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Stroke

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What is covered

This interactive flowchart covers the diagnosis and initial management of acute stroke and 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 interactive flowchart 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 interactive flowchart 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 interactive flowchart

27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
18 December 2018 Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia in adults (NICE interventional procedures guidance 634) added to swallowing.
7 November 2017 Extracranial to intracranial bypass for intracranial atherosclerosis (NICE interventional procedures guidance 596) added to prevention.
21 June 2016 Transcervical extracorporeal reverse flow neuroprotection for reducing the risk of stroke during carotid artery stenting (NICE interventional procedures guidance 561) added to prevention and assessing and managing carotid stenosis following acute non-disabling stroke.
11 April 2016
  • Structure revised, and summarised recommendations replaced with full recommendations.
  • Endoscopic carbon dioxide laser cricopharyngeal myotomy for relief of oropharyngeal dysphagia (NICE interventional procedures guidance 550) added to swallowing.
  • Updated statements for stroke in adults (NICE quality standard 2) added.
23 February 2016 Mechanical clot retrieval for treating acute ischaemic stroke (NICE interventional procedures guidance 548) added to thrombolysis and mechanical clot retrieval.
11 June 2013 Stroke rehabilitation in adults (NICE guideline CG162) added.
26 September 2012 Updated guidance on alteplase for treating acute ischaemic stroke (NICE technology appraisal guidance 264) added to thrombolysis and mechanical clot retrieval.

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing, diagnosing and managing stroke and transient ischaemic attack (TIA) in people over 16 in an interactive flowchart

What is covered

This interactive flowchart covers the diagnosis and initial management of acute stroke and 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 interactive flowchart 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 interactive flowchart 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 interactive flowchart

27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
18 December 2018 Transcutaneous neuromuscular electrical stimulation for oropharyngeal dysphagia in adults (NICE interventional procedures guidance 634) added to swallowing.
7 November 2017 Extracranial to intracranial bypass for intracranial atherosclerosis (NICE interventional procedures guidance 596) added to prevention.
21 June 2016 Transcervical extracorporeal reverse flow neuroprotection for reducing the risk of stroke during carotid artery stenting (NICE interventional procedures guidance 561) added to prevention and assessing and managing carotid stenosis following acute non-disabling stroke.
11 April 2016
  • Structure revised, and summarised recommendations replaced with full recommendations.
  • Endoscopic carbon dioxide laser cricopharyngeal myotomy for relief of oropharyngeal dysphagia (NICE interventional procedures guidance 550) added to swallowing.
  • Updated statements for stroke in adults (NICE quality standard 2) added.
23 February 2016 Mechanical clot retrieval for treating acute ischaemic stroke (NICE interventional procedures guidance 548) added to thrombolysis and mechanical clot retrieval.
11 June 2013 Stroke rehabilitation in adults (NICE guideline CG162) added.
26 September 2012 Updated guidance on alteplase for treating acute ischaemic stroke (NICE technology appraisal guidance 264) added to thrombolysis and mechanical clot retrieval.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Stroke rehabilitation in adults (2013) NICE guideline CG162
Alteplase for treating acute ischaemic stroke (2012) NICE technology appraisal guidance 264
Extracranial to intracranial bypass for intracranial atherosclerosis (2017) NICE interventional procedures guidance 596
Mechanical clot retrieval for treating acute ischaemic stroke (2016) NICE interventional procedures guidance 548
Endovascular stent insertion for intracranial atherosclerotic disease (2012) NICE interventional procedures guidance 429
Carotid artery stent placement for symptomatic extracranial carotid stenosis (2011) NICE interventional procedures guidance 389
Air pollution: outdoor air quality and health (2019) NICE quality standard 181
Stroke in adults (2010 updated 2016) NICE quality standard 2
Transient ischaemic attack: clopidogrel (2013) NICE evidence summary ESUOM23
Cerebrotech Visor for detecting stroke (2018) NICE medtech innovation briefing 165
Mechanical thrombectomy devices for acute ischaemic stroke (2018) NICE medtech innovation briefing 153

Quality standards

Air pollution: outdoor air quality and health

These quality statements are taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

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 rehabilitation in adults (NICE guideline CG162) 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.

Strategic plans

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution.

Rationale

Local authorities should be strategic leaders of local initiatives to address air pollution, working in a coordinated way with key partners to ensure a consistent and planned approach. Identifying their approach to air pollution in the Local Plan, local transport plan and other key strategies will provide a clear framework for joined-up local action. The key components of their approach should include enabling zero- and low-emission travel (including active travel such as cycling or walking) and developing buildings and spaces to reduce exposure to air pollution.

