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Acute stroke

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Stroke

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

21 June 2016 Transcervical extracorporeal reverse flow neuroprotection for reducing the risk of stroke during carotid artery stenting (NICE interventional procedure guidance 561) added to prevention and assessing and managing carotid stenosis following acute non-disabling stroke.
11 April 2016 Pathway restructured, summarised recommendations replaced with full recommendations and endoscopic carbon dioxide laser cricopharyngeal myotomy for relief of oropharyngeal dysphagia (NICE interventional procedure guidance 550) added to swallowing in the path on stroke rehabilitation: therapy. Updated statements for stroke in adults (NICE quality standard 2) added.
23 February 2016 Mechanical clot retrieval for treating acute ischaemic stroke (NICE interventional procedure guidance 548) added to thrombolysis and mechanical clot retrieval.
16 December 2015 Link to NICE pathway on mental wellbeing and independence in older people added.
30 November 2015 Link to NICE pathway on transition between inpatient hospital settings and community or care home settings for adults with social care needs added.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
17 July 2014 Link to NICE pathway on cardiovascular disease prevention added.
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.
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 in adults guideline.
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.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on stroke and transient ischaemic attack (TIA) for adults and young people over 16 in an interactive flowchart.

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

21 June 2016 Transcervical extracorporeal reverse flow neuroprotection for reducing the risk of stroke during carotid artery stenting (NICE interventional procedure guidance 561) added to prevention and assessing and managing carotid stenosis following acute non-disabling stroke.
11 April 2016 Pathway restructured, summarised recommendations replaced with full recommendations and endoscopic carbon dioxide laser cricopharyngeal myotomy for relief of oropharyngeal dysphagia (NICE interventional procedure guidance 550) added to swallowing in the path on stroke rehabilitation: therapy. Updated statements for stroke in adults (NICE quality standard 2) added.
23 February 2016 Mechanical clot retrieval for treating acute ischaemic stroke (NICE interventional procedure guidance 548) added to thrombolysis and mechanical clot retrieval.
16 December 2015 Link to NICE pathway on mental wellbeing and independence in older people added.
30 November 2015 Link to NICE pathway on transition between inpatient hospital settings and community or care home settings for adults with social care needs added.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
17 July 2014 Link to NICE pathway on cardiovascular disease prevention added.
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.
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 in adults guideline.
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.

Sources

NICE guidance and other sources used to create this pathway.
Stroke rehabilitation in adults (2013) NICE guideline CG162
Mechanical clot retrieval for treating acute ischaemic stroke (2016) NICE interventional procedure guidance 548
Endovascular stent insertion for intracranial atherosclerotic disease (2012) NICE interventional procedure guidance 429
Extracranial to intracranial bypass for intracranial atherosclerosis (2010) NICE interventional procedure guidance 348
Alteplase for treating acute ischaemic stroke (2012) NICE technology appraisal guidance 264
Stroke in adults (2012 updated 2016) NICE quality standard 2

Quality standards

Quality statements

Prompt admission to specialist acute stroke units

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

Quality statement

Adults presenting at an accident and emergency (A&E) department with suspected stroke are admitted to a specialist acute stroke unit within 4 hours of arrival.

Rationale

Specialist acute stroke units are associated with improved patient safety due to better outcomes, such as reduced disability and mortality, because of the range of specialist treatments they provide. Admission to these units should be within 4 hours of arrival at A&E, so that treatment can begin as quickly as possible, and to help prevent complications. Some adults with acute stroke may need treatment in higher level units, such as high dependency or intensive care units.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults presenting at an A&E department with suspected stroke are admitted to a specialist acute stroke unit within 4 hours of arrival.
Data source: Local data collection.
Process
Proportion of A&E department presentations of suspected stroke in adults in which the person is admitted to a specialist acute stroke unit within 4 hours of arrival.
Numerator – the number in the denominator in which the person is admitted to a specialist acute stroke unit within 4 hours of arrival.
Denominator – the number of A&E department presentations of suspected stroke.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) question 1.15 and the NHS England CCG Outcomes Indicator Set indicator 3.5.
Outcome
a) Mortality rates of adults who have a stroke.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) question 7.1 and the NHS England CCG Outcomes Indicator Set indicator 1.5.
b) Change in Modified Rankin Score at 6 months after a stroke.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) question 7.4.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as secondary care providers) ensure that systems are in place for adults presenting at an A&E department with suspected stroke to be admitted to a specialist acute stroke unit within 4 hours of arrival.
Healthcare professionals admit adults presenting at an A&E department with suspected stroke to a specialist acute stroke unit within 4 hours of arrival.
Commissioners (such as clinical commissioning groups) ensure that they commission services that can demonstrate that adults presenting at A&E departments with suspected stroke are admitted to a specialist acute stroke unit within 4 hours of arrival.

