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Stroke overview

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Stroke HAI

About

What is covered

This pathway covers the diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) as well as long-term rehabilitation after a stroke. 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.
Most of the interventions described by this pathway in the acute stage of a stroke ('acute stroke') or TIA relate to 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.
This pathway also covers rehabilitation after a stroke. Stroke rehabilitation is a multidimensional process, which is designed to facilitate restoration of, or adaptation to the loss of, physiological or psychological function when reversal of the underlying pathological process is incomplete. Rehabilitation aims to enhance functional activities and participation in society and thus improve quality of life.
Key aspects of rehabilitation care include multidisciplinary assessment, identification of functional difficulties and their measurement, treatment planning through goal setting, delivery of interventions which may either effect change or support the person in managing persisting change, and evaluation of effectiveness.

Updates

Updates to this pathway

17 July 2014 Link to NICE pathway on cardiovascular disease prevention added.
16 July 2014 Rebuilt IFP section (live pathway had headings going to incorrect hyperlinks)
17 June 2014 Link to the atrial fibrillation pathway added to stroke primary and secondary prevention in the overview path.
27 May 2014 'Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia' (NICE interventional procedure guidance 490) added to swallowing in the path on assessment and therapy in specific areas for people with stroke.
28 April 2014 Minor maintenance update
4 March 2014 Minor maintenance update
29 January 2014 Minor maintenance update
17 December 2013 Minor maintenance update
19 November 2013 Minor maintenance update
13 September 2013 Minor maintenance update
23 July 2013 Link to 'Mechanical clot retrieval for treating acute ischaemic stroke' (NICE interventional procedure guidance 458) added to the path on specialist care for people with acute stroke.
11 June 2013 Addition of the stroke rehabilitation guideline.
25 January 2013 Minor maintenance updates
04 December 2012 Minor maintenance updates
28 September 2012 Minor maintenance updates
26 September 2012 Updated guidance on 'Alteplase for treating acute ischaemic stroke' (NICE technology appraisal guidance 264) added to thrombolysis with alteplase in the acute stroke path
25 October 2011 Minor maintenance updates

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – 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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) and long-term rehabilitation after a stroke

What is covered

This pathway covers the diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) as well as long-term rehabilitation after a stroke. 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.
Most of the interventions described by this pathway in the acute stage of a stroke ('acute stroke') or TIA relate to 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.
This pathway also covers rehabilitation after a stroke. Stroke rehabilitation is a multidimensional process, which is designed to facilitate restoration of, or adaptation to the loss of, physiological or psychological function when reversal of the underlying pathological process is incomplete. Rehabilitation aims to enhance functional activities and participation in society and thus improve quality of life.
Key aspects of rehabilitation care include multidisciplinary assessment, identification of functional difficulties and their measurement, treatment planning through goal setting, delivery of interventions which may either effect change or support the person in managing persisting change, and evaluation of effectiveness.

Updates

Updates to this pathway

17 July 2014 Link to NICE pathway on cardiovascular disease prevention added.
16 July 2014 Rebuilt IFP section (live pathway had headings going to incorrect hyperlinks)
17 June 2014 Link to the atrial fibrillation pathway added to stroke primary and secondary prevention in the overview path.
27 May 2014 'Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia' (NICE interventional procedure guidance 490) added to swallowing in the path on assessment and therapy in specific areas for people with stroke.
28 April 2014 Minor maintenance update
4 March 2014 Minor maintenance update
29 January 2014 Minor maintenance update
17 December 2013 Minor maintenance update
19 November 2013 Minor maintenance update
13 September 2013 Minor maintenance update
23 July 2013 Link to 'Mechanical clot retrieval for treating acute ischaemic stroke' (NICE interventional procedure guidance 458) added to the path on specialist care for people with acute stroke.
11 June 2013 Addition of the stroke rehabilitation guideline.
25 January 2013 Minor maintenance updates
04 December 2012 Minor maintenance updates
28 September 2012 Minor maintenance updates
26 September 2012 Updated guidance on 'Alteplase for treating acute ischaemic stroke' (NICE technology appraisal guidance 264) added to thrombolysis with alteplase in the acute stroke path
25 October 2011 Minor maintenance updates

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Stroke. NICE clinical guideline 68 (2008)
Nutrition support in adults. NICE clinical guideline 32 (2006)
Type 1 diabetes. NICE clinical guideline 15 (2004)
Stroke (acute, ischaemic) - alteplase. NICE technology appraisal guidance 264 (2012)
Vascular disease - clopidogrel and dipyridamole. NICE technology appraisal guidance 210 (2010)
Mechanical clot retrieval for treating acute ischaemic stroke. NICE interventional procedure guidance 458 (2013)
Endovascular stent insertion for intracranial atherosclerotic disease. NICE interventional procedure guidance 429 (2012)
Carotid artery stent placement for symptomatic extracranial carotid stenosis. NICE interventional procedure guidance 389 (2011)
Extracranial to intracranial bypass for intracranial atherosclerosis. NICE interventional procedure guidance 348 (2010)

Quality standards

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 the public, can be found in ‘Stroke: information for the public' (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

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – 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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

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.
Loss or impairment of the ability to use and comprehend language, usually resulting from brain damage.
Apraxia of speech is a difficulty in initiating and executing the voluntary movement needed to produce speech when there is no weakness of speech muscles. It may cause difficulty producing the correct speech or changes in the rhythm or rate of speaking.
Difficulty in articulating words.
Difficulty in swallowing.
Difficulty in planning and executing movement.
A service for people after stroke which allows transfer of care from an inpatient environment to a primary care setting to continue rehabilitation, at the same level of intensity and expertise that they would have received in the inpatient 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
Blindness in one half of the visual field of one or both eyes
Malnutrition Universal Screening Tool. A tool used to identify adults who are malnourished or at risk of malnutrition.
An inability to orient towards and attend to stimuli, including body parts, on the side of the body affected by the stroke.
A stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability.
A device that supports or corrects the function of a limb or the torso.
Recognition of Stroke in the Emergency Room. A scale used to confirm a diagnosis of stroke or TIA.
A process of identifying people with particular impairments. People can then be offered information, further assessment and appropriate treatment. Screening may be performed as a precursor to more detailed assessment.
A stroke service designed to deliver stroke rehabilitation either in hospital or in the community.
An environment in which multidisciplinary stroke teams deliver stroke care in a dedicated ward which has a bed area, dining area, gym, and access to assessment kitchens.
A TIA (transient ischaemic attack) is defined as stroke symptoms and signs that resolve within 24 hours.

Paths in this pathway

Pathway created: May 2011 Last updated: July 2014

© NICE 2014

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