Download Acute Stroke - the Case for Improvement

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 an acknowledgment of the source. Requests and inquiries concerning reproduction and rights for
purposes other than those indicated 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 and developing this case for improvement. Many other individuals and organisations generously
gave their time and expertise, particularly other members of the Stroke Topic Working Group. The involvement
and willingness of all concerned to share their experience 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 development. 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 Standard. 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.
Contents
Acute Stroke Clinical Care Standard
2
Purpose3
Acute stroke – the Case for Improvement4
Quality statement 1 – Early assessment
6
Quality statement 2 – Time-critical therapy
7
Quality statement 3 – Stroke unit care9
Quality statement 4 – Early rehabilitation11
Quality statement 5 – Minimising risk of another stroke13
Quality statement 6 – Carer training and support15
Quality statement 7 – Transition from hospital care16
Glossary17
References
19
Acute Stroke - the Case for Improvement, May 2016
1
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.
2A 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
4A 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.
5A patient with stroke, while in hospital, starts treatment and
education to reduce their risk of another stroke.
6A 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.
7Before 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.
2
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
• clinicians to make decisions about appropriate
care
• health services to examine the performance of
their organisation and make improvements in the
care they provide.
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.
This document outlines the following for each
quality statement:
• Why is it important?
• What is known about current practice?
• What could be achieved with more consistent
application of the aspects of care described?
When possible, examples are provided showing
how specific approaches or systems for
implementing best practice have demonstrated
measurable change.
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
3
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.
4
Acute Stroke - the Case for Improvement, May 2016
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
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:
• an understanding of the capacity and limitations
of each component of the healthcare system
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.
Acute Stroke - the Case for Improvement, May 2016
5
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?
What could be achieved?
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.
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
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
admitted to hospital with a final diagnosis of stroke,
in 2015.6
6
Acute Stroke - the Case for Improvement, May 2016
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 Australia 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
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
four-and-a-half hours of stroke onset results in 5%
more patients being disability-free.22 Simulation
modelling has shown that for each minute of onsetto-treatment 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?
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:
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
• 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)
Currently, approximately 8% of all patients with
ischaemic stroke receive intravenous thrombolysis
in Australia.6 In the 2015 National Stroke Audit:
• between three and four-and-a-half hours of
stroke onset have 26% greater odds of disabilityfree survival (OR 1.26, 95% CI 1.05-1.51).22
• 66% of patients with stroke were transported
by ambulance to a hospital able to provide
thrombolysis
• may cause bleeding in the brain, a risk that is
minimised by careful screening of a patient’s
suitability for the medicine.
• 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
Acute Stroke - the Case for Improvement, May 2016
7
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 prenotification 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 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
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
aCosts 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.
8
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
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
cost-effective 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 more b 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.
bCost has been adjusted to 2014 equivalent of that originally published, using the health price index published by the Australian
Institute of Health and Welfare. The original cost was from 1997.
Acute Stroke - the Case for Improvement, May 2016
9
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.
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
10
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:
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.
• 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
Acute Stroke - the Case for Improvement, May 2016
11
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
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
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.
12
Acute Stroke - the Case for Improvement, May 2016
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?
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:
• is associated with better risk factor management
in the short term after stroke 47
• 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:
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
What is current practice?
Only 56% of patients receive education on risk
factor modification while in hospital.6
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
• lower blood pressure (even if blood pressure is
not elevated)
• prevent harmful blood clots (for example, aspirin,
warfarin or newer oral anticoagulants)
• lower cholesterol.
Acute Stroke - the Case for Improvement, May 2016
13
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
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 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
14
Acute Stroke - the Case for Improvement, May 2016
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
cost-effective 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
15
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
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
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.
cCosts 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
16
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
non-registered practitioners, or a team of health
professionals providing health care who spend the
majority of their time providing direct clinical care.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
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
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
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.
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
Haemorrhagic stroke: A type of stroke caused
by bleeding from a ruptured artery (or other blood
vessel) in the brain or its surrounding.3
Rehabilitation: Restoration to optimal physical and
psychological functional independence of a person
with a disability.1
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
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
17
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
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.
18
Acute Stroke - the Case for Improvement, May 2016
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Acute Stroke - the Case for Improvement, May 2016
Australian Commission on Safety and Quality in Health Care
Level 5, 255 Elizabeth Street, SYDNEY NSW 2000
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