Strokes: progressive stroke pathway

5. Recognition and Referral

Raising and maintaining awareness of the symptoms of stroke and transient ischaemic attack (TIA) in the population, its recognition, and the need to immediately seek help are key to optimising treatment and outcomes.

5.1 Improving individual awareness and recognition of stroke

The FAST campaign is a UK wide awareness campaign designed to help detect and enhance responsiveness to the needs of a person having a stroke. The acronym stands for:

• Facial drooping
• Arm weakness
• Speech difficulties
• Time to call emergency services

Awareness campaigns should be shaped by evidence about what methods (e.g. TV/radio advertising, social media) most effectively reach target populations. It is especially important to consider how best to reach people who may face inequalities in access to information, or awareness of stroke. This includes:

• People for whom English is not a first language
• People living in areas of deprivation
• Younger people who may not be aware of their risk of stroke

5.2 Improving referral pathways

Early assessment and triage for people with stroke or TIA is important because the time windows for delivering the most effective interventions, such as thrombolysis, thrombectomy & commencement of secondary prevention, are measured in hours. The earlier treatment is started the more effective it is.

Most services in Scotland have a system in place to allow urgent patient referral for rapid specialist assessment, though unwarranted variation should be identified and addressed.

The National Stroke Voices highlighted the importance of raising awareness about recognition of stroke and TIA within primary care, and identified emergency departments as a key area for improvement. Targeted education on FAST and clear referral guidelines could support health care professionals to recognise symptoms and signs of stroke, including in circumstances where presentation may not be typical (for example where the FAST test might be negative, or where the person experiencing stroke is young).

5.2.1 Referral to TIA services

In instances where the symptoms of stroke have resolved rapidly and an acute stroke is not suspected, then the person should be referred into TIA services. Key aspects of these services are outlined in detail in Section 5: TIA Services. The most common sources of referral to TIA services will be from primary care, emergency departments, ophthalmology/optometry services, medical wards and Scottish Ambulance Service. Clear pathways should be in place for all referrers.

In some locations TIA telephone hotlines are in place which allow paramedics, primary care clinicians and emergency department professionals to talk directly to a stroke physician at the time of the patient first accessing healthcare. This enables early specialist intervention and treatment whilst the patient is waiting to have the diagnosis and treatment refined.

All patients referred to TIA services should be told that they must not drive for one month - as per Driver and Vehicle Licensing Agency (DVLA) recommendations - and should be advised regarding current regulations around resuming driving. This should be supported by a robust and rapid electronic referral system e.g., SCI gateway or TRAK workbench, which should prompt driving advice and secondary prevention prescription. These referrals should be monitored, or have notification systems, to ensure prompt appointing to specialist review.

5.2.2 Suspected acute stroke – taking prompt action

In instances where symptoms of stroke persist and an acute stroke is suspected, the patient should be transferred by ambulance to the nearest 'stroke ready' hospital – that is a hospital with facilities to scan patients, offer hyperacute treatment with thrombolysis and provide assessment of eligibility for thrombectomy.

There are 25 such hospitals across Scotland, 22 of these are Acute Stroke Centres (ASCs). The remaining three are Comprehensive Stroke Centres (CSCs), which in addition to the facilities described above, can also deliver thrombectomy and neurosurgical interventions.

All stroke centres will have stroke units unless they serve a very small population (such as occurs in remote and rural areas where the essential features of a stroke unit are delivered within a single ward area). This is described in more detail in Section 9.2.

In a progressive stroke pathway, it will be important to ensure ambulance response times are as short as possible, through appropriate assessment and prioritisation of emergency calls.

NHS 24 or 999 call handlers use algorithms to assess the urgency of calls and the likelihood that the person has had a stroke. Improved algorithms based on analysis of linked data about triage and resulting actual diagnoses could help reduce delays to effective treatments. Such an approach would be maximised by targeted training for call handlers in awareness and identification of stroke.

Ambulance crews should be supported with continued training in the most up-to date tools to improve diagnosis and assessment of the patients' need for hyperacute treatments and early secondary prevention.

Once the ambulance crew has made an assessment it is necessary to consider robust and transparent algorithms for the prioritisation of SAS resources, including air transfers, which take account of availability, the benefits and risks to the patient, the time urgency of the interventions and the cost effectiveness to ensure that the optimum improvement in outcomes from the available resources can be achieved. These should be developed through analysis of linked data from SAS and the Scottish Stroke Care Audit.

5.3 Recommendations

0. Effective campaigns to raise awareness of stroke and TIA, their impact on people who experience them, and tools for timely recognition should consider how best to reach people who may face inequalities in access to information, or awareness of stroke.

1. Support the use of FAST and work to embed other pre-hospital stroke tools -particularly those which support assessment for hyperacute treatment - in a standardised way across NHS 24, primary care and SAS.

2. Improved algorithms and training for NHS 24 or SAS call handlers and crews should be deployed to support the assessment of the urgency of calls and the likelihood that the patient has had a stroke, and enable effective prioritisation of SAS resources, including air transfers.

3. Ensure appropriate referral of people with all stroke events, including those with acute ongoing symptoms, acute but resolved symptoms and other stroke-like events.

4. Referral systems should prompt driving advice and secondary prevention prescription.

5. All patients referred to TIA services should be told not to drive for one month (as per DVLA recommendations) at the point of referral and advised on current regulations for resuming driving.