National Clinical Guideline for Stroke 2023 PDF

2023 edition www.strokeguideline.org Contents What’s new in the 2023 edition...................................................................................................................... 4 Organisation of stroke services..........................................................................................................................4 Acute care...........................................................................................................................................................4 Rehabilitation and recovery...............................................................................................................................5 Long-term management and secondary prevention..........................................................................................6 1 Guideline development.......................................................................................................................... 7 1.0 Introduction...........................................................................................................................................7 1.1 Scope.....................................................................................................................................................8 1.2 Context and use of this guideline..........................................................................................................8 1.3 Models underpinning guideline development......................................................................................9 1.4 Methodology of guideline development...............................................................................................9 1.5 Funding and conflicts of interest.........................................................................................................10 1.6 Treatments not mentioned in this guideline.......................................................................................10 1.7 Participation in clinical research..........................................................................................................10 1.8 Licensing and approval of medication.................................................................................................10 1.9 Contributors........................................................................................................................................11 1.10 Notes on the text.................................................................................................................................11 2 Organisation of stroke services............................................................................................................. 12 2.0 Introduction.........................................................................................................................................12 2.1 Public awareness of stroke..................................................................................................................12 2.2 Definitions of specialist stroke services...............................................................................................12 2.3 Transfer to acute stroke services.........................................................................................................13 2.4 Organisation of inpatient stroke services............................................................................................14 2.5 Resources – inpatient stroke services.................................................................................................16 2.6 Location of service delivery.................................................................................................................20 2.7 Transfers of care – general principles..................................................................................................21 2.8 Transfers of care from hospital to home – community stroke rehabilitation.....................................21 2.9 Remotely delivered therapy and telerehabilitation............................................................................25 2.10 Measuring rehabilitation outcomes....................................................................................................25 2.11 Psychological care – organisation and delivery...................................................................................26 2.12 Vocational rehabilitation.....................................................................................................................28 2.13 Follow-up review and longer term support.........................................................................................29 2.14 Stroke services for younger adults......................................................................................................29 2.15 End-of-life (palliative) care..................................................................................................................30 2.16 Carers...................................................................................................................................................31 2.17 People with stroke in care homes.......................................................................................................32 2.18 Service governance and quality improvement....................................................................................33 3 Acute care............................................................................................................................................. 35 3.0 Introduction.........................................................................................................................................35 3.1 Pre-hospital care..................................................................................................................................35 3.2 Management of TIA and minor stroke ‒ assessment and diagnosis...................................................36 3.3 Management of TIA and minor stroke – treatment and vascular prevention....................................38 3.4 Diagnosis and treatment of acute stroke – imaging............................................................................41 3.5 Management of ischaemic stroke.......................................................................................................42 3.6 Management of intracerebral haemorrhage.......................................................................................49 3.7 Management of subarachnoid haemorrhage......................................................................................53 3.8 Cervical artery dissection.....................................................................................................................54 3.9 Cerebral venous thrombosis................................................................................................................55 3.10 Acute stroke care.................................................................................................................................56 3.11 Positioning...........................................................................................................................................58 3.12 Early mobilisation................................................................................................................................59 2023 Edition, 04 April 2023 1 3.13 Deep vein thrombosis and pulmonary embolism...............................................................................60 4 Rehabilitation and recovery.................................................................................................................. 62 Principles of rehabilitation............................................................................................................................ 62 4.0 Introduction.........................................................................................................................................62 4.1 Rehabilitation potential.......................................................................................................................62 4.2 Rehabilitation approach – intensity of therapy (motor recovery and function).................................64 4.3 Rehabilitation approach ‒ goal setting................................................................................................66 4.4 Self-management................................................................................................................................67 4.5 Remotely delivered therapy and telerehabilitation............................................................................69 4.6 Self-directed therapy...........................................................................................................................70 Activity and participation.............................................................................................................................. 71 4.7 Introduction.........................................................................................................................................71 4.8 Independence in daily living................................................................................................................72 4.9 Hydration and nutrition.......................................................................................................................73 4.10 Mouth care..........................................................................................................................................75 4.11 Continence...........................................................................................................................................77 4.12 Extended activities of daily living........................................................................................................78 4.13 Sex.......................................................................................................................................................79 4.14 Driving..................................................................................................................................................80 4.15 Return to work.....................................................................................................................................81 Motor recovery and physical effects of stroke.............................................................................................. 