Guidelines For Management Of Stroke Research Articles

Report from the European Stroke Organization 2014.

We are delighted to announce the new annual European Stroke Organization Conference (ESOC), the first of which will be held in Glasgow from April 17 to 19, 2015. We invite the international scientific and clinical stroke community to join us. ESO is the leading clinical and scientific stroke association in Europe and conducts a wide range of educational, political, and scientific activities. For example, it generates the European Guidelines for Stroke Management and runs the Summer and Winter Schools, the Stroke Masters program, the European …

Factors affecting speech pathologists’ implementation of stroke management guidelines: a thematic analysis

Purpose: Although clinical practice guidelines can facilitate evidence-based practice and improve the health outcomes of stroke patients, they continue to be underutilised. There is limited research into the reasons for this, especially in speech pathology. This study provides the first in-depth, qualitative examination of the barriers and facilitators that speech pathologists perceive and experience when implementing guidelines. Methods: A maximum variation sample of eight speech pathologists participated in a semi-structured interview concerning the implementation of the National Stroke Foundation's Clinical Guidelines for Stroke Management 2010. Interviews were transcribed, thematically analysed and member checked before overall themes were identified. Results: Three main themes and ten subthemes were identified. The first main theme, making implementation explicit, reflected the necessity of accessing and understanding guideline recommendations, and focussing specifically on implementation in context. In the second theme, demand versus ability to change, the size of changes required was compared with available resources and collaboration. The final theme, Speech pathologist motivation to implement guidelines, demonstrated the influence of individual perception of the guidelines and personal commitment to improved practice. Conclusions: Factors affecting implementation are complex, and are not exclusively barriers or facilitators. Some potential implementation strategies are suggested. Further research is recommended.Implications for RehabilitationIn most Western nations, stroke remains the single greatest cause of disability, including communication and swallowing disabilities.Although adherence to stroke clinical practice guidelines improves stroke patient outcomes, guidelines continue to be underutilised, and the reasons for this are not well understood.This is the first in-depth qualitative study identifying the complex barriers and facilitators to guideline implementation as experienced by speech pathologists in stroke care.Suggested implementation strategies include local monitoring of guideline implementation (e.g. team meetings, audits), increasing collaboration on implementation projects (e.g. managerial involvement, networking), and seeking speech pathologist input into guideline development.

Use of medications for secondary prevention in stroke patients at hospital discharge in Australia

Stroke is one of the leading causes of death and disability. Significant proportions (33 %) of stroke presentations are by patients with a previous stroke or transient ischaemic attack. Consequently, the stroke management guidelines recommend that all ischaemic stroke patients should receive three key evidence-based preventive drug therapies: antihypertensive drug therapy, a statin and an antithrombotic drug therapy (anticoagulant and/or antiplatelet). To determine the rates of utilization of the three key evidence-based drug therapies for the secondary prevention of stroke and to identify factors associated with use of treatment at discharge. Five metropolitan hospitals in New South Wales, comprising two tertiary referral centres and three district hospitals. A retrospective clinical audit was conducted in the study hospitals. Patients discharged with a principal diagnosis of ischaemic stroke during a 12-month time period (July 2009-2010) were identified for review. The rate of utilization of each of the three key evidence-based drug therapies and the factors associated with use of treatment at discharge. A total of 521 medical records were reviewed. Of these, 469 patients were discharged alive with a mean age of 73.6 ± 14.4 years. Overall, 75.4 % were prescribed an antihypertensive agent at discharge versus only 65.7 % on admission (P < 0.05). Three hundred-sixty patients (77.6 % of the eligible patients) were prescribed a statin at discharge (compared to only 43.9 % on admission, P < 0.05), of whom 74.0 % received monotherapy. Almost all (97.6 %) eligible patients were prescribed an antithrombotic drug therapy at discharge, of whom 68.5 % were prescribed monotherapy and 28.2 % were prescribed dual therapy. Only 60.0 % of eligible patients were discharged on all three key guideline recommended secondary preventive drug therapies. Multivariate logistic regression analyses showed that hypertension (OR 6.67; 95 % CI 4.35-11.11), hypercholesterolemia (OR 2.04; 95 % CI 1.32-3.23), and discharge destination (OR 0.22; 95 % CI 0.10-0.48) were associated with the utilization of all three guideline recommended therapies. There is a scope for improvement in implementing the stroke management guidelines when it comes to prescribing secondary preventive drug therapies using antihypertensives, antithrombotics and statins. Appropriate risk/benefit assessment is indispensable for optimal prescribing and maximizing patient outcomes, particularly in older people.

