Stroke

Short Text

Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)

Introduction

Introduction

This pathway covers the diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). It also includes a quality standard that covers care provided to adult stroke patients by healthcare staff during diagnosis and initial management, acute-phase care, rehabilitation and long-term management.
Stroke is a major health problem in the UK. It accounts for around 11% of deaths, results in significant morbidity in people who survive, and represents a substantial health and resource burden. Symptoms of stroke include numbness, weakness or paralysis, slurred speech, blurred vision, confusion and severe headache. A TIA is defined as stroke symptoms and signs that resolve within 24 hours.
This pathway covers interventions in the acute stage of a stroke ('acute stroke') or TIA. Most of the information relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered. There is evidence that rapid diagnosis, admission to a specialist stroke unit, and immediate brain imaging and use of thrombolysis where indicated can all contribute to a better outcome for patients. For people who have had a TIA, rapid assessment for risk of subsequent stroke allows appropriate treatment to be initiated to reduce the likelihood of stroke occurring.

Source guidance

The NICE guidance that was used to create the pathway.
Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). NICE clinical guideline 68 (2008)
Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE clinical guideline 32 (2006)
Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. NICE clinical guideline 15 (2004)
Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (review of technology appraisal guidance 90). NICE technology appraisal guidance 210 (2010)
Alteplase for the treatment of acute ischaemic stroke. NICE technology appraisal guidance 122 (2007)
Carotid artery stent placement for symptomatic extracranial carotid stenosis. NICE interventional procedure guidance 389 (2011)
Carotid artery stent placement for asymptomatic extracranial carotid stenosis. NICE interventional procedure guidance 388 (2011)
Percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism. NICE interventional procedure guidance 349 (2010)
Extracranial to intracranial bypass for intracranial atherosclerosis. NICE interventional procedure guidance 348 (2010)
Functional electrical stimulation for drop foot of central neurological origin. NICE interventional procedure guidance 278 (2009)
Endovascular stent insertion for intracranial atherosclerotic disease. NICE interventional procedure guidance 233 (2007)
Percutaneous closure of patent foramen ovale for the prevention of cerebral embolic stroke. NICE interventional procedure guidance 109 (2005)

Quality standards

Stroke quality standard

These quality statements are taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.
1Ambulance screening and stroke unit
2Neuro-imaging
3Admission of patients with suspected stroke
4Swallowing screening and nutrition management
5Assessment and management of patients with stroke
6Ongoing inpatient rehabilitation
7Ongoing rehabilitation
8Continence management
9Mood disturbance and cognitive impairments
10Ongoing outpatient rehabilitation assessment
11Carer provisions

Quality statements

Ambulance screening and transfer to an acute stroke unit

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

People seen by ambulance staff outside hospital, who have sudden onset of neurological symptoms, are screened using a validated tool to diagnose stroke or transient ischaemic attack (TIA). Those people with persisting neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, and who have a possible diagnosis of stroke, are transferred to a specialist acute stroke unit within 1 hour.

Quality measure

Structure
(a) Evidence of local arrangements to ensure that a validated tool is used by ambulance staff to screen for stroke or TIA in people with sudden onset of neurological symptoms.
(b) Evidence of local arrangements to ensure those people with persistent neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, who have a possible diagnosis of stroke, are transferred to a specialist acute stroke unit within 1 hour.
Process
(a) Proportion of people with sudden onset of neurological symptoms who are screened for stroke or TIA outside hospital by ambulance staff using a validated tool.
Numerator: the number of people screened for stroke or TIA using a validated tool.
Denominator: the number of people with sudden onset of neurological symptoms seen outside hospital by ambulance staff.
(b) Proportion of people with persisting neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, who have a possible diagnosis of stroke, who are transferred to a specialist acute stroke unit within 1 hour.
Numerator: the number of people who are transferred to a specialist acute stroke unit within 1 hour.
Denominator: the number of people with persisting neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, who have a possible diagnosis of stroke.

