Clinical Guidelines for Acute Stroke Management - Living on the EDge

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intracerebral haemorrhage has been included and specifically discussed. Furthermore this guideline has been expanded from the first edition (2003) to include a number of new topics, <strong>for</strong> example, assessment and management of TIA. Development of the <strong>Guidelines</strong> The <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Acute</strong> <strong>Stroke</strong> <strong>Management</strong> have been developed according to processes prescribed by the NHMRC 2 under the direction of an interdisciplinary Expert Working Group (EWG) (see Appendix A). The draft ‘Additional levels of evidence and grades <strong>for</strong> recommendations <strong>for</strong> developers of guidelines pilot program 2005-2007’ has been used to assist in grading the recommendations along with specifying levels of evidence. 3 Consultation from other individuals and organisations was also included in the development process in line with NHMRC standards. Details about the development methodology and consultation process are outlined in Appendix A. Consumer versions of the <strong>Guidelines</strong> Consumer versions of the <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Acute</strong> <strong>Stroke</strong> <strong>Management</strong> and <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Stroke</strong> Rehabilitation and Recovery documents have been developed through partnerships between the National <strong>Stroke</strong> Foundation and State <strong>Stroke</strong> Associations throughout Australia. Given the different needs of stroke survivors and their families at different stages of recovery, the two <strong>Clinical</strong> Guideline documents are presented as three books <strong>for</strong> consumers. These books are available through the National <strong>Stroke</strong> Foundation and State <strong>Stroke</strong> Associations. Revision of the <strong>Guidelines</strong> The National <strong>Stroke</strong> Foundation aims to combine, review and update the <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Acute</strong> <strong>Stroke</strong> <strong>Management</strong> along with the <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Stroke</strong> Rehabilitation and Recovery by 2010. Using the <strong>Guidelines</strong> The primary goal in developing guidelines is to help health care workers improve the quality and effectiveness of the care they provide. The guidelines should not be seen as an inflexible recipe <strong>for</strong> stroke care; rather, they provide a framework that is based on the best available evidence that can be adapted to local needs, resources and individual circumstances. <strong>Guidelines</strong> are also different to clinical or care pathways (also referred to as critical pathways, care paths, integrated care pathways, case management plans, clinical care pathways or care maps). <strong>Guidelines</strong> are an overview of the current best evidence translated into clinically relevant statements. On the other hand, care pathways are seen as a resource which applies the guidelines in a local setting based on local needs. Care pathways are based on best practice guidelines but provide a local link between the guidelines and their use. 8 The guidelines and the preambles provide an overview of the evidence. Those wishing to implement it may need to find out more in<strong>for</strong>mation, <strong>for</strong> example, the exact processes involved in use of a particular screening tool. Strategies planned to encourage this transfer of evidence into clinical practice may include, but are not limited to: > distribution via existing networks, key professional and lay organisations, publications in professional journals, and electronic access via the internet; > development and use of decision making tools and summary documents (e.g. care pathways); > educational meetings / conferences; > use of local opinion leaders; > audit, feedback and reminders; > use of networks. In considering implementation of these <strong>Guidelines</strong> at a local level, health professionals are encouraged to identify the barriers and facilitators to evidence-based care within their environment to determine the best strategy <strong>for</strong> local needs. Further in<strong>for</strong>mation regarding implementation is discussed in Appendix A. Implications <strong>for</strong> service equity In addition to providing an avenue to improve the health outcomes <strong>for</strong> people with stroke, these guidelines provide an opportunity to discuss and address the difficulty of equity in health. The impact of stroke is dependent on a number of socioeconomic characteristics including gender, culture/ethnicity, education, occupation, income, location of residence, and lifestyle. It is known, <strong>for</strong> example, that the incidence of stroke varies depending on different socioeconomic characteristics. 9-17 One of these studies found access to some services during hospital care (e.g. physiotherapy, occupational therapy and speech pathology) differed depending on socioeconomic factors, even though there was universal access to health care. 13 However, few Introduction 3
