• Acute stroke management. Acute aspirin therapy. In: Canadian best practice recommendations for stroke care: 2006. Ottawa (ON): Canadian Stroke Network, Heart & Stroke Foundation of Canada; 2006. p. 59-60.

This is the current release of the guideline.

The Canadian Best Practice Recommendations for Stroke Care 2006 will be updated every two years to remain current and incorporate new research findings.

Ischemic stroke

Management
Prevention
Treatment

Critical Care
Emergency Medicine
Family Practice
Internal Medicine
Neurology

Advanced Practice Nurses
Emergency Medical Technicians/Paramedics
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians

To synthesize available literature and recommend best practices in stroke care appropriate to the Canadian context

All patients with acute ischemic stroke in whom intracranial hemorrhage has been ruled out

Acute-phase aspirin therapy

• Incidence of ischemic stroke
• Incidence of recurrent ischemic stroke
• Myocardial infarction
• Vascular death

Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Background

Over the past few years, extensive work reviewing stroke care guidelines has been done in Canada. Rather than duplicate this work, the Working Group used as a starting point two recent initiatives: the Canadian Stroke Quality of Care Study (CSQCS), which focuses on acute care, telestroke, and secondary prevention; and the Stroke Canada Optimization of Rehabilitation through Evidence (SCORE) project, which focuses on rehabilitation. These studies of best practices and performance measurement in stroke care flow from four Canadian consensus panels (three for CSQCS and one for SCORE) conducted during 2004–2006.

• CSQCS reviewed stroke guideline recommendations and developed a core set of performance measures for several phases along the continuum of stroke care. This was achieved through modified Delphi survey methodology involving national expert consensus panels, and discussions at Canadian consensus panel meetings using nominal group process methods. Additional rating rounds followed the panel meetings to ensure final agreement on the performance indicators by panel members.
• SCORE identified Clinical Practice Guidelines for stroke rehabilitation, evaluated each guideline's quality of development using the AGREE instrument, and undertook an extensive review process of the guideline content to reach agreement on stroke rehabilitation recommendations for Canada.

The rigorous work of the CSQCS and the SCORE projects formed the foundation of the work of the Best Practices and Standards Working Group (BPS-WG) and provided direction for the identification of Phase I Primary Guidelines and topics.

Methodology

The BPS-WG chose a conceptual framework to follow for the identification and selection of stroke recommendations. The Practice Guideline Evaluation and Adaptation Cycle guided development of the recommendations, which included the following steps: systematic searching for existing practice guidelines; appraising the quality of guidelines using a validated tool; content analysis of guideline recommendations; selecting recommendations for inclusion in the BPS-WG document; obtaining external expert feedback on the proposed recommendations.

Identification of Primary Guidelines

In December 2005, the BPS-WG reviewed the SCORE project's ratings of a number of published stroke care guidelines. Those which had the highest scores on the AGREE tool and/or those which were considered most relevant to the Canadian context were selected as the Primary Guidelines for the development of the Phase I recommendations. It was agreed that additional guidelines (European Stroke Initiative, guidelines released since the SCORE/CSQCS projects were completed) would be considered as required to support the recommendation development process.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Several rating systems are used by guideline developers to evaluate the strength of the evidence for their recommendations. These systems vary in the nomenclature used (alpha versus numeric), but there is usually reasonable equivalence in the definitions across the levels of evidence. Each recommendation in the original guideline document provides the levels of evidence for the recommendation as well as the reference for the Primary Guideline(s) that were adapted or contributed most to the wording of the recommendation.

*Refer to Appendix One in the original guideline document for a detailed table defining the evidence rating system used by each primary guideline referenced in this document.

Systematic Review with Evidence Tables

A Stroke Best Practices Recommendations Matrix was developed that mapped other existing stroke-related recommendations and their levels of evidence onto topic areas identified as relevant to optimal stroke care in Canada (i.e., blood pressure management, organization of care).

The list of topics was generated by identifying recommendations with the highest levels of evidence in each of the reference guidelines. Where similar or related recommendations on a particular topic appeared in more than two guidelines, it was added to the topic list. The final list of topics was then cross-referenced with SCORE and the Canadian Stroke Quality of Care Study (CSQCS) studies.

The Best Practices Recommendations Matrix was created through an iterative process of review and discussion among the members of the sub-group and the BPS-WG as a whole.

Evaluation of Levels of Evidence

Each recommendation included in this document was evaluated against several criteria: strength of the available research evidence to support the recommendation; degree to which the recommendation drives system change or processes of care delivery; overall validity and relevance as a core recommendation for stroke care along the continuum of care. The levels of evidence included in this document are determined through a structured ranking system which measures the strength of the results in a clinical trial or research study. The design of the study (such as a case report for an individual patient or a randomized double-blinded controlled clinical trial) and the endpoints measured (such as survival or quality of life) affect the strength of the evidence.