Description of what the quality statement means for each audience

Service providers ensure that there are agreed local policies and protocols for ambulance staff to use validated tools to screen for stroke or TIA in people with sudden onset of neurological symptoms outside hospital, and that there is immediate access (1 hour) to a specialist acute stroke unit for those with persisting neurological symptoms.
Ambulance personnel ensure that they use a validated tool to screen for stroke or TIA in people with sudden onset of neurological symptoms outside hospital. They ensure that people with persisting neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, and who have a possible diagnosis of stroke, are transferred to a specialist acute stroke unit within 1 hour.
Commissioners ensure that services are in place for ambulance staff to assess people who have sudden onset of neurological symptoms outside hospital using a validated tool. They ensure that services are in place for people with persisting neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, and who have a possible diagnosis of stroke, to be transferred to a specialist acute stroke unit within 1 hour.
People with sudden onset of neurological symptoms can expect to be assessed by ambulance staff using a validated tool to diagnose stroke or TIA. People with persisting neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded, and who have a possible diagnosis of stroke, can expect to be transferred to a specialist acute stroke unit within 1 hour.

Definitions

The goal of 1 hour set by this statement has been selected to take into account the differences between urban, rural and remote locations. However, trusts can set appropriate targets for their local service configurations.
Examples of validated tools are Face-Arm-Speech-Test (FAST) or the Recognition of Stroke in the Emergency Room (ROSIER) Scale.
Symptoms are assumed to be persistent if they are still present when ambulance staff arrive at the patient's location.

Data source

Structure
Local data collection.
Process
Trusts can collect data via the Sentinel Stroke Audit and through local data collection.

Neuro-imaging

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.

Quality measure

Structure
Evidence of local arrangements to ensure patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.
Process
Proportion of patients with acute stroke who meet any of the indications for immediate imaging who have had brain imaging within 1 hour of arrival at the hospital.
Numerator: the number of patients who have had brain imaging within 1 hour of arrival at the hospital.
Denominator: the number of patients with acute stroke attending hospital who meet any of the indications for immediate imaging.

Description of what the quality statement means for each audience

Service providers ensure facilities and protocols are available for patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.
Healthcare professionals ensure that patients under their care with acute stroke receive brain imaging within 1 hour of arrival at the hospital if the criteria for immediate imaging are met.
Commissioners ensure that services they commission enable patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.
Patients with acute stroke with any of the indications for immediate brain imaging can expect to receive this within 1 hour of arrival at the hospital.

Definitions

NICE clinical guideline 68 states that brain imaging should be performed immediately for people with acute stroke if any of the following apply:
  • Indications for thrombolysis or early anticoagulation treatment (for further information, please refer to NICE technology appraisal 122 'Alteplase for the treatment of acute ischaemic stroke'.)
  • On anticoagulant treatment.
  • A known bleeding tendency.
  • A depressed level of consciousness (Glasgow Coma Score below 13).
  • Unexplained progressive or fluctuating symptoms.
  • Papilloedema, neck stiffness or fever.
  • Severe headache at onset of stroke symptoms.

Data source

Structure
Local data collection.
Process
Trusts can collect data via the Sentinel Stroke Audit, Hospital Episode Statistics (HES) data and through local data collection.

Admission of patients with suspected stroke

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients with suspected stroke are admitted directly to a specialist acute stroke unit and assessed for thrombolysis, receiving it if clinically indicated.

Quality measure

Structure
Evidence of local arrangements to ensure that patients with suspected stroke are admitted directly to a specialist acute stroke unit and are assessed for thrombolysis, receiving it if clinically indicated.
Process
(a) Proportion of patients admitted directly to a specialist acute stroke unit and assessed for thrombolysis.
Numerator: the number of patients admitted directly to a specialist acute stroke unit and assessed for thrombolysis.
Denominator: the number of patients with suspected stroke admitted to hospital.
(b) Proportion of patients with suspected stroke assessed for thrombolysis who receive it in accordance with NICE technology appraisal guidance 122 (2007) and NICE clinical guideline CG68 (2008).
Numerator: the number of patients who received thrombolysis in accordance with NICE technology appraisal guidance 122 (2007) and NICE clinical guideline CG68 (2008).
Denominator: the number of patients with suspected stroke assessed to require thrombolysis.

