Clinical Guidelines for Acute Stroke Management - Living on the EDge

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CONSUMER 1.13 STROKE SERVICE IMPROVEMENT GRADE LEVEL RATING a) All acute stroke services should be involved in quality improvement B Level I 77 – activities that include regular audit and feedback (‘regular’ is considered at least every two years). b) Indicators based on nationally agreed standards of care should be ✓ – – used when undertaking any audit. Per<strong>for</strong>mance can then be compared to similar stroke services as described by the National <strong>Stroke</strong> Unit Program. Section 1 Organisation of Services 15
2 PRE-HOSPITAL CARE Section 2 Pre-Hospital Care There is growing evidence that good early stroke management can reduce damage to the brain and minimise the effects of stroke. Because of this early recognition of stroke the subsequent response of individuals to having a stroke and the timing and method by which people are transferred to hospital are important to ensure optimal outcomes. In this hyperacute phase of care, the ambulance service provides a central, coordinating role. <strong>Stroke</strong> patients should not only receive a high triage priority but the system should facilitate early notification of the receiving hospital and ensure that the correct hospital is selected (i.e. one with organised stroke unit care) where a choice exists. Studies involving pre-hospital approaches have found: > Education regarding the signs of stroke and the critical nature of stroke delivered to emergency medical service staff, emergency department staff and the general public increased the use of ambulance transport, decreased admission delays and improved the number of patients receiving thrombolysis. 39, 81, 82 While it is unclear how often education should be provided to improve early recognition current practice suggested that local services should incorporate such education into routine, ongoing education at least annually. > High priority by emergency medical services and early notification to hospital emergency departments improves efficient acute stroke management. 83-85 However, this is one component of a multifaceted strategy and it is difficult to determine the effect of this strategy alone. > Preferential transportation to known stroke specialist centres, based on agreed local protocols, has been suggested in several low level studies. 39-41 Again, this is one component of a multifaceted strategy and it is difficult to determine the effect of this strategy alone. However, there are clear benefits <strong>for</strong> admission to a stroke unit. Hence, where practical (e.g. hospitals located within the same local area), ambulance services should transport patients with suspected stroke to hospitals with such organised services. > Several validated pre-hospital screening tools have been developed, <strong>for</strong> example, the Los Angeles Prehospital <strong>Stroke</strong> Screen or the Melbourne Ambulance <strong>Stroke</strong> Screen (MASS). 86-89 > Specific training <strong>for</strong> emergency medical services staff improves diagnostic accuracy and reduces pre-hospital delays. 39, 83 For example, a one hour training session based on the only Australian tool, the MASS, increased the diagnostic accuracy of pre-hospital emergency service staff from 78 to 94%. 83 > Pre-hospital initiation by paramedics of intravenous magnesium sulphate has been shown to be feasible and safe in one small pilot study 90 and a subsequent RCT is ongoing. CONSUMER 2 PRE-HOSPITAL CARE GRADE LEVEL RATING a) Ambulance services, health care professionals and the general C III-3 & IV 39 9.5/10 public should receive education concerning the importance of early recognition of stroke, emphasising stroke is a medical emergency. b) <strong>Stroke</strong> patients should be given a high priority grouping by C Level III-2 9.6/10 ambulance services. 83, 84 c) Ambulance services should be trained in the use of validated B Level III-2 9.7/10 rapid pre-hospital stroke screening tools and incorporate such 86-89 tools into protocols <strong>for</strong> all pre-hospital assessment of people with suspected stroke. d) Ambulance services should preferentially transfer suspected ✓ – – patients to a hospital with stroke unit care. 16
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 and 20: 2Introduction > Nurses perf
Page 21 and 22: 4Introduction studies were identifi
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 34 and 35: 3 EARLY ASSESSMENT AND DIAGNOSIS Th
Page 36 and 37: A notification system between emerg
Page 38 and 39: 3.4 INVESTIGATIONS GRADE LEVEL a) T
Page 40 and 41: Intravenous rt-PA was licensed by t
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
Page 50 and 51: of very early versus delayed mobili
Page 52 and 53: The first step in planning manageme
Page 54 and 55: 5.7 INCONTINENCE GRADE LEVEL a) All
Page 56 and 57: 6 PREVENTION AND MANAGEMENT OF COMP
Page 58 and 59: 6.2 DEEP VENOUS THROMBOSIS (DVT) AN
Page 60 and 61: 7 SECONDARY PREVENTION 7.1 Behaviou
Page 62 and 63: diuretic. 398 A subsequent trial co
Page 64 and 65: There remains uncertainty about the
Page 66 and 67: asymptomatic stenosis
Page 68 and 69: adults living at home with diabetes
Page 70 and 71: equires a home visit. Factors to co
Page 72 and 73: 8.6 Community rehabilitation Often
Page 74 and 75: 9 COST AND SOCIOECONOMIC IMPLICATIO
Page 76 and 77: stroke units that used care pathway
Page 78 and 79: 9.2.5 Carer training One study was
Page 80 and 81: 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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Clinical Guidelines for Acute Stroke Management - Living on the EDge

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