National Clinical Guidelines For Stroke Research Articles

An Occupational Therapy Functional Upper Limb Group Programme on the Acute Stroke Unit: A 3 Month Pilot

Abstract Background The 2023 National Clinical Guidelines for Stroke recommend that stroke survivors with motor recovery goals should receive a minimum of 3 hours of rehabilitation 5/7 days a week (National Clinical Guideline for Stroke for the UK and Ireland, 2023). Schneider et al (2019) deem it feasible for stroke survivors to undertake extra upper limb practice (including group sessions) to support in achieving upper limb motor recovery goals. With staffing limitations, creative methods of intervention delivery must be adopted to enhance usual intervention sessions. Methods In an Irish hospital, a pilot project hypothesised the benefit of two one-hour Occupational Therapy functional upper limb group intervention sessions to support adherence to effective weekly dosage of upper limb motor recovery. An audit was completed on dosage of usual Occupational Therapy intervention, prior to group formation. Seven patients were identified with an average daily dosage of 35.4 minutes of usual intervention (5/7 days a week). Two one-hour group sessions were adopted in conjunction with usual therapy. Group intervention dosage was recorded. Patient self-reported satisfaction was obtained using a ten-point Likert scale. Results A total of twenty-nine patients, over 3 months, attended Occupational Therapy upper limb group interventions during an admission on the Acute Stroke Unit. The addition of two one-hour group intervention sessions supported an average actual increase in dosage of 113 extra minutes per week (36.15% increase). There was a 95% self-reported satisfaction rate among patients. Conclusion The addition of two one-hour Occupational Therapy functional upper limb groups increased upper limb motor recovery dosage by 113 minutes per week. Group intervention was a feasible tool that can be used on an Acute Stroke Unit in conjunction with usual therapy to support motor recovery guideline adherence and patient satisfaction. Despite these efforts, patients are not receiving the recommended daily intensity as highlighted by National Clinical Guidelines.

An Audit of Carotid Dopplers in Sligo University Hospital

Abstract Background Stroke is a common and often disabling condition impacting thousands of individuals in Ireland annually 1. Timely screening for underlying etiologies is important in all patients presenting with stroke or transient ischaemic attack (TIA) to reduce recurrence risk. Carotid artery disease is frequently implicated as the cause 3. The 2023 National Clinical Guideline for Stroke for the United Kingdom and Ireland recommends carotid imaging be completed within one week of diagnosis of ischemic stroke or TIA for patients in whom potential carotid intervention would be appropriate. We aimed to assess the timing of Carotid Doppler scans in our hospital for patients presenting clinically with stroke or TIA. Methods The National Integrated Medical Imaging System (NIMIS) was used to generate a list of patients that had a Carotid Doppler scan over a six- month period (1st July 2022 to 31st December 2022). NIMIS was also used to identify the indication, setting, requesting department and timeliness of scans. Results A total of 96 Carotid & Vertebral Dopplers were performed. Majority of studies were performed on males (65%). The mean age of patients was 70 (±11.5) years. Most studies (55%) were done in an inpatient setting. Of all Carotid Dopplers performed, 94 (97%) had an appropriate indication. With regards to timeliness of carotid imaging, the median time from order to study completion varied between inpatients [2 days (IQR 1-3)] and outpatients [16 days (IQR 9-38)]. The majority (95%) of inpatient studies were completed within 7-days of order, while only 14% of outpatient studies were performed in this timeframe. Of the untimely outpatient scans done to investigate stroke or TIA, 2/33 (6%) had significant carotid stenosis. Conclusion Majority of Carotid Dopplers were done for appropriate indications. While inpatients studies were largely done in a timely manner, there is a significant delay in the completion of most outpatient studies.

