Strokes: progressive stroke pathway

10. Acute stroke care

10.1 Provision of 'the bundle' of care.

The majority of people who experience a stroke will not be eligible to receive hyperacute treatments such as thrombolysis or thrombectomy. The emphasis of care for the majority of stroke patients, is therefore to deliver the stroke bundle.

There are four components to the bundle:

• Swallow screen (100% within 4 hours of arrival, and before any food, fluids or oral medication is administered), - we believe this reduces the risk of pneumonia, dehydration, malnutrition and death.
• Brain imaging (90% within 12 hours accepting that hyperacute patients require a scan as soon as possible after arrival), since confirmation of the stroke diagnosis and distinguishing strokes due to ischaemic and bleeding has wide-reaching effects on management from the earliest stages.
• Aspirin for those with ischaemic stroke (95% on day or admission or following day) – which is a very simple and almost universally applicable treatment which improves patients outcome.
• Admission to stroke unit (90% on day of admission or following day) which reliably provides a wide range of targeted interventions. This reduces the risks of complications, improves the patients' experience and is known to improve functional outcomes and reduce mortality.

In general, brain imaging and aspirin standards are met across Scotland. However, there remains significant challenges in swallow screen and access to stroke units. Consequently, the overall adherence to the stroke bundle performance remains low.

Where patients are at risk of post stroke complications (e.g., infection, venous thromboembolism, dehydration, malnutrition, pressure sores), and depending on the established aims of treatment, patients should receive evidence-based interventions such as parenteral fluids, early tube feeding, intermittent pneumatic compression and antibiotics. At present, delivery of these important aspects of stroke care is assessed through sprint audits within the Scottish Stroke Care Audit or local audits. These have demonstrated variable delivery. Such audits had to rely on review of paper or electronic health records which identifies issues in delivery only in retrospect.

TRAKcare, the electronic health record used across Scotland does not support the sort of data capture, extraction and analysis to provide real-time data on delivery of important aspects of stroke unit care. An improved approach is required where failures of delivery are identified in real time, when they can be rectified to avoid patient harm. However, IT systems which are available to do this for only certain aspects of care (e.g. delivery of the National Early Warning System (NEWS) of observations to avoid in hospital deterioration and cardiac arrest) are not currently used to provide improvements in delivering specialty specific aspects of care, such as those in a stroke unit.

10.2 Access to stroke unit care

Stroke unit care is the central feature of a modern stroke service. As it can benefit most stroke patients, even those who also undergo hyperacute treatments, it is important that the important role of stroke unit care within hospitals is recognized and supported.

Through engagement with the National Stroke Voices, we heard that receiving care in a stroke unit was important to people.

''My treatment was much better and much more focused when I was placed in the Stroke Unit'' – National Stroke Voices participant.

Every stroke patient should receive the core service characteristics of stroke unit care from initial assessment to discharge from hospital. Key features of a stroke unit in a progressive stroke pathway should include:

A geographically-defined unit

• A co-ordinated multi-disciplinary team that meets at least once a week for the exchange of information about in-patients with stroke.
• Information, advice and support for people with stroke and their family/carers.
• Management protocols for common problems, based upon the best available evidence.
• Close links and protocols for the transfer of care with other in-patient stroke services, early supported discharge teams and community services.
• Training for healthcare professionals in the specialty of stroke.
• The provision of holistic assessment of need for every patient which incorporates the views of patients and their families, which informs decisions about care.
• All interactions and interventions are carried out under a person-centred approach.

Although the core features are well described, services have sought to deliver stroke unit care in a variety of different ways. The size and configuration of stroke units depends on factors such as rurality and the other services and resources available within the local area.

Of the 22 ASCs, the seven smallest general hospitals in Scotland define stroke unit admission as entering the appropriate acute medical ward. While this means that the hospitals do not meet the first criteria of a geographically defined unit, they should meet all other criteria outlined above. In some instances, this may mean that remote stroke specialist support is required to provide early specialist assessments and a coordinated, regular multi-disciplinary team meeting. This is an appropriate response to maintaining local services, and reduced time to thrombolysis, for people with stroke in these areas.

The Scottish Stroke Care Audit 'bundle' reflects access to stroke unit care and shows that this is currently variable between health boards and sites.

