The levels of evidence supporting the recommendations (I-IV) and grades of recommendations (A-D and clinical practice points [CPP]) are defined at the end of the "Major Recommendations" field.
The original guideline document also includes a consumer rating that identifies aspects of care considered to be critical from a patient perspective.
These guidelines use the ABCD2 tool (see "Definitions" at the end of the "Major Recommendations" field); patients with a rating >4 are designated HIGH risk and those <4 are LOW risk.
Stroke Unit Care
All people with stroke should be admitted to hospital and be treated in a comprehensive stroke unit with an interdisciplinary team). (Grade A; Level I [Stroke Unit Trialist's Collaboration, 2001; Foley, Salter, & Teasell, 2007])
Smaller hospitals should consider models of stroke unit care that adhere as closely as possible to the criteria for stroke unit care. Where possible, patients should receive care on geographically discrete units. (Grade B, Level I [Stroke Unit Trialist's Collaboration, 2001; Langhorne et al., 2005])
Organisation of Services for Transient Ischaemic Attack (TIA)
All patients with suspected TIA should be managed in services that allow rapid assessment and treatment to be undertaken within 24-48 hours of symptom onset:
- Those identified at high risk (ABCD2 score >4) should be admitted to a stroke unit (or where available referred to a specialist TIA clinic if the person can be assessed within 24-48 hours) to facilitate rapid assessment and treatment. (CPP)
- Those identified at low risk (ABCD2 score <4) may be managed in the community by a general practitioner, private specialist or where possible referred to a specialist TIA clinic and seen within 7-10 days. (CPP)
Organisation of Care for Rural Centres
All health services caring for people with stroke should use networks which link large stroke specialist centres with smaller regional and rural centres. (Grade D; Level IV [Audebert et al., 2005; Kwan, Hand, & Sandercock, 2004; Wang et al., 2000])
These networks should assist to establish appropriate stroke units along with protocols governing rapid assessment, pathways for direct communication with stroke specialist centres ("telestroke" services), and rapid transfers centres. (Grade D; Level IV [Audebert et al., 2005; Audebert et al., 2006; Kwan, Hand, & Sandercock, 2004; Wang et al., 2000])
Care Pathways
All stroke patients admitted to hospital may be managed using an acute care pathway. (Grade C; Level II [Kwan & Sandercock, 2004])
Inpatient Care Coordinator
A stroke coordinator may be used to foster coordination of services and assist in discharge planning. (CPP)
Team Meetings
The multidisciplinary stroke team should meet regularly (at least weekly) to discuss assessment of new patients, review patient management and goals, and plan for discharge. (Grade C, extrapolated from Level I [Langhorne et al., 2002])
Family Meetings
The stroke team should meet regularly with the person with stroke and the family/carer to involve them in management, goal setting and planning for discharge. (Grade C, extrapolated from Level I [Langhorne et al., 2002])
Information and Education
All stroke survivors and their families/carers should be provided with timely, up-to-date information in conjunction with opportunities to learn via education from members of the interdisciplinary team and other appropriate community service providers. Simple information provision alone is not effective. (Grade A; Level I [Bhogal et al., 2003; Forster et al., 2001])
Early Supported Discharge
Health services with organised inpatient stroke services should provide comprehensive interdisciplinary community rehabilitation and support services for people with stroke and their family/carer. (Grade A; Level I [Early Supported Discharge Trialists', 2005; Larsen, Olsen, & Sorenson, 2006; Outpatient Services Trialists, 2002])
If interdisciplinary community rehabilitation services and carer support services are available, then early supported discharge should be offered for all stroke patients with mild to moderate disability. (Grade A; Level I [Early Supported Discharge Trialists, 2005; Larsen, Olsen, & Sorenson, 2006])
Shared Care
All patients with stroke or TIA should have their risk factors reviewed and managed long term by a general practitioner with input and/or referral to a stroke physician for specialist review where available. (Grade C; Level II [Joubert et al., 2006])
