadian Institute for Health Information in the Discharge Abstract Database (CIHI in the DAD) as part of Special Project 740, a provincial initiative. The information collected will allow decision makers to understand Ontario’s needs for stroke rehabilitation and inform future system planning. Completion of the AlphaFIM assessment on Day 3 is also an indicator in Quality-Based Procedures Funding Model.
6. PATIENT HAS TRANSFERRED FACILITIES I. What if I get a stroke patient who was transferred from another acute care facility? Do I need to re-do the AlphaFIM® assessment? AlphaFIM® instrument data is collected on all admitted stroke patients. If the patient has transferred to your facility, you will need to complete the AlphaFIM® assessment to support discharge planning. The AlphaFIM® assessment should be completed on Day 3 following admission to the new facility. Day 1 is considered the date of transfer or admission to the new facility.
7. PATIENT HAS HAD A SECOND STROKE SINCE BEING ADMITTED I. What if the patient was admitted for stroke and had a second stroke since being admitted? Do I have to do an AlphaFIM® assessment after their second stroke? Yes, if the patient has a second stroke during their hospital stay, re-do the AlphaFIM assessment on Day 3 following the second stroke. This may mean that the patient gets the AlphaFIM® assessment twice, but it is important to measure the patient’s burden of care following their second stroke since it may have changed as a result. Indicate on the AlphaFIM® recording form (paper or electronic) that it is the patient’s second stroke. 8. ADMINISTERING THE ALPHAFIM INSTRUMENT I. Who can administer the AlphaFIM® instrument? Updated July 7, 2016
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IMPLEMENTATION OF THE ALPHAFIM® INSTRUMENT FOR STROKE PATIENTS IN ONTARIO FREQUENTLY ASKED QUESTIONS FOR CLINICIANS Any credentialed acute care clinician can administer the AlphaFIM® instrument. Contact your Regional Stroke Rehabilitation Coordinator for information about becoming credentialed. II.
Does the assessment need to be done one-on-one with the patient? One-on-one assessment is preferred, but not necessary.
III.
Can one team member complete the entire assessment on their own without input from other interprofessional team members? Where can I get the information I need to complete the AlphaFIM® assessment? “Use the best available information. Base the AlphaFIM® ratings on the best available information. Direct observation of the patient's performance is preferred, but you may gather credible reports regarding usual performance from the patient, other staff members, and the patient's family and friends. The patient's medical record may also provide additional information about such factors as bowel accidents and inappropriate behaviors.” (The AlphaFIM® Instrument Guide, Version 4.03, 2012, p.10. Buffalo: UDSMR)
IV.
What time frame should be considered when completing the AlphaFIM® instrument? The AlphaFIM assessment completed on Day 3 should be based on the patient’s performance of activities on the day of assessment, with the exception of bowel rating which should consider the previous 24 hours.
9. WHAT IF I MISS DAY 3? If for some reason the AlphaFIM® assessment was not completed on Day 3, complete it as close to Day 3 as possible. The AlphaFIM® assessment should be completed on Day 3 regardless of where the patient is in the acute care hospital (e.g. even in the ICU the AlphaFIM® assessment should be completed on Day 3).
10. EARLY ALPHAFIM ASSESSMENTS I.
Should I complete an AlphaFIM® assessment on a patient who is anticipated to be discharged before Day 3? Yes, for patients with stroke who are anticipated to be discharged before Day 3, the AlphaFIM® assessment should be administered prior to discharge to any other setting (e.g. rehab, home, other facility).
II.
Should I do the AlphaFIM® assessment on Day 2 if I know it won’t get done on Day 3 (e.g. Day 3 is Saturday and no weekend staff are credentialed in the AlphaFIM® instrument)? The AlphaFIM® assessment should be completed as close to Day 3 as possible.
Updated July 7, 2016
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