What the quality statement means for patients and carers

Adults with suspected stroke who go to A&E are admitted to an acute stroke unit within 4 hours of arriving at A&E. An acute stroke unit has special equipment and a team of doctors, nurses, physiotherapists and other healthcare professionals who provide specialist treatment as quickly as possible and help to prevent further problems.

Source guidance

Definitions of terms used in this quality statement

Admission to a specialist acute stroke unit
Admission should be within 4 hours of arrival at the A&E department for adults with suspected stroke, following an initial assessment (unless their care needs should be provided elsewhere, such as an intensive care unit).
[Adapted from Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NICE guideline CG68) recommendation 1.3.1.1 and Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP)]
Specialist acute stroke unit
A discrete area in the hospital designated for people with stroke. It is staffed by a specialist stroke multidisciplinary team, who have access to equipment for monitoring and rehabilitation. The Stroke Unit Trialists’ Collaboration provide 5 key characteristics of markers of a good specialist acute stroke unit:
  • a consultant physician with responsibility for stroke
  • formal links with patient and carer organisations
  • multidisciplinary meetings at least weekly to plan patient care
  • provision of information to patients about stroke
  • funding for external courses and uptake.

Intensity of stroke rehabilitation

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

Quality statement

Adults having stroke rehabilitation in hospital or in the community are offered at least 45 minutes of each relevant therapy for a minimum of 5 days a week.

Rationale

Higher intensity stroke rehabilitation therapies can improve the quality of life for adults who have had a stroke. The improvements that an adult with stroke should expect to achieve will depend on their health and abilities before and after the stroke, the severity of the stroke and the intensity of the rehabilitation therapy. The intensity of stroke rehabilitation should be suitable for the person, so that they are able to participate and make progress towards their functional goals.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults having stroke rehabilitation in hospital or in the community are offered at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Data source: Local data collection.
Process
a) Proportion of adults having stroke rehabilitation in hospital who receive at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Numerator – the number in the denominator who receive at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Denominator – the number of adults having stroke rehabilitation in hospital.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) questions 4.5 and 4.6.
b) Proportion of adults having stroke rehabilitation in the community who receive at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Numerator – the number in the denominator who receive at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Denominator – the number of adults having stroke rehabilitation in the community.
Data source: Local data collection.
Outcome
Change in Modified Rankin Score at 6 months after a stroke.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) question 8.4.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as secondary care providers and community care providers) ensure that adults having stroke rehabilitation are offered at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Health and social care practitioners offer adults having stroke rehabilitation at least 45 minutes of each relevant therapy for a minimum of 5 days a week.
Commissioners (such as clinical commissioning groups and local authorities) ensure that they commission services in which adults having stroke rehabilitation are offered at least 45 minutes of each relevant therapy for a minimum of 5 days a week.

What the quality statement means for patients and carers

Adults having rehabilitation therapy after a stroke are offered at least 45 minutes of each type of rehabilitation therapy that they need on at least 5 days a week. Rehabilitation therapy is long term support to help people regain their independence and cope with any remaining disabilities after a stroke. It may involve many different specialists, such as physiotherapists, speech therapists and occupational therapists. They can help people who have problems with their memory and concentration; speaking, reading and writing; emotions and feelings; sight; swallowing and eating; strength, balance and movement; and shoulder pain. They also include help to encourage physical activity and independent living.

Source guidance

Definitions of terms used in this quality statement

Relevant stroke rehabilitation
Adults who have had a stroke should be offered all rehabilitation therapies that are suitable for their needs, as long as they have the ability to participate and make progress towards their functional goals. Adults with stroke should be able to access rehabilitation at any stage of the stroke care pathway when needed.
[Adapted from Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.2.16 and expert opinion]

Equality and diversity considerations

Some adults who have had stroke may not have the mental or physical ability to participate in 45 minutes of each rehabilitation therapy. Service providers should ensure that therapy is still offered 5 days a week but for a shorter amount of time. It should be given at an intensity that allows the person to actively participate and at a level that enables them to make progress.

Access to a clinical psychologist

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

Quality statement

Adults who have had a stroke have access to a clinical psychologist with expertise in stroke rehabilitation who is part of the core multidisciplinary stroke rehabilitation team.