83 4.16 Introduction.........................................................................................................................................83 4.17 Motor Impairment...............................................................................................................................84 4.18 Arm function........................................................................................................................................88 4.19 Ataxia...................................................................................................................................................93 4.20 Balance................................................................................................................................................94 4.21 Falls and fear of falling.........................................................................................................................96 4.22 Walking................................................................................................................................................97 4.23 Pain....................................................................................................................................................100 4.23.1 Neuropathic pain (central post-stroke pain)......................................................................................100 4.23.2 Musculoskeletal pain..........................................................................................................................101 4.23.3 Shoulder subluxation and pain...........................................................................................................101 4.24 Spasticity and contractures...............................................................................................................103 4.25 Fatigue...............................................................................................................................................105 4.26 Swallowing.........................................................................................................................................108 Psychological effects of stroke.................................................................................................................... 112 4.27 Introduction.......................................................................................................................................112 4.28 Psychological effects of stroke – general...........................................................................................112 4.29 Cognitive screening...........................................................................................................................114 4.30 Cognitive assessment........................................................................................................................116 4.31 Apraxia...............................................................................................................................................116 4.32 Attention and concentration.............................................................................................................117 4.33 Memory.............................................................................................................................................118 4.34 Executive function.............................................................................................................................119 4.35 Mental capacity.................................................................................................................................119 4.36 Perception.........................................................................................................................................121 4.37 Neglect...............................................................................................................................................121 4.38 Mood and well-being.........................................................................................................................123 4.39 Anxiety, depression and psychological distress.................................................................................123 4.40 Apathy...............................................................................................................................................126 4.41 Emotionalism.....................................................................................................................................127 Communication and language..................................................................................................................... 128 2023 Edition, 04 April 2023 2 4.42 Introduction.......................................................................................................................................128 4.43 Aphasia..............................................................................................................................................128 4.44 Dysarthria..........................................................................................................................................131 4.45 Apraxia of speech..............................................................................................................................131 Sensory effects of stroke............................................................................................................................. 132 4.46 Introduction.......................................................................................................................................132 4.47 Sensation...........................................................................................................................................132 4.48 Vision.................................................................................................................................................133 5 Long-term management and secondary prevention........................................................................... 135 5.0 Introduction.......................................................................................................................................135 5.1 A comprehensive and personalised approach..................................................................................135 5.2 Identifying risk factors.......................................................................................................................136 5.3 Carotid artery stenosis......................................................................................................................137 5.4 Blood pressure...................................................................................................................................139 5.5 Lipid modification..............................................................................................................................142 5.6 Antiplatelet treatment......................................................................................................................144 5.7 Anticoagulation.................................................................................................................................146 5.8 Other risk factors...............................................................................................................................149 5.9 Paroxysmal atrial fibrillation..............................................................................................................150 5.10 Patent foramen ovale........................................................................................................................151 5.11 Other cardioembolism.......................................................................................................................153 5.12 Vertebral artery disease....................................................................................................................153 5.13 Intracranial artery stenosis................................................................................................................154 5.14 Oral contraception and hormone replacement therapy...................................................................155 5.14.1 Oral contraception..............................................................................................................................155 5.14.2 Hormone replacement therapy..........................................................................................................156 5.15 Obstructive sleep apnoea..................................................................................................................156 5.16 Antiphospholipid syndrome..............................................................................................................157 5.17 Insulin resistance...............................................................................................................................158 5.18 Fabry disease.....................................................................................................................................158 5.19 Cerebral amyloid angiopathy............................................................................................................159 5.20 CADASIL.............................................................................................................................................161 5.21 Cerebral microbleeds........................................................................................................................162 5.22 Lifestyle measures.............................................................................................................................163 5.23 Physical activity.................................................................................................................................163 5.24 Smoking cessation.............................................................................................................................165 5.25 Nutrition (secondary prevention)......................................................................................................165 5.26 Life after stroke.................................................................................................................................167 5.27 Further rehabilitation........................................................................................................................168 5.28 Social integration and participation..................................................................................................171 6 Implementation of this guideline........................................................................................................ 174 6.0 Introduction.......................................................................................................................................174 6.1 Overall structure of stroke services...................................................................................................174 6.2 Acute stroke services.........................................................................................................................176 6.3 Secondary prevention services..........................................................................................................176 6.4 Stroke rehabilitation services............................................................................................................177 6.5 Long-term support services...............................................................................................................178 Glossary...................................................................................................................................................... 