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.
Ambulance services, health care professionals and the general public should receive education concerning the importance of early recognition of stroke, emphasising stroke is a medical emergency. (Grade C; Level III-3 & IV [Kwan, Hand, & Sandercock, 2004])
Stroke patients should be given a high priority grouping by ambulance services. (Grade C; Level III-2 [Bray et al., "An interventional study," 2005; Belvis et al., 2005])
Ambulance services should be trained in the use of validated rapid pre-hospital stroke screening tools and incorporate such tools into protocols for all pre-hospital assessment of people with suspected stroke. (Grade B; Level III-2 [Bray et al., "Paramedic identification of stroke," 2005; Kidwell et al., 2000; Nor et al., 2004; Kothari et al., 1999])
Ambulance services should preferentially transfer suspected patients to a hospital with stroke unit care. (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
Grading 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 |