Description of what the quality statement means for each audience

Service providers ensure that patients with suspected stroke are admitted directly to a specialist acute stroke unit to be assessed for thrombolysis, receiving it if clinically indicated.
Healthcare professionals admit all patients with suspected stroke directly to a specialist acute stroke unit to be assessed for thrombolysis, which is administered if clinically indicated.
Commissioners ensure services admit all patients with suspected stroke directly to a specialist acute stroke unit to be assessed for thrombolysis, which is administered if clinically indicated.
Patients with suspected stroke can expect to be admitted directly to a specialist acute stroke unit to be assessed for thrombolysis, which is administered if clinically indicated.

Definitions

Direct admission to a specialist acute stroke unit includes those who first attended emergency departments. It is not defined as transfers from other departments such as medical assessment units or emergency admission units.
Each specialist acute stroke unit should have immediate access to:
  • clinical staff specially trained in the delivery of acute medical care to stroke patients, including the diagnostic and administration procedures needed for the safe and effective delivery of thrombolysis
  • nursing staff trained in the management of acute stroke, covering both its neurological and general medical aspects
  • imaging and laboratory services
  • specialist rehabilitation staff.

Data source

Structure
Local data collection.
Process
Trusts can collect data via Stroke Improvement Programme National Project 2009-10 (SINAP), HES data and through local data collection.

Swallowing screening and nutrition management

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients with acute stroke have their swallowing screened by a specially trained healthcare professional within 4 hours of admission to hospital, before being given any oral food, fluid or medication, and they have an ongoing management plan for the provision of adequate nutrition.

Quality measure

Structure
Evidence that arrangements are in place to ensure that all people with acute stroke have their swallowing screened and have an ongoing management plan for the provision of adequate nutrition, administered by a specially trained healthcare professional.
Process
Proportion of patients with acute stroke who have their swallowing screened by a specially trained healthcare professional within 4 hours of admission to hospital, before being given any oral food, fluid or medication.
(a) Numerator: the number of patients who have their swallowing screened by a specially trained healthcare professional within 4 hours of admission to hospital, before being given any oral food, fluid or medication.
Denominator: the number of patients with acute stroke admitted to hospital.
(b) Numerator: the number of patients with an ongoing management plan for the provision of adequate nutrition.
Denominator: the number of patients with acute stroke admitted to hospital.

Description of what the quality statement means for each audience

Service providers ensure facilities and protocols are available to ensure that each patient with acute stroke has their swallowing screened by a specially trained healthcare professional within 4 hours of admission to hospital, and prior to the oral administration of food, fluid or medication, and that each patient has an ongoing management plan for the provision of adequate nutrition.
Healthcare professionals are trained to screen the swallowing of patients with acute stroke within 4 hours of admission before being given any oral food, fluid or medication, and that they implement ongoing management plans for the provision of adequate nutrition.
Commissioners ensure that services are in place for patients with acute stroke to have their swallowing screened by a specially trained healthcare professional within 4 hours of admission, prior to the oral administration of food, fluid or medication, and for the implementation of an ongoing management plan for the provision of adequate nutrition.
Patients admitted with acute stroke can expect to have their swallowing screened by a specially trained healthcare professional within 4 hours of admission, before being given any food, drink or medication by mouth, and also to have an ongoing management plan for the provision of adequate nutrition.

Definitions

Professionals trained to perform a swallow screen include nurses, doctors, and speech and language therapists.

Data source

Structure
Local data collection.
Process
Trusts can collect data via the Sentinel Stroke Audit, SINAP, HES data and through local data collection.

Assessment and management of patients with stroke

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients with stroke are assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within 5 days.

Quality measure

Structure
Evidence of local arrangements to ensure that services are commissioned to provide patients with stroke with prompt access to specialist rehabilitation services.
Process
(a) Proportion of patients with stroke assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital.
Numerator: the number of patients assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital.
Denominator: the number of patients with a new stroke episode admitted to hospital.
(b) Proportion of patients with stroke assessed and managed by all relevant members of the specialist rehabilitation team within 72 hours of admission to hospital.
Numerator: the number of patients assessed and managed by all relevant members of the specialist rehabilitation team within 72 hours of admission to hospital.
Denominator: the number of patients with a new stroke episode admitted to hospital.
(c) Proportion of patients with stroke with documented multidisciplinary goals agreed within 5 days of admission to hospital.
Numerator: the number of patients with documented multidisciplinary goals agreed within 5 days of admission to hospital.
Denominator: the number of patients with a new stroke episode admitted to hospital.