There are marked variations in the size of stroke units, their staffing levels (medical, nursing, allied health professionals, clinical and neuropsychologists and social work staff) and the training of those staff.

While every stroke patient should have access to stroke unit care as defined above, in some instances, patients may require more intensive care. This is the case for those who undergo thrombectomy. In such instances, those people should receive care within a stroke unit which can also provide:

• Specialist staffing and technology that provide close clinical and continuous physiological monitoring for all, and especially those at higher risk of early deterioration or complications.
• Seamless working with intensive care units and high dependency units where required.
• Continuous access to a consultant with expertise in stroke medicine, with consultant review seven days per week.
• Immediate access to specialist medical, nursing, rehabilitation, and diagnostic staff trained in the hyperacute management of people with stroke, plus tertiary services for endovascular therapy, neurosurgery and vascular surgery.

These features are often available within a hyperacute stroke unit (HASU) where patients often stay for just the first couple of days, or a hyperacute bay within a stroke unit.

All stroke services should have protocols for the monitoring, referral and urgent transfer of patients, where there is a risk of patients requiring neurosurgical intervention, to regional neurosurgical centres.

Systems of joint working should be developed to establish broadly agreed referral criteria for carefully selected cases, e.g., those patients who might benefit from decompressive hemicraniectomy for malignant middle cerebral artery (MCA) syndrome.

As outlined in the introduction of this paper, supporting shared decision making helps to ensure treatments are delivered which are most likely to deliver the outcome valued by the patient and/or family. This remains important in the acute and hyperacute phases and is likely to be optimised by early involvement of senior clinicians with access to systems to share tailored information with patients and their family.

10.3 End of Life Care

About one in 20 people with acute stroke will be receiving end-of-life care within 72 hours of onset, and one in seven people with acute stroke will die in hospital.

Therefore, providing high quality end-of-life care should be a core activity for the multi-disciplinary stroke team. The key aim is to appropriately and holistically manage distress associated with the end-of-life experience for the person and the family/carers, in line with guideline advice.

Patients with severe stroke resulting in a high risk of death or poor functional outcome, should be involved at an early stage in shared decision making about the aims of treatments including cardiopulmonary resuscitation, critical care, hemicraniectomy, and treatments to reduce the risk of serious complications. Where the patient lacks capacity then next of kin or advocate should be involved.

Advanced care planning should take place for those people who may survive the acute stroke with limited life expectancy, to facilitate timely referral to specialist palliative care services, where required.

10.4 Recommendations

1. Patients with acute stroke should have their clinical status monitored closely and managed according to clinical guidelines.

2. Stroke services should deliver the stroke bundle, meeting the Scottish Stroke Care Audit Standards for:

• Swallow screen
• Brain imaging
• Provision of aspirin for those with ischaemic stroke
• Admission to stroke unit

3. Healthcare professionals responsible for the assessment and management of patients with acute stroke should be trained in how to position and mobilise patients in a way that is safe and consistent with clinical guidelines.

4. Acute stroke patients should be managed in a stroke unit that meets the core requirements outlined in Section 9.2.

5. A stroke unit should have continuous access to a consultant with expertise in stroke medicine, with consultant review 5 days per week.

6. Staff working in stroke units should have completed the necessary training as outlined in the national educational template and should follow standardised management protocols for the assessment & management of acute stroke according to clinical guidelines.

7. Staff working in stroke units should have access to IT systems which optimise the reliability of assessments and treatment delivery.

8. People with rehabilitation needs should be assessed by a therapist and ongoing management planned according to clinical guidelines and in line with the progressive vision of rehabilitation outlined in Section 10.

9. Services providing acute and ongoing care for people with stroke should provide high quality end-of-life care for those who need it, including advanced care planning and timely access to specialist palliative care if required.

10. All stroke services should have protocols for the monitoring, referral and urgent transfer of patients, where there is a risk of patients requiring neurosurgical intervention, to regional neurosurgical centres.

11. In addition, for patients who require closer monitoring:

• A so called hyperacute stroke unit or area which is providing close monitoring of patients post thrombectomy should have continuous access to a consultant with expertise in stroke medicine, with consultant review 7 days per week.
• These units should in addition have immediate access to specialist medical, nursing, rehabilitation, and diagnostic staff trained in the management of people with stroke, plus tertiary services for endovascular therapy, neurosurgery and vascular surgery.