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Acute Stroke –
the Case for Improvement
May 2016
© Commonwealth of Australia 2016
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of a n
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above require the written permission of the Australian Commission on Safety and Quality in Health Care, GPO Box 5480 Sydney NSW
2001 or [email protected].
ISBN 978-1-925224-05-4
Suggested citation
Australian Commission on Safety and Quality in Health Care. Acute Stroke – the Case for Improvement.
Sydney: ACSQHC, 2016.
Acknowledgments
The Commission wishes to thank Associate Professor Dominique Cadilhac and Joosup Kim for their work in researching a nd
developing this case for improvement. Many other individuals and organisations generously gave their time and expertise, part icularly
other members of the Stroke Topic Working Group. The involvement and willingness of all concerned to share their experi ence and
expertise is greatly appreciated.
Disclaimer
The Australian Commission on Safety and Quality in Health Care has produced this Case for Improvement to support the
implementation of the corresponding Clinical Care Standard. The Case for Improvement and the Clinical Care Standard support the
delivery of appropriate care for a defined clinical condition and are based on the best evidence available at the time of dev elopment.
Healthcare professionals are advised to use clinical discretion and consideration of the circumstances of the individual patient, in
consultation with the patient and/or their carer or guardian when applying information contained within the Clinical Care Sta ndard.
Consumers should use the information in the Clinical Care Standard as a guide to inform discussions with their healthcare professional
about the applicability of the Clinical Care Standard to their individual condition.
Acute Stroke – the Case for Improvement, May 2016
1
2
| Australian Commission on Safety and Quality in Health Care
Contents
Acute Stroke Clinical Care Standard
3
Purpose
4
Acute stroke – the Case for Improvement
5
Quality statement 1 – Early assessment
7
Quality statement 2 – Time-critical therapy
8
Quality statement 3 – Stroke unit care
10
Quality statement 4 – Early rehabilitation
12
Quality statement 5 – Minimising risk of another stroke
14
Quality statement 6 – Carer training and support
16
Quality statement 7 – Transition from hospital care
17
Glossary
18
References
20
Acute Stroke – the Case for Improvement, May 2016
3
Acute Stroke Clinical Care Standard
1
A person with suspected stroke is immediately assessed at first contact using
a validated stroke screening tool, such as the F.A.S.T. (Face, Arm, Speech
and Time) test.
2
A patient with ischaemic stroke for whom reperfusion treatment is clinically
appropriate, and after brain imaging excludes haemorrhage, is offered a
reperfusion treatment in accordance with the settings and time frames
recommended in the Clinical guidelines for stroke management.1
3
A patient with stroke is offered treatment in a stroke unit as defined in the
Acute stroke services framework.2
in interpreting an ECG within 10 minutes of the first emergency
clinical contact.
4 A patient’s rehabilitation needs and goals are assessed by staff trained in
rehabilitation within 24–48 hours of admission to the stroke unit.
Rehabilitation is started as soon as possible, depending on the patient’s
clinical condition and their preferences.
4
5
A patient with stroke, while in hospital, starts treatment and education to
reduce their risk of another stroke.
6
A carer of a patient with stroke is given practical training and support to
enable them to provide care, support and assistance to a person with stroke.
7
Before a patient with stroke leaves the hospital, they are involved in the
development of an individualised care plan that describes the ongoing care
that the patient will require after they leave hospital. The plan includes
rehabilitation goals, lifestyle modifications and medicines needed to manage
risk factors, any equipment they need, follow-up appointments, and contact
details for ongoing support services available in the community. This plan is
provided to the patient before they leave hospital, and to their general
practitioner or ongoing clinical provider within 48 hours of discharge.
Acute Stroke – the Case for Improvement, May 2016
Purpose
This document supports the implementation of the Acute Stroke Clinical Care Standard by
highlighting what is known about the evidence, best practice and current practice and the
opportunities to bring these closer together.
A Clinical Care Standard is a small number of
quality statements that describe the clinical care that
a patient should be offered for a specific clinical
condition. A Clinical Care Standard supports:
 people to know what care should be offered by
their healthcare system and to make informed
treatment decisions in partnership with their
clinician
This document outlines the following for each quality
statement:
 Why is it important?

clinicians to make decisions about appropriate
care

health services to examine the performance of
their organisation and make improvements in
the care they provide.
When possible, examples are provided showing
how specific approaches or systems for
implementing best practice have demonstrated
measurable change.
While there are well-developed guidelines for
managing stroke1, not all patients are treated
consistently, suggesting that there is a gap between
knowledge and practice.