180 Abbreviations and acronyms....................................................................................................................... 186 Bibliography................................................................................................................................................ 189 2023 Edition, 04 April 2023 3 What’s new in the 2023 edition _____________________________________________________________________________________ Out of 538 recommendations in this guideline, almost 300 have been updated, added or endorsed since the 2016 edition. Here are highlights of some of the changes, together with the change to the geographical remit of the guideline, which now covers the four nations of the United Kingdom, and the Republic of Ireland. Organisation of stroke services Hyperacute, acute and rehabilitation stroke services should provide specialist medical, nursing and rehabilitation staffing levels matching the recommendations in Table 2.5. [see 2.5 B and Table 2.5] A stroke rehabilitation unit should have access to a consultant specialising in stroke rehabilitation (medical or non-medical, i.e. nurse or therapist, where professional regulation permits). [see 2.5 K] Stroke rehabilitation units with non-medical consultant leadership should have daily medical cover (ward doctors, GPs), enabling admissions and discharges 7 days a week. [see 2.5 L] People undergoing rehabilitation after stroke who are not eligible for early supported discharge should be referred to community stroke rehabilitation if they have ongoing rehabilitation needs when transferred from hospital. [see 2.8 B] The intensity and duration of intervention provided by the community stroke rehabilitation team should be established between the stroke specialist and the person with stroke and be based on clinical need tailored to goals and outcomes. [see 2.8 E] A multidisciplinary service providing early supported discharge and community stroke rehabilitation should adopt a minimum core team structure. [see 2.8 F] In the case of people with stroke with limited life expectancy, the multidisciplinary team should establish whether there is any existing documentation of the patient’s wishes regarding management of risks associated with continued eating and drinking. [see 2.15 E] Acute care Dual antiplatelet therapy with either aspirin and clopidogrel, or aspirin and ticagrelor, should be considered in patients presenting within 24 hours of TIA and minor stroke. [see 3.3 B] Patients with acute ischaemic stroke within 4.5 hours of known onset should be considered for thrombolysis with alteplase or tenecteplase. [see 3.5 A] Patients with acute ischaemic stroke who were last known to be well more than 4.5 hours earlier should be considered for thrombolysis with alteplase between 4.5-9 hours of known onset, if there is evidence of the potential to salvage brain tissue on CT perfusion or MRI (DWI-FLAIR mismatch). [see 3.5 B] Patients eligible for mechanical thrombectomy should receive prior intravenous thrombolysis as rapidly as possible (unless contraindicated), irrespective of whether they have presented to an acute stroke centre or a thrombectomy centre. [see 3.5 F] 2023 Edition, 04 April 2023 4 Patients presenting with acute anterior circulation ischaemic stroke and large artery occlusion between 6 and 24 hours previously, including wake-up stroke, should receive mechanical thrombectomy on the basis of a combination of ASPECTS score and target or clinical imaging mismatch. [see 3.5 I] Patients presenting with acute ischaemic stroke in the posterior circulation within 12 hours of onset should be considered for mechanical thrombectomy if they have a confirmed intracranial vertebral or basilar artery occlusion. [see 3.5 K] Patients with acute spontaneous intracerebral haemorrhage with a systolic BP of 150-220 mmHg should be considered for urgent treatment within 6 hours of symptom onset, aiming to achieve a systolic BP of 130-139 mmHg within one hour and sustained for at least 7 days. [see 3.6 C] Early non-invasive cerebral angiography (CTA/MRA within 48 hours of onset) should be considered for patients with acute spontaneous intracerebral haemorrhage where a macrovascular cause is likely to be identified. [see 3.6 H] Rehabilitation and recovery People with stroke should be considered to have the potential to benefit from rehabilitation at any point after their stroke. [see 4.1 A] People with stroke should be routinely screened for delirium. [see 4.29 B] People with stroke should be screened for cognitive problems as soon as it is medically appropriate and they are able to participate in a brief interaction, usually within the initial days after onset of stroke. [see 4.29 C] People with stroke should be routinely screened for anxiety and depression using standardised tools, the results of which should be used alongside other sources of information. [see 4.39 B] People with motor recovery goals following stroke should receive at least 3 hours a day of therapy (therapist-delivered) and should be supported to remain active for up to 6 hours a day. [see 4.2 A]. For people with stroke who show diminished motivation, reduced goal-directed behaviour or decreased emotional responsiveness that is persistent and affects engagement with rehabilitation or functional recovery, apathy should be considered alongside other cognitive and mood disorders. [see 4.40 A] People with some upper limb movement, or impaired mobility or balance after stroke, should be offered repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath. [see 4.18 A, 4.20 B and 4.22 C] People with mild-moderate arm weakness after stroke may be considered for transcutaneous vagus nerve stimulation in addition to usual therapy. Implanted vagus nerve stimulation should only be used in the context of a clinical trial. [see 4.18 H] Stroke rehabilitation services should ensure they have adequate equipment, including the technology requirements to provide telerehabilitation, to enable provision of the treatments recommended within this guideline. [see 6.4 D] Stroke services should consider building links with recreational fitness facilities such as gyms or leisure centres, or providing equipment in outpatient departments, to enable people with stroke to access treadmills and other relevant fitness equipment. [see 4.22 I] 2023 Edition, 04 April 2023 5 People with stroke should be offered cardiorespiratory training or mixed training once they are medically stable, regardless of age, time since stroke and severity of impairment. [see 4.17 E] People with stroke should be assessed and periodically reviewed for post-stroke fatigue, including for factors that might precipitate or exacerbate fatigue (e.g. depression and anxiety, sleep disorders, pain) and these factors should be addressed accordingly. Appropriate time points for review are at discharge from hospital and then at regular intervals, including at 6 months and annually thereafter. [see 4.25 C] People with aphasia after stroke should be given the opportunity to improve their language and communication abilities as frequently and for as long as they continue to make meaningful gains, including access to appropriate practice-based digital therapies. [see 4.43 B and C] Long-term management and secondary prevention Home blood pressure monitoring should be considered for guiding the management of BP-lowering treatment, with a typical home systolic BP target below 125 mmHg. [see 5.4 A and F] Lipid-lowering treatment for people with ischaemic stroke or TIA and evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol below 1.8 mmol/L (equivalent to a non-HDL-cholesterol below 2.5 mmol/L in a non-fasting sample). [see 5.5 C] People who have an intracerebral haemorrhage whilst taking an antithrombotic medication to prevent vascular occlusive events may be considered for restarting antiplatelet treatment. [see 5.6 C] People with ischaemic stroke and atrial fibrillation or flutter should be considered for anticoagulation within 5 days of onset for mild stroke and may be considered for anticoagulation from 5-14 days of onset for moderate to severe stroke. Wherever possible people in the latter category should be offered participation in a trial of the timing of initiation of anticoagulation after stroke. [see 5.7 A] Selected people below the age of 60 with ischaemic stroke or TIA of otherwise undetermined aetiology, in association with a patent foramen ovale (PFO) and a right-to-left shunt or an atrial septal aneurysm, should be considered for endovascular PFO device closure within 6 months of the index event to prevent recurrent stroke. [see 5.10 B] People with lobar intracerebral haemorrhage (ICH) associated with probable cerebral amyloid angiopathy (CAA) may be considered for antiplatelet therapy for the secondary prevention of vaso- occlusive events, and those with atrial fibrillation (AF) may be considered for oral anticoagulation. Wherever possible these people should be offered participation in a randomised controlled trial of antithrombotic treatment after ICH associated with CAA. [see 5.19 B and C] People with CADASIL should be considered for intensive cardiovascular risk factor management, including antiplatelet therapy to prevent secondary vascular events. [see 5.20 B and C] In people with ischaemic stroke or TIA requiring antithrombotic treatment the presence of cerebral microbleeds (regardless of number or distribution) need not preclude the use of such treatment. [see 5.21 A] People with stroke should be offered cardiorespiratory training or mixed training, for at least 30-40 minutes, 3 to 5 times a week for 10-20 weeks regardless of age, time since stroke onset or severity of impairments, guided by their goals and preferences. [see 5.23 C] People with stroke should be supported to develop their own self-management plan, based on their individual needs, goals, preferences and circumstances. [see 5.27 F] 2023 Edition, 04 April 2023 6 1 Guideline development _____________________________________________________________________________________ 1.0 Introduction Purpose of guideline The National Clinical Guideline for Stroke provides authoritative, evidence-based practice guidance to improve the quality of care delivered to every adult who has a stroke in the United Kingdom and Ireland, regardless of age, gender, type of stroke, location, or any other feature. The guideline is intended for: - those providing care – nurses, doctors, therapists, care staff; - those receiving care – patients, their families, their carers; - those commissioning, providing or sanctioning stroke services; - anyone seeking to improve the care of people with stroke. Parties responsible for guideline The 2023 edition, like the previous editions of this guideline, was produced by the Intercollegiate Stroke Working Party. The Working Party was originally set up by the Royal College of Physicians and is a group of senior representatives from the professional bodies in England, Wales and Northern Ireland involved in stroke care, as well as the voluntary sector and patient voice representatives. For this edition encompassing the