Dr Anthony Rudd and Penny Irwin explain how the new RCP stroke guidelines will improve the delivery of care to patients and promote secondary prevention
A GP with an average practice will see approximately five patients with new stroke each year. Of these, 30% will die within the first 3 months, half of the remaining patients will have significant long-term disability, and all will need skilled management of their risk factors to prevent recurrence. Over 10% of patients will have a second stroke within a year of the first.
While, in inner-city districts, hospital admission rates for the acute event are about 80%, it is nevertheless important for the individual GP to act appropriately at the time of the acute event, and subsequently to have the knowledge and skills to manage the patient following discharge from hospital.
Increasingly the GP will be responsible, through the primary care group structure, for the design of local stroke services. This provides an opportunity to develop services that are currently disorganised and ineffective in many areas.
The need for a clear national strategy to improve stroke care is evident. The National Sentinel Audit,1 the Stroke Association report on stroke services2 and the Clinical Standards Advisory Group (CSAG)3 have all shown major deficiencies in the delivery of care, which need to be addressed urgently. One of the findings of the CSAG was the difficulty that clinicians had in accessing evidence-based recommendations for stroke care.
The National Guidelines for Stroke4 are an attempt to provide this information. Commissioned by the DoH, the guidelines have been written by the Intercollegiate Stroke Working Party at the RCP, London. The group included representatives from all the professions relevant to the care of staoke patients including the Royal College of General Practitioners and health service managers.
The objective was to produce a document that complied with the appraisal instrument set out by Cluzeau et al.5 Each of the members contributed to the process of literature review within their own area of expertise, and in reaching consensus in areas where evidence was lacking. Wherever possible, stroke specific literature was used to inform the guidelines; however, in many areas, particularly rehabilitation, the only evidence available was from non-stroke specific trials.
The views of patients and carers were obtained through a specially commissioned report from the College of Health,6 and incorporated into the guidelines document.
The most important recommendation in the document is that every organisation involved in the care of stroke patients over the first 6 months should ensure that stroke patients are the responsibility of and are seen by services specialising in stroke and rehabilitation (Table 1).
Within the hospital this means the provision of a stroke unit of sufficient size to be able to provide care for most patients admitted with stroke. If patients are managed at home, GPs are obliged to involve specialists in the care of the patient.
The recommendations cover all aspects of care (except primary prevention), from the acute event to aspects of long-term disability and handicap. Some of the key recommendations of particular relevance to primary care are given in the article. The detailed evidence on which the guidelines are written is available in the main document. The grading of the strength of the recommendations is as described by Eccles et al.7
While the guidelines do not specifically state that all patients should be admitted, the recommendations regarding acute management mean that in most areas it will be not be possible to comply with standards without admission (Table 2).
For the patient, therapy, especially physiotherapy, is the key component of treatment after stroke. There is now reasonable evidence to confirm the importance of rehabilitation following stroke, with some research showing a dose-response relationship. The guidelines therefore state that 'patients should see a therapist each working day if possible (B) and they should receive as much as they can be given and find tolerable (A)'.
Stroke is a family illness. Initially, as in any other acute illness, relatives need information and support through the crisis. But stroke is different from many other acute illnesses, in that patients will usually need long-term practical, emotional, social and financial support to cope with the many residual problems.
The extent of the stress of caring for a disabled person and the factors influencing the nature and extent of stress have only recently been the subject of research. The evidence supports the provision of good information and the use of stroke family support workers.
|Table 1: Organisation of care|
Every organisation involved in the care of stroke patients over the first 6 months should ensure that stroke patients are the responsibility of and are seen by services specialising in stroke and rehabilitation (A)
The stroke service should comprise:
|Specialist stroke services can be delivered to patients, after the acute phase, equally effectively in hospital or in the community, provided that the patient can transfer from bed to chair before going home (A)|
|Specialist day hospital rehabilitation or specialist domiciliary rehabilitation can be offered to outpatients with equal effect (A)|
|Each district should conduct a needs assessment exercise to determine the level of service so that all stroke patients in the area have access to the same standards of care (C)|
|Table 2: Hospital or home?|
Patients should only be managed at home if:
|Otherwise patients should be admitted to hospital for initial care and assessment (A)|
The guidelines on diagnosis relate particularly to the use of brain scanning and the need to involve stroke specialists in reviewing the diagnosis (Table 3, below).