What is known about current practice?
What could be achieved with more consistent
application of the aspects of care described?
This document will be of interest to a wide audience,
including clinicians and health services, policy
makers, health system managers, researchers and
the general public, and all those with an interest in
the implementation of the Acute Stroke Clinical Care
Standard.
The causes for this variation may be as diverse as
the possible solutions – and depend on the local
and individual circumstances.
Acute Stroke – the Case for Improvement, May 2016
5
Acute stroke – the Case for Improvement
Strokes affect thousands of Australians each year and are a major cause of death and
disability.3 About 37 000 Australians were admitted to hospital with acute stroke in 2012,
equating to one stroke every 15 minutes.4 In 2009, there were an estimated 375 800
survivors of stroke, a third of whom had a disability as a result of their stroke. 3
The Acute Stroke Clinical Care Standard aims to
ensure that a person having a stroke or suspected
of having a stroke, receives optimal treatment during
the acute phase of their care. It covers recognition
of stroke, rapid assessment, early management and
early initiation of an individualised rehabilitation
plan.
Stroke is a major health burden
Stroke poses a substantial burden on patients,
carers and the healthcare system. Stroke caused
8300 deaths in 2010, which was 6% of all deaths, or
23 deaths each day.3 The past two to three decades
have seen a substantial decline in stroke mortality,
due, in part, to better risk factor control and
improvements in stroke care.3 However, with the
ageing of the population, the total number of people
affected by stroke has increased.3 In 2009, an
estimated 131 000 stroke survivors were living with
a disability caused by the stroke and an estimated
75 000 co-resident primary carers provided
assistance to people with stroke.3
In addition to primary prevention strategies,
minimising disability caused by stroke and
preventing stroke recurrence will be critical for
reducing the health burden of stroke in Australia.
Variation in treatments and outcomes
Despite national stroke guidelines1 and recent
improvements in care, not all people with suspected
stroke receive timely and appropriate care.5 Less
than half of people with suspected stroke presented
to hospital within three hours of symptom onset, in
2013.5 In 2015, about 8% of patients with ischaemic
stroke received intravenous thrombolysis, a timecritical medicine that dissolves blood clots (also
known as a reperfusion treatment).6
Receiving care in a stroke unit increases a person’s
chance of a good outcome following a stroke.7 In
6
Acute Stroke – the Case for Improvement, May 2016
2015, two-thirds of patients with stroke were treated
in a stroke unit, but only 39% spent 90% of their
hospital stay in a unit.6 According to the National
Acute Stroke Services Framework 2015, hospitals
that see more than 75 patients with stroke per year
should have a stroke unit.8 In the 2015 survey of
hospitals that admit patients with stroke, 10% of
hospitals with 75 or more admissions for stroke a
year reported that they did not have a stroke unit.6
There is social and geographical variation in both
the incidence and prevalence of stroke. In 2010,
Aboriginal and Torres Strait Islander peoples had
twice the rate of hospitalisation for stroke, and were
1.6 times more likely to die from stroke, than nonIndigenous Australians.3 People living in remote and
very remote areas had 1.4 times the rate of stroke
hospitalisation as people living in major cities.
People from the lowest socioeconomic group had
1.3 times the rate of stroke hospitalisation of people
from the highest socioeconomic group.3
Secondary prevention begins during
the admission for acute stroke
About one in ten people who have a stroke will have
a recurrence within a year.9 It is likely that some
readmissions (and associated costs) could be
prevented with more consistent application of
guideline recommendations for the secondary
prevention of stroke. Starting treatment and
education before a patient is discharged from
hospital improves the chances that patients will
adhere to treatment.10
Systems of care can improve
outcomes
Clinical pathways and clinical care networks that
cross hospital and health service boundaries have
been shown to improve outcomes for people with an
acute stroke. Regions with improved coordination of
pre-hospital and emergency care have achieved
thrombolysis rates three times that of the national
rate.11, 12
An integrated, systems-based approach supported
by health services and networks of services is
therefore central to the delivery of patient-centred
care identified in this Clinical Care Standard.
Key elements of this approach include:

across metropolitan, regional and remote
settings, including pre-hospital, within and
across hospitals, through to community and
other support services