Assessing Adherence to Acute Stroke Therapy Guidelines: An Audit Study

Abstract Background The 2023 National Clinical Guidelines for stroke for the UK and Ireland recommended that people with motor recovery goals post stroke should receive at least 3 hours (180 minutes) of rehabilitation per day on at least 5 out of 7 days a week. This is a significant change to previous guidelines that recommended that patients receive at least 45 minutes of each therapy for a minimum of 5 days (NICE 2013). In 2022, the UK Sentinel Stroke National Audit Programme found that only 11.9% received more than 45 minutes of physiotherapy. This highlights that many services were not achieving previous recommendations. Methods In an Irish hospital, two new stroke assistant posts were funded with the aim to maximise therapy time. An audit was performed on compliance with the 2023 national guidelines on an acute stroke unit in august 2023 for patients that were identified as having motor goals post stroke. Data was collected in the form of minutes of direct patient contact time by each therapy –physiotherapy, occupational therapy, speech and language therapy and therapy assistants. This data was compared against recommended therapy time and presented as a percentage of this. Results 9 acute stroke patients who were identified as having motor goals were randomly selected. It was found that none of these patients were meeting current therapy guidelines. When compared to the recommendations, the average amount of therapy that patients received per day ranged from 44 minutes – 132 minutes. On average, patients received 49.1% of recommended therapy. It was also found that therapy assistants were providing, on average, 59.3% of the actual therapy received. Conclusion Stroke patients are not receiving the recommended amount of therapy as per the most recent guidelines. Although the addition of stroke assistants significantly increased therapy time, guidelines were still not achieved.

An Innovative Approach To Increasing Speech And Language Therapy Intensity For Stroke Patients

Abstract Background Different national guidelines exist for the provision of Speech and Language Therapy (SLT) intensity for stroke patients. The National Institute for Health and Care Excellence (NICE) guidelines on stroke rehabilitation in Adults (2023) advises 3 hours of multidisciplinary therapy a day, five days a week. The National Clinical guideline for Stroke for the UK and Ireland (2023) does not include SLT in this 3-hour provision of motor therapy, but advises 45 minutes of SLT a day, 5 days a week. Poor SLT staffing levels are commonplace, more recently exacerbated by the HSE recruitment embargo, posing significant challenges to rehabilitation provision. Methods A Speech and Language Therapist in a stroke service assessed whether the use of Therapy assistants could add to the delivery of the targeted 45 minutes of SLT. Training was provided in the execution of speech, language and swallow rehabilitation exercises, using patient specific exercise packs. A month of data collection started on 8 patients. Intensity was measured in 3 percentage groups: Results When rehabilitation was provided by SLT alone, 7 patients received insufficient therapy intensity. One patient scored in the moderate group. With the added input of stroke assistants, 4 patients received sufficient therapy time, 3 patients scored in the moderate group and only one patient received insufficient therapy. Conclusion Use of Stroke assistants for the provision of SLT rehabilitation exercises, can be an effective tool in increasing SLT intensity. Training is time intensive, but essential to make assistants knowledgeable and competent in their abilities. All rehabilitation should be under direct supervision of SLT. However, we should not use stroke assistants to mask or minimise the need for adequate SLT resourcing, as specified in international standards.

Review of Current Early Bed Positioning Practice by Occupational Therapists With Patients Post-Acute Stroke

Abstract Background Many patients experience varied degrees of physical impairments post stroke, which can impact their ability to adjust their posture and position independently. National guidelines state that positioning should be assessed promptly and within 4 hours of arrival to hospital (National Clinical Guideline for Stroke for the UK and Ireland, 2023). Therefore, occupational therapists (OTs) working in stroke should prioritise positioning as early as possible within the intervention process. Aim: To highlight current practice and appraise in line with clinical standards to promote the importance of early bed positioning for acute stroke patients. Methods A two-month audit on positioning intervention by OTs was completed locally. Data was collated on a secure logbook. Results 59 patients were admitted with a stroke between January and February of 2024. 15 patients required bed positioning. Only 2 patients received bed positioning on initial assessment. Documented reasons for not completing bed positioning included time constraints, pain, and resources. Conclusion OTs are not meeting current standards in relation to bed positioning in SVUH. Time constraints, referral times and staffing were highlighted as contributing factors. A service development opportunity was identified and rolled out during the completion of this audit. Implications for practice: Ward based education and an information resource booklet on bed positioning was provided to the staff on the stroke ward. This has prompted a review of the OT initial assessment form to include bed positioning as part of the assessment, and the development of a positioning guidelines hand-out for the stroke interdisciplinary team to implement upon admission.