whole of the UK and Ireland, the Working Party established a Guideline Development Group with representatives from the Working Party, from the Scottish Intercollegiate Guidelines Network (SIGN) and from the Irish National Clinical Programme for Stroke. Production of the 2023 edition was supported by a project team based at the Sentinel Stroke National Audit Programme (SSNAP), King’s College London. More information about contributors to the guideline is in Section 1.9 Contributors. The 2023 guideline is endorsed for use in clinical practice by the Royal College of Physicians of London, the Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of Physicians of Ireland. Relationship to guidance from NICE and SIGN In appraising the updated evidence base the Guideline Development Group has paid close attention to the content of the most recent NICE guidance on stroke: - NICE guideline [NG128] Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (last updated in 2022) https://www.nice.org.uk/guidance/ng128; - NICE quality standard [QS2] Stroke in adults (last updated in 2016) https://www.nice.org.uk/guidance/qs2/chapter/Quality-statement-2-Intensity-of-stroke- rehabilitation; - NICE guideline [CG162] Stroke rehabilitation in adults (last updated in 2013, update due late 2023) https://www.nice.org.uk/guidance/cg162. This guideline is referred to as SIGN 166 and replaces the following SIGN guidelines: - SIGN 119: Management of patients with stroke: Identification and management of dysphagia (published 2010, withdrawn 2020); - SIGN 118: Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning (published 2010, withdrawn 2020); - SIGN 108: Management of patients with stroke or TIA: Assessment, investigation, immediate management (published 2008, withdrawn 2018). 2023 Edition, 04 April 2023 7 1.1 Scope This guideline covers the management in adults (i.e. people aged over 16 years) of: - stroke (ischaemic stroke and primary intracerebral haemorrhage [ICH]) and transient ischaemic attack (TIA), including ocular or retinal stroke and amaurosis fugax; - subarachnoid haemorrhage (SAH): immediate management required at an admitting hospital. The guideline does not cover: - primary prevention of stroke; - detailed recommendations on (neuro-)surgical techniques (but the role of surgery is addressed); - management of children with stroke; - surgical or neuroradiological interventions for SAH; - general aspects of healthcare, unless there are specific issues relating to stroke. 2023 edition The 2023 edition is a partial update of the 2016 edition. The scope of the update is available here. This edition includes updated evidence published since 2015, with literature searches completed up to September 2022 and with some major publications since that date also included. This 2023 edition of the guideline includes Scotland and the Republic of Ireland for the first time, as well as England, Wales, Northern Ireland, and the Isle of Man. This expansion of the guideline’s remit will affect some of the nomenclature, which differs between nations and health systems, and clinicians may need to interpret recommendations in the context of their healthcare system. 1.2 Context and use of this guideline This guideline relates to those aspects of clinical management that are specific to stroke; it does not seek to address areas of routine clinical practice and good governance such as courtesy and respect for the individual, shared decision making and supporting patient choice, accurate record keeping etc. This guideline is not intended to overrule regulations or standards concerning the provision of services and should be considered in conjunction with them. In considering and implementing this guideline, users are advised to also consult and follow all appropriate legislation, standards and good practice. No clinical guideline can account for every eventuality, and recommendations should be taken as statements that inform and guide the clinician, the patient and any other user, and not as rigid rules. The clinician remains responsible for interpreting the recommendations taking into account the circumstances at hand (e.g. medical, psychosocial, cultural) and including competing priorities for the patient and co-morbidities such as frailty, and for considering whether new evidence might exist that could alter the recommendation. In doing so, clinicians should consider Sweeney’s three levels of significance when applying the evidence to the person in front of them: statistical significance (is the evidence valid?), clinical significance (does the evidence apply to this clinical situation?) and personal significance (does the evidence apply to this person’s particular circumstances and priorities?) (Sweeney et al, 1998). Clinicians can reasonably expect guidelines to be unambiguous about the first and to give guidance about the second, but the third level of significance can only be understood within the relationship between the treating clinician and their patient, and may provide the justification for deviations from recommended management in particular cases. 2023 Edition, 04 April 2023 8 1.3 Models underpinning guideline development This guideline has used several models or frameworks to structure its recommendations and layout. In summary these are: - the Donabedian model (Donabedian, 1978) for considering healthcare: structure, process and outcome; - the healthcare process: diagnosis, assessment, intervention (treatment and support), and evaluation; - the WHO international classification of functioning, disability and health (WHO ICF) model (World Health Organization, 1978; Wade & Halligan, 2004); - time: prevention, acute, post-acute/recovery and long-term. The WHO ICF model is a useful conceptual framework for disease management, particularly one with such long-term impact as stroke. This framework is articulated in terms of: - pathology (the disease processes within organs); - impairment (symptoms/signs; the manifestations of disease in the individual); - activities (the impact of impairments on the person’s usual activities); - participation (the impact of activity limitations on a person’s place in family and society). 1.4 Methodology of guideline development The same methodology was followed for the 2023 update as for the 2016 edition. It includes seven distinct steps to ensure a thorough and rigorous process. The detailed methodology is available in the methodology overview [here]. The seven steps are: 1. Development of scope (see process and final scope, including research questions, here); 2. Searching the scientific literature (see search strategies here); 3. Selection of studies for inclusion; 4. Assessment of the quality of the evidence (see evidence tables here); 5. Moving from evidence to recommendations; 6. Health economic considerations; 7. External peer review and public consultation (see peer review and public consultation document here, and peer review comments and responses in the peer review report here). Grading of recommendations and consensus recommendations As with the 2016 and earlier editions, the methodology followed has: - not graded recommendations. In many clinical guidelines, recommendations are given a grade which derives entirely from the design of the studies providing the evidence. Methodologically strong evidence for less important interventions gives the linked recommendation an apparently higher priority than an important recommendation where the evidence is weaker. The strength depends solely upon the study design and ignores other important features of the evidence such as its plausibility, generalisability, and the absolute benefit to the total population of people with stroke; - used quantitative and qualitative evidence where appropriate. In choosing between making a recommendation based on less than perfect evidence and making no recommendation at all, the guideline seeks to guide practice using the best available evidence; - allowed for recommendations to be developed by consensus: o in areas of practice where evidence is absent or of such poor quality or quantity that a recommendation cannot be derived; 2023 Edition, 04 April 2023 9 o where formal literature searching of a narrowly defined research question would not have adequately encompassed the clinical implications of the topic. (See the methodology guide here for more details). Strength of recommendations Depending on the strength of the evidence, recommendations in this guideline are either strong (a treatment or service ‘should be provided/offered’) or conditional (a treatment ‘should be considered’ or ‘may be considered’). More detail about the wording of recommendations can be found in the methodology overview here. NICE accreditation The 2016 edition was accredited by NICE. NICE has agreed to extend the accreditation to the 2023 edition. This applies until December 2023. NICE accreditation processes are changing and the accreditation status of this guideline may change in future. 1.5 Funding and conflicts of interest Funding for the guideline project team was received from the following external sources on condition that the Guideline Development Group retained complete editorial independence over the guideline development process and content: - Stroke Association; - Johnson & Johnson Medical Ltd (through an educational grant agreement); - Welsh Assembly Government; - NIMAST (Northern Ireland Multidisciplinary Association for Stroke Teams). The editors and the Intercollegiate Stroke Working Party wish to express their immense gratitude and appreciation for the financial support granted freely by these organisations, without which production of this edition would not have been possible. The policy on declarations of interests is here and the interests recorded by guideline contributors are here. 1.6 Treatments not mentioned in this guideline Users of this guideline should apply the general rule that if an intervention covered by the scope of this guideline is not mentioned, then it is not recommended for use, and commissioners and service planners are not obliged to obtain it for the populations they serve. 1.7 Participation in clinical research A small number of specific recommendations that patients should not be offered a treatment except ‘in the context of clinical trial’ have been included. This has been done when there is already some research which leaves uncertainty about the benefits and harms, but there is insufficient evidence to either recommend an intervention, or to avoid its use. 1.8 Licensing and approval of medication Recommendations in this guideline about the use of specific medicines (and devices) do not specify whether the medicine is licensed or approved by the Medicines and Healthcare products Regulatory 2023 Edition, 04 April 2023 10 Agency (MHRA) or European Medicines Agency (EMA) for that particular use. It is the responsibility of the individual clinician and their healthcare provider to decide whether to permit the unlicensed/off- label use of medication in their formulary, including by referring to the source data from the appropriate regulator. The Guideline Development Group may have considered it appropriate to recommend medication which has not been licensed for specific situations (e.g. aspirin in acute ischaemic stroke) or is not available in certain jurisdictions (e.g. injectable lipid-lowering therapies in the Republic of Ireland). Additional advice on the use of new and existing medicines is provided by the National Institute for Health and Care Excellence (NICE), which evaluates technologies for the NHS in England and Wales, the Scottish Medicines Consortium (SMC) for NHSScotland and the National Centre for Pharmacoeconomics (NCPE) for the Health Service Executive (HSE) in Ireland. 