clear lines of communication across
components of the healthcare system

appropriate coordination so that people receive
timely access to optimal care regardless of how
or where they enter the system.
an understanding of the capacity and limitations
of each component of the healthcare system
Acute Stroke – the Case for Improvement, May 2016
7
Quality statement 1 – Early assessment
A person with a suspected stroke is immediately assessed at first contact using a validated
stroke screening tool, such as the F.A.S.T. (Face, Arm, Speech and Time) test.
Why is this important?
The care provided in the first 24 to 48 hours after
the onset of stroke is crucial for improving patient
outcomes.13 Some therapies must be administered
soon after the onset of symptoms to be effective.
For example, intravenous thrombolysis, a
reperfusion treatment for ischaemic stroke, can only
be given within four-and-a-half hours of stroke
onset. Therefore, it is crucial that patients with
suspected stroke are rapidly transferred to hospital
so that they can be assessed for their eligibility to
receive this therapy.
People with poor awareness of stroke symptoms
may delay seeking medical care, which can reduce
their chances of early treatment and likelihood of
better outcomes. Educating the public about how to
recognise stroke signs and symptoms and the need
to act quickly may increase the number of people
who can access early treatment. Similarly, better
identification of stroke by ambulance services may
result in more timely delivery of stroke therapies.
What is current practice?
Presently, there is no single recommended
screening tool for stroke, but a simple screening
tool, such as the F.A.S.T. test is likely to be the most
useful. This is because the F.A.S.T. test is validated
for use by ambulance services and is also used in
community awareness campaigns.14 Other stroke
screening tools have been used to improve the
recognition of stroke by ambulance services, and
many Australian ambulance services currently use a
tool approved for their jurisdiction. For example in
Victoria, the Melbourne Ambulance Stroke Screen
(MASS), which is similar to F.A.S.T., has been used
since 2005.15
In emergency departments, a validated stroke
screening tool was used for 38% of patients
8
Acute Stroke – the Case for Improvement, May 2016
admitted to hospital with a final diagnosis of stroke,
in 2015.6
What could be achieved?
Improvements in diagnostic accuracy of stroke by
ambulance services are possible. In a study in East
Melbourne, an educational intervention on stroke
diagnosis was provided to paramedics. This
included information on how to use a stroke
screening tool (the MASS). Paramedics who
received the intervention improved their diagnostic
accuracy from 78% (pre-intervention) to 94% (postintervention), while control paramedics’ diagnostic
accuracy remained similar (pre 78%, post 80%).16
In a similar study in Newcastle, NSW, ambulance
services were trained on how to use a stroke
screening tool. In addition, a pre-notification system
was established so that ambulance services could
immediately inform neurologists if an incoming
patient had met the criteria for suspected stroke. As
a result of this intervention:

time from symptom onset to hospital arrival and
admission decreased

more patients with ischaemic stroke were
treated with intravenous thrombolysis: 4.7%
(pre-intervention) to 21.4% (post-intervention).11
While there are limited Australian data, evidence
suggests that early arrival to hospital following
stroke is associated with better patient outcomes at
discharge.17, 18 There is also evidence that patients
may benefit with early admission to stroke units
even when they do not receive intravenous
thrombolysis.19 In the United Kingdom, patients
admitted to a stroke unit within four hours of arrival
spent a greater proportion of inpatient time in a
stroke unit, and had significantly shorter lengths of
stay.20
Quality statement 2 – Time-critical therapy
A patient with ischaemic stroke for whom reperfusion treatment is clinically appropriate, and
after brain imaging excludes haemorrhage, is offered a reperfusion treatment in accordance
with the settings and time frames recommended in the Clinical guidelines for stroke
management.1
Why is this important?
Approximately 80% of strokes are caused by a
blood clot that blocks a blood vessel in the brain
(ischaemic stroke).21 Some patients with ischaemic
stroke can be treated with a medicine that dissolves
the blood clot (intravenous thrombolysis with
alteplase [rt-PA]). Intravenous thrombolysis is a type
of reperfusion treatment as it helps to restore blood
flow to an area of the brain deprived of blood flow
for a period of time. The major limitations of
intravenous thrombolysis are that it:

is effective only if administered within a short
time window after a stroke

may cause bleeding in the brain, a risk that is
minimised by careful screening of a patient’s
suitability for the medicine.
The earlier intravenous thrombolysis is given, the
greater the chance of a favourable outcome.22, 23
Compared with patients with ischaemic stroke who
do not receive alteplase, those treated:

within three hours of stroke onset have 75%
greater odds of disability-free survival (odds
ratio [OR] 1.75, 95% confidence interval [CI]
1.35-2.27)