Description of what the quality statement means for each audience

Service providers ensure protocols are in place so that patients with stroke are assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within 5 days of admission to hospital.
Health and social care professionals ensure that patients with stroke are assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within 5 days of admission to hospital.
Commissioners ensure that services are in place so that patients with stroke can be assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within 5 days of admission to hospital.
Patients with stroke can expect to be assessed and managed by stroke nursing staff and by at least one member of the specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within 5 days of admission to hospital.

Definitions

Given the range of problems faced by patients with stroke, the core of the specialist rehabilitation team will include physiotherapy, occupational therapy, speech and language therapy, and psychology. Support and input from social work, dietetics, pharmacy, orthotics and orthoptics should be available as required to address patients' needs.

Data source

Structure
Local data collection.
Process
Trusts can collect data via the Sentinel Stroke Audit, SINAP, HES data and through local data collection.

Ongoing inpatient rehabilitation

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and treatment are treated in a specialist stroke rehabilitation unit.

Quality measure

Structure
Evidence of local arrangements to ensure all patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and treatment are treated in a specialist stroke rehabilitation unit.
Process
Proportion of patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and treatment who are treated in a specialist stroke rehabilitation unit.
Numerator: the number of patients who are treated in a specialist stroke rehabilitation unit.
Denominator: the number of patients who need ongoing specialist stroke rehabilitation after completion of their acute diagnosis and treatment.

Description of what the quality statement means for each audience

Service providers ensure all patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and treatment are treated in a specialist stroke rehabilitation unit.
Healthcare professionals treat patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and treatment in a specialist stroke rehabilitation unit.
Commissioners ensure that specialist stroke rehabilitation units are commissioned to treat patients who need inpatient rehabilitation after completion of their acute diagnosis and treatment.
Patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and treatment can expect to be treated in a specialist stroke rehabilitation unit.

Definitions

A specialist stroke rehabilitation unit should meet all of the following criteria:
  • It should be a discrete unit within the hospital.
  • It should have a coordinated multidisciplinary team that meets at least once a week to exchange information about patients.
  • Staff should have specialist expertise in stroke and rehabilitation.
  • Educational programmes and information should be provided for staff, patients and carers.

Data source

Structure
Local data collection.
Process
Trusts can collect data via the Sentinel Stroke Audit and through local data collection.

Ongoing rehabilitation

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it.

Quality measure

Structure
Evidence that local arrangements are in place for the provision of a minimum of 45 minutes of each active therapy for a minimum of 5 days a week that enables patients with stroke to meet their rehabilitation goals.
Process
Proportion of patients with stroke who are offered 45 minutes of each active therapy that is required, for as long as they are continuing to benefit from the therapy and are able to tolerate it.
Numerator: the number of patients who are offered a minimum of 45 minutes of each active therapy for a minimum of 5 days a week.
Denominator: the number of patients with a new stroke episode in hospital.

Description of what the quality statement means for each audience

Service providers ensure that there are agreed local policies and protocols to offer patients with stroke a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days each week, that enables them to meet their rehabilitation goals for as long as they continue to benefit from the therapy and are able to tolerate it.
Healthcare professionals offer patients with stroke a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days a week, to enable them to meet their rehabilitation goals, for as long as they continue to benefit from the therapy and are able to tolerate it.
Commissioners ensure that active therapy services are available to offer patients with stroke a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days each week, that enables them to meet their rehabilitation goals for as long as they continue to benefit from the therapy and are able to tolerate it.
Patients with stroke can expect to be offered at least 45 minutes of each active therapy, for a minimum of 5 times each week, to enable them to meet their rehabilitation goals, as long as they are continuing to benefit from it and are able to tolerate it.

Definitions

Therapy services are defined as physiotherapy, occupational therapy, and speech and language therapy. Individual patients may require treatment from other professionals such as psychology and dietetics.
Active therapy is defined as face-to face-contact, which may be individual or group treatment, and may include tele-therapy. It does not include administrative tasks related to patients.
Tolerate is defined as having sufficient physical and mental capacity to be able to participate in the treatment, and individual patients consenting to treatment.
Continue to benefit is defined as showing evidence on objective assessment of improving over time.
This standard applies to therapy delivered in both hospital and community settings.