1.9 Contributors The Intercollegiate Stroke Working Party is extremely grateful to the following groups who contributed their time and expertise (considerably above and beyond the usual call of duty) to producing this edition: - the four guideline editors; - members of the Guideline Development Group; - topic group leads; - members of topic groups and other contributors. In addition, the Working Party is grateful to all those who contributed to their organisation’s peer review of the draft guideline and those who submitted public consultation comments. Finally, the Working Party thanks the members of the stroke guideline project team and SIGN. The guideline would not exist without the hard work of all the contributors, who are listed here. 1.10 Notes on the text Unchanged text from the 2016 edition is marked. Text is marked when: - the recommendation and supporting text are new since the 2016 edition; - the recommendation and supporting text have been updated since the 2016 edition as a result of new evidence; - the recommendation was reviewed but not amended from the 2016 edition since the new evidence did not support a change. The supporting text has been updated. The 2016 edition was prepared by the Intercollegiate Stroke Working Party (‘Working Party’). The 2023 edition is the responsibility of the Guideline Development Group. In the case of consensus recommendations, sources for 2016 recommendations refer to ‘Working Party consensus’, whereas sources for 2023 recommendations refer to ‘Guideline Development Group consensus’. Some 2016 text has been changed to ensure it is applicable to Scotland and Ireland as well as to England, Wales and Northern Ireland, without changing the sense. These changes are not marked. This edition is published online only. Apart from as indicated above, the text from 2016 is unchanged but may be in a different order from the 2016 publication. Sections may also have been re-titled and re- numbered (particularly in the Rehabilitation and Recovery chapter). 2023 Edition, 04 April 2023 11 2 Organisation of stroke services _____________________________________________________________________________________ 2.0 Introduction This chapter considers stroke management from a population perspective, addressing the means of organising services to deliver high quality stroke care. If services for people with stroke are poorly organised, outcomes will also be poor despite the evidence-based practice and best endeavours of individual clinicians. Furthermore, if clinical teams do not have sufficient knowledge and skills, and are not consistent in their clinical practice, many people will receive sub-optimal care. The recommendations in this chapter affect the full range of services within a comprehensive acute and community stroke service, and many of them have a strong evidence base and are among the most important contained in this guideline. 2.1 Public awareness of stroke In recent years mass media campaigns such as the Face Arm Speech Time (FAST) campaign, have been delivered with the aim of increasing public awareness of the symptoms and signs of stroke (available at http://www.nhs.uk/actfast/Pages/know-the-signs.aspx; https://irishheart.ie/campaigns/fast/; https://www.thinkfast.org.uk/). Public awareness of stroke prevention and treatment are also important. 2.1 Recommendation A Public awareness campaigns of the symptoms of stroke should be recurrent, targeted at those most at risk of stroke, and formally evaluated. 2.1 Sources A Lecouturier et al, 2010a,b; Working Party consensus 2.1 Evidence to recommendations The available research indicates some trends with regard to mass media campaigns, for example: television may be more effective than posters and newspaper advertisements; campaigns need to be repeated rather than short-term and one-off, and there are methodological weaknesses in the research (Lecouturier et al, 2010a). The evidence for a direct link between awareness and recommended behaviour is weak, especially among older members of the population, minority ethnic groups and those with lower levels of education, all of which are population groups at greater risk of stroke (Jones et al, 2010). Campaigns aimed at both public and healthcare professionals may have more impact on professionals than the public (Lecouturier et al, 2010b). More research in the area of improving public awareness and appropriate action is needed. 2.2 Definitions of specialist stroke services ‒ A specialist is defined as a healthcare professional with the necessary knowledge and skills in managing people with stroke and conditions that mimic stroke, usually by having a relevant further qualification and keeping up to date through continuing professional development. This does not require the healthcare professional exclusively to manage people with stroke, but does require them to have specific knowledge and practical experience of stroke. ‒ A specialist team or service is defined as a group of specialists who work together regularly managing people with stroke and conditions that mimic stroke, and who between them have the 2023 Edition, 04 April 2023 12 knowledge and skills to assess and resolve the majority of problems. At a minimum, any specialist unit, team or service must be able to deliver all the relevant recommendations made in this guideline. This does not require the team exclusively to manage people with stroke, but the team should have specific knowledge and practical experience of stroke. Types of acute stroke service are described in Section 2.4 Organisation of inpatient stroke services. 2.3 Transfer to acute stroke services 2.3 Recommendations A Community health services and ambulance services (including call handlers and primary care reception staff) should be trained to recognise people with symptoms indicating an acute stroke as an emergency requiring transfer to a hyperacute stroke centre with pre- alert notification to the stroke team. B People with an acute neurological presentation suspected to be a stroke should be admitted directly to a hyperacute stroke unit that cares predominantly for patients with stroke, with access to a designated thrombectomy centre 24 hours a day, 7 days a week for consideration of mechanical thrombectomy. C Acute hospitals receiving medical admissions that include people with suspected stroke should have arrangements to admit them directly to a hyperacute stroke unit on site or at a designated neighbouring hospital as soon as possible to monitor and regulate basic physiological functions such as neurological status, blood glucose, oxygenation, and blood pressure. D Acute hospitals that admit people with stroke should have prioritised access to a specialist stroke rehabilitation unit on site or at a neighbouring hospital. E Local health economies/health boards (geographic areas or populations covered by an integrated group of health commissioners/service planners and/or providers) should aim to have a specialist neurovascular service capable of assessing and treating people within 24 hours of transient cerebrovascular symptoms. F Public and professional education programmes should be run to increase awareness of stroke and the need for urgent diagnosis and treatment. 2.3 Sources A, B Follows from the evidence concerning the emergency diagnosis and treatment of stroke (Section 3.4 Diagnosis and treatment of acute stroke – imaging, Section 3.5 Management of ischaemic stroke, Section 3.6 Management of intracerebral haemorrhage, Section 3.7 Management of subarachnoid haemorrhage) C Follows from the evidence concerning acute stroke care (Section 3.10 Acute stroke care) D Follows from the evidence concerning specialist stroke units (Section 2.2 Definitions of specialist stroke services, Section 2.4 Organisation of inpatient stroke services) E Follows from the evidence concerning TIA diagnosis and treatment (Section 3.2 Management of TIA and minor stroke – assessment and diagnosis, Section 3.3 Management of TIA and minor stroke – treatment and vascular prevention) F Follows from the evidence concerning the emergency diagnosis and treatment of stroke (Section 3.4 Diagnosis and treatment of acute stroke – imaging, Section 3.5 Management of ischaemic stroke, Section 3.6 Management of intracerebral haemorrhage, Section 3.7 Management of subarachnoid haemorrhage) 2023 Edition, 04 April 2023 13 2.3 Evidence to recommendations Effective stroke care needs an organisational structure that facilitates best treatments at the right time. This section makes recommendations that follow from studies of treatment efficacy; e.g. intravenous thrombolysis can only be given within the eligible time window if people arrive in the appropriate setting within that time. Major urban reorganisations of stroke services have taken place in some parts of the UK and Ireland to improve access to hyperacute stroke unit care. Evidence from Manchester and London suggests that such care should be in hyperacute stroke centres available 24 hours a day, 7 days a week, and should be for all people with acute stroke, not just those who might be suitable for intravenous thrombolysis (Ramsay et al, 2015). The RACECAT trial in Catalonia, Spain tested whether transporting people with acute stroke suspected to be due to large artery occlusion directly to a thrombectomy centre (ambulance redirection or bypass) improves outcomes compared with being taken to the patient’s nearest acute stroke centre (Pérez de la Ossa et al, 2022). This multi-centre, cluster RCT did not demonstrate a clinical outcome advantage from redirection, but in many respects RACECAT is not directly applicable to many parts of the UK and Ireland. The strategy for adopting either a secondary transfer or an ambulance redirection service model for thrombectomy will depend upon local and regional services and the population served (Ford et al, 2022). There is an urgent need for research addressing this question that is directly applicable to the NHS and HSE. Processes of care are important for optimising patient outcomes and these apply at both the referring acute stroke centre and the receiving thrombectomy centre. If local acute stroke centre workflow cannot be optimised, then redirection to a thrombectomy centre may be better and should be considered regionally. For secondary transfers that are longer than one hour, helicopter-based transfer may improve speed of access to thrombectomy and associated patient outcomes (Coughlan et al, 2021). Mobile stroke units (MSUs) are ambulances equipped with brain imaging equipment and specialist staff that are capable of delivering thrombolysis or identifying large artery occlusion when equipped with CT angiography. In data largely from non-randomised trials with a standard ambulance comparator group and blinded outcome assessments, after deployment of an MSU, patients with ischaemic stroke had a better clinical outcome, were more likely to receive thrombolysis and incur shorter onset to thrombolysis times (Turc et al, 2022a). However, it is uncertain what the effects of MSUs are on an unselected stroke population, the cost-effectiveness of MSU care, how to integrate MSUs into pre- hospital pathways and how these might be applied across both rural and urban regions. Ongoing randomised trials may answer some of these questions, although modelling of costs and benefits applied across different regions and service models is likely to be required (Chen et al, 2022). 