between three and four-and-a-half hours of
stroke onset have 26% greater odds of
disability-free survival (OR 1.26, 95% CI 1.051.51).22
Despite an absolute increase of about 2% in the risk
of early death by intracranial haemorrhage from
alteplase, treatment within three hours of stroke
onset results in 10% more patients being disabilityfree at 3-6 months.22 Alteplase within three and fourand-a-half hours of stroke onset results in 5% more
patients being disability-free.22 Simulation modelling
has shown that for each minute of onset-totreatment time saved, an average of 1.8 extra days
of healthy life (95% prediction interval, 0.9-2.7) can
be gained.24
What is current practice?
It is recommended that intravenous thrombolysis is
administered as early as possible, but may be
administered up to four-and-a-half hours after the
onset of stroke.1 Not all hospitals have the required
personnel, infrastructure and processes necessary
to administer this medicine. In the 2015 National
Stroke Audit, 76% of Australian hospitals surveyed
offered this medicine for stroke care.6
Currently, approximately 8% of all patients with
ischaemic stroke receive intravenous thrombolysis
in Australia.6 In the 2015 National Stroke Audit:

66% of patients with stroke were transported by
ambulance to a hospital able to provide
thrombolysis

24% of patients with ischaemic stroke who
arrived within four-and-a-half hours of stroke
onset received thrombolysis

26% of patients who received thrombolysis did
so within 60 minutes of hospital arrival.6
What could be achieved?
Patients with ischaemic stroke who receive
intravenous thrombolysis can have considerably
better outcomes than those who do not receive the
medicine. Streamlining the acute treatment of stroke
with screening tools and hospital pre-notification can
increase access to intravenous thrombolysis –
reducing mortality and morbidity from stroke.11, 25 A
new model of pre-notification, patient assessment
and delivery of intravenous thrombolysis has been
shown to reduce the time between arrival at hospital
and administration of intravenous thrombolysis.25
Acute Stroke – the Case for Improvement, May 2016
9
Some hospitals in Australia have achieved
thrombolysis rates of up to 21%.11
Intravenous thrombolysis can be provided at a
relatively low additional cost over standard care to
achieve the extra health benefits. In the first year
after stroke, intravenous thrombolysis provided
within four-and-a-half hours costs AUD $3639 more
a
10
per life year saved and AUD$2262 more per quality
adjusted life year gained, than standard care.a,27
This is far below the commonly used threshold for
societal willingness to pay for additional health
benefits, of about $50 000 per quality adjusted life
year gained.28, 29
Costs have been adjusted to 2014 equivalents of those originally published, using the health price index, published by the Australian
Institute of Health and Welfare. The original costs were from the North East Melbourne Stroke Incidence Study (NEMESIS) 26 in
1997.
Acute Stroke – the Case for Improvement, May 2016
Quality statement 3 – Stroke unit care
A patient with stroke is offered treatment in a stroke unit as defined in the Acute stroke
services framework.2
Why is this important?
The term ‘stroke unit’ refers to a dedicated area
within a hospital that ensures specialist,
multidisciplinary management of people who have
experienced a stroke. Patients in a stroke unit are
cared for by health professionals specially trained in
treating patients with stroke. Stroke units have
evidence-based procedures for assessment, early
management and ongoing rehabilitation of
patients.30 There is consistent evidence that patients
with stroke treated in stroke units have better
outcomes than patients with stroke not treated in
stroke units.31
All adults with stroke benefit from stroke-unit care,
regardless of age or whether the stroke is ischaemic
or haemorrhagic.32
What is current practice?
It is recommended that patients with stroke be
treated in a stroke unit.1 While many patients with
stroke currently receive stroke unit care, there is still
underuse, even when a hospital has this facility.
Approximately 67% of patients in Australia with a
stroke are treated in a stroke unit.6 Only 39% of
patients with acute stroke spend most of their
admission in a stroke unit.6
Even in hospitals with stroke units, patients are not
always admitted directly to a stroke unit. There is
some evidence that a lack of capacity is not the
reason. The 2015 National Stroke Audit of acute
services found that 32% of patients with stroke, in
hospitals with a stroke unit, were admitted to other
wards despite the availability of stroke unit beds.6
Compared to patients with ischaemic stroke,
patients with haemorrhagic stroke are less often
admitted to stroke units (34% versus 26%,
respectively) and are more likely to be admitted to
b
intensive care or high dependency units.33 However,
as a consequence, it appears that patients with
haemorrhagic stroke often have less access to allied
health care and other important aspects of care.33
What could be achieved?
Compared with an alternative acute management
ward, care provided in a stroke unit provides a:

13% reduced odds of death (OR=0.87, 95% CI
0.69 to 0.94)

