| To undertake a clinical assessment of a suspected stroke or TIA in an adult patient referred as an emergency to hospital or in an out-patient setting
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|---|
| Knowledge |
|---|
| Functional anatomy of the brain, spinal cord and peripheral nervous system | CbD 1
|
| Anatomy and physiology of the blood supply and venous drainage of the brain and spinal cord | CbD 1
|
| Pathology of cerebrovascular disease | CbD 1
|
| Methods of assessing, including scoring systems, early risk of stroke recurrence | CbD 1
|
| Presenting features of stroke, other vascular diseases of the brain and acute neurological disorders | CbD 1
|
| Common and rare causes of stroke at all ages | CbD 1
|
| Genetic causes of stroke | CbD 1
|
| Clinical stroke classification schemes, e.g. OCSP and TOAST and their application in the research and clinical setting | CbD, mini-CEX 1 |
| Conditions that mimic stroke in the context of systemic disease | mini-CEX 1 |
| Conditions that stroke can mimic which may delay a diagnosis (stroke chameleons) | CbD,mini-CEX 1
|
| SKILLS |
|---|
|
| Ability to take a rapid and appropriately detailed neurological and cardiovascular history from patients, carers and bystanders | CbD, MSF 1,3
|
|
| Ability to receive, assess and prioritise a referral received by telephone, in person or a written referral from a general practitioner or other health professional | CbD 1,2,3 |
|
| Ability to manage acute stroke emergency admissions prioritising cases as appropriate and ensuring continuity of care in hand-over between shifts | ACAT 1,2,3 |
|
| Ability to perform a rapid and appropriately detailed neurological examination and examination of other relevant systems | mini-CEX 1 |
| Ability to formulate an appropriate differential diagnosis including stroke mimics | CbD, mini-CEX 1 |
| Ability to identify likely pathophysiological mechanism and anatomical side of stroke based on history and examination | mini-CEX 1 |
| Ability to conduct a bedside assessment of cognitive and communication function | mini-CEX 1 |
| Ability to identify functional illness mimicking stroke | CbD, mini-CEX 1 |
| Ability to perform the Glasgow Coma Score, NIH stroke score and other rating scales in stroke patients | mini-CEX 1
|
| BEHAVIOURS |
|---|
| To value the contribution of GPs and other health professionals and facilitate the rapid access of emergency patients for acute assessment | MSF 3
|
| Tolerance of communication difficulties resulting from cognitive impairment, sensory impairment, language or other factors | mini-CEX, MSF 3
|
| Ability to approach individuals identically, irrespective of gender, race, religion or age | MSF 4
|
| Appreciation of the distress caused by stroke | CbD, MSF 3,4
|
| Openness to alternative lifestyles | MSF 4
|
| Sympathetic attitude to psychiatric and functional illness | CbD, MSF 1,3,4 |
| SECTION 2: To arrange and interpret appropriate investigations to support or exclude diagnosis of a suspected stroke or TIA and its cause
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|---|
| Knowledge Assessment Methods GMP
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| Knowledge |
|---|
| Knowledge of risks of X-ray exposure and IRMER regulation relevant to patient safety | CbD 1,2
|
| Principles and Interpretation of brain and vascular imaging, including CT, MRI, perfusion imaging, cerebral angiography, carotid artery ultrasound, transcranial Doppler | CbD 1
|
| Principles and Interpretation of investigations relevant to stroke | CbD 1
|
| Principles of diagnosis of diabetes, hyperlipidaemia and hypertension in the primary and secondary prevention of stroke | CbD 1
|
| Investigation of secondary causes of hypertension | CbD 1
|
| Investigation of familial causes of dyslipidaemia | CbD 1
|
| Investigation of cardiogenic causes of stroke and their Interpretation e.g. arrhythmia and structural disease of the heart | CbD, mini-CEX 1 |
| Principles of autoimmune serology and testing for suspected vasculitis | CbD 1
|
| Principles and utility of other neurological investigations e.g. EEG, CSF |
CbD 1
|
| Role of biomarkers in diagnosis of stroke | CbD 1
|
| Investigation of conditions that mimic stroke and role of other specialties | CbD 1
|
| SKILLS |
|---|
| Ability to initiate appropriate investigations, taking into account the patient?s age and clinical features and degree of urgency | CbD 1
|