Rationale

Many adults who have had a stroke experience psychological difficulties, including low mood and anxiety, as well as difficulties with cognition such as problems with memory and information processing. Psychological therapies may help people and their families or carers with these difficulties. Having a clinical psychologist as part of the core multidisciplinary stroke rehabilitation team can help to ensure that people have access to psychological therapy tailored to their needs.

Quality measures

Structure
Evidence of local arrangements and protocols to ensure that services providing stroke care have a core multidisciplinary stroke rehabilitation team that includes a clinical psychologist with expertise in stroke rehabilitation.
Data source: Local data collection.
Outcome
Quality of life for adults who have had a stroke.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as secondary care providers) ensure that the core multidisciplinary stroke rehabilitation team includes a clinical psychologist with expertise in stroke rehabilitation.
Health and social care practitioners are aware of the need for a clinical psychologist with expertise in stroke rehabilitation to be part of the core multidisciplinary stroke rehabilitation team.
Commissioners (such as clinical commissioning groups) ensure that they commission services that have a clinical psychologist with expertise in stroke rehabilitation as part of their core multidisciplinary stroke rehabilitation team.

What the quality statement means for patients, service users and carers

Adults who have had a stroke who need help with psychological problems can see a clinical psychologist who specialises in stroke rehabilitation. The psychologist is part of the stroke rehabilitation team.

Source guidance

Definitions of terms used in this quality statement

The core multidisciplinary stroke team
The team should comprise the following professionals with expertise in stroke rehabilitation:
  • consultant physicians
  • nurses
  • physiotherapists
  • occupational therapists
  • speech and language therapists
  • clinical psychologists
  • rehabilitation assistants
  • social workers.
[Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.1.3]

Early supported discharge

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

Quality statement

Adults who have had a stroke are offered early supported discharge if the core multidisciplinary stroke team assess that it is suitable for them.

Rationale

Early supported discharge is an intervention for adults after a stroke that allows their care to be transferred from an inpatient environment to a community setting. It enables people to continue their rehabilitation therapy at home, with the same intensity and expertise that they would receive in hospital. This may not be suitable for all adults with stroke or in all circumstances. The decision to offer early supported discharge is made by the core multidisciplinary stroke team after discussion with the person and their family or carer if applicable.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults who have had a stroke are offered early supported discharge if the core multidisciplinary stroke team assess that it is suitable for them.
Data source: Local data collection.
Process
a) Proportion of adults who have had a stroke and are assessed as suitable for early supported discharge by the core multidisciplinary stroke team who receive it.
Numerator – the number in the denominator who receive early supported discharge.
Denominator – the number of adults who have had a stroke and are assessed as suitable for early supported discharge by the core multidisciplinary stroke team.
Data source: Local data collection.
b) Proportion of adults who have had stroke who are treated by an early supported discharge team.
Numerator – the number in the denominator who are treated by an early supported discharge team.
Denominator – the number of adults who have had a stroke.
Data source: National data is collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP), which estimates that approximately 34% of all stroke patients are considered eligible for early supported discharge.
Outcome
a) Length of hospital stay for adults who have had a stroke.
Data source: Local data collection.
b) Quality of life for adults who have had a stroke.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as secondary care providers) ensure that systems are in place to offer early supported discharge to adults who have had a stroke if it is assessed to be suitable for them by the core multidisciplinary stroke team.
Health and social care practitioners in the core multidisciplinary stroke team are aware of discharge pathways and offer early supported discharge to adults who have had a stroke if it is suitable for them.
Commissioners (clinical commissioning groups) ensure that they commission services that can provide early supported discharge services for adults who have had a stroke if it is assessed to be suitable for them by the core multidisciplinary stroke team.

What the quality statement means for patients and carers

Adults who have had a stroke are offered ‘early supported discharge’ if their stroke team decides that it is suitable for them. This means that they are supported to go home from hospital as early as possible and have the same rehabilitation care at home. This is only offered if the person is well enough and it can be done safely.