Data source

Structure
Local data collection.
Process
Trusts can collect data via HES data and through local data collection.

Continence management

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Patients with stroke who have continued loss of bladder control 2 weeks after diagnosis are reassessed to identify the cause of incontinence, and have an ongoing treatment plan involving both patients and carers.

Quality measure

Structure
Evidence of local arrangements to ensure that patients with loss of bladder control at 2 weeks are reassessed and have treatment plans implemented involving both patients and carers.
Process
The proportion of patients with loss of bladder control at 2 weeks who were reassessed to identify the cause, and had a treatment plan implemented involving patients and carers.
(a) Numerator: the number of patients reassessed to identify the cause.
Denominator: the number of stroke patients with loss of bladder control at 2 weeks.
(b) Numerator: the number of patients with a treatment plan involving both patients and carers.
Denominator: the number of patients with stroke who have loss of bladder control at 2 weeks.

Description of what the quality statement means for each audience

Service providers ensure that all patients with loss of bladder control at 2 weeks are reassessed to identify the cause and have treatment plans implemented, involving both patients and carers.
Health and social care professionals ensure that all patients with loss of bladder control at 2 weeks are reassessed to identify the cause and have a treatment plan implemented, involving both patients and carers.
Commissioners ensure that services are in place to ensure that service providers reassess and treat all patients with loss of bladder control at 2 weeks appropriately.
Patients with loss of bladder control at 2 weeks can expect to be reassessed to identify the cause, and have a treatment plan implemented involving both patients and carers

Definitions

Patients with stroke who have continued loss of bladder control 2 weeks from diagnosis should only be discharged home with continuing incontinence after carers (family members) or patients are fully trained and adequate arrangements for social services and a continuing supply of continence aids are confirmed and in place.

Data source

Structure
Local data collection.
Process
Local data collection. Trusts can collect data via the Sentinel Stroke Audit and local data collection.

Mood disturbance and cognitive impairments

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment.

Quality measure

Structure
Evidence that patients with stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment.
Process
Proportion of patients with stroke who have been screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment.
(a) Numerator: the number of patients with stroke screened for mood disturbance using a validated screening tool within 6 weeks of a diagnosis of stroke.
Denominator: the number of patients diagnosed with a new episode of stroke.
(b) Numerator: the number of patients with stroke who have been screened for cognitive impairment within 6 weeks of diagnosis.
Denominator: the number of patients diagnosed with a new episode of stroke.

Description of what the quality statement means for each audience

Service providers ensure that there are agreed local policies and guidelines for screening patients with stroke within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment.
Healthcare professionals ensure patients with stroke are screened for mood disturbance and cognitive impairments using a validated screening tool within 6 weeks of diagnosis.
Commissioners ensure that services are in place to enable the screening of all stroke patients for mood disturbance and cognitive impairments using a validated screening tool within 6 weeks of diagnosis.
Patients with stroke can expect to be screened for mood disturbance and cognitive impairments using a validated screening tool within 6 weeks of diagnosis.

Definitions

This standard applies in both hospital and community settings. Administration of the screening tools should be conducted by trained staff.
When using validated tools to identify mood disturbance or cognitive impairments, healthcare professionals should be mindful of the need to secure equality of access to treatment for patients from different ethnic groups (in particular those from different cultural backgrounds) and patients with disabilities.

Data source

Structure
Local data collection.
Process
Local data collection. Trusts can collect data via the Sentinel Stroke Audit, SINAP and local data collection.

Ongoing outpatient rehabilitation assessment

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

All patients discharged from hospital who have residual stroke-related problems are followed-up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management.

Quality measure

Structure
Evidence of local arrangements to ensure patients discharged from hospital who have residual stroke-related problems are followed-up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management.
Process
Proportion of patients discharged from hospital with residual stroke-related problems who are followed up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management.
Numerator: the number of patients followed-up by specialist stroke rehabilitation services for assessment and ongoing management within 72 hours of discharge from hospital.
Denominator: the number of patients discharged from hospital with residual stroke-related problems.