The various types of study designs, in descending order of strength, include:

1. Randomized controlled clinical trials (double-blinded or nonblinded) are considered the gold standard of study design.
2. Meta-analyses of randomized studies offer a quantitative synthesis of previously conducted studies. The strength of evidence from a meta-analysis is based on the quality of the conduct of individual studies. Meta-analyses of randomized studies are placed in the same category of strength of evidence as are randomized studies.
3. Nonrandomized controlled clinical trials.
4. Case series: population-based, consecutive series; consecutive cases (not population-based); or, non-consecutive cases. These clinical experiences are the weakest form of study design, but often they can be the only available or practical information.

Several rating systems are used by guideline developers to evaluate the strength of the evidence for their recommendations. These systems vary in the nomenclature used (alpha versus numeric), but there is usually reasonable equivalence in the definitions across the levels of evidence. Each recommendation in the original guideline document provides the levels of evidence for the recommendation (see "Rating Scheme for the Strength of the Evidence" field), as well as the reference for the Primary Guideline(s) that were adapted or contributed most to the wording of the recommendation.

Expert Consensus (Consensus Development Conference)
Expert Consensus (Delphi)
Other

The Best Practices and Standards Working Group (BPS-WG) chose a conceptual framework to follow for the identification and selection of stroke recommendations. The Practice Guideline Evaluation and Adaptation Cycle guided development of the recommendations, which included the following steps: systematic searching for existing practice guidelines; appraising the quality of guidelines using a validated tool; content analysis of guideline recommendations; selecting recommendations for inclusion in the BPS-WG document; obtaining external expert feedback on the proposed recommendations.

Drafting of the 2006 Stroke Recommendations

Once agreement on a core set of reference Guidelines, topic areas, and the content of the Matrix was reached, the Working Group formed four Ad-hoc Groups to:

• Review all recommendations on the Matrix in their areas of expertise
• Propose draft recommendation statements for each topic
• State a rationale for inclusion of the recommendation and its relevance to stroke care delivery or patient outcomes
• Identify any additional reference sources used to guide their decision-making

There were some recommendations from the core reference Guidelines which had high levels of supporting evidence but which did not appear on the draft topic list. These were considered by the Ad Hoc Groups; as a result, some topics were revised and three topics (post-stroke depression, post-stroke shoulder pain, and community rehabilitation) were added. No topics were eliminated.

Following this process, a full set of draft recommendations was presented to a group of 40 stroke experts and relevant stakeholders from across the country during the Best Practices and Standards National Consensus Conference, held in Halifax in April 2006.

Break-out sessions were held in which participants met in groups relevant to their expertise and reviewed a specific set of recommendations. Each group was made up of members of the original Ad Hoc Groups as well as other consensus conference participants who were new to the process. These break-out groups had access to all documentation used to develop the recommendations, particularly the Matrix and its supporting documents. They discussed each proposed recommendation with respect to relevance, current evidence and practice, and challenges to uptake and implementation. Each group then presented the results of their discussion to the full group, and suggested changes were debated and approved, rejected, or tabled for further discussion by the Best Practices and Standards Working Group (BPS-WG).

See Section C.4 in the original guideline document for a description of the methods used to develop performance measures.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Following the Consensus Conference, the original Ad Hoc Groups reconvened to review the feedback and propose final wording for the 2006 recommendations. This process was complete by June 2006. A final round of external reviews was completed prior to publication.

None provided

The type of evidence is specifically stated for each recommendation.

This document is the result of an extensive review of national and international evidence-based stroke best practice recommendations and guidelines.

Appropriate acute-phase aspirin (ASA) therapy to reduce the risk of early recurrent ischemic stroke

Hemorrhagic complications of aspirin therapy

• Intracranial hemorrhage must be ruled out by brain imaging before administering acute-phase aspirin (ASA) therapy to a stroke patient.
• ASA therapy should be delayed for 24 hours in stroke patients who have received thrombolytic therapy.

It is recognized that resource issues (financial, system, and human) will make it difficult to implement all recommendations in this document. However, the Best Practices and Standards Working Group consider these recommendations to be "gold standard" benchmarks toward which all stroke care services should be striving. Additionally, these recommendations can also serve as significant starting points for lobbying and advocacy work in aid of improved stroke care services.

Dissemination and Uptake

Concomitant with the development of the document, consideration was given to methods of dissemination and uptake, including:

• Consultation with research experts in the field of knowledge translation and guideline dissemination across Canada.
• Sharing progress with other Canadian Stroke Strategy (CSS) working groups to ensure alignment and collaboration in dissemination.
• Presentation and discussion during draft stages of development to provincial stroke champions.
• Consultation with other national guideline groups in related fields (hypertension, dyslipidemia, diabetes).
• Presentation for discussion at the Annual General Meeting of the Canadian Stroke Network, with a break-out session on dissemination and uptake.
• Presentation for discussion at the Annual General Meeting of the Canadian Association of Neurological Nurses, and Ontario Stroke Rehabilitation Working Group. Break-out sessions were held to get feedback on the recommendations and have discussion on dissemination and uptake.

Additional knowledge translation activities will be undertaken following initial recommendations release. This will include seeking feedback at local and regional consultation sessions, and providing a guideline review tool for structured feedback as part of the recommendation dissemination package.