Source guidance

Definitions of terms used in this quality statement

Early supported discharge
An intervention for people who have had a stroke that allows care to be transferred from an inpatient environment to a community setting to continue rehabilitation. The intensity of care and the expertise of those providing it is maintained.
[Stroke rehabilitation in adults (NICE guideline CG162)]
Suitable for early supported discharge
The core multidisciplinary stroke team will assess whether early supported discharge is suitable for adults who have had a stroke. The assessment takes into account the person’s functional, cognitive and social circumstances. This may include, for example, the person’s ability to transfer from bed to chair independently or with assistance, and whether a safe and secure environment can be provided at home.
[Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.1.8 and expert consensus]
The core multidisciplinary stroke team
The team should comprise the following professionals with expertise in stroke rehabilitation:
  • consultant physicians
  • nurses
  • physiotherapists
  • occupational therapists
  • speech and language therapists
  • clinical psychologists
  • rehabilitation assistants
  • social workers.
[Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.1.3]

Equality and diversity considerations

Early supported discharge is only suitable in a safe and secure environment. Therefore, it may not be suitable for some people because of their living arrangements, for example, if they are homeless recent refugees, asylum seekers or migrant workers. It may not be suitable for people with significant cognitive and functional impairments.

Return to work

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

Quality statement

Adults who have had a stroke are offered active management to return to work if they wish to do so.

Rationale

After a stroke, adults may have significant disabilities that prevent them from returning to work. Work can contribute to a person’s identity and perceived status, has financial benefits, and can improve their quality of life and reduce ill health. Being able to return to work is also a sign that rehabilitation has been successful.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults who have had a stroke are offered active management to return to work if they wish to do so.
Data source: Local data collection.
Process
Proportion of adults who have had a stroke who receive active management to return to work if they wish to do so.
Numerator – the number in the denominator who receive active management to help them return to work.
Denominator – the number of adults who have had a stroke who wish to return to work.
Data source: Local data collection.
Outcome
a) Quality of life for adults who have had a stroke.
Data source: Local data collection.
b) Quality of life for carers of adults who have had a stroke.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as community services) ensure that systems are in place for adults who have had a stroke to be offered active management to return to work if they wish to.
Health and social care practitioners offer adults who have had a stroke active management to return to work if they wish to.
Commissioners (such as local councils) ensure that they commission services that offer adults who have had a stroke active management to return to work if they wish to.

What the quality statement means for patients, service users and carers

Adults who have had a stroke and wish to return to work are offered help and support to do this. This should include help to identify and manage any problems that might make it difficult to return to work.

Source guidance

Definitions of terms used in this quality statement

Active management to return to work
Active management to return to work should include:
  • identifying the physical, cognitive, communication and psychological demands of the job (for example, multitasking by answering emails and telephone calls in a busy office)
  • identifying any impairments on work performance (for example, physical limitations, anxiety, fatigue preventing attendance for a full day at work, cognitive impairments preventing multitasking, and communication deficits)
  • tailoring an intervention (for example, teaching strategies to support multitasking or memory difficulties, teaching the use of voice activated software for people with difficulty typing, and delivery of work simulations)
  • educating about the Equality Act 2010 and support available (for example, an access to work scheme)
  • workplace visits and liaison with employers to establish reasonable accommodations, such as provision of equipment and graded return to work.
[Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.10.5]

Equality and diversity considerations

Services should make reasonable adjustments to help adults with significant cognitive impairment and stroke to stay in work or education or find new employment, volunteering and educational opportunities.
Some adults may be unable to work, so other occupational or education activities should be considered, including prevocational training.

Regular review of rehabilitation goals

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

Quality statement

Adults who have had a stroke have their rehabilitation goals reviewed at regular intervals.

Rationale

Regularly reviewing the goals of an adult who has had a stroke helps to identify their values, beliefs and preferences, which may affect the kind of rehabilitation that would be suitable for them. It may also help to encourage and motivate the person, and improve the outcomes of rehabilitation. Goals should be set within 5 days of arrival at an accident and emergency (A&E) department to ensure they are established from the start of the rehabilitation process. They should then be reviewed at regular intervals to ensure that the goals are still relevant to the person who has had a stroke.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults who have had a stroke have their rehabilitation goals reviewed at regular intervals.
Data source: Local data collection.
Process
a) Proportion of adults who have had a stroke who have their rehabilitation goals agreed within 5 days of arrival at A&E.
Numerator – the number in the denominator who have their rehabilitation goals agreed within 5 days of arrival at A&E.
Denominator – the number of adults who have had a stroke.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) question 4.7.
b) Proportion of adults who have had a stroke who have their rehabilitation goals reviewed at regular intervals.
Numerator – the number in the denominator who have their rehabilitation goals reviewed at regular intervals.
Denominator – the number of adults who have had a stroke with agreed rehabilitation goals.
Data source: Local data collection.
Outcome
a) Quality of life for adults who have had a stroke.
Data source: Local data collection.
b) Readmission rates of adults who have had a stroke.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as primary, secondary and community care providers) ensure that systems are in place for adults who have had a stroke to have their rehabilitation goals reviewed at regular intervals.
Healthcare professionals review regularly the rehabilitation goals of adults who have had a stroke.
Commissioners (such as local councils, NHS England and clinical commissioning groups) ensure that they commission services in which adults who have had a stroke have their rehabilitation goals reviewed at regular intervals.

