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Recommendations for better management of stroke

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VOL: 103, ISSUE: 29, PAGE NO: 23

Nerys Hairon

The Royal College of Physicians of London has recently published its National Sentinel Stroke Audit for 2006, which…


The Royal College of Physicians of London has recently published its National Sentinel Stroke Audit for 2006, which includes both organisational and clinical audits (Hoffman et al, 2007). The report says stroke clinicians, managers and politicians can feel proud of advances over the last 10 years but it also highlights a number of key areas where improvements need to be made, through a range of recommendations.



The Department of Health has published a consultation document on a national strategy for stroke this month, detailing its findings so far (DH, 2007). The document sets out the views of six working groups contributing to the development of the strategy (see Box p24 for main themes).





Catheterisation and incontinence


The RCP audit found that overall 29% of patients were catheterised following their stroke. Of these, 35% (about 10% of all stroke admissions) were catheterised because of urinary incontinence. The authors argue that while it is appropriate to catheterise patients in urinary retention, where the patient has been admitted with a catheter in situ or where there is a need for accurate fluid balance monitoring, urinary incontinence per se is not usually an acceptable indication.



The authors point out that catheterisation increases the risk of infection. It is an unpleasant experience for patients and prevents any attempt being made to regain continence. The 10% catheterised overall represents a small reduction in catheterisation for incontinence from 12% in 2004 but the report states that the figure remains ‘unacceptably high’.



Effective management of urinary incontinence is extremely important for the patients for whom it is a distressing and disabling complication of stroke. The authors say that just over half of patients with incontinence had any evidence of a written plan to promote continence, stating this is ‘appalling’, and add: ‘This aspect of stroke care should be given the highest priority for service development over the next year.’



The report recommends that, by the time of the 2008 audit, no patient should be catheterised without good reason and all patients should have adequate assessment for the cause of incontinence and a management plan implemented.





Some 34% of patients with atrial fibrillation were discharged on an anticoagulant, the audit found. While not all patients in atrial fibrillation will be suitable for anticoagulation (because of severe stroke, risk of falling and other contraindications), the report states this figure ‘is lower than one would predict for ideal stroke management’. Use of anticoagulation has risen since 2001 but is still underused. A key action required is that all patients in atrial fibrillation should be anticoagulated unless there are clearly documented contraindications.



Brain imaging


The National Clinical Guidelines for Stroke (Intercollegiate Stroke Working Party, 2004) recommend scanning within 24 hours of the onset of symptoms of stroke to confirm the diagnosis. The report authors said this was achieved in 42% of all patients, worse than the 59% achieved in the 2004 audit and ‘unacceptably low’. They added that this round of audit differs from previous rounds in that a much greater proportion of patients were regarded as applicable, which means the standard has therefore become more stringent. Speed of access to imaging needs to be radically improved, the report recommends.



The audit found that of the patients scanned (6,559 with times of stroke and scan known) only 9% had their scan within three hours of stroke. The delay from stroke to brain scan suggests that patients who are not scanned during daytime hours on the day of admission have to wait until the next working day before the scan is performed.



The report recommends that, by 2008, all patients should have brain imaging within a maximum of 24 hours of admission.



Primary and secondary prevention


The audit found that only 9% of admitted patients were recorded as being smokers. There was evidence that most of them had been advised to quit.



Exercise after stroke is valuable as a way of improving fitness and losing weight. However, fewer than half of people who had regained the ability to walk were recorded as having been given advice about exercise.



The report says that nearly all stroke patients should receive dietary advice, particularly about salt intake, cholesterol and calories. Only 42% had any documentation to show this had been provided.



In addition, the audit found that 72% of patients were on an antihypertensive, an antithrombotic, an antiplatelet or a lipid-lowering drug before admission. The authors argue that the fact that so many patients are on antiplatelet agents and antihypertensive drugs before admission highlights an urgent need for research to ascertain whether these drugs should be stopped, continued or changed following an acute stroke.



Care planning


The report highlights that problems remain with stroke patients having timely access to speech and language therapists, physiotherapists, occupational therapists and social workers. It warns that not only is this likely to lead to worse outcomes but also will almost certainly increase the time patients spend in hospital.



The authors assert that part of the problem is the ‘persistence of policies within the NHS that attempt to provide all ‘routine’ care between 9am and 5pm Mondays to Fridays’. They add: ‘The service needs to acknowledge that illness does not recognise days of the week or times of day.’ The report also recommends greater than 90% compliance with the standards for assessment by therapists in the National Clinical Guidelines for Stroke (Intercollegiate Stroke Working Party, 2004) by the time of the next audit.





The report found that inpatient specialist care has made ‘enormous progress’, with increases in both the proportion of hospitals with a stroke unit (from 79% in 2004 to 91% in 2006) and the size of the units in England. Some 62% of patients in the sample were admitted to a stroke unit during their stay and 54% spent more than half of their stay in a stroke unit, both figures having gone up from 46% and 40% respectively in 2004.



The audit found that patients managed on a stroke unit had considerably better results for the key indicators than patients in other settings. They were much more likely to have a swallow screen, to have started aspirin within 48 hours, been assessed by therapists within recommended time frames and have rehabilitation goals documented.



The RCP report recommends that all trusts managing stroke patients should increase the proportion who spend the majority of their hospital stay on a stroke unit to over 80% by the time of the next audit in 2008.



The audit concluded that the late launch of a national service framework in Wales in 2006 appears to have hindered the development of specialist stroke services in the country, which the authors state need ‘urgent attention’. They describe the very low rate of stroke unit provision and admission as ‘unacceptable’. The authors say that Wales needs to identify systems to raise the quality of stroke care across the whole patient pathway, particularly through the development of stroke units.



In the general area of staffing and stroke care, the audit found that there remain quite large variations between hospitals in the numbers of professionals employed to deliver stroke care. Consultant nurse posts in stroke are still low in number and over a quarter of hospitals have no form of senior stroke nurse specialist.



- NICE (2007) has recently published an appraisal on alteplase for the treatment of acute ischaemic stroke. It states that alteplase is recommended for 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.





- ‘Time is brain’ - this focuses on minimising damage done by a stroke through prompt action in the early hours and days.



- ‘Life after stroke’ - this looks at improving rehabilitation and support in the months and years following a stroke.



- ‘Working together’ - this sets out proposals for improved working across disciplines and clinical networks.



- ‘Everyone’s challenge’ - this focuses on improving public awareness, choices in treatment and the involvement of stroke survivors in services.

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