Systematic review of the quality of clinical guidelines for aphasia in stroke management

Aphasia affects up to 38% of stroke survivors. Clinical guidelines can improve patient care and outcomes. Given the importance of aphasia management in stroke care, the purpose of this study was to systematically search for, retrieve and assess the quality of currently published clinical guidelines for aphasia in stroke management. Systematic search of bibliographic resources, publications, association websites, databases, Internet and pearling revealed multidisciplinary stroke and speech pathology-specific clinical guidelines, which were evaluated using the Appraisal of Guidelines and Research and Evaluation (AGREE) II tool. Guidelines obtaining a rigour of development score above 66.67% in AGREE II evaluations underwent further ADAPTE Collaboration tool analysis. There was significant variability in methodological rigour, reporting of guideline development processes and scope of coverage of recommendations pertaining to aphasia management provided within the guidelines. The Australian Clinical Guidelines for Stroke Management (2010) and New Zealand Clinical Guidelines for Stroke Management (2010) achieved the highest scores (74% and 81%, respectively) in AGREE II analysis and both obtained a 'yes' in all seven ADAPTE domains. The Scottish Intercollegiate Guideline Network 108 (2008) guideline achieved 73% in AGREE II and six out of seven 'yes' in ADAPTE, however, contained no aphasia-specific recommendations. The Royal College of Speech and Language Therapists (2005) guideline provided the most comprehensive aphasia coverage, however, demonstrated lower methodological rigour in AGREE II (64%) and ADAPTE evaluations (three 'yes' out of seven). Improvement is needed in the quality of methodological rigour in development and reporting within clinical guidelines, and in aphasia-specific recommendations within stroke multidisciplinary clinical guidelines.

Postępowanie w udarze mózgu – wytyczne Grupy Ekspertów Sekcji Chorób Naczyniowych Polskiego Towarzystwa Neurologicznego. Aktualizacja 2013: leczenie trombolityczne

Thrombolysis is the most effective therapy for ischaemic stroke. The current guidelines and approvals have limited its use to patients available for treatment within 4.5 hours of onset and those aged 80 or less. There are also a number of other limitations derived from clinical trial protocols, i.e. minor and major strokes. The available evidence has indicated its possible efficacy in patients treated within 6 hours of onset and not fulfilling other limitations.Last year, the results of the IST-3 (Third International Stroke Trial: Thrombolysis) and a meta-analysis of all available trials including IST-3 were published. They point out the possible benefit of thrombolysis in patients not meeting the current criteria, which has been acknowledged in the Polish guidelines for management of stroke.

Contextualizing Western guidelines for stroke and low back pain to a developing country (Philippines): an innovative approach to putting evidence into practice efficiently

Contextualizing Western guidelines for stroke and low back pain to a developing country (Philippines): an innovative approach to putting evidence into practice efficiently Consuelo Gonzalez-Suarez,1,2,3 Karen Grimmer-Somers,1 Janine Margarita Dizon,1 Ellena King,1 Sylvan Lorenzo,2 Carolina Valdecanas,2 Ephraim Gambito,2 Belinda Fidel2,31International Center for Allied Health Evidence, University of South Australia, Adelaide, Australia; 2Philippine Academy of Rehabilitation Medicine, Quezon City, Philippines; 3University of Santo Tomas, Manila, PhillipinesBackground: High-quality evidence-based clinical guidelines are widely available for many diseases. Clinical guidelines support evidence-based care decisions and improved health outcomes. Most clinical practice guidelines have been developed in the Western world and reflect a developed country&rsquo;s health systems and services, disease epidemiology, and workforce. Such guidelines are therefore not immediately relevant or generalizable to developing countries. Guidelines are expensive to produce, and it is more resource efficient for developing countries to contextualize available Western guidelines, rather than develop their own. This paper describes a leadership initiative by the Philippines Association of Rehabilitation Medicine to contextualize high-quality relevant Western guidelines for local management of stroke and low back pain.Methods: Twenty-one steps were developed, covering initial training and establishing the framework within which recommendations were contextualized; then guideline searching, critiquing, and including; and then contextualization, review, and implementation. A writing guide assisted the group to endorse recommendations in a standard manner, relevant to a &ldquo;typical&rdquo; patient journey, and to contextualize recommendations for local settings.Results: Recommendations were extracted from eight low back pain and five stroke clinical guidelines. Philippines Association of Rehabilitation Medicine endorsements were made, reflecting summarized recommendations and underpinning strength of the evidence body. Philippines Association of Rehabilitation Medicine context points contextualized the recommendations in terms of local health service delivery.Conclusion: A systematic reproducible process was applied to contextualize high-quality, relevant Western guidelines for immediate application to one developing country. This approach focused resources on contextualization, implementation, and uptake rather than de novo development. This leadership initiative offers a resource efficient way to implement evidence-based practice in developing countries when there is neither time nor resources for de novo guideline development.Keywords: PARM, clinical guidelines, Philippines, endorsements, context points, evidence-based practice