22% reduced odds of death or institutionalised
care (OR 0.78, 95% CI 0.68 to 0.89)

21% reduced odds of death or dependency (OR
0.79, 95% CI 0.68 to 0.90).7
There is evidence that stroke units are cost effective
when compared to conventional care, where a costeffective intervention is defined as one that provides
a quality-adjusted life-year gain at a cost of $50 000
or less.28, 29 Compared with general ward care, care
provided in a stroke unit costs about $2128 moreb
per disability-adjusted life-year recovered (DALY).34
In other words, every year of life free of disability
gained by a patient managed in a stroke unit instead
of a general medical ward, costs an additional
$2128.
Where health systems have been redesigned to
increase access to stroke units in Australia, similar
benefits have been reported to those found in
controlled clinical trials. Compared with a time
period before a system redesign in metropolitan
New South Wales, patients who had a stroke after
the redesign were more often admitted directly to a
stroke unit (71% versus 13%) and more often
received care in a stroke unit (81% versus 16%).35
These patients also had 27% reduced odds (OR
0.73; 95% 0.57 to 0.94) of having a disabling
outcome at discharge from hospital.
Cost has been adjusted to 2014 equivalent of that originally published, using the health price index published by the
AustralianInstitute of Health and Welfare. The original cost was from 1997.
Acute Stroke – the Case for Improvement, May 2016
11
The redesign also resulted in more patients
receiving evidence-based clinical care such as
medicines to prevent recurrent strokes, diagnostic
imaging, and assessment and rehabilitation with
allied health professionals.35 Similar benefits have
also been found in rural locations, with a
contributing factor being the employment of
dedicated clinical stroke care coordinators to
establish clinical pathways and the stroke unit
infrastructure.36
Further improvements in care provided in stroke
units are attainable. In the Quality in acute stroke
care study, a new nurse-led protocol for the
management of fever, hyperglycaemia and
swallowing dysfunction on stroke units reduced the
risk of death or dependency at 90 days after
admission.37
12
Acute Stroke – the Case for Improvement, May 2016
Quality statement 4 – Early rehabilitation
A patient’s rehabilitation needs and goals are assessed by staff trained in rehabilitation
within 24-48 hours of admission to the stroke unit. Rehabilitation is started as soon as
possible, depending on the patient’s clinical condition and their preferences.
Why is this important?
After a stroke, many patients have impairments in
their mobility, vision, swallowing ability,
communication, and their ability to think and feel.
Stroke rehabilitation therapies improve recovery
from these impairments, and help patients regain
their ability to perform usual activities of daily living
and participate in everyday life.38 Typically,
rehabilitation is provided by a multidisciplinary team
that includes doctors, physiotherapists, nurses,
speech therapists and occupational therapists.39
Other health professionals involved in stroke care
may include dietitians, psychologists, pharmacists
and therapy assistants.
What is current practice?
It is recommended that patients with stroke are
mobilised early (e.g. out-of-bed activities, such as
sitting, standing and walking) and that therapy for
dysphagia is offered as early as tolerated.1 Despite
these recommendations, there is evidence from
observational studies across Australia that patients
have limited contact with therapists (e.g.
physiotherapists, speech therapists, occupational
therapists) in the first 14 days after stroke.40, 41
According to the 2013 national clinical audit of 124
hospitals, approximately:

