More stroke patients should be considered for thrombolysis

The recommendation is one of several updates to the guideline, which acts as a blueprint for stroke care across England and Wales, aiming to improve the quality of care for stroke patients. It includes over 100 sources of evidence of major developments in stroke research during the past 4 years, and continues to include the NICE quality standards and guidelines for stroke care.

Professor Tony Rudd, chair of the Intercollegiate Stroke Working Party, describes the key updates in the latest guidance:

This stroke guideline is the most comprehensive ever produced and acts as a template for the commissioning, organisation and delivery of stroke care at a time of major upheaval in the health service. It reinforces the message that care needs to be integrated all across the stroke care pathway, no matter who is providing the care. The guideline, produced by the Intercollegiate Stroke Working Party at the Royal College of Physicians (RCP) is being launched today at a joint one-day conference of the RCP and the British Association of Stroke Physicians’ (BASP) – ‘Squeezing the best out of stroke care’.

Stroke remains the third-biggest killer in the UK and one of the most important causes of significant adult disability with over 100,000 strokes each year.

Major recommendations, and changes to the previous guideline include:

• Commissioning stroke services across the whole stroke pathway, from acute to long-term care. Rehabilitation therapies should be commissioned alongside these services and available for the whole pathway. All acute patients should be considered for thrombolysis regardless of age or stroke severity.
• Patients with stroke should be offered 45 minutes of appropriate therapies for a minimum of five days a week in the early stages after stroke. This is to enable the patient to meet their rehabilitation goals and should continue for as long as the therapy is of benefit and the patient can tolerate it.
• Prescribing the anti-platelet drug clopidogrel as the first-line treatment after both stroke and transient ischaemic attack (TIA) because it is better tolerated and more cost-effective, and to ensure a unified approach to managing both conditions. This contradicts the most recent NICE guidance, which recommends aspirin for TIA because clopidogrel is currently licensed only for the treatment of stroke and not TIA.
• All patients should have a brain scan within a maximum of 12 hours. This is a reduction from the previous 24 hours to ensure all patients admitted out of hours are scanned the following day.
• Carotid endarterectomy for asymptomatic carotid stenosis should not be routinely undertaken, other than in exceptional circumstances or as part of a randomised controlled trial.

The guideline follows the patient experience from admission to discharge and aims to provide a reference for what will happen (in terms of processes) if they are admitted to hospital following stroke or TIA. It extends beyond the hospital setting with guidance for the patient about resuming life after the stroke; such as how to prevent a further stroke, and what to expect from rehabilitation therapies.

The guideline includes updated sections for rehabilitation, longer-term care after a stroke, and secondary prevention, as well as profession-specific concise guides for nurses, dietitians and therapy professions.

Professor Tony Rudd, chair of the Intercollegiate Stroke Working Party, said:

Stroke is a complex disease that requires the skills of multiple professionals to ensure the best-quality outcome and the best use of resources. This guideline summarises a wealth of evidence and provides expert consensus statements on areas where the evidence is lacking. No professional should ever use the excuse that they don’t know what the evidence is for treating stroke patients. The patient version of the guideline ensures that patients know what care they should be receiving.

Professor Peter Langhorne, president of the British Association of Stroke Physicians, said:

In the UK, stroke physicians and their multidisciplinary team colleagues are very fortunate to have ready access to such a comprehensive, rigorous and up-to-date source of guidance that covers all their respective areas of interest. Please use it.

Professor Ross Naylor, president of the Vascular Society, said:

The 2012 National Stroke Guidelines highlight the importance of delivering expedited, high-quality medical and surgical care to patients suffering a TIA or stroke. It is essential that hospitals, commissioners and clinicians reconfigure services to ensure that patients throughout England and Wales are offered the best chance of minimising long-term disability.

Rosemary Cunningham, representative of the Royal College of Speech and Language Therapists said:

The stroke guideline is a multidisciplinary tool that provides an excellent template for raising standards of stroke care by health and social care professionals.

Dr Audrey Bowen, representative of the British Psychological Society, said:

The psychological impact of stroke is rightly emphasised in these guidelines. There is a clear message that promoting wellbeing is not just for psychologists and the newly recommended stepped approach encourages developing levels of skill within multidisciplinary team members.

For further information, please contact Hannah Bristow, Clinical Standards communications officer, on +44 (0)20 3075 1447 / 07584 303 784 or email Hannah.Bristow@rcplondon.ac.uk