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2 Specialties Stroke medicineThe role of the carerA stroke in one person often affects the whole family,and relatives need information and support. 6 Familiesprovide much of the long-term care, often finding theirown lives radically altered. The needs of carers must beconsidered at each stage. Family support workers helpto reduce carer distress. 6Patient support groupsThe Stroke Association (www.stroke.org) plays a majorrole in developing, delivering and monitoring strokeservices. Different Strokes (www.differentstrokes.co.uk), Connect (www.ukconnect.org)andSpeakability (www.speakability.org.uk)alsoprovidewritten, web-based and telephone advice. Most areashave local support groups.Access to informationPatients with stroke and TIA report that one of theirmain needs is for information. This must be provided atappropriate times and in suitable formats includingthose suitable for people who do not speak English, andthose with stroke-related impairments such as visualand language difficulties.Availability of clinical records/resultsAvailability of clinical records, including results of brainimaging, is particularly important when the patientmoves from one part of the service to another.Role of the expert patientStroke patients should be routinely involved in serviceplanning and evaluation, 6 and may participate ineducation for staff and service users.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary team workingThe specialist stroke team includes specialist strokenurses, therapists from all professions and psychologists.Other professions include orthotics and seating services,orthoptics and ophthalmology, podiatry, and hospitaland community social work services. The World HealthOrganization international classification of functioning,disability and health (WHO ICF) 8 provides a usefulframework for shared working. Documentation andtransfer of information are particularly important; astroke proforma and integrated record (shared by allmembers of the MDT) are good practice.Working with other specialistsPriority access to appropriate and specialised imaging isof fundamental importance. Stroke physicians alsowork closely with physicians, geriatricians, neurologists,vascular surgeons, neurosurgeons and accident andemergency (A&E) departments. Liaison with psychiatry(cognitive impairment, anxiety and depression),gastroenterology and nutrition (complex feedingissues), and with palliative care and pain managementteams, is expected.Working with GPs and GPs with aspecial interestStroke physicians work with the primary care team at allstages of the stroke pathway, including primary andsecondary prevention, acute care of people withstroke/TIA and long-term support of stroke patientswith residual disability.5 Delivering a high-quality servicePeoplewhohaveastrokearemorelikelytosurviveandrecover more function if admitted promptly to ahospital-based stroke unit with care provided by aspecialist team within an integrated service. 7Maintaining and improving the qualityof careService developments to improve the qualityof careStroke care has been a focus for the Department ofHealth (DH) for over 10 years and a UK leader in theNational Sentinel Audit Programme (100%participation since 2004). The National sentinel strokeaudit 9 was developed by the RCP Stroke Programme(Clinical Effectiveness and Evaluation Unit, RCP,through the Intercollegiate Stroke Working Party,ICSWP). The National stroke strategy 7 was implementedby the Stroke Improvement Programme (DH) until 2012.Services for stroke patients have been transformedunder the influence of these and other key drivers (seeBox 2). BASP and the RCP have developed a Joint PeerReview Programme. Stroke is now a key component ofthe General Medical Services (GMS) contract forprimary care; there are seven key indicators for stroke inthe 2012–13 quality and outcomes framework (QOF). 10Stroke is also represented in the NHS outcomesframework 11 and the Clinical Commissioning GroupsOutcomes Indicator Set 2013–14. 12C○ Royal College of Physicians 2013 257
Consultant physicians working with patientsBox 2 Specialty and national guidelines and audits, quality tools and national frameworksSpecialty and national guidelines National clinical guideline for stroke, 4th edn 2012 6 NICE clinical guideline: management of acute stroke and TIA 2008 5 NICE Quality standard for stroke 2010 14 Stroke in childhood: clinical guidelines for diagnosis, management and rehabilitation 15 Meeting the future challenge of stroke. Stroke medicine consultant workforce requirements 2011–2015 (BASP) 4Specialty and national audit Sentinel Stroke National Audit Programme (SSNAP) 3 (previously: National Sentinel Stroke Audit 9 )and Stroke Improvement National Audit Programme (SINAP) 13 UK audit of vascular surgery services and carotid endarterectomy 16Quality tools and service frameworks National service framework for older people 2001 17 National service framework for long-term conditions 2005 18 Reducing brain damage: faster access to better stroke care 2005 19 Improving stroke services: a guide for commissioners 2006 20 National stroke strategy 2007 7 Welsh Health Circulars 058 and 082 2007 21 Improving stroke services in Northern Ireland. 2008 22 Progress in improving stroke care 2010 1Leadership role and the introduction of servicedevelopmentsStroke physicians play a key role in developing andimplementing modern stroke services.Education, training, mentoringand appraisalStroke physicians train and mentor members of thestroke team, and participate in education for staff,patients and carers.Continuing professional developmentBASP holds regular educational meetings including anannual meeting, at the UK Stroke Forum. Strokepractitioners join relevant professional societies andattend research and educational meetings as well asgeneral continuing professional development (CPD)activities.Clinical governanceAll stroke physicians participate in local and nationalaudit and reporting. The National sentinel audit ofstroke 9 (England, Wales and Northern Ireland) has beensuperseded by the Sentinel Stroke National AuditProgramme, SSNAP (currently for England). 3 Itcomprises organisational audits and prospective datacollection for all stroke patients. It will provide a coredataset, optional further data collection, spotlightaudits (on topics not regularly covered) and sprintaudits (focusing on areas of concern). Real-time datacollection for stroke patients in England commenced in2010 as the Stroke Improvement National AuditProgramme (SINAP). SINAP data for 10,069 patientsadmitted between July and September 2012 show thatthey had improved access to imaging (92% had a brainscan within 24 hours), quicker time to arrival on astroke unit (66% within 4 hours), and that morepatients received thrombolysis (69% of eligiblepatients). 13 The first SSNAP acute organisationalaudit found that 95% of patients were on a stroke uniton the day of the audit. However, only about 50%of patients are admitted directly to such a unit.Sixty-six per cent of services provide early supporteddischarge, but community rehabilitation remainsunder-developed. 3258 C○ Royal College of Physicians 2013
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