65% of patients were assessed by a speech
pathologist within 48 hours

56% had their swallow function checked within
24 hours

83% were assessed by an occupational
therapist.5
The majority of hospitals provide physiotherapist
services (97%) and 92% of patients with stroke are
assessed by a physiotherapist.5, 42 While the 2015
audit found that only 68% of patients with stroke
were assessed by a physiotherapist within 48 hours
of admission, 82% began some form of
rehabilitation therapy within 48 hours of the initial
assessment.6
Early assessment and initiation of mobilisation
activities following stroke is important to help
minimise the risk of complications.1 However, the
optimal frequency and intensity of mobilisation
activities is yet to be established.43 In a large,
randomised, controlled trial, very early and intensive
mobilisation resulted in worse outcomes at three
months after stroke than usual care, which
consisted of early but less intensive mobilisation.44
Both groups mobilised within a few days, with 98%
and 93% of patients in the very early and usual care
groups, respectively, starting out-of-bed activities
within 48 hours. Rates of serious complications
related to immobility were low for both groups (less
than 6% in each group). The findings support
mobilisation within a few days of stroke, but more
research is required to determine optimal ‘dosing’
(type of activity, frequency and intensity) for out-ofbed activity.
What could be achieved?
Assessment and treatment with physiotherapists,
speech therapists and occupational therapists are
considered clinical best practice, and the National
Stroke Audit suggests there is scope to improve the
initiation of these. From a practical perspective, the
earlier the assessment occurs, the more likely it is
that rehabilitation therapy can begin within the
hospital stay, when appropriate for the individual
patient. In Australia, models of stroke unit care vary
and there is some evidence that stroke units with a
rehabilitation focus provide more physiotherapy and
occupational therapy per day (60 minutes versus
Acute Stroke – the Case for Improvement, May 2016
13
five minutes, p<0.001) and have more patients
returning directly home, than acute stroke units
without a focus on rehabilitation.45
Speech therapy provided during the hospital stay
has been shown to reduce the severity of
14
Acute Stroke – the Case for Improvement, May 2016
communication problems in patients with speech
impairments following stroke.46 However there are
few studies that have quantified the benefit of these
services for patients with stroke when these
services are provided within 24-48 hours.
Quality statement 5 – Minimising risk of another stroke
A patient with stroke, while in hospital, starts treatment and education to reduce their risk of
another stroke.
Why is this important?
What is current practice?
The risk of stroke recurrence is approximately 11%
after one year, 26% after five years and 40% ten
years after the first stroke.9 People who have had a
stroke can reduce this risk by taking appropriate
preventive medicines and by making lifestyle
changes.1 There is evidence that starting therapies in
hospital:
Only 56% of patients receive education on risk factor
modification while in hospital.6

is associated with better risk factor management
in the short term after stroke47

promotes long-term adherence to medicines10 and
better long-term outcomes.33, 34
Educating patients about the medicines and lifestyle
changes that reduce their risk of stroke recurrence is
likely to improve their adherence to recommended
therapies.48
Assessment of patients is necessary to determine
their individual risk factors. The medicines
recommended for the prevention of recurrent stroke
depend on the type of stroke and whether the patient
has atrial fibrillation (a condition causing an irregular
heartbeat).1 Medicines recommended after an
ischaemic stroke include those which:

lower blood pressure (even if blood pressure is
not elevated)

prevent harmful blood clots (for example, aspirin,
warfarin or newer oral anticoagulants)