Locally developed protocols and pathways should be used to efficiently link primary and secondary care for people with stroke or TIA, including rapid assessment and referrals, acute management, direct communication links, efficient discharge services and long term management. (CPP)
Rural practitioners should participate in networks linking them to regional or metropolitan centres with specialty in stroke care. (CPP)
Standardised Assessment
Clinicians should use validated and reliable assessment tools or measures that meet the needs of the patient and guide clinical decision making. (CPP)
Clinicians should provide timely and efficient assessment of patients with acute stroke. Where possible a multidisciplinary assessment should be undertaken and documented within two days of admission. (CPP)
Assessment findings should be discussed at the team meeting and communicated to the patient and family/carer in a timely and appropriate manner. (CPP)
Palliation and Death
A pathway for acute stroke palliative care may be used to improve palliation for people dying after acute stroke. (Grade D; Level IV [Jack et al., 2004])
An accurate assessment of imminent death should be made for patients with severe stroke or those who are deteriorating. Any assessment must consider prognostic risk factors along with the wishes of the patient and their family/carer. (CPP)
Acute stroke patients should have access to specialist palliative care services as needed. (CPP)
People with stroke who are dying, and their families, should have care that is consistent with the principles and philosophies of palliative care. (CPP)
Stroke Service Improvement
All acute stroke services should be involved in quality improvement activities that include regular audit and feedback ('regular' is considered at least every two years). (Grade B; Level I [Jamtvedt et al., 2006])
Indicators based on nationally agreed standards of care should be used when undertaking any audit. Performance can then be compared to similar stroke services as described by the National Stroke Unit Program. (CPP)
Definitions:
Levels of Evidence
Level |
Intervention |
Diagnosis |
Prognosis |
Aetiology |
Screening |
I |
A systematic review of Level II studies |
A systematic review of Level II studies |
A systematic review of Level II studies |
A systematic review of Level II studies |
A systematic review of Level II studies |
II |
A randomised controlled trial |
A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation |
A prospective cohort study |
A prospective cohort study |
A randomised controlled trial |
III-1 |
A pseudo-randomised controlled trial (i.e., alternate allocation or some other method) |
A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation |
All or none |
All or none |
A pseudo-randomised controlled trial (i.e., alternate allocation or some other method) |
III-2 |
A comparative study with concurrent controls:
- Non-randomised experimental trial
- Cohort study
- Case-control study
- Interrupted time series without a parallel control group
|
A comparison with a reference standard that does not meet the criteria required for Level II and Level III-1 evidence |
Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial |
A retrospective cohort study |
A comparative study with concurrent controls:
- Nonrandomised, experimental trial
- Cohort study
- Case-control study
|
III-3 |
A comparative study without concurrent controls:
- Historical control study
- Two or more single arm study
- Interrupted time series without a parallel control group
|
Diagnostic case-control study |
A retrospective cohort study |
A case-control study |
A comparative study without concurrent controls:
- Historical control study
- Two or more single arm study
|
IV |
Case series with either post-test or pre-test/post-test outcomes |
Study of diagnostic yield (no reference standard) |
Case series or cohort study of patients at different stages of disease |
A cross-sectional study |
Case series |
Grades of Recommendations
Grade |
Description |
A |
Body of evidence can be trusted to guide practice |
B |
Body of evidence can be trusted to guide practice in most situations |
C |
Body of evidence provides some support for recommendation(s) but care should be taken in its application |
D |
Body of evidence is weak and recommendation must be applied with caution |
Clinical Practice Points |
CPP |
Recommended best practice based on clinical experience and expert opinion |
ABCD2 Tool*
A Age: >60 years (1 point)
B Blood pressure: >140/90 mmHg (1 point)
C Clinical features: unilateral weakness (2 points), speech impairment without weakness (1 point)
D Duration: >60mins (2 points), 10-59 mins (1 point)
D Diabetes (1 point)
|
*(Johnston et al., 2007)