Quality measures

Structure
a) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including who is responsible for delivering key actions.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
b) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable active travel.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
c) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable travel by zero- and low-emission vehicles.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
d) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will develop buildings and spaces to reduce exposure to air pollution.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them.
Data source: Local data collection, for example, progress on actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local authorities work with partners to ensure the Local Plan, local transport plan, and other key strategies identify the approach to addressing air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution. Local authorities work together to prevent migration of traffic and emissions to other communities, which may result in areas of poor air quality.
People in the community know that their local authority and other local organisations are working together to protect them from the effects of air pollution.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.1.1, 1.1.2 and 1.1.3

Definitions of terms used in this quality statement

Local authorities
All tiers of local government including county, district and unitary authorities, as well as regional bodies and transport authorities.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1]
Other key strategies
Relevant local strategies, such as the air quality action plan, commissioning and procurement strategy, core strategy, environment strategy, and health and wellbeing strategy.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and expert opinion]
Zero- and low-emission travel
Includes cycling and walking; travel by zero- and low-emission vehicles such as electric cars, buses, bikes and pedal cycles; and car sharing schemes or clubs.
[Adapted from NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and terms used in this guideline]
Developing buildings and spaces to reduce exposure to air pollution
This could include:
  • siting and designing new buildings, facilities and estates to reduce the need for motorised travel
  • minimising the exposure of vulnerable groups to air pollution by not siting buildings (such as schools, nurseries and care homes) in areas where pollution levels will be high
  • siting living accommodation away from roadsides
  • avoiding the creation of street and building configurations (such as deep street canyons) that encourage pollution to build up where people spend time
  • including landscape features such as appropriate species of trees and vegetation in open spaces or as 'green' walls or roofs where this does not restrict ventilation
  • considering how structures such as buildings and other physical barriers will affect the distribution of air pollutants.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.2]

Equality and diversity considerations

Local authorities should ensure that strategic plans identify areas where air pollution is highest and, in particular, locations where people who are vulnerable to air pollution may be exposed to high levels of air pollution, such as schools, nurseries, hospitals and care homes, so that targeted approaches can be put in place.
Local authorities should ensure that they assess the impact on vulnerable groups if local charges on certain classes of vehicle in clean air zones are proposed. If necessary, actions to mitigate the impact of charges on specific groups should be identified.

Planning applications

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.

Rationale

The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. Addressing air pollution at the planning stage for major developments may reduce the need for more expensive remedial action at a later stage. It can also help to maintain people’s health and wellbeing during and after construction. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based.

Quality measures

Structure
a) Evidence of local processes and guidance that ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution.
Data source: Local data collection, for example, review of supplementary planning guidance.
b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.
Data source: Local data collection, for example, review of supplementary planning guidance.
Process
Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Numerator – the number in the denominator with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Denominator – the number of planning applications for major developments granted permission.
Data source: Local data collection, for example, local planning application system.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local planning authorities ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution during and after construction. Local planning authorities provide guidance for applicants and have a clear framework for assessing proposals in line with the Local Plan, local transport plan and other key strategies. Local guidance should make it clear that proposals to minimise or mitigate road-traffic-related air pollution must be evidence based. Local planning authorities monitor compliance with planning conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Local authority planning officers assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments using an agreed local framework to ensure they are evidence based. Local authority planning officers encourage applicants to modify their planning applications if necessary, to include evidence-based approaches to minimise or mitigate road-traffic-related air pollution.
Planning applicants for major developments know that the local planning authority will assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications to ensure they are evidence based. Planning applicants can get information on what the local planning authority is looking for and how the proposals will be assessed. Planning applicants for major developments modify their application to improve the approach to minimising or mitigating road-traffic-related air pollution if required by the local authority.
People in the community know that their local planning authorities require developers to show how they will minimise road-traffic-related air pollution and improve local air quality around big building projects when they apply for planning permission. This is to help protect local people from the effects of air pollution on their health.

Source guidance

Definitions of terms used in this quality statement

Major developments
Development involving any one or more of the following:
  • the winning and working of minerals or the use of land for mineral-working deposits
  • waste development
  • the provision of dwelling houses where:
    • the number of dwelling houses to be provided is 10 or more or
    • the development is to be carried out on a site having an area of 0.5 hectares or more and the number of dwelling houses is not known
  • the provision of a building or buildings where the floor space to be created by the development is 1,000 square metres or more or
  • development carried out on a site having an area of 1 hectare or more.

Equality and diversity considerations

Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities.

Reducing emissions from public sector vehicle fleets

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Public sector organisations reduce emissions from their vehicle fleets to address air pollution.

Rationale

The public sector fleet is substantial and includes various vehicle types, some of which are highly polluting. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. Public sector organisations can extend their impact by commissioning transport or fleet services from organisations that reduce emissions from their vehicle fleets to address air pollution. By publicising their approach, public sector organisations can encourage organisations in other sectors to take action to reduce emissions from their vehicle fleets.