| Interpretation of CT, MRI, cerebral angiography, carotid ultrasound and other emergent techniques in suspected stroke and TIA patients | mini-CEX 1 |
| Interpretation of abnormal haematology, biochemistry, clotting, thrombophilia and autonomic investigations | CbD 1
|
| Interpretation of 12-lead ECG, 24 hour ECG and blood pressure monitoring recordings | CbD, mini-CEX 1 |
| Ability to obtain consent from a patient for invasive investigations that would likely be performed by the trainee (e.g. lumbar puncture) | mini-CEX 1,2,3
|
| Ability to explain results in lay language understood by the patient and carers | mini-CEX, MSF 1,3
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| Referral to appropriate specialties when required | CbD 2,3
|
| BEHAVIOURS |
|---|
| Appreciation of the urgency of imaging and other investigations in acute stroke | CbD 1,2
|
| Communication of rationale for (urgent) investigations to appropriate team | MSF 1,3
|
| Appreciation of the pressures on investigatory departments | CbD, MSF 1,3
|
| Sensitivity to the anxieties of patients and carers | MSF 3,4
|
| Appreciation of patient's right to refuse investigation | MSF 3,4
|
| SECTION 3: To manage hyperacute treatment for stroke TIA and common stroke mimics
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|---|
| Knowledge Assessment Methods GMP
|
| Knowledge |
|---|
| Physiology of cerebral blood flow regulation and Physiology of oxygen transport | CbD 1
|
| Pathophysiology of blood pressure and autonomic function control | CbD 1
|
| Pathophysiology of cerebral infarction and haemorrhage | CbD 1
|
| Pathophysiology of platelets, clotting mechanisms and endothelial function | CbD 1
|
| Action and side effects of drugs used in Management of stroke and TIA | CbD 1,2
|
| Potential indication of other interventional treatments (e.g. intra-arterial thrombolysis, mechanical embolectomy) | CbD 1,2
|
| Indications, contraindications and Management of intravenous thrombolysis and other interventional treatments in acute stroke | CbD 1,2
|
| Neuroprotective strategies | CbD 1
|
| Methods of non-invasive physiological monitoring | CbD 1
|
| Indications for neurosurgery in cerebral haemorrhage and cerebral infarction | CbD 1
|
| Presenting features, diagnosis and treatment of cerebral aneurysms and arteriovenous malformations | CbD, mini-CEX 1 |
| Role of MDT in detailed assessment of patient | CbD 1
|
| Management of thrombolysis and other interventional treatments | CbD, mini-CEX 1 |
| Management of stroke and TIA in pregnancy | CbD 1
|
| Management of cerebral venous thrombosis | CbD 1
|
| Causes of deterioration in acute stroke | CbD 1
|
| Indications for respiratory and cardiac support | CbD 1
|
| The evidence base to justify acute stroke treatments, including randomised trials, completed and ongoing, and the Cochrane Stroke Database | CbD 1
|
| Relevant sections of the National Service Framework, NICE appraisals, the National Clinical Guidelines for Stroke, and the National Stroke Strategy, as applied locally and more widely in the UK | CbD 1
|
| Understand that consent is a process that may culminate in, but is not limited to, the completion of a consent form | CbD 1
|
| Knowledge of strategies to break bad news | CbD 1
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| SKILLS |
|---|
| Selection of appropriate patients and safe administration of intravenous thrombolysis and other interventions including appropriate consent and supervision of post treatment Management, including complications | CbD, mini-CEX 1,2
|
| Assessment of swallowing | mini-CEX 1,2
|
| Interpretation and Management of the changes in physiological variables, including hypoxaemia, abnormal cardiac rhythms, hypotension, hypertension, hypoglycaemia and hyperglycaemia | CbD 1
|
| Assessment and Management of fluid balance | mini-CEX 1 |
| Interpretation and management of the changes in physiological variables, including hypoxia, abnormal cardiac rhythms, hypotension, hypertension, hypoglycaemia and hyperglycaemia | CbD 1
|
| Ability to formulate appropriate strategies for prevention of Deep Vein Thrombosis (DVT) and early stroke recurrence | CbD, mini-CEX 1,2
|
| Interpretation of neurological observation charts | mini-CEX 1 |
| Appropriate referrals to neurosurgery and interventional neuroradiology | CbD 1,3
|
| Ability to involve and co-ordinate the multidisciplinary team | CbD 1,3
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| Appropriate referrals to ICU | CbD 1,3
|