lower cholesterol.
Generally, patients with haemorrhagic stroke are
recommended blood-pressure lowering
(antihypertensive) medicines only.
In addition, all patients should be supported to make
lifestyle changes that reduce the risk of recurrent
stroke, including smoking cessation, reducing alcohol
consumption, increasing physical activity levels,
reducing weight if they are overweight and improving
diet.1
When discharged from hospital, 66% of eligible
patients with haemorrhagic stroke are prescribed
antihypertensive medicines, while 64% of eligible
patients with ischaemic stroke are prescribed
combined therapy with a cholesterol-lowering
medicine, an antithrombotic medicine (either an
anticoagulant or antiplatelet medicine to prevent
blood clots, as appropriate) and an antihypertensive
medicine.6
What could be achieved?
Antihypertensive medicines reduce the odds of
another stroke by 29% (OR 0.71, 95% CI 0.59 to
0.86) and cardiovascular events by approximately
31% (OR 0.69, 95% CI 0.57 to 0.85) in patients with
stroke or transient ischaemic attack (TIA) compared
with placebo.49 Cholesterol-lowering medicines
reduce the odds of another cerebrovascular event by
22% (OR 0.78, 95% CI 0.67 to 0.92)50, and
antiplatelet medicines reduce the relative risk of
vascular events by about 13% (95% CI 6% to 19%) in
patients with ischaemic stroke, compared with
placebo.51 In patients with non-valvular atrial
fibrillation and ischaemic stroke, warfarin reduces the
relative risk of a major disabling or fatal stroke by
62% (hazard ratio [HR] 0.38, 95% CI 0.18-0.81),
compared with placebo.52 Newer oral anticoagulants
may have further benefits in this regard. 53
The cumulative risk reduction from using a
combination of these medicines may be substantial.
There is limited direct evidence of the benefits of
combination therapy in patients with stroke, but for
patients with cardiovascular disease it has been
estimated that a 75% relative-risk reduction in stroke,
heart attack and death could be achieved with
lifestyle modification and a combination of secondary
prevention medicines.54, 55
Acute Stroke – the Case for Improvement, May 2016
15
Education has also been shown to be effective for
improving clinical outcomes in patients with heart
disease, and so may be similarly effective for patients
who have suffered stroke.56 In patients with heart
disease, secondary prevention programs that
16
Acute Stroke – the Case for Improvement, May 2016
included risk factor education and counselling,
reduced the relative risk of all-cause mortality by 15%
(relative risk 0.85, 95% CI 0.77 to 0.94), improved risk
factor profiles, and improved the use of preventive
medicines.56
Quality statement 6 – Carer training and support
A carer of a patient with stroke is given practical training and support to enable them to
provide care, support and assistance to a person with stroke.
Why is this important?
What could be achieved?
Many patients with stroke have carers who assist
them with activities of daily living. In Australia, 74%
of stroke survivors at three months required
assistance with activities of daily living and received
care from a family member or friend.26 There is a
burden associated with being a caregiver of a
person who has had a stroke.57 Stroke survivor
characteristics found to be associated with an
increased burden on caregivers include older age,
male gender, poor mental health and level of
functional disability.58 A lack of support is also
associated with an increased burden on
caregivers.59, 60
There is evidence that providing training to
caregivers helps. In a UK study, caregivers who
were provided training had better quality of life and
less often had anxiety or depression compared with
caregivers who were not trained. Stroke survivors
cared for by trained caregivers were also less often
anxious or depressed.61 Total health and social cost
savings from caregiver training was estimated to be
GBP4043 at one year after stroke.62
What is current practice?
Guidelines recommend that the caregiver of a
person with stroke be provided with practical training
on how to provide care, support and assistance for
the patient, before they leave hospital.1 In Australian
hospitals in 2015, 59% of carers received a support
needs assessment and 48% received training.6
Further research on interventions to reduce
caregiver burden is needed, particularly in the
Australian context. There is some recent evidence
that caregiver training does not improve quality of
life and mood impacts of caregivers, and is not costeffective compared with standard care.63
Investigators should consider the timing of training
and individualising training when designing new
interventions to support and reduce the impacts of
caregivers of stroke survivors.
Acute Stroke – the Case for Improvement, May 2016
17
Quality statement 7 – Transition from hospital care
Before a patient with stroke leaves the hospital, they are involved in the development of an
individualised care plan that describes the ongoing care that the patient will require after they
leave hospital. The plan includes rehabilitation goals, lifestyle modifications and medicines
needed to manage risk factors, any equipment they need, follow-up appointments, and
contact details for ongoing support services available in the community. This plan is provided
to the patient before they leave hospital, and to their general practitioner or ongoing clinical
provider within 48 hours of discharge
Why is this important?
What could be achieved?
There is evidence that many patients could be
provided better care once they are discharged from
hospital. Many patients with stroke are not
prescribed medicines that may help to prevent
another stroke and often they have poorly controlled
risk factors.64 In addition, many patients report
having unmet needs.65
Individualised discharge planning reduces the length
of stay by about 9% and the relative risk of
readmission by 18%, compared with routine
discharge care not tailored to the individual
patient.66
An individualised care plan, which is developed with
the patient while in hospital, may improve continuity
of care once the patient returns to the community.
This is different to a discharge letter used to notify a
patient’s general practitioner of the stroke event and
hospitalisation. It is recommended that patients
discuss their individualised care plan with their
general practitioner once they are discharged from
hospital.
General practitioners and patients are encouraged
to review these plans periodically. The plan typically
includes information on risk factors, equipment
required, and contact details of community support
services.
What is current practice?
Guidelines recommend that an individualised care
plan be developed in conjunction with the patient