|Table 3: Diagnosis of stroke|
|It should be recognised that 'stroke' is primarily a clinical diagnosis, and that the clinical diagnosis can be relied upon in most cases; care is needed in the young, if the history is uncertain, or if there are other unusual clinical features such as gradual progression over days, unexplained fever, severe headache or symptoms and signs of raised intracranial
|Brain imaging should be undertaken to detect intracerebral or subarachnoid haemorrhage, and to exclude other causes of the stroke syndrome, in all patients within 48 hours of onset unless there are good clinical reasons for not doing so (C)|
Brain imaging should be undertaken as a matter of urgency if: (B)
|Table 4: Acute treatment of stroke|
|Aspirin (300mg) should be given as soon as possible after the onset of stroke symptoms if a diagnosis of haemorrhage is considered unlikely (A)|
|Anticoagulation should be considered for all patients in atrial fibrillation, but not started until intracerebral haemorrhage has been excluded by brain imaging, and usually only after 14 days (A)|
|Thrombolytic treatment with tissue plasminogen activator (tPA) should only be given provided that it is administered within 3 hours of onset of stroke symptoms, that haemorrhage has been definitively excluded, and that the patient is in a specialist centre with appropriate experience and expertise (A) (There is no licence in the UK at the time of going to press)|
|Local policies should be agreed in relation to the early management of hypertension, hyperglycaemia, hydration and pyrexia (C)|
|Table 5: Management of continence and sexual function|
|Continence services should cover both hospital and community, to provide continuity of care (C)|
|There should be active bowel and bladder management from admission (C)|
|Catheters should be used only after full assessment, and as part of a planned catheter management plan using an agreed protocol (e.g. smallest size that functions) (B)|
|Further tests (urodynamics, anorectal physiology tests) should be considered when incontinence persists (C)|
|Incontinent patients should not be discharged until adequate arrangements for continence aids and services have been arranged at home and the carer has been adequately prepared (C)|
|Sexual function should be considered, particularly the potential problems associated with an indwelling catheter (C)|
Many of the guidelines relating to assessment and rehabilitation could equally well apply to other chronic disabling conditions. For example, the importance of using validated measures for documenting level of consciousness, swallowing, pressure sore risk and nutritional status are identified, as is the need for clear policies on the training of staff in handling and positioning patients.
Mood disturbance following stroke is common, occurring in up to 40% of patients. Data from the National Sentinel Audit1 have shown how badly psychological problems are managed following stroke. The guidelines stress the need to be proactive in identifying depression and anxiety. Severe emotionalism and depression should be treated with an antidepressant.
One of the key functions of the guidelines is to encourage interdisciplinary and cross-sector working. Planning discharge from hospital is one example where this is particularly important (see Table 6).
|Table 6: Discharge planning|
|Early hospital discharge should only be considered if there is a specialist stroke rehabilitation team in the community (A)|
|Early hospital discharge to generic (non-specialist) community services should not be undertaken (A)|
Hospital services should have a protocol and local guidelines for discharge (A), to check that, before discharge occurs:
|Patients are given information about, and offered contact with, appropriate local statutory and voluntary agencies (C)|
The decision as to how long to continue rehabilitation is often difficult. It is common for the therapist to conclude that further rehabilitation is of no value, before the patient reaches this decision. There is little research to guide clinicians as to how long to continue treatment.
There is however, evidence to support the view that reassessment is of value to indicate where further rehabilitation might be of value. The guidelines state: 'Any patient with disability at 6 months or later after stroke should be assessed for a period of further targeted rehabilitation to be given where appropriate (A)'.
Perhaps the most important role of the GP in the management of stroke patients is to ensure adequate secondary prevention (see Table 7, below). The National Sentinel Audit, as well as other research studies, have shown that even apparently simple interventions, such as provision of aspirin following ischaemic stroke or the identification and treatment of hypertension are often omitted.