What the quality statement means for patients and carers

Adults who have had a stroke have the opportunity to discuss and agree goals (things they would like to achieve) for their recovery and have them reviewed regularly to ensure they are still relevant.

Source guidance

Definitions of terms used in this quality statement

Rehabilitation goals
Goals for rehabilitation should:
  • be meaningful and relevant to adults with stroke
  • focus on activity and participation
  • be challenging but achievable
  • include both short term and long term elements.
[Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.2.8]
Reviewing goals at regular intervals
Goals should be set within 5 days of arrival at A&E. Reviewing goals should take place at intervals suitable to the ability of the individual and nature of the goal, such as at 6 weeks, 3 months, 6 months and annually thereafter. Reviews should take place in goal setting meetings that are timetabled into the working week and involve the person with stroke, and where appropriate, their family or carer.
[Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NICE guideline CG68) recommendations 1.2.9 and 1.2.12, and expert consensus]

Equality and diversity considerations

When setting goals for rehabilitation, healthcare professionals should be aware that adults with stroke may have cognitive or physical impairments, and at the acute stage participation for some adults may be limited until the person feels ready and more confident.
Discussion about goals should take into account any additional needs, such as physical, sensory or learning disabilities, and the needs of people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Regular review of health and social care needs

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

Quality statement

Adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

Rationale

Reviewing the health and social care needs of adults who have had a stroke enables health and social care practitioners to identify any problems or difficulties the person who had the stroke and their family or carers may be experiencing. This can help adults who have had a stroke and their family or carers to make changes to their care according to their needs.

Quality measures

Structure
Evidence of local arrangements and written protocols to ensure that adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.
Data source: Local data collection.
Process
a) Proportion of adults who have had a stroke who have a structured health and social care review at 6 months after the stroke.
Numerator – the number in the denominator who have a structured health and social care review at 6 months after the stroke.
Denominator – the number of adults who have had a stroke.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP) question 8.1.
b) Proportion of adults who have had a stroke and had a structured health and social care review at 6 months after the stroke who have a review 1 year after the stroke.
Numerator – the number in the denominator who have a review 1 year after the stroke.
Denominator the number of adults who have had a stroke and had a structured health and social care review at 6 months after the stroke.
Data source: Local data collection.
c) Proportion of adults who have had a stroke and had a structured health and social care review at 6 months and 1 year after the stroke, who have annual reviews thereafter.
Numerator – the number in the denominator who have annual reviews.
Denominator – the number of adults who have had a stroke and had a structured health and social care review at 6 months and 1 year after the stroke.
Data source: Local data collection.
Outcome
a) Quality of life for adults who have had a stroke.
Data source: Local data collection.
b) Readmission rates of adults who have had a stroke.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as primary, secondary and community care providers) ensure that systems are in place for adults who have had a stroke to have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.
Health and social care practitioners ensure that adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.
Commissioners (such as clinical commissioning groups, NHS England and local authorities) ensure that they commission services that enable adults who have had a stroke to have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

What the quality statement means for patients and carers

Adults who have had a stroke have a check at 6 months and 1 year after their stroke, and then once every year to make sure they are getting the care and support that they need.

Source guidance

Definitions of terms used in this quality statement

Structured health and social care review
These reviews should address the person’s ability to participate in daily activities and their role in their community, as well as secondary prevention and continuing rehabilitation. An agreed local structured health and social care review tool can be used, for example the Greater Manchester Stroke Assessment Tool (GM-SAT).
[Stroke rehabilitation in adults (NICE guideline CG162) recommendation 1.11.5 and expert opinion]

Equality and diversity considerations

Any review should take into account any additional needs, such as physical, sensory or learning disabilities, and the needs of people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
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

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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 and 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
European Carotid Surgery Trialists' Collaborative Group
face arm speech test, a test used to screen for a diagnosis of stroke or TIA
Glasgow coma score
blindness in one half of the visual field of one or both eyes
international normalised ratio
an inability to orient towards and attend to stimuli, including body parts, on the side of the body affected by the stroke
North American symptomatic carotid endarterectomy trial
National Institutes of Health Stroke Scale
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: June 2016

© NICE 2016

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