Identification and Management of Post-Stroke Spasticity

Abstract Background Spasticity is thought to affect up to 40% of people with severe weakness after stroke, with 15% of those experiencing severe and disabling spasticity. Untreated, it can lead to pain, increased dependence, contracture and other motor impairments (National clinical guideline for stroke for the UK and Ireland, 2023). Guidelines recommend that people with motor weakness should be assessed for spasticity, and spasticity guidelines recommend that all people with problematic spasticity should be managed within a specialist service, using physical and pharmacological management as appropriate (Royal College of Physicians, 2018). The objective of this study was to determine the prevalence of spasticity reported by patients attending a post stroke review clinic, and the subsequent management of these patients. Methods Participants: All patients attending a post-stroke review clinic between March 2023 and April 2024. Data: All patients were asked if they experience stiffness, cramping or spasms. Responses and subsequent onward referrals were recorded. Where patients were referred onward for further assessment and management, the interventions employed were recorded. Analysis was performed using descriptive statistics. Results During the data collection period, 270 patients visited the clinic. Stiffness, cramps or spasms were reported by 32 (11.9%), with the majority of these (n=27, 84%) referred to a specialist physiotherapist with expertise in spasticity management for comprehensive assessment. Of the referred patients, 5 (18.5%) did not attend their appointments, 5 (18.5%) are still awaiting appointments, 6 (22.2%) were diagnosed with non-neural stiffness, and 9 (33.3%) received botulinum toxin injections at a specialist physiotherapist-led spasticity clinic. Conclusion Data from this exploratory study indicates the importance of assessing spasticity in patients post stroke and highlights the importance of access to a physiotherapist with specialist knowledge and skills in spasticity management.

191 Intermittent: an audit of venous thromboembolism prophylaxis on our stroke unit

Abstract Background The National Clinical Guideline for Stroke for the United Kingdom and Ireland recommends immobile stroke patients receive Intermittent Compression Stockings (IPCs) to prevent Venous Thromboembolism (VTE) from days 3 to 30 of admission. We set out to audit IPC usage on the stroke unit in our hospital. Methods Data was collected for all 31 stroke unit patients on a single day by two NCHDs. We documented age, gender, length of stay, and mobility status. We recorded completion of the VTE risk section of the medication chart, and if the patient was prescribed single antiplatelet (SAPT), dual antiplatelet (DAPT), direct oral anticoagulant (DOAC) or IPCs. We also noted if the patient’s stroke was ischaemic or haemorrhagic. Results 16 patients were male (52%). Mean age was 72 years old. Median length of stay was 29 days. 23 patients had ischaemic strokes (74%), 8 had haemorrhagic strokes (26%). 21 patients had their VTE risk section completed (68%). 9 ischaemic stroke patients were on DOAC, 9 on SAPT, 4 on DAPT, and 1 was on no therapy. 19 patients (61%) were immobile (assistance of one or higher dependency). Of these, 9 had been admitted for between 3 and 30 days. None had IPCs prescribed and only 1 (11%) had them in situ. 3 were on DOAC therapy (33%). One other patient (admitted 41 days prior) had IPCs in situ but not prescribed. Conclusion 89% of appropriate stroke patients did not have IPCs in situ, and 56% had no VTE prophylaxis at all. The VTE risk section of the medication chart was blank in 32% of cases. Based on these results we are conducting a root cause analysis as to why guidelines are not adhered to. This will guide a planned quality improvement initiative.

304 Increasing the intensity of physiotherapy in a subacute stroke rehabilitation unit—results of audit and intervention

Abstract Background The National Clinical Guideline for Stroke (2023) recommend the delivery of high intensity therapy to optimise physical recovery post-stroke. Previous guidelines suggested 45 minutes but now suggest a total of 3 hours daily. The aim of this intervention was to review current practice and implement the stroke guidelines aiming to augment the dosage of therapy sessions. Methods Given the guidelines’ recommendation to improve the reporting of exercise prescription, a chart audit was completed comparing the dosage of physiotherapy from 2020–2022 on a random sample of 10 charts per year. Strategies to increase intensity included a restructure of the stroke exercise class, run twice weekly. The class structure moved towards a circuit class of 5x 6-minute stations followed by group outdoor mobility. Use of tally counters, increased semi-supervised practice and introduction of a ‘champions board’ to celebrate individuals’ achievements also contributed to a culture of high intensity therapy. Results The chart audit showed an improvement in the recording of repetitions each year. The average recorded repetitions per week for stroke survivors increased from 77.9 repetitions in 2020 to a weekly average of 1,043 in 2022 (2020 range 0–288 repetitions; 2022 range 245–2095 repetitions). The average repetitions in the stroke exercise class in 2022 was 462 and was previously not measured. A review of annual patient statistics from 2021 and 2022 showed that stroke survivors spent more time in physiotherapy in 2022. This was likely affected by variables such as staffing allocation and COVID-19 restrictions limiting the ability to provide gym-based therapy or group classes. Conclusion The measurement and recording of intensity has improved and increased in 2022 although this may have been affected by factors outside of this intervention. Future iterations of this project would be to increase dosage of upper limb therapy, and to increase physical activity outside therapy, such as use of pedometers outside therapy hours.

