Consensus Statement on Stroke Treatment and Service Delivery November 2000

Consensus Statement

The needs of stroke patients are not being adequately met in the UK at present. Wide variation exists in the quality of services and, in many parts of the country, fewer than 25% of patients receive specialist care in a stroke unit. The organisation of services needs to improve, particularly since the burden of the disease is set to increase due to demographic changes.

As a first step, each health district should develop a comprehensive, integrated specialist hospital and community-based stroke service for all patients. Routine data collection by health districts should include information about all stroke patients whether in hospital or at home in order to be able to determine the incidence locally and how their needs are met.

A public awareness campaign should also be mounted, alerting both the public and health professionals to the symptoms of stroke to ensure that early attention is sought. Services must therefore be organised to enable patients to be "fast tracked" to appropriate specialist investigation and treatment.

While most of the attention is on specialist care, equal importance needs to be given to high quality, community- based primary and secondary prevention. The integrated primary care team approach to chronic disease management, including the modification of risk factors, and the maintenance of local disease registers to support the delivery of high quality care, is now well established for conditions such as coronary artery disease, hypertension and diabetes. Such an approach should be developed and adopted for stroke disease.

Patients should be treated with dignity and respect at all times. It is disappointing that patient surveys consistently show this is still not the case.

While trials of the efficacy of novel drugs in acute stroke and secondary prevention are vital, there is an urgent need for greater funding for non-drug treatment and, in particular, into aspects of stroke service delivery and organisation.

This statement is directed at services in the UK but will have relevance elsewhere.

WHOM TO ADMIT AND WHEN?

  1. Stroke is a medical emergency. Patients with suspected acute stroke should gain access to specialist secondary care by the fastest route possible.

  2. All patients with symptoms suggestive of a stroke should be referred to the stroke service for assessment including CT (computerised tomography) brain scan ideally within 24 hours. Any patient with moderate or severe symptoms should be referred with the expectation of admission to a stroke unit. Exceptions may include those relatively few patients for whom the diagnosis will make no difference to management. Inequalities in access to health care in remote and rural communities and some urban areas need to be addressed. Evidence from the development of managed clinical networks (e.g. cancer services) should be used to inform the development of similar networks for stroke.

  3. For patients with symptoms suggestive of TIA (transient ischaemic attack), all clinicians should have rapid access to specialist advice and investigation. If assessment in a neurovascular clinic is agreed to be appropriate by the referring clinician and the specialist, this should be carried out within a week.

HOW SHOULD HOSPITAL CARE BE ORGANISED?

  1. Strong evidence exists in favour of care being provided in dedicated stroke units. The key elements of such units are co-ordinated expert interdisciplinary team working in a geographically-based setting with regular team meetings. All staff, qualified and unqualified, should undertake ongoing training and education in stroke management.

  2. The tasks of the team are to establish an accurate diagnosis, including quick access to appropriate diagnostic services, observe vital signs, maintain homeostasis, provide acute treatment, prevent complications, implement early rehabilitation and initiate secondary prevention strategies. These patients often have complex medical problems and staff should be equipped to manage comorbidity.

  3. Stroke unit care should combine acute care, including early rehabilitation, with longer term rehabilitation. However, local circumstances may dictate separation of these functions. All patients regardless of age, sex and stroke severity should be able to gain access to stroke unit care. The size and composition of units should reflect local needs.

  4. The management of patients should adhere to national clinical guidelines. The quality and quantity of services should be evaluated on an ongoing basis and participation in research encouraged.

  5. The particular needs of certain groups, for example younger patients and those from ethnic minorities, should be taken into account when planning management.

WHERE SHOULD REHABILITATION TAKE PLACE - HOSPITAL OR HOME ?

  1. Rehabilitation following stroke is an interdisciplinary process which provides interventions to reduce impairments, optimise abilities and increase participation. The aim is to improve quality of life by reducing emotional, functional, cognitive, physical and communication disorders. Stroke rehabilitation includes specialist, detailed assessment, involving the patient and carer in goal planning, providing information, monitoring progress and implementing specific therapies at an intensity appropriate to the needs of the patient. This should lead to long term support and follow-up by a knowledgeable and familiar team.

  2. Management in a stroke unit which combines both acute assessment and the full range of rehabilitation should be the pathway of choice.

  3. Discharge planning should begin early in the course of admission and should consider the needs of patients and carers. A clear plan for implementation of secondary prevention and further rehabilitation if necessary should be formulated prior to discharge and the patient given a named contact who can help co-ordinate care. Good discharge planning will involve full collaboration with primary health care and local social services. Uncoordinated discharge is unacceptable.

  4. Integrated (hospital, primary care and social services) early supported discharge schemes have been found to reduce length of stay without compromising outcome. For those stroke patients able to be rehabilitated at home after initial management in hospital, there is evidence that this is preferred by some patients. Rehabilitation of a diffuse and uncoordinated nature whether in hospital or in the community has been demonstrated to have poor outcomes and should be discouraged. For this reason, community-based rehabilitation services should develop partnerships with stroke services. Special attention should be given to minimising carer stress where patients are being rehabilitated at home.

  5. Patients and carers want timely, meaningful, accessible, reliable, co-ordinated and supportive rehabilitation, which both incorporates and is driven by their goals and is carried out by well trained and knowledgeable staff.

  6. Whether the benefits achieved by stroke units can be replicated in settings outside district hospitals such as community hospitals or nursing homes needs to be evaluated.

  7. The expertise of the specialist rehabilitation services should, where appropriate, inform and support the wider community services.

  8. Patients and carers value a stroke co-ordinator/liaison personnel and practical local information wherever they are.

CAN WE REDUCE THE EMOTIONAL IMPACT OF STROKE?

  1. The importance of mood disorders after stroke needs recognition. The emotional impact of stroke can include: anger, denial, anxiety, depression, emotionalism and post-traumatic stress disorder. These states have been found to be present in approximately 40-50% of stroke patients in hospital and 25% in the community and are associated with worse outcomes.

  2. Stroke patients and their carers may require emotional support and should be given the opportunity to discuss concerns and ask questions of those involved in their care. In addition, some patients with mood disorder may require treatment by staff skilled in psychological approaches.

  3. There is a need for a co-ordinated approach requiring the development of validated assessment tools for mood disorders which can be practically applied in all healthcare settings to stroke patients with cognitive and language disorders.

  4. Evidence to support the widespread implementation of therapies is limited. It is not yet possible to recommend specific therapies to treat and prevent mood disorder after stroke. There is evidence to support an individual intervention which could be drawn from the following:

    • anti-depressants for depression or emotionalism;

    • psychological therapies;

    • support approaches (including patient and carer support groups);

  5. Carers may experience considerable stress and there is evidence that this can be reduced by interventions such as family support services.

  6. There is a need for systematic research, including dose-finding studies, leading to RCTs (Randomised Controlled Trials) at different time points after stroke.

Should you wish to print or quote parts of, or the whole of, this statement, prior permission must be secured from:

Graeme McAlister,
Publications Department of the Royal College of Physicians of Edinburgh,
9 Queen Street, Edinburgh EH2 1JQ.
Telephone: 0131 247 3693
Fax: 0131-226-6124

 
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