2.3 Implications These recommendations have significant implications for the organisation of acute medical services within any ‘health economy’ (locality). At a regional or subregional level, those who commission and provide stroke services are required to configure these services to achieve the maximum benefit to the population from the delivery of time-sensitive treatments, and to consider issues relating to the co- location of other emergency services that are beyond the scope of this guideline. It is important that, with such reconfiguration of services, there is a robust governance infrastructure in place to monitor the quality of stroke services delivered. 2.4 Organisation of inpatient stroke services There is strong evidence that specialised stroke unit care initiated as soon as possible after the onset of stroke provides effective treatments that reduce long-term brain damage, disability and healthcare costs. An acute stroke service consists of either: a) a comprehensive stroke centre (CSC) providing hyperacute, acute and inpatient rehabilitation including thrombectomy (thrombectomy centre) and neurosurgery; or b) an acute stroke centre (ASC) providing hyperacute, acute and inpatient 2023 Edition, 04 April 2023 14 rehabilitation. A stroke rehabilitation unit (SRU) provides inpatient rehabilitation only. All components of a specialist acute stroke service should be based in a hospital that can investigate and manage people with acute stroke and their medical and neurological complications, but this requirement does not apply to services designed to provide stroke care only in the rehabilitation phase. 2.4 Recommendations A People with the sudden onset of focal neurological symptoms seen by community-based clinicians (e.g. ambulance paramedics) should be screened for hypoglycaemia with a capillary blood glucose, and for stroke or TIA using a validated tool. Those people with persisting neurological symptoms who screen positive using a validated tool should be transferred to a hyperacute stroke unit as soon as possible with pre-alert notification to the admitting stroke team. B People with suspected acute stroke (including people already in hospital) should be admitted directly to a hyperacute stroke unit and be assessed for emergency stroke treatments by a specialist clinician without delay. C Acute stroke services should provide specialist multidisciplinary care for diagnosis, hyperacute and acute treatments, normalisation of homeostasis, early rehabilitation, prevention of complications and secondary prevention. D Acute stroke services should have management protocols for the admission pathway including links with the ambulance service, emergency stroke treatments, acute imaging, neurological and physiological monitoring, swallowing assessment, hydration and nutrition, vascular surgical referrals, rehabilitation, end-of-life (palliative) care, secondary prevention, the prevention and management of complications, communication with people with stroke and their family/carers and discharge planning. E Acute stroke services should have continuous (24/7) access to brain imaging including CT or MR angiography and perfusion when necessary and should be capable of undertaking immediate brain imaging when clinically indicated. F Acute stroke services should have protocols for the monitoring, referral and transfer of patients to thrombectomy centres for mechanical thrombectomy and regional neurosurgical centres where available for decompressive hemicraniectomy, surgical management of intracranial haemorrhage and the management of symptomatic hydrocephalus including external ventricular drain insertion. G Acute stroke services should ensure that people with conditions that mimic stroke are transferred without delay into a care pathway appropriate to their diagnosis. H People with a diagnosis of stroke that was not made on admission should be transferred without delay into that part of the stroke service most appropriate to their needs. I Patients with acute neurological symptoms that resolve completely within 24 hours of onset (i.e. suspected TIA) should be given aspirin 300 mg immediately, unless contraindicated, and be assessed urgently within 24 hours by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit. J Acute stroke services should have an education programme for all staff providing acute stroke care (including ambulance services and the emergency department as appropriate) and should provide training for healthcare professionals in the specialty of stroke. K Acute stroke services should participate in national and local audit, multicentre research and quality improvement programmes. 2.4 Sources A, B Follows from the evidence concerning emergency stroke treatments (Section 3.4 2023 Edition, 04 April 2023 15 Diagnosis and treatment of acute stroke – imaging, Section 3.5 Management of ischaemic stroke, Section 3.6 Management of intracerebral haemorrhage, Section 3.7 Management of subarachnoid haemorrhage) C Follows from the evidence concerning emergency treatments and monitoring (Section 3.5 Management of ischaemic stroke, Section 3.6 Management of intracerebral haemorrhage, Section 3.7 Management of subarachnoid haemorrhage, Section 3.10 Acute stroke care) D Follows from the evidence concerning specialist stroke units (Section 2.5 Resources: inpatient stroke services) E Wardlaw et al, 2004; follows from the evidence concerning emergency stroke treatments (Section 3.5 Management of ischaemic stroke) F Follows from the evidence concerning emergency stroke treatments (Section 3.5 Management of ischaemic stroke, Section 3.6 Management of intracerebral haemorrhage) G, H Working Party consensus I Follows from the evidence concerning TIA diagnosis and treatment (Section 3.2 Management of TIA and minor stroke – assessment and diagnosis, Section 3.3 Management of TIA and minor stroke – treatment and vascular prevention) J Follows from the evidence concerning specialist stroke units (Section 2.5 Resources: inpatient stroke services) K Obligations under the NHS Standard Contract; Working Party consensus 2.4 Evidence to recommendations Given that 1 in 20 strokes occur in people already in hospital (Intercollegiate Stroke Working Party, 2016), clinicians in high-risk clinical areas (e.g. cardiology or renal wards, cardiothoracic units) should have a high level of awareness of acute stroke and the time-critical nature of interventions to improve outcome, including how to contact a stroke specialist for advice, arrange imaging and transfer patients to a hyperacute stroke unit. Any person with the acute onset of a focal neurological syndrome with persisting symptoms and signs (i.e. suspected stroke) needs urgent diagnostic assessment to differentiate between acute stroke and other causes. Progress in the medical management of acute stroke demands a corresponding increase in the availability of advanced imaging techniques, and all hyperacute stroke services will need immediate and timely access to multi-modal brain imaging including CT or MR angiography and perfusion when necessary. 2.4 Implications These recommendations have significant implications for the organisation of clinical services within acute hospitals. Systems need to be adapted to ensure that people with acute stroke have rapid access to an acute stroke unit and to facilitate rapid transfer out of the unit once acute management is complete. 2.5 Resources – inpatient stroke services Leadership and culture are important contributors to delivering high quality stroke care, and they should be evident at all levels, e.g. individual professionals, teams, units, trusts/hospitals and across networks. Culture and tone ‘from the top’ matters and are key enablers of joint working across professional and organisational boundaries and important to the provision of holistic and compassionate care to patients and their families (Francis, 2013; Getting it Right First Time, 2022). A well-led, appropriately staffed and skilled multidisciplinary stroke unit is the cornerstone of holistic and compassionate care for people with 2023 Edition, 04 April 2023 16 stroke. In parts of the UK, legislation is due to be implemented in 2024 to ensure ‘safe staffing’ for nurses and medical practitioners in health and social care settings (Scottish Government, 2019). 2.5 Recommendations A People with stroke should be treated in a specialist stroke unit throughout their hospital stay unless their stroke is not the predominant clinical problem. B A hyperacute, acute and rehabilitation stroke service should provide specialist medical, nursing, and rehabilitation staffing levels matching the recommendations in Table 2.5 below. Table 2.5 Recommended levels of staffing for hyperacute, acute and rehabilitation units Consultant- Clinical Speech and Consultant level Physio- Occupation psychology language Dietetics Nursing stroke practitioner- therapy al therapy / neuro- therapy physician led ward psychology rounds WTE per 24/7 Whole-time equivalents (WTE) per 5 beds* availability; bed minimum Hyper- 6.0 Twice daily acute 2.9 (80:20 thrombolysis ward round stroke unit registered: trained 1.02 0.95 0.48 0.28 0.21 unregis- physicians tered) on rota Acute stroke unit: Acute Acute stroke daily ward stroke unit 1.35 (65:35 unit: 7 day round** cover with & stroke registered: 1.18 1.13 0.56 0.28 0.21 adequate Stroke rehab- unregis- out of hours rehabilit- ilitation tered) arrange- ation unit: unit ments** twice- weekly ward round** * WTE figures are for 7-day working for registered staff and include non-clinical time (such as supervision and professional development) as well as non-face-to-face clinical activity. Registered staff should be augmented by support workers and rehabilitation assistants to achieve the intensity and dose of therapy recommended in Section 4.2 Rehabilitation approach – intensity of therapy (motor recovery and function). ** Consultant stroke physician input may need to be adjusted according to the acuity of the unit. All acute and rehabilitation units should have at least 2 ward rounds per week led by a consultant-level practitioner (physician, nurse or therapist; see Recommendation 2.5K). For recommendations regarding orthoptist staffing, see Section 4.48 Vision. C A hyperacute stroke unit should have immediate access to: ‒ specialist medical staff trained in the hyperacute and acute management of people with