|Table 7: Secondary prevention|
|All patients should have their blood pressure checked, and hypertension persisting for over one month should be treated. The British Hypertension Society guidelines state: Optimal blood pressure treatment targets are systolic blood pressure <140mmHg and diastolic blood pressure <85mmHg; the minimum accepted level of control recommended is <150/90 mmHg (A)|
|All patients not on anticoagulation should be taking aspirin (50–300mg) daily (A), or a combination of low-dose aspirin and dipyridamole modified release (MR). Where patients are aspirin intolerant, an alternative antiplatelet agent (clopidogrel 75mg daily or dipyridamole MR 200mg twice daily) should be used (A)|
|For atrial fibrillation (A), mitral valve disease, prosthetic heart valves, or within 3 months of myocardial infarction (C), anticoagulation should be considered for all patients who have ischaemic stroke.|
|Anticoagulation should not be used after transient ischaemic attacks or minor strokes unless cardiac embolism is suspected (A)|
Any patient with a carotid artery area stroke, and minor or absent residual disability should be considered for carotid endarterectomy (A)
All patients should be assessed for other vascular risk factors and be treated or advised about life-style factors (B)
|Therapy with a statin should be considered for all patients with a past history of myocardial infarction and a cholesterol >5.0mmol/l following stroke (A)|
Implementation of the guidelines will require an active strategy within all areas of the health service, if they are not to end up with many of the other guidelines accumulating dust in the corner of the office. Local advocates for the guidelines will be identified to carry forward the process of implementation.
The publication during 2000 of the National Service Framework (NSF) for Elderly People, which includes stroke, may also provide an impetus to the use of the guideline. The NSF had access to the guidelines in producing their recommendations; if the Government does endorse their findings, trusts may find the guidelines useful in reconfiguring services.
The role that the National Institute for Clinical Excellence (NICE) will play in implementing clinical guidelines has yet to be clarified.
The guidelines are published in paper format and electronically through the Royal College of Physicians' website (www.rcplondon.ac.uk).
It is anticipated that they will be updated on a regular basis. Without this, for a condition such as stroke, where the evidence base is developing rapidly, the guidelines will become redundant within 1–2 years.
Work also needs to continue on making the guideline more accessible and useful to doctors, nurses and therapists in their daily work.
Development of electronic patient records linked to the guidelines, and using such records for routine data collection for the purposes of audit and clinical governance, are possible ways in which modern technology could help deliver improvements in the quality of stroke care.
Ultimately the most powerful way of improving care is to inform and empower stroke patients. For this reason a patient and carer version of the National Guideline has also been produced, with the hope that this will become widely available in hospitals and primary care. When patients become aware of the recommended standards of care and start demanding them, change will come rapidly.
Improving the quality of stroke care does not necessarily require significant extra resources. Reorganising existing services may indeed improve efficiency and result in savings.
The average district general hospital will have between 20 and 30 patients occupying beds as a result of stroke. Ways in which services may be reorganised include:
|Bringing patients with stroke together in one ward|
|Providing training for staff|
|Creating effective interdisciplinary teams|
|Developing enhanced community services|
|Involving patients and carers in planning care|
|Setting clear objectives|
|Cooordinating and communicating with community services|
All of the above are achievable with a little willpower and some knowledge. We hope that the stroke guidelines will help with the latter.
- Rudd AG, Irwin P, Rutledge Z, Lowe D, Morris R, Pearson MG. The national sentinel audit of stroke: a tool for raising standards of care. J R Coll Physicians 1999; 30: 460-4.
- Ebrahim S, Redfern J. Stroke Care – A matter of chance: a national survey of stroke services. London: The Stroke Association, 1999 .
- Clinical Standards Advisory Group Report on Clinical Effectiveness using Stroke as an example. London: The Stationery Office, 1998.
- Intercollegiate Working Party for Stroke. National Clinical Guidelines for Stroke. Royal College of Physicians. London, 2000.
- Cluzeau F, Littlejohns P, Grimshaw J, Feder G. Appraisal Instrument for Clinical Guidelines. Version 1. Health Care & Evaluation Unit. St George's Hospital Medical School. London, 1997.
- Kelson M, Ford C, Rigge M. Stroke Rehabilitation: patient and carer views. A report by the College of Health for the Intercollegiate Working Party for Stroke. London: Royal College of Physicians, 1998.
- Eccles M, Clapps Z, Grimshaw J et al. North of England evidence based guidelines development project: methods of guideline development. Br Med J 1996; 312: 760-2.
- The National Clinical Guidelines for Stroke are available from the RCP Publications Unit on 020 7935 1174 ext 254, price £22 including UK p&p. They have also been published on the RCP website at www.rcplondon.ac.uk/college/ceeu_stroke_home.htm