National Clinical Guideline for Stroke for the United Kingdom and Ireland: Part I – An overview of the updated recommendations

National Clinical Guideline for Stroke for the United Kingdom and Ireland: Part I – An overview of the updated recommendations

National Clinical Guideline for Stroke for the UK and Ireland: Part ll – The challenges and opportunities posed for occupational therapists

National Clinical Guideline for Stroke for the UK and Ireland: Part ll – The challenges and opportunities posed for occupational therapists

230 DEVELOPMENT AND IMPLEMENTATION OF A STROKE PASSPORT IN THE HYPER-ACUTE STROKE UNIT: SUPPORTING PEOPLE POST-STROKE

Abstract Background A Multi-Disciplinary Team (MDT) approach is instrumental to post-stroke management in the Hyper Acute Stroke Unit (HASU). There is strong evidence highlighting the importance of patients’ social needs post-stroke (UK National Clinical Guideline for Stroke, 2016) and the need for a clear plan and resource combining both health and social care. This is outlined in the National Stroke Strategy (2020-2025). Stroke care involves a cohesive multi-disciplinary approach. In 2021, members of the MDT in HASU identified a service gap and implemented a unified tool. The aim of this project was to develop a user-friendly resource “Stroke Passport” to ensure the patient was central to their own stroke journey. Methods National and international guidelines were reviewed and benchmarking of other acute services was completed. The Stroke Passport was specialised to the HASU to include key stakeholders including stroke Consultant, stroke MDT and stroke Nursing Staff. Key stakeholders contributed to the development and adjustments were made after feedback. A sample of stroke patients piloted the passport (n=10). Education was provided for staff and patients through information sessions. Results This project resulted in the development of a resource that captured the following key areas:(i)Causes of Stroke (ii) Risk Factors (iii) Stroke Team (iv) Rehabilitation Goals (v) Useful Contacts (vi) and Medication List (vii). Qualitative feedback from the pilot study included: consistent awareness into stroke type, rehabilitation goals and discharge plan. The passport was successfully implemented to meet the organisational demands of the service while including the patient’s voice and is now embedded into standard practice in the HASU. Conclusion The development and implementation of a Stroke Passport ensured inclusion of the patient central to rehabilitation goal setting and discharge planning. The project supports an integrated approach to care and allows for patient centred care from admission to safe discharge.

146 GOLD STANDARD GOAL-SETTING: ARE WE HITTING THE MARK? IMPLEMENTING AN INTERDISCIPLINARY GOAL-SETTING PATHWAY IN STROKE REHABILITATION

Abstract Background The cornerstone of rehabilitation is effective and realistic interdisciplinary goal-setting with patient and family engagement across the continuum of recovery. The Royal College of Physicians National Clinical Guidelines for Stroke (2016) highlights the importance of encouraging self-management and self-efficacy to support a more person-orientated approach. This quality improvement initiative aimed to introduce a structured interdisciplinary goal-setting pathway on a post-acute 14-bed stroke unit. Methods An interdisciplinary working group was established comprising of Physiotherapy, Occupational Therapy, Speech & Language Therapy, Medical Social Work and Nursing. Quality improvement methodology was used to sequentially implement change over a 6-month period. The restructure included the introduction of an initial and review goal-focused family meeting. An interdisciplinary tool was developed based on the East Kent Outcome System (EKOS). A series of workshops was delivered to support implementation. Results An interdisciplinary goal-setting pathway is currently being piloted for 6 months on the stroke unit. To date, 22 staff have been trained and 9 patients have progressed through the updated pathway. Analysis has provided useful clinical insights and qualitative feedback has been collated regarding the benefits of the early opportunity to meet the team, establishing patient’s personal goal priorities and clear timeframes.Furthermore, repeat trials followed by reflections have enabled the team to develop consistency and confidence in person-centred, interdisciplinary goal-setting. It is acknowledged that this initiative has been a significant change process for the team and that adjustments are being made, in line with the principles of quality improvement. Conclusion This person-orientated interdisciplinary process is evidence-based and in line with national standards and guidelines for stroke rehabilitation. Formal training in EKOS is planned and a clinical audit will follow the pilot phase to systematically evaluate the change in practice.

