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Stroke
Short Text
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. 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)
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)
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)
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.
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
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.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
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.
Information about acute stroke and TIA
Information about drug treatments
Information about surgery
Information about the NICE quality standard on stroke
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 someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. 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. If a young person is moving between paediatric and adult services their 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.
Updates to this pathway
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 (technology appraisal guidance 264, replacing TA122) added to thrombolysis with alteplase in the acute stroke path
11 September 2012 Updated guidance on endovascular stent insertion for intracranial atherosclerotic disease (interventional procedure guidance 429, replaces IPG233) added to the stroke overview path
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 clinically confirmed acute stroke
Person with clinically confirmed acute stroke
Person with clinically confirmed acute stroke
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
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeIndications for immediate brain imaging
Indications for immediate brain imaging?
Indications for immediate brain imaging?
Perform brain imaging immediately if any of these apply:
- indications for thrombolysis or early anticoagulation treatment
- on anticoagulant treatment
- a known bleeding tendency
- a depressed level of consciousness (GCS [Glasgow Coma Score] <13)
- unexplained progressive or fluctuating symptoms
- papilloedema, neck stiffness or fever
- severe headache at onset of stroke symptoms.
('Immediately' is defined as 'ideally the next slot and definitely within 1 hour, whichever is sooner', in line with the National Stroke Strategy.)
Otherwise perform brain imaging as soon as possible. ('As soon as possible' is defined as 'within a maximum of 24 hours after onset of symptoms', in line with the National Stroke Strategy.)
Quality standards
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeImmediate brain imaging
Immediate brain imaging
Immediate brain imaging
'Immediately' is defined as 'ideally the next slot and definitely within 1 hour, whichever is sooner', in line with the National Stroke Strategy.
Quality standards
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeIndications for thrombolysis
Indications for thrombolysis?
Thrombolysis with alteplase
Thrombolysis with alteplase
Thrombolysis with alteplase
Alteplase is recommended within its marketing authorisation for treating acute ischaemic stroke in adults if:
- treatment is started as early as possible within 4.5 hours of onset of stroke symptoms, and
- intracranial haemorrhage has been excluded by appropriate imaging techniques.
This recommendation is from alteplase for treating acute ischaemic stroke (NICE technology appraisal guidance 264).
NICE has produced information for the public explaining the guidance on alteplase.
The following additional recommendations are from the Stroke clinical guideline (NICE clinical guideline 68):
Alteplase should be administered only within a well-organised stroke service with:
- staff trained in delivering thrombolysis and in monitoring for any associated complications
- level 1 and level 2 nursing care staff trained in acute stroke and thrombolysis
- immediate access to imaging and re-imaging, and staff trained to interpret the images.
Staff in A&E who are trained and supported can administer thrombolysis (in accordance with its marketing authorisation) if patients are managed within a specialist acute stroke service.
Protocols should be in place for the delivery and management of thrombolysis, including post-thrombolysis complications.
For information on blood pressure reduction in people who are candidates for thrombolysis, see the specialist care for people with acute stroke section of this pathway.
Quality standards
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleBrain imaging as soon as possible (within 24 hours)
Brain imaging as soon as possible (within 24 hours)
Brain imaging as soon as possible (within 24 hours)
'As soon as possible' is defined as 'within a maximum of 24 hours after onset of symptoms', in line with the National Stroke Strategy.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSpecialist acute stroke unit
Direct admission to a specialist acute stroke unit
Direct admission to a specialist acute stroke unit
Admit anyone with a suspected stroke directly to a specialist acute stroke unit after assessment, from either the community or A&E.
Quality standards
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePharmacological treatment: antiplatelets (acute ischaemic stroke) and reversal of anticoagulation (haemorrhagic stroke)
Pharmacological treatment: antiplatelets (acute ischaemic stroke) and reversal of anticoagulation (haemorrhagic stroke)
Pharmacological treatment: antiplatelets (acute ischaemic stroke) and reversal of anticoagulation (haemorrhagic stroke)
Aspirin for people with acute ischaemic stroke without primary intracerebral haemorrhage
Give aspirin 300 mg as soon as possible, and certainly within 24 hours:
- orally if the person is not dysphagic
- rectally or by enteral tube if they have dysphagia.
Continue aspirin for 2 weeks after symptom onset (or until discharge if sooner) and then initiate long-term antithrombotic treatment.
Give a proton pump inhibitor in addition to aspirin if previous dyspepsia with aspirin is reported.
Give an alternative antiplatelet agent if the person is allergic to or genuinely intolerant of aspirin (aspirin intolerance is defined as either a proven hypersensitivity to aspirin-containing medicines or a history of severe dyspepsia induced by low-dose aspirin).
Do not give anticoagulants routinely for treatment of acute strokeThere may be a subgroup of people for whom the risk of venous thromboembolism outweighs the risk of haemorrhagic transformation. People considered to be at particularly high risk of venous thromboembolism include anyone with complete paralysis of the leg, a previous history of venous thromboembolism, dehydration or comorbidities (such as malignant disease), or who is a current or recent smoker. Such people should be kept under regular review if they are given prophylactic anticoagulation. For further information about preventing venous thromboembolism, see the venous thromboembolism pathway. .
Clopidogrel and modified-release dipyridamole
Clopidogrel is recommended as an option to prevent occlusive vascular events for people who have had an ischaemic stroke.
Modified-release dipyridamole in combination with aspirin is recommended as an option to prevent occlusive vascular events for people who have had an ischaemic stroke only if clopidogrel is contraindicated or not tolerated.
Modified-release dipyridamole alone is recommended as an option to prevent occlusive vascular events for people who have had an ischaemic stroke only if aspirin and clopidogrel are contraindicated or not tolerated.
Treatment with clopidogrel to prevent occlusive vascular events should be started with the least costly licensed preparation.
These recommendations relating to people who have had an ischaemic stroke are an extract from Vascular disease - clopidogrel and dipyridamole (NICE technology appraisal guidance 210).
NICE has produced information for the public explaining the guidance on clopidogrel and modified-release dipyridamole.
Reversal of anticoagulation in people with haemorrhagic stroke
Return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving anticoagulants before their stroke (and have elevated INR [international normalised ratio]), using a combination of prothrombin complex concentrate and intravenous vitamin K.
For more information about anticoagulant treatment for people who have had a stroke, see the specialist care for people with acute stroke section of this pathway.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSpecialist care for acute stroke
View the 'Specialist care for people with acute stroke' pathPaths in this pathway
- Acute stroke
- Specialist care for people with acute stroke
- TIA: assessment, early management and imaging
- Carotid imaging and carotid endarterectomy for people with TIA or non-disabling stroke
Pathway created: May 2011 Last updated: January 2013
Copyright © 2013 National Institute for Health and Care Excellence. All Rights Reserved.