stroke, including the diagnostic and administrative procedures needed for the safe and timely delivery of emergency stroke treatments; ‒ specialist nursing staff trained in the hyperacute and acute management of people with stroke, covering neurological, general medical and rehabilitation aspects; ‒ stroke specialist rehabilitation staff; 2023 Edition, 04 April 2023 17 ‒ diagnostic, imaging and cardiology services; ‒ tertiary services for endovascular therapy, neurosurgery and vascular surgery. D A hyperacute stroke unit should have continuous access to a consultant physician with expertise in stroke medicine, with consultant review 7 days per week. E An acute stroke unit should provide: ‒ specialist medical staff trained in the acute management of people with stroke; ‒ specialist nursing staff trained in the acute management of people with stroke, covering neurological, general medical and rehabilitation aspects; ‒ stroke specialist rehabilitation staff; ‒ access to diagnostic, imaging and cardiology services; ‒ access to tertiary services for neurosurgery and vascular surgery. F An acute stroke unit should have continuous access to a consultant physician with expertise in stroke medicine, with consultant review 5 days per week. G Where telemedicine is used for the assessment of people with suspected stroke by a specialist physician, the system should enable the physician to discuss the case with the assessing clinician, talk to the patient and/or family/carers directly and review radiological investigations. Telemedicine should include a high quality video link to enable the remote physician to observe the clinical examination. H Staff providing care via telemedicine (at both ends of the system) should be appropriately trained in the hyperacute assessment of people with suspected acute stroke, in the delivery of thrombolysis and the use of this approach and technology. The quality of care and decision making using telemedicine should be regularly audited. I A stroke rehabilitation unit should predominantly care for people with stroke, and should maintain the staffing and skill levels required of a stroke unit regardless of size, location or mix of conditions of the patients being treated. J A stroke rehabilitation unit should have a single multidisciplinary team including specialists in: ‒ medicine; ‒ nursing; ‒ physiotherapy; ‒ occupational therapy; ‒ speech and language therapy; ‒ dietetics; ‒ clinical psychology/neuropsychology; ‒ social work; ‒ orthoptics; with timely access to rehabilitation medicine, specialist pharmacy, orthotics, specialist seating, assistive technology and information, advice and support (including life after stroke services) for people with stroke and their family/carers. K A stroke rehabilitation unit should have access to a consultant specialising in stroke rehabilitation (medical or non-medical, i.e. nurse or therapist, where professional regulation permits) at least 5 days a week, with twice weekly consultant-led ward rounds. L Stroke rehabilitation units with non-medical consultant leadership should have daily medical cover (ward doctors, GPs), enabling admissions and discharges 7 days a week, with support available from stroke physicians as required. 24 hour on-site medical cover may not be required depending on patient admission criteria, with adequate out of hours arrangements. M A facility that provides treatment for inpatients with stroke should include: 2023 Edition, 04 April 2023 18 ‒ a geographically-defined unit; ‒ a co-ordinated multidisciplinary team that meets at least once a week for the exchange of information about inpatients with stroke; ‒ information, advice and support for people with stroke and their family/carers; ‒ management protocols for common problems, based upon the best available evidence; ‒ close links and protocols for the transfer of care with other inpatient stroke services, early supported discharge teams and community services; ‒ training for healthcare professionals in the specialty of stroke. N Specialist inpatient stroke services should include sufficient administration and management (including data management) support. 2.5 Sources A Stroke Unit Trialists' Collaboration, 2013 B Bray et al, 2014; Ramsay et al, 2015; Guideline Development Group consensus C-F Follows from the evidence and recommendations concerning emergency treatments and monitoring (Section 3.5 Management of ischaemic stroke, Section 3.6 Management of intracerebral haemorrhage, Section 3.7 Management of subarachnoid haemorrhage, Section 3.10 Acute stroke care) G, H Meyer et al, 2008; Working Party consensus I-L Stroke Unit Trialists' Collaboration, 2013; NICE, 2016d; Guideline Development Group consensus M Working Party consensus N Guideline Development Group consensus 2.5 Evidence to recommendations The previous sections have been concerned with the organisational structure of stroke services. It is equally important to have appropriate resources available for the care of people with stroke: the workforce, buildings, and technological support required. Minimum staffing levels on stroke units were originally defined in hyperacute stroke service reconfigurations such as that in London, and are supported by observational evidence from UK registries about acute care processes that are associated with substantial benefits to patients, including those admitted outside office hours and at weekends (Ramsay et al, 2015; Turner et al, 2016). The evidence regarding the optimal size of a hyperacute stroke unit was similarly confined to observational studies, reflecting a level of institutional experience and competence in the provision of specialist hyperacute treatments such as intravenous thrombolysis (Bray et al, 2013) that corresponds with a volume of at least 500 acute stroke admissions per year. The evidence supporting stroke unit care from the stroke unit trialists in the 1990s was updated in a 2013 Cochrane review, which found that people with stroke who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after their stroke (Stroke Unit Trialists' Collaboration, 2013). The benefits were only apparent in units based in a discrete ward. Increased access to stroke unit care has made a vital contribution to reducing stroke mortality and remains an imperative for all inpatients with stroke. The Guideline Development Group endorses an updated recommendation regarding staffing levels of registered staff on inpatient stroke units expressed as whole-time equivalents (WTE) in Table 2.5. These recommendations take into account therapy delivered across seven days. Achieving the recommendations in Section 4.2 Rehabilitation and recovery – intensity of therapy (motor recovery and function) will also require unregistered support workers and rehabilitation assistants delivering 2023 Edition, 04 April 2023 19 rehabilitation under the supervision of registered staff. SSNAP reports 2021-22 (Sentinel Stroke National Audit Programme, 2022) indicate that for suitable patients, up to a third of physiotherapy and occupational therapy is currently being delivered by unregistered rehabilitation assistants. An understanding of the local context, together with these recommendations, will be required to inform more detailed service specifications (including banding/seniority), which may include increased staffing if deemed appropriate. Staffing recommendations also include non-clinical time (such as supervision and professional development) as well as non-face-to-face clinical activity such as environmental visits, family contact and equipment ordering. Units with a small bed base may need to consider revisions to these staffing levels to ensure adequate registered staffing cover across the week, taking account of rotas and days off for weekend working. Recommendations for orthoptist staffing levels in hyperacute and acute stroke units are made in Section 4.48 Vision. Sufficient administrative and management support (including data management) is essential to the efficiency and governance of the core stroke unit team and should also be included. Telemedicine is used in some centres to support decision making in the hyperacute management of people with stroke because of significant practical or geographical obstacles. Observational evidence suggests that telemedicine is associated with more protocol violations and longer treatment times (Meyer et al, 2008; Dutta et al, 2015). Furthermore, unless telemedicine is used as part of an otherwise well-developed acute stroke service, outcomes may suffer (Heffner et al, 2015). 2.5 Implications These recommendations will require a considerable increase in the provision of some specialties in stroke services, including clinical psychology/neuropsychology and social work. The Guideline Development Group is concerned by the findings from national registries indicating continued poor provision of these specialties for people with stroke. Patterns of work need to be reviewed to deliver sufficient direct therapy by removing some administrative duties and ensuring that time is not spent by registered therapists on tasks that could be done by unregistered staff. Restoring adequate social work provision will require close integration with social services. 2.6 Location of service delivery Stroke services should be organised to treat a sufficient number of patients to ensure that the specialist skills of the workforce are maintained. At the same time, the closer a rehabilitation service is to the person’s home the more that family/carers can be engaged and the more targeted the rehabilitation can be. This section provides a recommendation on the location of delivery of services, aiming for an appropriate balance between care in hospital, on an outpatient basis and at home. 2.6 Recommendation A People with acute stroke who cannot be admitted to hospital should be seen by the specialist team at home or as an outpatient within 24 hours for diagnosis, treatment, rehabilitation, and risk factor management at a standard comparable to that for inpatients. 2.6 Source A Working Party consensus 2023 Edition, 04 April 2023 20 2.7 Transfers of care – general principles After stroke, many people will interact with several different services during their recovery: primary care, specialist acute stroke services, specialist rehabilitation services, social services, housing, generic community services etc. This section covers general principles around the transfers of care between these agencies. Transfers of care out of hospital are covered in Section 2.8 Transfers of care from hospital to home – community stroke rehabilitation. 2.7 Recommendations A Transfers of care for people with stroke between different teams or organisations should: ‒ occur at the appropriate time, without delay; ‒ not require the person to provide information already given; ‒ ensure that all relevant information is transferred, especially concerning medication; ‒ maintain a set of person-centred goals; ‒ preserve any decisions about medical care made in the person’s best interests. B People with stroke should be: ‒ involved in decisions about transfers of their care if they are able; ‒ offered copies of written communication between organisations and teams involved in their care. C Organisations and teams regularly involved in caring for people with stroke should use a common, agreed terminology and set of data collection measures, assessments and documentation. 