Description of what the quality statement means for each audience

Service providers ensure that all patients discharged from hospital who have residual stroke-related problems are followed up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management.
Healthcare professionals ensure that patients with residual stroke-related problems are followed up by specialist stroke rehabilitation services within 72 hours for assessment and ongoing management.
Commissioners ensure that specialist stroke rehabilitation services are available so that all patients discharged from hospital who have residual stroke-related problems are followed up within 72 hours.
Patients with residual stroke-related problems can expect to be followed up by stroke specialist rehabilitation services for assessment and ongoing management within 72 hours of their discharge from hospital.

Data source

Residual problems can include physical problems, loss of cognitive or communication skills, anxiety, depression or other psychological problems.
Structure
Local data collection.
Process
Local data collection. Trusts can collect data via HES data, the Sentinel Stroke Audit and through local data collection.

Carer provisions

This quality statement is taken from the stroke quality standard. The quality standard defines clinical best practice in stroke care and should be read in full.

Quality statement

Carers of patients with stroke have: a named contact for stroke information; written information about patient's diagnosis and management plan; and sufficient practical training to enable them to provide care.

Quality measure

Structure
(a) Evidence of local arrangements to ensure that carers of patients with stroke have: a named contact for stroke information; written information about patient's diagnosis and management plan; and sufficient practical training to enable them to provide care.
(b) Evidence that a carer's experience survey has been completed.
Process
Proportion of patients with stroke whose carers have: a named contact for stroke information; written information about patient's diagnosis and management plan; and sufficient practical training to enable them to provide care.
Numerator: the number of carers who have:
(a) a named contact for stroke information
(b) written information about the patient's diagnosis and management plan
(c) sufficient practical training to provide care.
Denominator: the number of carers of patients with stroke.

Description of what the quality statement means for each audience

Service providers ensure that local policies are in place to ensure that the carers of all patients with stroke have: a named contact for stroke information; written information about the patient's diagnosis and management plan; and sufficient practical training to enable them to provide care. They obtain the carer's opinion through a carer's experience survey.
Health and social care professionals ensure that carers of all patients with stroke have: a named contact for stroke information; written information about the patient's diagnosis and management plan; and sufficient practical training to enable them to provide care.
Commissioners ensure that services are in place to enable carers of every patient with stroke to have: a named contact for stroke information; written information about the patient's diagnosis and management plan; and sufficient practical training to enable them to provide care. Commissioners ensure that service providers obtain the carer's opinion through a carer's experience survey.
Carers have: a named contact for stroke information; written information about the patient's diagnosis and management plan; and sufficient practical training to enable them to provide care. The carer's opinion will be obtained through a carer's experience survey

Data source

Written information for patients can be found in the RCP booklet 'Care after stroke or transient ischaemic attack' (2008). Information about NICE guidance, written specifically for patients can be found in 'Stroke: understanding NICE guidance' (NICE clinical guideline 68, 2008).
Structure
Local data collection.
Process
Local data collection using a carer survey.
Commissioning for Quality and Innovation (2010/2011) Patient Experience Goal 2
Improve response to personal needs of patients
Each describes a different element of the overarching theme – response to personal needs:
  • Involvement in decisions about treatment and care.
  • Hospital staff are available to talk about worries or concerns.
  • Privacy when discussing the condition or treatment.
  • Information about medication side-effects.
  • Information about who to contact if worried about the condition after leaving hospital.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning guides

Commissioning guides provide information on key clinical and service-related issues to consider during the commissioning process. Each guide contains a commissioning and benchmarking tool, which is a resource that can be used to estimate and inform the level of service needed locally as well as the cost of local commissioning decisions.
Service for the diagnosis and initial management of acute stroke: commissioning guide
Service for the diagnosis and initial management of transient ischaemic attack and non-disabling stroke: commissioning guide

Costing support

Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Acute stroke and TIA: costing report
Acute stroke and TIA: costing template
Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events: costing template
Alteplase for the treatment of acute ischaemic stroke: costing template
Stroke quality standard: cost impact and commissioning assessment

Slide set

Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Acute stroke and TIA: slide set

Pathway information

Information for patients and the public

NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on each of the following topics.

