Specifying a service for the diagnosis and initial management of acute stroke

Service components

The key components of an acute stroke service are:

• rapid referral, assessment and investigation of acute stroke
• rapid treatment and direct admission to an acute stroke unit
• developing a high-quality acute stroke service.

Rapid referral, assessment and investigation of acute stroke

The prompt recognition of symptoms of stroke and transient ischaemic attack are described in NICE clinical guideline CG68 on stroke. The National Stroke Strategy recommends that all front-line staff should be competent in identifying people with suspected stroke. It also recommends that commissioners ensure that care pathways and protocols are in place so that all people with suspected acute stroke are transferred immediately by ambulance to a hospital with access to a 24-hour, 7-day a week (24/7) acute stroke service that can provide a stroke triage system, expert clinical assessment, timely imaging and intravenous thrombolysis.

Immediate access to brain imaging is critical because treatments such as aspirin or thrombolysis (clot-busting drugs) are dangerous for patients with haemorrhagic stroke. The 2008 national sentinel stroke audit found that some hospitals had difficulty providing rapid (within 24 hours of admission) access to brain imaging and CT (computed tomography) scanning, particularly during evenings and weekends. NICE clinical guideline CG68 on stroke makes recommendations for the management of acute stroke that may necessitate brain and/or carotid imaging and CT scanning, and the timescales within which this should be done. Commissioners should review the availability of brain scanning and imaging slots to ensure prompt access to services with skilled radiological staff and clinicians able to interpret the results on a 24/7 basis.

Rapid treatment and direct admission to an acute stroke unit

Urgent treatment and direct access to an acute stroke unit have been shown to improve stroke outcomes. NICE clinical guideline CG68 on stroke recommends that all people with suspected stroke should be admitted directly to a specialist stroke unit following initial assessment, either from the community or from the accident and emergency department. Commissioners should ensure that the acute stroke unit is a discrete area in the hospital that is staffed by specialist stroke multidisciplinary teams. The teams should have access to equipment for monitoring and rehabilitating patients and hold regular multidisciplinary team meetings for goal setting.

NICE clinical guideline CG68 on stroke recommends a number of pharmacological treatments to be used in the treatment of acute stroke. In particular, commissioners should be aware of the recommendations that relate to thrombolysis and the administration of alteplase. NICE clinical guideline CG68 on stroke and NICE technology appraisal TA122 Alteplase for the treatment of acute ischaemic stroke recommend alteplase for the treatment of acute ischaemic stroke, when used by physicians trained and experienced in the management of acute stroke. It should only be administered in centres with facilities that enable it to be used in full accordance with its marketing authorisation.

Developing a high-quality acute stroke service

NICE clinical guideline CG68 on stroke recommends that alteplase should be administered only within a well organised stroke service with:

• staff trained in delivering thrombolysis and in monitoring for any complications associated with thrombolysis
• level 1 and level 2 nursing care staff trained in acute stroke and thrombolysis
• immediate access to imaging and re-imaging, and staff trained to interpret the images.

Staff in accident and emergency departments, if appropriately trained and supported, can administer alteplase for the treatment of acute ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neurological and stroke physician support.

Commissioners should use payment by results tariffs to support thrombolysis provision and may also wish to refer to NICE Thrombolysis for stroke (alteplase) - national tariff uplift for 2008/09, as additional costs may be incurred in the administration of alteplase.

The National Stroke Strategy states that stroke survival is strongly associated with processes of care that are carried out more frequently in stroke units, such as early mobilisation, early feeding and measures to prevent aspiration. The Intercollegiate Stroke Working Party guidelines on good acute stroke care recommend that acute stroke units need a multidisciplinary team with the skills and equipment to provide:

• appropriate care and monitoring (for example, of neurological function, blood pressure, cardiac rhythm, respiratory function, oxygen saturation and blood glucose)
• access to physiotherapy
• access to speech and language therapy (including swallowing)
• access to a dietetic service (including nutrition screening)
• critical care for stroke patients who require enhanced monitoring or who develop complications
• prompt access to support from specialist critical care colleagues
• good communication with patients, their families and the patient's GP.

The National Stroke Strategy recommends the establishment of stroke care networks covering populations of 0.5 to 2 million to review and organise delivery of stroke services across the care pathway. Stroke care networks consist of a range of organisations involved with stroke care, including PCTs, local authorities, voluntary sector organisations, primary care providers and NHS acute trusts. Commissioners may wish to engage with their local stroke care network when considering service redesign. Collaborative commissioning arrangements and discussions across a network of stroke providers and ambulance trusts may be necessary to ensure that acute stroke care, including thrombolysis, is available 24/7.

NICE clinical guideline CG68 on stroke makes recommendations for surgical intervention in a small number of carefully selected people with stroke. The National Stroke Strategy states that commissioners should ensure that services are available to investigate and treat unusual causes of stroke; commissioners should work collaboratively with other PCTs, and across a stroke network, so that each stroke unit is linked to a regional neuroscience centre. Strategic health authorities should make specialised commissioning arrangements to support the coordination of specialist neurological care, including interventional neuroradiology and neurosurgery. Commissioning arrangements should include an estimation of the number of patients likely to be referred.

Commissioners may wish to consider delivering an acute stroke service in a variety of ways, and mixed models of provision may be appropriate. Examples include:

• A hub and spoke service model with a 24/7 hyperacute stroke unit (hub) staffed by an acute stroke team with 24/7 radiology access, including advanced imaging. People who have had a stroke would be treated in the hyperacute unit and could then be transferred to a spoke unit within 48 hours. Some spoke units may provide specialist services but not on a 24/7 basis.
• A model in which assessment and imaging are carried out in local hospitals that have appropriate teleradiology and telemedicine support. This type of model may be particularly suitable in rural areas. Selected patients would be transferred to a hyperacute stroke unit.

Local stakeholders, including service users and their carers, should be involved in determining what is needed from an acute stroke service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with stroke.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service, including training in the recognition of stroke symptoms and use of validated tools for front-line staff
• the expected number of patients needing direct admission to an acute stroke unit (taking into account how quickly any changes in service provision are likely to take place)
• ease of access and service location; ensuring there is rapid transport by ambulance to a receiving hospital with 24/7 access to a stroke specialist, urgent brain scanning and expertise in interpretation, and direct admission to an acute stroke service
• care and referral pathways
• information and audit requirements, including IT support and infrastructure
• service monitoring criteria.

Useful sources of information may include:

• The NHS networks: learning from practice database contains examples of innovative commissioning across the NHS and its partners.
• The Map of medicine provides an information resource that visually organises care pathways.
• The NICE shared learning database contains examples of how organisations have implemented NICE guidance locally.
• Mending hearts and brains.
• Implementing the National Stroke Strategy - an imaging guide sets out best practice and provides guidance on how imaging services may develop to provide gold standard TIA and stroke care.
• Workforce planning resource supports stroke-related workforce planning alongside the National Stroke Strategy.
• Heart Improvement - rapid access models.
• NICE costing report on stroke: diagnosis and initial management of acute stroke and transient ischaemic attack.
• Providers guidance for stroke services - ASSET(1) is an evaluation toolkit created to help health care organisations improve and transform stroke services for patients.
• Commissioning guidance for stroke services - ASSET (2) provides advice to commissioners on good practice in improving stroke services and highlights key issues to consider.