National Institute for Health and Clinical Excellence (NICE)
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PATIENTS WITH SUSPECTED STROKE SHOULD BE ADMITTED DIRECTLY TO SPECIALIST STROKE UNITS

Two new clinical guidelines launched today, 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 included in this media pack and are also available, together will the full NICE guideline at 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 National Clinical Guidelines for Stroke are included in this media pack. 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.”

Alan Bowmaster, patient representative and GDG member said: “When I suffered from a stroke ten years ago, my family and I were extremely frustrated by the length of time it took to find out what was wrong with me as there was no specialist stroke unit. This guideline recognises that a TIA or ‘mini stroke’ is a warning sign that a stroke may be imminent. It is good news that people who have had a suspected TIA will receive specialist assessment and investigation within 24 hours of the onset of symptoms, and start on aspirin immediately. By taking these steps, a stroke and the severe disability associated with it can be prevented.”

Diana Day, Guideline Development Group member and stroke nurse, said:
These guidelines are an excellent development for stroke. They lay out the optimal care each stroke patient should receive, rapid transfer to hospital, assessment for thrombolysis, rapid stroke unit admission and hyper acute nursing care. The guidelines give a mandate to take forward and improve stroke care for all stroke patients. They highlight the need for urgent assessment for patients experiencing ‘mini strokes’ (called transient ischaemic attacks), enabling early treatment and prevention of many strokes each year. From a nursing point of view, the guidelines emphasise the importance of the nursing role in assessment and hyper acute care. The challenge is to ensure delivery of the guidelines which will require some radical service re-organisation.”

Joe Korner, Director of Communications at the Stroke Association, said:
“These guidelines show exactly what treatment and care everyone should get if they have a stroke. Too often in the past, vital stroke guidelines such as these have been put on a shelf and ignored, causing unnecessary deaths, disability and loss of independence for many thousands of people. But stroke is now a top priority in the health service across the UK and the guidelines will underpin the step change in stroke services that we all want to see. They need to be acted upon by health managers and commissioners throughout the country, as well as by health professionals. For the sake of the 150,000 people who will have a stroke next year and each year after that, The Stroke Association is determined to make sure that this happens.”

Notes to Editors


NICE guideline is available at www.nice.org.uk/CG68

The RCP guideline is available at www.rcplondon.ac.uk/pubs/brochure.aspx?e=250


About NICE


1.The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2.NICE produces guidance in three areas of health:

public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS

clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

The Stroke Association
The Stroke Association is the only UK charity solely concerned with combating stroke in people of all ages. The charity funds research into prevention, treatment, better methods of rehabilitation and helps stroke patients and their families directly through its community services, which include communications support, family and carer support, information services, welfare grants, publications and leaflets. The Stroke Association also campaigns, educates and informs to increase knowledge of stroke at all levels of society acting as a voice for everyone affected by stroke.

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