Clinical Guidelines for Acute Stroke Management - Living on the EDge

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APPENDIX A: Guideline development process report Development of <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Acute</strong> <strong>Stroke</strong> <strong>Management</strong> The <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Acute</strong> <strong>Stroke</strong> <strong>Guidelines</strong> have been developed by the National <strong>Stroke</strong> Foundation according to processes prescribed by the National Health and Medical Research Council (NHMRC) toolkit series under the direction of an interdisciplinary Expert Working Group (EWG). The EWG has worked through a collaborative process, and networked with a number of <strong>for</strong>mal and in<strong>for</strong>mal groups and individuals from around Australia and overseas. Expert Working Group The National <strong>Stroke</strong> Foundation is extremely grateful to the following members of the working group who were responsible <strong>for</strong> the development of these guidelines: Dr Alan Barber Neurologist, Auckland City Hospital Dr Christopher Beer Senior Lecturer, University of Western Australia and Geriatrician/<strong>Clinical</strong> Pharmacologist Royal Perth and Mercy Hospitals and Swan Health Service Prof Justin Beilby Executive Dean, Faculty of Health Sciences and Professor of General Practice, University of Adelaide Assoc Prof Julie Bernhardt Physiotherapist, National <strong>Stroke</strong> Research Institute Prof Christopher Bladin Neurologist, Box Hill Hospital Ms Brenda Booth Consumer, Working Aged Group with <strong>Stroke</strong>, NSW Dr Julie Cichero Speech Pathologist, Private Practice & University of Queensland Ms Louise Corben Occupational Therapy, Monash Medical Centre & Bruce Lefroy Centre Murdoch Children's Research Institute Dr Denis Crimmins (chair) Neurologist, Gos<strong>for</strong>d Hospital Dr Richard Gerraty Neurologist, Alfred Hospital and Monash University Mr Kelvin Hill Manager, <strong>Guidelines</strong> Program, National <strong>Stroke</strong> Foundation Dr Erin Lalor Chief Executive Officer, National <strong>Stroke</strong> Foundation Assoc Prof Christopher Levi Neurologist, John Hunter Hospital Prof Richard Lindley Professor of Geriatric Medicine, University of Sydney and Westmead Hospital Prof Sandy Middleton School of Nursing (NSW & ACT), Australian Catholic University Ms Fiona Simpson Dietitian and Senior Research Fellow, Royal North Shore Hospital Sydney The members of the expert working group assisted in: > Reviewing the framework of existing guidelines; > Identifying, reviewing and classifying relevant literature; > Developing the draft clinical guidelines; > Providing feedback gained through the consultation process; > Developing a plan <strong>for</strong> communication, dissemination and implementation; and > Developing recommendations <strong>for</strong> periodically updating the guidelines. All members of the working group completed and signed a declaration of potential conflicts of interest with development of these guidelines. Most had no perceived conflicts. The reasons provided <strong>for</strong> potential conflicts primarily involved receiving money from non commercial and commercial organisations specifically <strong>for</strong> undertaking clinical research. This was expected given the expertise of members of the working group in clinical research. Only a small number of members had received financial support from commercial companies <strong>for</strong> providing consultancy or lecturing. Additional expertise and significant input was gratefully received from the following people: Ms Anne Parkhill In<strong>for</strong>mation Manager, Aptly Independent consultant who undertook the systematic database searches during the process. Ms Dominique Cadilhac Manager Public Health Division, National <strong>Stroke</strong> Research Institute Apendix A Guideline Development Process Report 63
A Guideline Development Process Repor t A pendix Assoc Prof Helen Dewey Neurologist and Associate Director, National <strong>Stroke</strong> Research Institute and the Austin Hospital Consultants from the National <strong>Stroke</strong> Research Institute who were responsible <strong>for</strong> writing section 9 (Economic and socioeconomic implications) of these guidelines. Additional people who kindly contributed to the guidelines development process during the appraisal and drafting process included: Dr Michael Briffa Palliative Care Specialist, Royal Adelaide Hospital Prof Stephen Davis Neurologist, Royal Melbourne Hospital Dr Petrea Cornwell Speech Pathology, University of Queensland Dr Maree Hackett Senior Research Fellow, the George Institute <strong>for</strong> International Health Prof Graeme Hankey Neurologist, Royal Perth Hospital Dr Tami Howe Speech Pathology, University of Queensland Prof Linda Worrall Speech Pathology, University of Queensland The NSF kindly acknowledges the support of the University of Sydney who allowed access to their database of electronic journals used to source relevant articles during the development process. Systematic searches and literature review The systematic identification of relevant literature was conducted according to NHMRC standards between July and November 2006. Previous international and national stroke guidelines were identified and evaluated using the AGREE tool. <strong>Guidelines</strong> developed by the Royal College of Physicians in the UK in 2004 were deemed the most recent and robust guidelines and hence were used as a basis <strong>for</strong> updating the literature searches. An external consultant was used to undertake all the electronic database searches. Question <strong>for</strong>mulation 89 clinical questions were developed by the EWG to address interventions relevant to acute stroke care. The questions generally queried the effects of a specific intervention and were developed in three parts: the intervention, the population and the outcomes. An example is “What is the effect of anticonvulsant therapy on reducing seizures in people with post-stroke seizures?” In this example, anticonvulsant therapy is the intervention, reduction of post-stroke seizures is the outcome, and the population is people with post-stroke seizures. Finding relevant studies For this guideline searching, there could be no single search coverage <strong>for</strong> all 89 questions: some sections of the guidelines need updating only from 2003, some are topics not previously addressed in the guidelines, some have already been well researched by other reputable guidelines authorities while some have no comprehensive meta-Analysis relating to them. In order to have some structure to the searching and to make filtering of the references more manageable, the questions were searched and stored in separate Endnote libraries by broad topics; 1. Organisation of care 2. Discharge planning, transfer of care and integrated community care 3. Pre hospital care 4. Early diagnostic assessment 5. <strong>Management</strong> in the emergency phase 6. Assessment and management of consequences of stroke 7. Prevention and management of complications 8. Early secondary prevention 9. Palliation and death 10. TIA Each reference within the library was then marked with the questions <strong>for</strong> which it was relevant. For Australasian Medical Index, EMBASE, Medline and Medline in-process & other non-indexed citations searching was conducted in four broad steps; a) Terms <strong>for</strong> the patient group (P) were abridged from the Cochrane Collaboration’s <strong>Stroke</strong> Group. b) Where appropriate, intervention or other factor terms were added. c) Relevant evidence filters (Cochrane sensitive filter or Medline diagnostic filter) were applied to the basic search strategies. 64 ?
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Stop stroke. Save lives. End Suffer
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About the National Stroke</
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SECTION 6: PREVENTION AND MANAGEMEN
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KEY MESSAGES iiKey Messages This se
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1. Organisation of Services Message
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viKey Messages 3.2: Triage in emerg
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Key Messages c) Patients who fail t
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xKey Messages > avoiding excessive
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Key Messages b) The stroke survivor
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2Introduction > Nurses perf
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1 ORGANISATION OF SERVICES 1 Organi
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CONSUMER 1.3 ORGANISATION OF CARE F
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