and their family or carer.1 A copy of this is then sent
to the patient’s general practitioner. According to the
2015 National Stroke Audit of acute services,
approximately 56% of patients with stroke received
an individualised care plan.6
C
There is, however, related evidence for patients with
heart disease that secondary prevention programs
and interventions, including individualised care
plans, can increase the use of preventive medicines
and reduce risks of recurrent heart attacks,
hospitalisations and mortality rates.56, 69 As patients
with stroke have similar risk factors and treatment
goals as patients with heart attack, the use of
individualised care plans are likely to have similar
benefits.
Costs have been adjusted to 2014 equivalents of those originally published, using the health price index, published by the Australian
Institute of Health and Welfare. The original costs were from 2004
18
Organisational interventions to improve secondary
prevention of stroke, including individualised care
plans, have been tested in only a few clinical trials,
which have involved relatively small numbers of
patients with stroke.67 These studies have used
varied approaches and have demonstrated benefits
for lowering blood pressure and promoting lifestyle
change, but not for reducing the risk of
cardiovascular disease. However, there is evidence
from economic modelling that individualised care for
the management of blood pressure and lifestyle risk
factors in patients with stroke is cost effective, with
the median cost per quality adjusted life year gained
between $2258 and $5865.c, 68
Acute Stroke – the Case for Improvement, May 2016
Glossary
Antihypertensive: A medicine that reduces blood
pressure.70
Atrial fibrillation: A condition where the heart beats
irregularly. The heartbeat is outside its usual rhythm
and is often faster than normal.70
Care plan (individualised): A written agreement
between a consumer and health professional (or
social services) to help manage day-to-day health.71
This information is identified in a health record.
Carer: A person who provides unpaid care and
support to a family member or friend who has a
disease, disability, mental illness, chronic condition,
terminal illness or general frailty. A carer includes a
parent or guardian caring for a child.72
Clinician: A healthcare provider, trained as a health
professional. Clinicians include registered and nonregistered practitioners, or a team of health
professionals providing health care who spend the
majority of their time providing direct clinical care.72
Face, Arm, Speech and Time (F.A.S.T.) test: A
test used to screen for the diagnosis of stroke or
transient ischaemic attack.73
First contact: The time when the person with stroke
symptoms first encounters someone who can help.
This can be a member of the community, a clinician,
or a carer.
Haemorrhagic stroke: A type of stroke caused by
bleeding from a ruptured artery (or other blood
vessel) in the brain or its surrounding.3
Health record: Information about a patient held on
paper or electronically. The health record may be
made up of clinical records (such as medical history,
treatment notes, observations, correspondence,
investigations, test results, photographs,
prescription records, medication charts),
administrative records (such as contact and
demographic information, legal and occupational
health and safety records) and financial records
(such as invoices, payments and insurance
information).72
Health service: A service responsible for the
clinical governance, administration and financial
management of units providing health care. A
service unit involves a grouping of clinicians and
others working in a systematic way to deliver health
care to patients, and can be in any location or
setting, including pharmacies, clinics, outpatient
facilities, hospitals, patients’ homes, community
settings, practices and clinicians’ rooms .72
Hospital: A licensed facility providing healthcare
services to people for short periods of acute illness,
injury or recovery.74
Individualised care plan: See care plan.
Ischaemic stroke: A type of stroke due to a
reduced or blocked supply of blood in the brain,
typically due to a clot.3
Medicine: A chemical substance given with the
intention of preventing, diagnosing, curing,
controlling or alleviating disease, or otherwise
improving the physical or mental welfare of people.
Prescription, non-prescription and complementary
medicines, irrespective of their administration route,
are included.75
Multidisciplinary team: The team of multiple
professionals looking after a patient, made up of
doctors, nurses, therapists, social workers,
psychologists and other health personnel.1
Rehabilitation: Restoration to optimal physical and
psychological functional independence of a person
with a disability.1
Reperfusion treatments: Treatments that restore
blood flow (and therefore oxygen supply) to an area
of the brain that has been deprived of blood flow for
a period of time. An example is intravenous
thrombolysis (a blood clot-dissolving medicine given
into a vein).
Risk factor: Any variable (e.g. smoking, obesity)
that is associated with a greater risk of a health
disorder, or other unwanted condition or event.1
Acute Stroke – the Case for Improvement, May 2016
19
Stroke: Sudden and unexpected damage to brain
cells that causes symptoms that last for more than
24 hours in the parts of the body controlled by those
cells. Stroke happens when the blood supply to a
part of the brain is suddenly disrupted, either by
blockage of an artery (ischaemic) or by bleeding
within the brain (haemorrhagic).1
Stroke unit: Co-located beds within a
geographically defined unit that is staffed by a
dedicated, multidisciplinary team who specialise in
stroke management, meet once a week to discuss a
patient’s care, and receive regular programs of staff
education and training related to stroke.8
20
Acute Stroke – the Case for Improvement, May 2016
Transient ischaemic attack: Stroke-like symptoms
that last less than 24 hours. While TIA is not actually
a stroke, it has the same cause. A TIA may be the
precursor to a stroke, and people who have had a
TIA require urgent assessment and intervention to
prevent a stroke.1
Thrombolysis: Emergency blood clot-dissolving (or
‘clot-busting’) medicine for a heart attack or stroke,
used to restore blood flow (reperfusion).
Validated screening tool: A tool that has been
shown to accurately and rapidly help identify people
with a certain medical condition. Examples of
validated stroke screening tools include the Face,
Arm, Speech, Time (F.A.S.T.) test, the Melbourne
Ambulance Stroke Screen (MASS) and the
Recognition of Stroke in the Emergency Department
(ROSIER) tool.
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23
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