4Introduction studies were identified during the development process regarding the impact of interventions <strong>for</strong> cute stroke. Further discussion about the socioeconomic impact of stroke is discussed in Section 9 of this document. Access is one of the major barriers to equitable services and is influenced by geography, culture and spiritual beliefs. Particular challenges are there<strong>for</strong>e noted <strong>for</strong> rural and remote services where resources, particularly human resources, may be limited. Whilst it is recognised that residents in rural and remote areas may have difficulty accessing health care as readily as their urban counterparts the aim in all settings must be to develop local solutions that ensure optimal practice and quality outcomes that are based on the best available evidence using the available resources. Careful consideration is also required <strong>for</strong> the differing needs of people with stroke. Appropriate resources may be required in a variety of languages and <strong>for</strong>mats <strong>for</strong> people with stroke and their carers. The particular needs of people from Aboriginal and Torres Strait Islander and those from culturally and linguistically diverse backgrounds also require special attention and resources. 17 Other groups of people (e.g. younger people with stroke) may also have specific needs that require particular resources or application of these guidelines. Format These guidelines are organised in nine sections to address issues deemed by the guideline developers as important in acute stroke care. The aim of the guidelines is to provide a logical framework from pre-hospital care through to discharge and follow up in the community. The introduction to each topic provides justification <strong>for</strong> the recommendation. The guidelines are then presented in a box and are summarised according to the ‘interim’ NHMRC expanded levels of evidence which are listed below. 3 Each recommendation is also graded according to the draft NHMRC grading system. The key references <strong>for</strong> each guideline are also included. Where no satisfactory Level I, II, III or IV evidence was available but there was sufficient consensus, clinical practice points based on expert opinion is provided by the EWG. The group tried at all times to organise each section as a logical flow from assessment to management. As such the order of the recommendations in each section is no indication of their importance. Designations of Levels of Evidence According to Type of Research Question 3 LEVEL INTERVENTION DIAGNOSIS PROGNOSIS AETIOLOGY SCREENING i A systematic A systematic review of A systematic A systematic A systematic review of Level II Level II studies review of Level II review of Level II review of Level II studies studies studies ii A randomised A study of test accuracy A prospective A prospective A randomised controlled trial with: an independent, cohort study cohort study controlled trial blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation iii-1 A A study of test accuracy All or none All or none A pseudorandomised with: an independent, pseudorandomised controlled trial blinded comparison with a controlled trial (i.e. alternate valid reference standard, (i.e. alternate allocation or some among non-consecutive allocation or some other method) patients with a defined other method) clinical presentation cont.
Page 1 and 2: Stop stroke. Save lives. End Suffer
Page 3 and 4: About the National Stroke</
Page 5 and 6: SECTION 6: PREVENTION AND MANAGEMEN
Page 7 and 8: KEY MESSAGES iiKey Messages This se
Page 9 and 10: 1. Organisation of Services Message
Page 11 and 12: viKey Messages 3.2: Triage in emerg
Page 13 and 14: Key Messages c) Patients who fail t
Page 15 and 16: xKey Messages > avoiding excessive
Page 17 and 18: Key Messages b) The stroke survivor
Page 19: 2Introduction > Nurses perf
Page 23 and 24: 1 ORGANISATION OF SERVICES 1 Organi
Page 26 and 27: CONSUMER 1.3 ORGANISATION OF CARE F
Page 28 and 29: 1.8 Information an
Page 30 and 31: 1.11 Standardised assessment Comple
Page 32 and 33: CONSUMER 1.13 STROKE SERVICE IMPROV
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Page 36 and 37: A notification system between emerg
Page 38 and 39: 3.4 INVESTIGATIONS GRADE LEVEL a) T
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Page 42 and 43: 4.1.3 Antithrombotic therapy Eviden
Page 44 and 45: Surgical management Surgical manage
Page 46 and 47: 4.3.4 NEUROPROTECTIVE AGENTS GRADE
Page 48 and 49: intense therapy, further high quali
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Page 54 and 55: 5.7 INCONTINENCE GRADE LEVEL a) All
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Page 58 and 59: 6.2 DEEP VENOUS THROMBOSIS (DVT) AN
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Page 66 and 67: asymptomatic stenosis
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equires a home visit. Factors to co
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8.6 Community rehabilitation Often
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9 COST AND SOCIOECONOMIC IMPLICATIO
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stroke units that used care pathway
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9.2.5 Carer training One study was
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APPENDIX A: Guideline development p
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d) If the search was for</s
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Consultation Public consultation wa
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A total of 44 consumers were involv
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A systematic review of the above di
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GLOSSARY AND ABBREVIATIONS Activiti
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REFERENCES 1 National Strok
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57 Larson J, Franzén Dahlin A, Bil
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109 Ferro JM, Pinto AN, Falcao I, e
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157 Gubitz G, Sandercock P, Counsel
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207 Palesch YY, Hill MD, Ryckborst
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262 Bamford J, Den
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317 Anderson CS, Hackett ML, House
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367 He FJ, MacGregor GA. Effect of
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415 Saxena R, Koudstaal P. Anticoag
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466 Glass TA, Berkman LF, Hiltunen
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517 Sesso HD, Chen RS, L'Italien GJ
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