Hub-and-spoke model for thrombectomy service in UK NHS practice

Mechanical thrombectomy is a highly effective but time dependent treatment for acute ischaemic stroke due to large vessel occlusion. In the UK, the national clinical guidelines for stroke and National Institute for Health and Care Excellence guidance endorses thrombectomy as an acute stroke treatment, and NHS England commissioned thrombectomy services. However, there are no UK 'real-world' data to verify the efficacy of the hub-and-spoke model in thrombectomy. There are currently 24 tertiary neuroscience centres in the UK that can provide thrombectomy treatment and many of these operate only within working hours. This study is the first to demonstrate that a hub-and-spoke thrombectomy service in routine UK 24/7 clinical practice is as effective and safe as in the setting of randomised controlled clinical trials. However, there are 9.3% of patients accepted for transfer to the thrombectomy centre who did not proceed to thrombectomy, mostly due to delays. Fifty-three per cent of thrombectomy cases were performed outside of standard working hours when transfer delays were increased. A 24/7 thrombectomy service is needed to maximise the benefit to all suitable patients. Measures, including improving workflow and optimising work forces, are needed to minimise the delays and continue to improve the service.

81 A Review of the Referrals to a Daily TIA Service and Subsequent Specialist Diagnosis

Abstract Background Current guidelines highlight the need for all patients experiencing transient ischaemic attacks (TIA) within the previous 7 days to be seen by a specialist service within 24 hours. (RCP National Clinical Guideline for Stroke 2016) Risk stratification tools are no longer recommended.(Lavallee 2007;Wardlaw, 2014) We reviewed the referrals to such a service to assess the proportion of patients who received a diagnosis of TIA and the time taken for assessment. Methods We used a retrospective review of 131 patients coded under the daily TIA clinic in 2018 and analysed the clinic letter from the attendance. We assessed the time taken from referral to clinic review and the percentage of patients diagnosed with TIA by the specialist service. Results Of 131 patients seen only 33.6% were diagnosed TIA by the stroke specialist team. Other frequently seen diagnoses were migraine (22.9%), presyncope (12.2%), transient global amnesia (4.6%). ‘Other’ diagnoses such as peripheral nerve palsy, cervical root impingement and delirium made up the remainder. Referrals from the emergency department only received TIA diagnosis in 25.3%, GP referrals (34.9%) and eye casualty (83.3%). The time from referral to review was a mean of 2.45 days. The patients diagnosed with TIA were seen with average of 2.14 days, non TIAs were 2.6 days. Conclusion Evidence shows that patients suffering TIA should be seen urgently within 24hrs. The degree of non TIA symptoms being reviewed risks these services being overrun. A review of our service has shown that the average time of referral to review is longer than desired, however only a third of patients seen were felt to have a TIA. Unless there is a change in the standard of referral it will continue to be difficult to see all true TIAs within 24hrs. This will require further education for our colleagues and a more robust triaging system.

Ten Years On - A Survey of Orthoptic Stroke Services in the UK and Ireland.

Aim:In 2007 a national orthoptic survey identified poor provision of vision assessment for stroke survivors. The purpose of this study is to report a 10-year update of this survey to identify changes in clinical practice over recent years.Methods:An online practice survey of registered orthoptists (British and Irish Orthoptic Society, BIOS) was undertaken to scope vision services for stroke survivors.Results:At the time of this survey, there were 223 orthoptic departments and 227 stroke units in the UK and Ireland. 317 responses were received representing 178 orthoptic departments – an 80% response rate for orthoptic departments. Of the respondents, 92% reported having a stroke unit in their hospital. A stroke/vision service was provided by 98% of responding orthoptic departments for 77% of stroke units but with only half providing a vision service on the stroke unit. Only 33% of vision services were funded and funding remains the primary barrier to providing a stroke/vision service. About 85% of respondents were aware of the national clinical guidelines for stroke and the BIOS extended practice guidelines for stroke.Conclusions:There has been a positive increase in awareness of stroke-related visual impairment and a steady improvement in provision of eye care for stroke survivors. However, there remains a lack of provision of specialist vision services specifically on stroke units which infers a health inequality for stroke survivors who have visual impairment. Their visual impairments can remain undetected and thus undiagnosed and unmanaged due to unsatisfactory patient care.