Quality measures

Structure
a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, a plan to reduce fleet emissions. Organisations could use the Sustainable Development Unit’s Health Outcomes of Travel Tool (HOTT) to develop a plan.
b) Evidence that public sector organisations require commissioned transport or fleet services to reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, commissioning specifications. Commissioning specifications could require adherence to the Department for Environment, Food and Rural Affairs’ Government Buying Standards for transport.
Outcome
a) Proportion of zero- or ultra-low-emission vehicles in public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.
b) Overall fuel consumption for public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.

What the quality statement means for different audiences

Service providers (such as local authorities, NHS trusts, police and fire and rescue services) develop a plan for how they will reduce emissions from their vehicle fleet to address air pollution and monitor the impact of the plan on vehicle type and total fleet CO2 emissions. Providers consider a range of approaches including:
  • replacing vehicles with zero- or ultra-low-emission vehicles over time
  • incentives to lease zero- or ultra-low-emission vehicles
  • training drivers to change their driving style
  • consolidating and sharing vehicles to ensure efficient use
  • action to minimise congestion caused by delivery schedules
  • specifying emission standards for private hire and other licensed vehicles.
Public sector fleet managers support the development and monitoring of a plan to reduce emissions from the vehicle fleet to address air pollution. Public sector fleet managers ensure that staff are aware of the plan and take action in line with the priorities identified.
Commissioners (such as local authorities, clinical commissioning groups, NHS England, and police and crime commissioners) ensure that commissioned transport or fleet services have a plan for how they will reduce emissions from their vehicle fleet to address air pollution and ensure providers monitor the impact of their plan on vehicle type and total fleet CO2 emissions.
People in the community know that public sector organisations are working to reduce pollution from their vehicles. This will help to reduce local air pollution and protect people from the effects on their health.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.4.1, 1.4.2, 1.4.3 and 1.4.6

Advice for people with chronic respiratory or cardiovascular conditions

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor.

Rationale

Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. Providing advice to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments will support self-management, improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition escalating.

Quality measures

Structure
a) Evidence that healthcare professionals carrying out routine health appointments with children, young people and adults with chronic respiratory or cardiovascular conditions are aware of the advice they should provide on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, training records.
b) Evidence of local processes to ensure that children, young people and adults with chronic respiratory or cardiovascular conditions attending routine health appointments are given advice on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, service protocols.
Process
Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor.
Numerator – the number in the denominator that were given advice on what to do when outdoor air quality is poor.
Denominator – the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Level of awareness among children, young people and adults with chronic respiratory or cardiovascular conditions on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, survey of children, young people and adults with chronic respiratory or cardiovascular conditions.
b) Rate of hospital attendance or admission for respiratory or cardiovascular exacerbations.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attacks, acute chronic obstructive pulmonary disease exacerbations, heart attacks, strokes, heart failure and angina attacks.

What the quality statement means for different audiences

Service providers (such as general practices, community health services, hospitals and community pharmacies) ensure that healthcare professionals are aware that information on air quality is available, what it means and what actions are recommended. Service providers ensure that processes are in place to provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments. Providers ensure that advice includes how to find out when outdoor air quality is expected to be poor such as from the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions who are attending a routine health appointment (and their families and carers, if appropriate). They also provide information on how to find out when outdoor air quality is expected to be poor, for example using the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Commissioners (such as clinical commissioning groups and NHS England) commission services that provide advice on what to do when outdoor air quality is poor to children, young people and adults (and their families and carers, if appropriate) at routine health appointments.
People with long-term breathing or heart conditions (and their family and carers, if appropriate) are given advice at routine health appointments on what to do when outdoor air quality is poor and how to find out when it is likely to be poor.

Source guidance

Definitions of terms used in this quality statement

Routine health appointments
Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions.
[Expert opinion]
Advice on what to do when outdoor air quality is poor
Advice should include how to minimise exposure to outdoor air pollution and manage any related symptoms such as:
  • Avoiding or reducing strenuous activity outside, especially in highly polluted locations such as busy streets, and particularly if experiencing symptoms such as sore eyes, a cough or sore throat.
  • Using an asthma reliever inhaler more often, as needed.
  • Closing external doors and windows facing a busy street at times when traffic is heavy or congested to help stop highly polluted air getting in.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.7.7 and the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]
Poor outdoor air quality
The Daily Air Quality Index describes air pollution on a scale of 1 to 10 and is divided into 4 bands from low to very high. Health effects may occur when air pollution is moderate (4 to 6), high (7 to 9) or very high (10).
[The Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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: February 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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