Core Elements of an Integrated Stroke Strategy*

The key components required across the continuum as part of a "system" for coordinated and integrated stroke care are identified in the table "Core Elements of an Integrated Stroke Strategy" in the original guideline document. The development of coordinated and integrated stroke strategies at the local, regional and/or provincial/territorial levels should include as many of these components as possible to ensure comprehensiveness of the stroke strategy, although, as stated previously, it is recognized that systemic and resource restrictions may make this difficult for some groups.

* Adapted from the Ontario Blue Book—Towards an Integrated Stroke Strategy for Ontario—Report of the Joint Stroke Strategy Working Group June 2000; the Ontario Best Practice Guidelines for Stroke Care; and the results of the Canadian Stroke Strategy Information & Evaluation Consensus Panel, September 2005.

System Implications

• Organized stroke care (stroke units with critical mass of trained staff, interdisciplinary team).
• Initial assessment performed by clinicians experienced in stroke to determine appropriateness for acute aspirin therapy.
• Protocols in place for timely access to diagnostic services (neuro-imaging).
• Protocols established for timely access to thrombolytic therapy (t-PA) and other reperfusion strategies.
• Definition, dissemination, and implementation of best practices for stroke patients in the acute phase.
• Mechanisms for ongoing monitoring and evaluation, with a feedback loop for interpretation of findings and opportunities for quality improvement.

Performance Measures

1. Proportion of ischemic stroke patients who receive acute aspirin therapy within the first 48 hrs following a stroke event.
2. Median time from stroke onset to administration of first dose of aspirin in hospital.

Getting Better
Staying Healthy

Effectiveness
Patient-centeredness
Timeliness

• Acute stroke management. Acute aspirin therapy. In: Canadian best practice recommendations for stroke care: 2006. Ottawa (ON): Canadian Stroke Network, Heart & Stroke Foundation of Canada; 2006. p. 59-60.

Not applicable: The guideline was not adapted from another source.

2006

Canadian Stroke Network - Disease Specific Society
Heart and Stroke Foundation of Canada - Disease Specific Society

Government Funding – National Centres of Excellence Program

Canadian Stroke Strategy Best Practices and Standards Working Group

Working Group Members: Dr. Stephen Phillips (Co-Chair), Director Acute Stroke Service, Queen Elizabeth II Health Sciences Centre, Nova Scotia; Ms. Alison McDonald (Co-Chair), Physiotherapist, Nova Scotia Rehabilitation Centre, Capital Health, Nova Scotia; Ms. Lisa Ashley, Senior Advisor, Public Health Agency of Canada; Dr. Nigel Ashworth, Director of Physical Medicine and Rehabilitation, Glenrose Rehabilitation Hospital, Alberta; Dr. Mark Bayley, Physiatrist, Associate, Medicine Toronto Rehabilitation Institute, Ontario; Dr. Alan Bell, Family Practitioner, College of Family Physicians of Canada; Dr. Lucie Brosseau, Associate Professor, Rehabilitation Sciences, University of Ottawa, Ontario; Ms. Nancy Cooper, Director of Policy and Professional Development, Ontario Long Term Care Association; Ms. Bev Culham, Project Manager, Alberta Provincial Stroke Strategy, Alberta; Dr. Ian Graham, Vice President, Knowledge Translation Canadian Institutes for Health Research (CIHR); Dr. Gordon Gubitz, Neurologist Acute Stroke Unit & Outpatient Neurovascular Clinic, Queen Elizabeth II Health Sciences Centre, Nova Scotia; Ms. Valerie MacGillivary, Speech Language Pathologist, British Columbia; Ms. Janel Nadeau, Patient Advocate, Stroke Recovery Association, Alberta; Ms. Louise Nichol, Community Team Manager, Home Care Program, Community Stroke Care Service, Manitoba; Ms. Christina O'Callaghan, Regional Stroke Program Manager, Ontario; Ms. Elizabeth Swain, Physiotherapist, British Columbia; Dr. John Witt, Director Acute Stroke Care, Department of Emergency Medicine, Royal University Hospital, Saskatchewan; Ms. Rika VanderLaan, Consultant, Heart and Stroke Foundation of Ontario; Ms. Mary Elizabeth Harriman, Associate Executive Director, Heart and Stroke Foundation of Canada; Ms. Katie Lafferty, Executive Director, Canadian Stroke Network; Ms. Debra Lynkowski, Director, Canadian Stroke Strategy; Dr. Patrice Lindsay, Co-Chair CSS Information & Evaluation Working Group, Canadian Stroke Strategy; Ms. Laurie Cameron, Program Coordinator and Executive Assistant, Canadian Stroke Strategy; Ms. Gail Williams, Consultant, Canadian Stroke Strategy

Not stated

World Stroke Organization - International Agency

This is the current release of the guideline.

The Canadian Best Practice Recommendations for Stroke Care 2006 will be updated every two years to remain current and incorporate new research findings.

This NGC summary was completed by ECRI Institute on July 14, 2008. The information was verified by the guideline developer on August 27, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.