2.7 Sources A Working Party consensus B Asplund et al, 2009; Working Party consensus C Working Party consensus 2.7 Implications These recommendations require those who commission and provide services across health and social care to consider the current situation and how it might be redesigned to reduce transfers of care between organisations and improve continuity. The person recovering from stroke and their family should experience seamless care without artificial distinctions between service providers or between health and social care. 2.8 Transfers of care from hospital to home – community stroke rehabilitation The most common transfer of care, and the most stressful for people with stroke and their family/carers, is that from in-hospital care to their home or to a care home. Many people report feeling afraid and unsupported, and carers report feelings of abandonment (Stroke Association, 2015). There is much that services can do to support and reassure people with stroke and their family/carers regarding the smooth transfer of care into the community. Community stroke rehabilitation services, including delivery of early supported discharge, are required to co-ordinate the transfer of care from hospital to home, working collaboratively with people with stroke and family members, stroke inpatient unit staff and informed by an assessment of the person’s home environment (Drummond et al, 2013). Through a specialist multidisciplinary team structure, early, effective community specialist stroke rehabilitation and disability management needs to be 2023 Edition, 04 April 2023 21 provided to all people with stroke leaving hospital who need it. Stroke rehabilitation should be provided in the person’s own home or place of residence, including residential or nursing homes (Fisher et al, 2011; Fisher et al, 2013; NHS England, 2022). 2.8 Recommendations A Hospital inpatients with stroke who have mild to moderate disability should be offered early supported discharge, with treatment at home beginning within 24 hours of discharge. B Patients undergoing rehabilitation after stroke who are not eligible for early supported discharge should be referred to community stroke rehabilitation if they have ongoing rehabilitation needs when transferred from hospital. C Early supported discharge and community stroke rehabilitation should be provided by a service predominantly treating people with stroke. D Therapy provided as part of early supported discharge should be at the same intensity as would be provided if the person were to remain on a stroke unit. E The intensity and duration of intervention provided by the community stroke rehabilitation team should be established between the stroke specialist, the person with stroke and their family/carers, and be based on clinical need tailored to goals and outcomes. F A multidisciplinary service providing early supported discharge and community stroke rehabilitation should adopt a minimum core team structure matching the recommendations in Table 2.8 and below. Table 2.8 Recommended levels of staffing for multidisciplinary services providing early supported discharge and community stroke rehabilitation Discipline WTE per 100 referrals to service p.a. Physiotherapy 1.0 Occupational therapy 1.0 Speech and language therapy 0.4 Up to 0.5 and at least 0.5 WTE per team Social worker recommended locally Rehabilitation assistant/assistant practitioners 1.0 Clinical psychology/neuropsychology 0.2-0.4* Up to 1.2 and at least 1 full time nurse per Nursing team Medicine 0.1 *This reflects the time that a team member should be co-located within the MDT and could include additional skill mix, e.g. assistant psychologist. The service should also include: ‒ Appropriate administration and management (including data management) support; ‒ Timely access to psychological and neuropsychological services (e.g. Improving Access to Psychological Therapies [IAPT] and community mental health services with stroke- specific training and appropriate supervision, psychology or neuropsychology departments), return to work and vocational rehabilitation services, dietetics, pharmacy, orthotics, orthoptics, spasticity services, specialist seating, assistive technology and information, pain management, advice and support for people with stroke and their family/carers. G Early supported discharge and community stroke rehabilitation services should include: 2023 Edition, 04 April 2023 22 ‒ a co-ordinated multidisciplinary team that meets at least once a week for the exchange of information about people with stroke in their care; ‒ provision of needs-based stroke rehabilitation, support and any appropriate management plans, with the option for re-referral after discharge if stroke rehabilitation needs and goals are defined, and with access to support services on discharge; ‒ information (aphasia-friendly), advice, and support for people with stroke and their family/carers; ‒ management protocols for common problems, based upon the best available evidence; ‒ collaboration, close links and protocols for the transfer of care with inpatient stroke services, primary care, community services and the voluntary sector; ‒ training for healthcare professionals in the specialty of stroke. H People with stroke and their family/carers should be involved in decisions about the transfer of their care out of hospital, and the care that will be provided. I Members of the early supported discharge and community stroke rehabilitation services should be involved in hospital discharge planning and decision making by attending stroke unit multidisciplinary team meetings. J Before the transfer of care for a person with stroke from hospital to home (including a care home) occurs: ‒ the person and their family/carers should be prepared, and have been involved in planning their transfer of care if they are able; ‒ primary healthcare teams and social services should be informed before or at the time of the transfer of care; ‒ all equipment and support services necessary for a safe transfer of care should be in place; ‒ any continuing treatment the person requires should be provided without delay by a co-ordinated, specialist multidisciplinary service; ‒ the person and their family/carers should be given information and offered contact with relevant statutory and voluntary agencies (e.g. stroke key worker). K Before the transfer home of a person with stroke who is dependent in any activities, the person’s home environment should be assessed by a visit with an occupational therapist. If a home visit is not considered appropriate, they should be offered an access visit or an interview about the home environment including viewing photographs or videos taken by family/carers. L People with stroke who are dependent in personal activities (e.g., dressing, toileting) should be offered a transition package before being transferred home that includes: ‒ visits or leave at home prior to the final transfer of care; ‒ training and education for their carers specific to their needs; ‒ telephone advice and support for three months. M Before the transfer of care for a person with stroke from hospital to home (including a care home) they should be provided with: ‒ a named point of contact for information and advice; ‒ personalised written information in an appropriate format about their diagnosis, medication and management plan. N People with stroke, including those living in care homes, should continue to have access to specialist services after leaving hospital, and should be provided with information about how to contact them, and supported to do so if necessary. 2023 Edition, 04 April 2023 23 O Early supported discharge and community stroke rehabilitation services should participate in national and local audit, multicentre research, and quality improvement programmes. 2.8 Sources A-I Fisher et al, 2011, 2013, 2016, 2020, 2021; Langhorne et al, 2017; NHS England, 2022 J Guideline Development Group consensus K Drummond et al, 2013; Guideline Development Group consensus L Grasel et al, 2006; Lannin et al, 2007a; Barras et al, 2010 M, N Guideline Development Group consensus O Obligations under the NHS Standard Contract; Guideline Development Group consensus 2.8 Evidence to recommendations Consensus studies and national policy guidance recommend that services are available to provide early supported discharge and community stroke rehabilitation in a timely way following hospital discharge. They also recommend that the duration and intensity of stroke rehabilitation provided needs to be based on clinical need and tailored to the person’s goals and outcomes (Fisher et al, 2011; Fisher et al, 2013; NHS England, 2022). There is strong evidence for the effectiveness of stroke specialist early supported discharge for those who experience mild to moderate disability after stroke. Trials and observational studies have demonstrated that early supported discharge can reduce long-term dependency and admission to institutional care and clinical trials demonstrated a reduction in length of hospital stay (Fisher et al, 2016; Langhorne et al, 2017). However, more recent evidence has found that the impact of early supported discharge on length of hospital stay in practice is less than was previously reported in clinical trials, likely due to the fact that the length of hospital stay for all inpatients with stroke is much shorter than when many of the trials were conducted (Fisher et al, 2021). It should be noted that evidence suggests that early supported discharge is only appropriate for a proportion of the stroke population (those with mild to moderate disability - up to 40% of patients) and is usually offered as a time-limited intervention (Fisher et al, 2011). Consensus-based recommendations state that people with more severe disability following a stroke, those with rehabilitation needs beyond early supported discharge or those going into residential or nursing homes need access to community stroke rehabilitation. This should be available following discharge from hospital, immediately following early supported discharge, or at a later point if needs are identified within the community (Fisher et al, 2013; NHS England, 2022). People with complex stroke- related needs are likely to require rehabilitation in hospital and should be transferred into the community only when they can be supported in their place of residence, including care homes, by a community stroke rehabilitation service (Fisher et al, 2013; NHS England, 2022). The greatest benefits of rehabilitation are associated with co-ordinated, multidisciplinary stroke specialist community services (Langhorne et al, 2017; Fisher et al, 2020). Stroke specialist care is defined as that provided by healthcare professionals with the necessary knowledge, skills and experience in managing stroke, evidenced by a suitable qualification and training. A stroke specialist team or service is defi

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