Information about acute stroke and TIA

Early assessment and treatment of people who have had a stroke or transient ischaemic attack (TIA)

Information about drug treatments

Clopidogrel and modified-release dipyridamole for preventing occlusive vascular events
Alteplase for the treatment of acute ischaemic stroke

Information about surgery

Treating symptomatic narrowed carotid arteries in the neck using stents
Treating asymptomatic narrowed carotid arteries in the neck using stents
Blocking the left atrial appendage of the heart to prevent stroke in non-valvular atrial fibrillation, using a catheter
Bypassing narrowed arteries caused by atherosclerosis in the head using arterial grafts
Treating drop foot using electrical stimulation
Widening a narrowed artery inside the skull using an expandable tube
Percutaneous closure of patent foramen ovale for the prevention of cerebral embolic stroke

Information about the NICE quality standard on stroke

Information for people who use NHS stroke services

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.
25 October 2011 Minor maintenance updates

Supporting information

Glossary

A prognostic score to identify people at high risk of stroke after a TIA.
A discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting.
Face Arm Speech Test. A test used to screen for a diagnosis of stroke or TIA.
The GDG (guideline development group) is a group of healthcare professionals, patients, carers and technical staff who develop the recommendations for a NICE clinical guideline
Malnutrition Universal Screening Tool. A tool used to identify adults who are malnourished or at risk of malnutrition.
A stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability.
Recognition of Stroke in the Emergency Room. A scale used to confirm a diagnosis of stroke or TIA.
A TIA (transient ischaemic attack) is defined as stroke symptoms and signs that resolve within 24 hours.

Person with suspected stroke or TIA

Person with suspected stroke or TIA

Rapid recognition of symptoms and diagnosis

Rapid recognition of symptoms and diagnosis

Rapid recognition of symptoms and diagnosis

Outside hospital, use a validated tool such as FAST to screen for a diagnosis of stroke or TIA in people with sudden onset of neurological symptoms.
Exclude hypoglycaemia as the cause of sudden-onset neurological symptoms.
In A&E, establish the diagnosis rapidly using a validated tool such as ROSIER.

Quality standards

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1Ambulance screening and stroke unit

Source guidance

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CG68

Have neurological symptoms resolved at time of assessment

Have neurological symptoms resolved at time of assessment?

Have neurological symptoms resolved at time of assessment?

The symptoms of a TIA usually resolve within minutes or a few hours at most, and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke.

Source guidance

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CG68

TIA

View the 'TIA: assessment, early management and imaging' path

Acute stroke

View the 'Acute stroke' path

Rehabilitation and long-term management

Rehabilitation and long-term management

Rehabilitation and long-term management

Quality standard

The stroke quality standard contains several quality statements about rehabilitation and long-term management for people with stroke.

NICE interventional procedures guidance

NICE interventional procedure guidance makes recommendations on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use.

Functional electrical stimulation for drop foot of central neurological origin

Current evidence on the safety and efficacy (in terms of improving gait) of functional electrical stimulation (FES) for drop foot of central neurological origin appears adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit.
Patient selection for implantable FES for drop foot of central neurological origin should involve a multidisciplinary team specialising in rehabilitation.
Further publication on the efficacy of FES would be useful, specifically including patient-reported outcomes, such as quality of life and activities of daily living, and these outcomes should be examined in different ethnic and socioeconomic groups.
These recommendations are from Functional electrical stimulation for drop foot of central neurological origin (NICE interventional procedure guidance 278).
NICE has written a booklet for patients and the public explaining this guidance.

Quality standards

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5Assessment and management of patients with stroke
6Ongoing inpatient rehabilitation
7Ongoing rehabilitation
8Continence management
9Mood disturbance and cognitive impairments
10Ongoing outpatient rehabilitation assessment
11Carer provisions

Source guidance

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IPG278

Stroke primary and secondary prevention

Stroke primary and secondary prevention

Stroke primary and secondary prevention

Related NICE clinical guidelines and pathways

NICE clinical guidelines on lipid modification and atrial fibrillation and the NICE pathway on hypertension include information about stroke prevention.

NICE interventional procedures guidance

NICE interventional procedure guidance makes recommendations on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use.

Percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism

Current evidence suggests that percutaneous occlusion of the left atrial appendage (LAA) is efficacious in reducing the risk of thromboembolic complications associated with non-valvular atrial fibrillation (AF). With regard to safety, there is a risk of life-threatening complications from the procedure, but the incidence of these is low. Therefore, this procedure may be used provided that normal arrangements are in place for clinical governance, consent and audit.
Patient selection should be carried out by a multidisciplinary team including a cardiologist and other appropriate clinicians experienced in the management of patients with AF at risk of stroke. Patients should be considered for alternative treatments to reduce the risk of thromboembolism associated with AF, and should be informed about these alternatives.
Percutaneous occlusion of the LAA is a technically challenging procedure which should only be carried out by clinicians with specific training and appropriate experience in the procedure.
This procedure should be carried out only in units with on-site cardiac surgery.
Any device-related adverse events resulting from the procedure should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA).
These recommendations are from Percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation for the prevention of thromboembolism (NICE interventional procedure guidance 349).
NICE has written a booklet for patients and the public explaining this guidance.

Extracranial to intracranial bypass for intracranial atherosclerosis

Current evidence on the efficacy and safety of extracranial to intracranial (EC–IC) bypass for intracranial atherosclerosis is inconsistent and remains limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.
Clinicians wishing to undertake EC–IC bypass for intracranial atherosclerosis should take the following actions.
  • Inform the clinical governance leads in their Trusts.
  • Ensure that patients and their carers understand the uncertainty about the procedure's safety and efficacy in relation to symptom reduction and stroke prevention, and provide them with clear written information. In addition, the use of NICE's information for patients ('Understanding NICE guidance') is recommended.
  • Audit and review clinical outcomes of all patients having EC–IC bypass for intracranial atherosclerosis (see section 3.1 of the guidance).
Patient selection for EC–IC bypass for intracranial atherosclerosis should be carried out by a multidisciplinary team with experience of managing patients with cerebral hypoperfusion syndromes who are undergoing this procedure. The team should include a neuroradiologist, neurologist/stroke physician and vascular neurosurgeon. The procedure should be done only by surgeons with specific training.
NICE encourages further research into EC–IC bypass for intracranial atherosclerosis. Research studies should clearly define patient selection criteria and report symptomatic and quality of life outcomes. NICE is aware of current clinical trials involving this procedure and may review the procedure on publication of further evidence.
These recommendations are from Extracranial to intracranial bypass for intracranial atherosclerosis (NICE interventional procedure guidance 348).

Endovascular stent insertion for intracranial atherosclerotic disease

The evidence on the efficacy of endovascular stent insertion for intracranial atherosclerotic disease is currently inadequate and the procedure poses potentially serious safety concerns. Therefore, this procedure should only be used in the context of clinical research including collecting data which should be submitted to a national register when available. Research should clearly define patient selection and be designed to provide outcome data based on follow-up of at least 2 years.
This recommendation is from Endovascular stent insertion for intracranial atherosclerotic disease (NICE interventional procedure guidance 233).
NICE has written a booklet for patients and the public explaining this guidance.

Percutaneous closure of patent foramen ovale for the prevention of cerebral embolic stroke

Current evidence suggests that there are no major safety concerns and that percutaneous closure of patent foramen ovale for the prevention of cerebral embolic stroke is efficacious in achieving closure of the foramen. However, its efficacy in preventing future strokes has not been clearly shown.
Clinicians wishing to undertake percutaneous closure of patent foramen ovale should take the following actions.
  • Ensure that patients understand the uncertainty about the procedure's efficacy and provide them with clear written information. Use of the Institute's Information for the public is recommended.
  • Audit and review clinical outcomes of all patients having percutaneous closure of patent foramen ovale.
The procedure should be performed in units where there are arrangements for cardiac surgical support in the event of complications.
The Department of Health runs the UK Central Cardiac Audit Database (UKCCAD) and clinicians are encouraged to enter all patients onto this database.
Further research will be useful and clinicians are encouraged to collect longer-term follow-up data. The Institute may review the procedure upon publication of further evidence.
These recommendations are from Percutaneous closure of patent foramen ovale for the prevention of cerebral embolic stroke (NICE interventional procedure guidance 109).

Implementation

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Extracranial to intracranial bypass for intracranial atherosclerosis: audit support

Source guidance

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IPG349
IPG348
IPG233
IPG109

Paths in this pathway

Pathway created: May 2011 Last updated: October 2011

Copyright © 2012 National Institute for Health and Clinical Excellence. All Rights Reserved.

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