| Ability to impart bad news in the context of stroke disease | mini-CEX 1,3
|
| Ability to obtain consent from patients and assent from carers to treatments undertaken by the trainees | mini-CEX 1,3
|
| Recognition of and use of appropriate end of life pathways | CbD 1,3
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| BEHAVIOURS |
|---|
| Keeps up to date with advances in treatment | CbD, MSF 1,2
|
| Provide leadership to junior members of the medical team and ensure appropriate communication between all members of the team | MSF 1,2,3
|
| Show willingness to seek advanced directives and discuss their relevance in relation to severity of stroke | CbD 1,3,4
|
| Respects wishes of patients and carers regarding treatment and end of life decisions even in situations where this may not be best medical treatment | CbD, MSF 3,4
|
| Take leadership in breaking bad news | CbD, MSF 1,3
|
| Respect the different ways people react to bad news | mini-CEX, MSF 1,3
|
| To develop the attributes of someone who is trusted to be able to manage complex human, legal and ethical problems | CbD 3
|
| SECTION 4: Management of patients undergoing cerebral reperfusion therapies in acute ischaemic stroke
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|---|
| Knowledge |
|---|
| Awareness of the evidence base and registry data for intravenous thrombolysis in ischaemic stroke | CbD 1
|
| Awareness of national guidelines (e.g. NICE TA122) for intravenous thrombolysis | CbD 1
|
| Familiarity with local guidelines and protocols (on an approved training programme) | CbD 1,2
|
| Awareness of indications and contraindications for treatment | CbD, mini-CEX 1,2
|
| Understanding of the role of other interventional treatments for acute ischaemic stroke (e.g. clot retrieval) in relation to intravenous thrombolysis | CbD 1
|
| Understanding that severe neurological deficit and CT detection of early infarction are associated with adverse outcomes including bleeding risk | CbD 1,2
|
| Knowledge of thrombolysis side effects (e.g. intra / extra cranial bleeding, anaphylaxis) and their specific Management | CbD 1,2
|
| SKILLS |
|---|
| Application of evidence base for thrombolysis to individual patient cases | CbD 1,2
|
| Taking of a focussed history (with corroboration if required) including symptom time of onset and identifies if symptoms have changed | CbD, mini-CEX 1 |
| Undertaking of a detailed clinical examination relevant and perform NIHSS | mini-CEX 1 |
| Evaluating capillary sugar value | CbD, mini-CEX 1,2
|
| Arrangement of timely appropriate neuroimaging and Interpretation (with radiologist or stroke physician input where required) | mini-CEX 1 |
| Ability to undertake a discussion about benefits and risk of treatment to patients and/ or care givers | CbD, mini-CEX 1,3,4
|
| Ability to calculate alteplase dose in mg/kg as both bolus and infusion over 60 minutes | mini-CEX 1 |
| Ability to demonstrate use of the infusion pump for bolus and infusion | mini-CEX 1 |
| Ability to recognise complications of thrombolysis including neurological deterioration, signs of angioedema and shock and can initiate a treatment plan for each | CbD, mini-CEX 1,2
|
| Ability to provide a clear post thrombolysis |
| Management plan including which observations, investigations and their timing | CbD, Mini-CE 1,2
|
| Safe handover of patient to relevant medical and/or nursing staff | mini-CEX 1,2,3
|
| Ability to effectively and empathetically communicate when thrombolysis is not indicated / contraindicated following assessment | mini-CEX 1,3,4
|
| BEHAVIOURS |
|---|
| Keeps up to date with advances in treatment, research and changes to guidelines | CbD, MSF 1,2
|
| Demonstrates safe decision making and practice relevant to treatment decision | mini-CEX, MSF 1,2
|
| Seeks the help of a second / senior opinion where decisions are not clear | CbD, mini-CEX 2,3
|
| Provides leadership to other members of the treating team | mini-CEX, MSF 1
|
| SECTION 6 : To provide appropriate end-of-life care for stroke patients
|
|---|
| Knowledge |
|---|
| Determinants of prognosis after stroke and the potential impact of additional co-morbidities | CbD, mini-CEX 1 |
| How Principles of palliation relate to the complications of stroke and the care provided by multidisciplinary stroke teams | CbD 1
|
| Causes and mechanisms of deterioration and death after stroke | CbD 1
|
| Outline the role of hospital, community palliative care teams and hospice services in relation to stroke patients needs | CbD, mini-CEX 1,3
