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Patients With Suspected Stroke Should Be Admitted Directly To Specialist Stroke Units

Two new clinical guidelines launched, one from the Royal College of Physicians (RCP) and one from The National Institute for Health and Clinical Excellence (NICE) recommend that all patients suspected of having a stroke should be admitted as quickly as possible to an acute stroke unit, either from the community or by being transferred from A&E. The unit should check if the patient is eligible for thrombolysis (clot-busting drugs) and administer them if appropriate.

Over one in ten people in the UK die from a stroke, and every year, an estimated 150,000 people have a stroke. It is the third largest cause of severe disability, with 250,000 people living with severe disabilities caused by stroke.

The NICE guideline covers the acute stage of stroke or transient ischaemic attack, and the RCP guideline is the third edition of the National Clinical Guideline for Stroke. The RCP guideline, produced by the Intercollegiate Stroke Working Party, incorporates the NICE guideline and also covers recovery and rehabilitation, secondary prevention, and long term care, and has new sections on commissioning and resources. The guidelines were produced in close collaboration with each other, and both reference and relate to the Department of Health’s National Stroke Strategy (2007).

NICE guideline

The NICE guideline ‘Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)’ covers the acute stage of a stroke or TIA, mainly the first 48 hours after symptoms start. TIA is defined as stroke symptoms and signs that resolve within 24 hours. There is evidence for stroke that rapid diagnosis, admission to a specialist stroke unit, immediate brain imaging and use of thrombolysis where indicated can all contribute to a much better outcome for patients. For people who have had a TIA, rapid assessment for risk of subsequent stroke allows appropriate treatment to be started quickly to reduce the chance of having another stroke.

Key recommendations:

All patients with suspected stroke should be tested with the FAST (Face Arm Speech Test) or similar test to recognize symptoms of acute stroke

- All patients with acute stroke should be taken to hospital as quickly as possible and transferred from A&E to an acute stroke unit
- Immediate CT scanning should be available 24/7 for those who need it
- High risk patients who have already had a TIA should receive a diagnosis, investigations and initial treatment within 24 hours
- All patients should receive a swallowing assessment within 24 hours of assessment and before being given any oral food, fluid or medication

The quick reference guide and patient versions of the NICE guideline are available, together with the full NICE guideline at http://www.nice.org.uk/CG68

RCP guidelines

The RCP guidelines contain 21 main recommendations covering all aspects of stroke care, and are aimed at improving the quality of care delivered to everyone who has a stroke in the UK regardless of age, gender, type of stroke, location or any other feature. The first two editions of the National Clinical Guideline for Stroke (2000 and 2004), coupled with the RCP’s National Sentinel Audit for Stroke, have led to major improvements in stroke care in the past decade, and this new edition using evidence published since the last guidelines includes specific recommendations for commissioners who purchase services for people with stroke.

Key recommendations

All hospitals receiving acute medical admissions that include patients with stroke should have a specialist acute stroke unit

Acute stroke units should have immediate access to medical staff specifically trained to treat stroke patients and deliver thrombolysis; nursing staff specifically trained to manage acute stroke; imaging and laboratory services; rehabilitation specialist staff

All patients not suitable for transfer home after completion of their acute diagnosis and treatment should be treated in a specialist stroke rehabilitation unit with expert staff, a multidisciplinary team and educational programmes for staff, patients and carers

Patients should have as much therapy as they are willing and able to cope with, and should have 45 minutes a day of each appropriate therapy in the early stages

All patients discharged home directly after acute treatment but with residual problems should be followed up by specialist stroke rehabilitation services

Hospital services should ensure that patients, families and primary care teams are fully prepared for the patient’s discharge

Carers of patients with stroke should be fully involved at all stages of the patient’s progress

Commissioners should ensure that they commission services for the full stroke pathway from prevention through acute care, early rehabilitation, later rehabilitation and initiation of secondary prevention on to palliation, later rehabilitation in the community and long-term support.

The Guidelines include a series of concise guides for health professionals including nurses, dietitians, occupational therapists, physiotherapists, and speech and language therapists.

Dr Tony Rudd, Chair of the NICE Guideline Development Group, and joint Chair of the Intercollegiate Stroke Working Party, said:

“At last the impact of stroke is being recognised and politicians and clinicians are accepting that stroke is a treatable disease. These guidelines contain recommendations that require a radical restructuring of health services. This process is already underway following the publication of the Department of Health National Stroke Strategy last year. Instead of waiting weeks to be assessed after a transient ischaemic attack, by which time many people will already have had their stroke, the expectation should now be that patients who are at high risk are seen and treated within 24 hours. All people who are involved with treating stroke and the general public who are at risk of having a stroke need to know what is in these guidelines so that fewer people in the UK have their lives devastated by this awful disease.”

The NICE guidelines are available at http://www.nice.org.uk/CG68

National Clinical Guideline for Stroke

Royal College of Physicians

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