national-clinical-guidelines-for-stroke-fourth-edition

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1 Introduction 1.0 Introduction 1.1 Scope This is the fourth edition of the UK National clinical guideline for stroke. Significant changes from the first three editions include: > the use of evidence published since 2008 > updating of some of the areas covered by the National Institute for Health and Clinical Excellence (NICE) guideline National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (National Institute for Health and Clinical Excellence 2008b), (see section 1.8) > ‘Evidence to recommendations’ sections, outlining in more detail why a particular recommendation has or has not been made. This section may include some references or evidence that the Intercollegiate Stroke Working Party (henceforth known as ‘the working party’) thought important but not sufficiently strong to justify a recommendation. We have, as with the third edition: > included specific recommendations for those who commission (purchase) services for people with stroke > identified areas where consideration of when actions may reasonably not be undertaken, or may be limited or stopped > used qualitative evidence where appropriate > referred to and incorporated relevant national documents including: the National stroke strategy (Department of Health, 2007), Quality standards for stroke (National Institute for Health and Clinical Excellence 2010d) and The national service framework for long-term conditions (Department of Health 2005). This guideline covers the management in adults (ie over 16 years) of: > stroke and transient ischaemic attack (TIA) – acute diagnosis and treatments – rehabilitation, all aspects – long-term care and support – secondary prevention – prevention of complications – organisation of stroke services > subarachnoid haemorrhage (SAH) – immediate management required by physicians at an admitting hospital. It does not cover surgical or neuro-radiological interventions. The guideline does not cover: > primary prevention of stroke (other guidelines concerning prevention of vascular disease should be used) © Royal College of Physicians 2012 1
National clinical guideline for stroke > detailed recommendations on (neuro-)surgical techniques, (but the role of surgery is considered) > management of children with stroke; guidelines concerning children are published separately (Paediatric Stroke Working Group 2004) > general aspects of healthcare, unless there are very specific issues relating to stroke. 1.2 Aims of the guideline There have been major developments in stroke care over the last four years necessitating this new edition. The goal of this guideline is to improve the quality of care delivered to everyone who has a stroke in the country regardless of age, gender, type of stroke, location or any other feature. Guidelines can only be one part of a quality improvement programme. Audit of the quality of care through national audit has been, and will in the future be, integral to raising the standards of stroke care. Not only has audit had a direct influence on care delivery but also indirectly through its influence on other organisations (eg National Audit Office 2005; National Audit Office 2010) and policies (eg the National service framework for older people (Department of Health 2001) and the English National Stroke Strategy (Department of Health 2007)). The guideline has been written with several specific audiences in mind: > commissioners involved in purchasing services for people with stroke > clinical staff who are involved with stroke patients > managers involved in providing services for people with stroke > patients with stroke, and their relatives and friends. A version is available for non-healthcare staff but we hope that the main document may also be useful to the lay public. The guideline is primarily developed for use in the UK, but many of the recommendations will be applicable in other countries and settings. 1.3 Organisation of the guideline 1.3.1 Chapter content 1.3.1.1 Chapter 1 – introduction This sets out the scope of the guideline, the methods by which it was developed and how it should be used. 1.3.1.2 Chapter 2 – commissioning This chapter covers the aspects that commissioners need to take into account when commissioning stroke services. Commissioners have a particularly important role in ensuring that services are appropriately organised and in identifying the efficiencies that can be achieved by altering where and how services are delivered. 2 © Royal College of Physicians 2012
Page 1 and 2: National clinical guideline for str
Page 3 and 4: The Royal College of Physicians The
Page 9 and 10: The Intercollegiate Stroke Working
Page 11 and 12: Conflicts of interest All working p
Page 13 and 14: Key recommendations Number Recommen
Page 17 and 18: Acknowledgements The Intercollegiat
Page 19 and 20: Glossary ABCD2 score Prognostic sco
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Page 36 and 37: 2 Commissioning of stroke services
Page 38 and 39: 2.1.2 Implications needed by patien
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Page 42 and 43: 3 Organisation of stroke services 3
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Page 48 and 49: 3.5.1 Recommendation 3.5.2 Source A
Page 50 and 51: 3.8 Transfers of care - discharge f
Page 52 and 53: B Clinicians in all settings should
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Page 58 and 59: evidence from randomised trials is
Page 60 and 61: 4 Acute phase care 4.0 Introduction
Page 62 and 63: E All patients with residual neurol
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Page 72 and 73: prevent rebleeding are urgent. CT s
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anticoagulants including direct thr
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Evidence to recommendations Studies
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● risk of developing skin pressur
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4.16 Positioning Impairment of moto
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section covers only the immediate,
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National clinical guideline for str
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7 Long-term management 7.0 Introduc
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● where appropriate refer the per
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experience appropriate to meet thei
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Profession-specific concise guideli
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● ensure that all relevant inform
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C People with stroke should be offe
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● avoiding the use of overhead ar
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Carers (informal, unpaid) (7.6.1) A
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● any continuing specialist treat
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Lipid-lowering therapy (5.6.1) B Al
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Occupational therapy concise guide
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C Bilateral arm training involving
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● be referred to a specialist in
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problems, such as using notebooks,
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Physiotherapy concise guide for str
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medically unstable, by an appropria
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numerical rating scale), the modifi
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Cognitive impairments - general (6.
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E Patients with suspected TIA who a
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Lipid-lowering therapy (5.6.1) A Al
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● ask about and identify any abso
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formal review at least every 6 mont
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Depression and anxiety (6.35.1) A A
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Perception (6.42.1) A Any person wh
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days per week, at a level that enab
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language function should be assesse
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● organising and supporting venue
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Appendix 1 Evidence table reviewers
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Appendix 2 Peer reviewers Commissio
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Dr Katerina Hilari City University
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QM7 Urgent response All patients wi
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References Abbott AL (2009) Medical
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Cirstea MC, Levin MF (2007) Improve
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Fung TT, Chiuve SE, McCullough ML,
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Koyuncu E, Nakipoglu YG, Dogan A, O
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Mitchell PH, Veith RC, Becker KJ, B
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Rothwell P, Eliasziw M, Gutnikov S,
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therapy for stroke inpatients. Clin
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