|
| Know that a referral to specialist palliative care is appropriate for patients with stroke disease | CbD, mini-CEX 1,3
|
| Understand the role of the second medical opinion in decisions about withdrawal of active treatment including medication and / or artificial nutrition and hydration in end of life decisions in stroke disease | CbD 1,2,3,4
|
| SKILLS |
|---|
| Use of palliative care models in stroke care settings | CbD 1
|
| Assessment of individual prognostic factors and the wishes of each patient during a decision to take a palliative approach following stroke | CbD, mini-CEX 1,4
|
| Conduct of appropriate discussions with patients, carers and the multidisciplinary team concerning Do not resuscitate (DNR) orders and withdrawal of medication and/or feeding in end-of-life situations | CbD, mini-CEX 1,3
|
| Referral to palliative care teams when appropriate | CbD 1
|
| Conduct of appropriate discussions with patients, carers and the multidisciplinary team concerning do not attempt cardiopulmonary resuscitation (DNA-CPR) orders and withdrawal of medication and/or feeding in end-of-life situations | CbD, mini-CEX 1,3
|
| BEHAVIOURS |
|---|
| Demonstrates awareness of stroke related influences upon end of life decisions e.g. understanding patient wishes in the presence of dysphasia and cognitive impairment | CbD, MSF 3
|
| Recognises of ethical and medico-legal guidance for issues especially relevant to palliation after stroke e.g. discontinuation of hydration and supported nutrition | CbD, MSF 4
|
| Demonstrates active |
| Management and ongoing assessment of symptoms in stroke patients undergoing palliative care | CbD, mini-CEX 1 |
| Recognises when care is complex and refers to specialist palliative care | CbD, mini-CEX 1,2,3
|
| SECTION 7 : To manage primary and secondary prevention strategies following stroke or TIA
|
|---|
| Knowledge Assessment Methods GMP
|
| Knowledge |
|---|
| Understand the influence of lifestyle on the incidence of stroke and factors that may influence the individual to change their lifestyle | CbD 1
|
| Quantification of early and subsequent predicted risk of recurrence and Knowledge of relative and absolute risk reduction resulting from specific interventions of treatments | CbD 1
|
| Awareness of evidence base for secondary prevention, current trial data and Ability to critically appraise and understand how to apply them to clinical practice | CbD 1,2
|
| Knowledge of the content and variety of guidelines relevant to secondary prevention | CbD 1
|
| Understanding the structure of service models which support rapid introduction of secondary prevention at various sties of presentation including A&E departments, GP referrals, and inpatients on general wards | CbD 1
|
| Optimum Management of hypertension, diabetes and lipid levels to maximise secondary prevention and impact of lifestyle approaches to this reduction | CbD 1
|
| Indications for cerebral revascularisation including endarterectomy, stenting and bypass surgery | CbD 1
|
| Awareness and understanding of obesity as a significant medical condition and its relationship with stroke and other medical conditions related to stroke (e.g. sleep disorders) | CbD 1
|
| SKILLS |
|---|
| Appropriate selection of secondary prevention strategies for Stroke and TIAs, including involvement of other specialists, medications or lifestyle changes | mini-CEX 1 |
| Ability to effectively and clearly communicate and explain to patients the reasons for secondary prevention in terms they understand so that compliance is improved | mini-CEX 1 |
| Communication of risk-benefit issues involved in secondary prevention. Ability to communicate clearly the absolute risk reduction of a treatment as well as risks or potential side effects of treatment | CbD, mini-CEX 1
|
| BEHAVIOURS |
|---|
| Non-judgmental attitude to lifestyle or choices about secondary prevention therapy | mini-CEX 3,4
|
| Positive proactive discussion with patients to explain treatments, lifestyle changes and other actions which will positively improve health (e.g. smoking cessation) which encourages them to ask questions and participate in self-Management | mini-CEX 3,4
|
| Awareness of age, gender and ethnic diversity issues in relation to compliance, perceptions or attitude to the benefits of secondary prevention | mini-CEX 3,4
|
| To promote the medical importance of weight loss in obesity and its maintenance | mini-CEX 3,4
|
