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Curriculum Mapping

(Updated 2nd October 2017)

Stroke Curriculum 2010-2013

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
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 bystandersCbD, 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
Knowledge Assessment Methods GMP
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
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
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
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
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
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
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

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