WED 259 The challenge of mood and cognition screening in hasu

The National Clinical guideline for stroke, recommends that services for people with stroke should provide screening for mood and cognition within six weeks of stroke using validated tools. In HASU assessing mood and cognition in a timely fashion has been challenging. In 2013 a previous audit showed cognitive screening at 48% and mood screening at only 7%. We instituted a number of measures to improve compliance including education events for MDT staff, a bespoke stroke clerking proforma, to include data collection boxes. We also introduced the briefer ‘YALE questionnaire’ for mood, and the Montreal Cognitive Assessment Tool (MOCA). We also piloted occupational therapy staff using a ‘screening sticker’ in patient notes. A daily MDT was also introduced, primarily to improve patient flow, but also to prompt action planning. Mood screening improved to 92% and cognition screening to 95% on detailed notes audit. These high compliance figures were however not fully reflected on SSNAPP although compliance has improved. SSNAP data input is completed by a single coder, non clinical staff member. We plan to employ a second data clerk and further revise the stroke proforma.

Research protocol: investigating the feasibility of a group self-management intervention for stroke (the GUSTO study)

BackgroundLife after stroke can be an ongoing struggle with over half of all survivors reporting unmet emotional and social needs. In the United Kingdom’s (UK) national clinical guidelines for stroke, self-management is suggested as one approach which can support long-term needs. In the UK NHS, self-management interventions are delivered in various ways. Regardless of the delivery mechanism, a tailored approach and ways to integrate peer support are advocated. Group delivery offers a platform for peer support and has the potential to remain individualised. However, before the efficacy of a group self-management intervention can be tested, the feasibility must be explored. This research investigates the feasibility of a GroUp Self-management intervention for sTrOke (GUSTO).MethodsA randomised waitlist control design will be used to investigate the feasibility of a group self-management intervention adapted from an existing one-to-one intervention called Bridges. A mixed methods approach will be used. Qualitative work will capture participant experience, while quantitative work will allow preliminary comparison between the intervention and waitlist groups (between subjects) and pre-post intervention measures (within subjects). Interviews will be conducted with stroke survivors and focus groups with family and friends to assess acceptability of the intervention.DiscussionThere is a growing interest in group-based self-management interventions for stroke as a method of supporting stroke survivors’ ongoing unmet needs. This is an area with limited research to date. This study will inform design of a fully powered trial which would assess the efficacy of a group self-management intervention following stroke.Trial registrationISRCTN19867168

Veldig tidlig mobilisering ved akutt hjerneslag

Since the first stroke units were established in the 1990s, early mobilisation has formed a key part of the acute treatment. In the context of an updating of national clinical guidelines for stroke, the Norwegian Directorate of Health commissioned the Institute of Public Health to prepare a systematic review of the efficacy and safety of very early mobilisation (within 24 hours) after stroke, compared with current practice, which is early mobilisation (within 48 hours). We have written a systematic review based on a previous review from the Cochrane Collaboration published in 2009. We performed literature searches for randomised controlled studies in MEDLINE, EMBASE and CENTRAL. Three randomised controlled studies were included. Very early mobilisation showed no statistically significant difference in mortality or functional level compared with early mobilisation. We have very little confidence in the results and are therefore uncertain of the efficacy of the intervention. Very early mobilisation, when prolonged and given regularly, can most likely result in increased mortality and poorer functional level. Early mobilisation is useful for many patients, but very early mobilisation, when frequent and prolonged, may also cause injury. Based on current research, we are uncertain of the optimal time to initiate mobilisation after stroke.

Advances in nursing assessment and management of urinary incontinence for stroke survivors

Urinary incontinence (UI) affects up to 60% of patients following stroke. National clinical guidelines in the UK, Australia and New Zealand recommend that people with stroke who have confirmed difficulties, once assessed, should have a continence management plan. Despite this, management is suboptimal, with less than two thirds of stroke units in the UK having a documented plan to promote continence. National clinical guidelines for stroke in the UK also recommend patients with stroke who have continued loss of bladder control 2 weeks after diagnosis should be reassessed to identify the cause of incontinence and have an ongoing treatment plan involving both patients and carers. Despite these guidelines, there is low reported use of assessment tools to screen, assess and manage UI in the acute setting, and the ongoing care and management of UI in rehabilitation and long-term care facilities is inconsistent. This review of the literature highlights the evidence base available and recommends that health professionals looking after stroke survivors should be urged to complete training and education to improve their understanding of the need for assessment and management of UI in stroke survivors for better patient care and recovery.

The latest national clinical guideline for stroke

Editor – There is lack of clarity in the latest National clinical guideline for stroke on cardiac monitoring if a cardio-embolic stroke is suspected.[1][1] It is estimated that between 25 and 60% of atrial fibrillations are paroxysmal (PAF) and approximately one third of the patients affected are