Stroke management: updated recommendations for treatment along the care continuum

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.

Exercise protects bone after stroke, or does it? A narrative review of the evidence.

Physical inactivity contributes to accelerated bone loss after stroke, leading to heightened fracture risk, increased mortality, and reduced independence. This paper sought to summarise the evidence for the use of physical activity to protect bone in healthy adults and adults with stroke, and to identify international recommendations regarding any means of bone protection after stroke, in order to guide rehabilitation practice and future research. A search was undertaken, which identified 12 systematic reviews of controlled trials which investigated the effect of physical activity on bone outcomes in adults. Nine reviews included healthy adults and three included adults with stroke. Twenty-five current international stroke management guidelines were identified. High-impact loading exercise appears to have a site-specific effect on the microarchitecture of healthy postmenopausal women, and physical activity has a small effect on enhancing or maintaining bone mineral density in chronic stroke patients. It is not known whether this translates to reduce fracture risk. Most guidelines included recommendations for early mobilisation after stroke and falls prevention. Two recommendations were identified which advocated exercise for the prevention bone loss after stroke, but supporting evidence was limited. Research is required to determine whether targeted physical activity can protect bone from early after stroke, and whether this can reduce fracture risk.

(P2-5) Pre- and in-Hospital Time Delays in Acute Stroke Management in Estonia

BackgroundShort intervals between stroke onset and thrombolysis determine the efficacy of this procedure. Guidelines for stroke management were introduced in 2005 in the West-Tallinn Stroke Centre and in 2008 in the Tallinn Emergency Medical Services. Since 2006, annual joint stroke meetings of pre- and in-hospital staff have been held. These meetings included analysis of time delays of thrombolyzed patients.ObjectiveThe aim of the study was to analyze changes in time delays in acute stroke management and adherence to treatment guidelines.MethodsPre- and in-hospital data of all consecutive ischemic stroke patients who received intravenous thrombolytic therapy were recorded prospectively at the Stroke Centre. Data from the implementation period of thrombolysis (2005–2008 i.e., 1st period) were compared to recent data from 2009 to 01 September 2010 (2nd period). The data from all stroke patients presenting to ambulance services were analyzed separately from 01 September 2009 to 01 September 2010. Recorded procedures were compared to current treatment guidelines.ResultsA total of 115 patients received thrombolysis at the Stroke Centre. The Alarm Centre assigned the correct priority (C, lights and sirens) for 31% of thrombolyzed patients during the 1st period, and for 80% during the 2nd period. The mean time ambulance personnel spent at the home was 20 minutes during both periods. In-hospital door-to-needle time was &lt; 60 minutes in 11% of patients during the 1st period, and in 56% during the 2nd period. Ambulance personnel treated 1,094 stroke patients during the study. All procedures were performed and documented correctly in 10% of visits. The most frequent deviation from guidelines was under-reported values of blood glucose. In 44.7% of patients, an ECG was performed, which is not required by guidelines.ConclusionsAcute stroke management improved significantly. Adherence to recently developed stroke guidelines in the ambulance services must be improved.

Knowledge Gaps in Stroke Care: Results of a Survey of Family Physicians in Pakistan

Family physicians play a pivotal role in stroke prevention (primary and secondary) and early management of stroke in developing countries. The objective of this study was to evaluate whether Pakistani family physicians' approach to stroke prevention and management was in accordance with established international guidelines. This was a cross-sectional survey of randomly selected family physicians in Pakistan, conducted in 2007. A total of 588 family physicians participated in the study. The data reveal that 88% of the physicians are aware of at least one of the 5 major symptoms of stroke, but only 46% are able to correctly idenitfy all 5 symptoms; 93% of the physicians check blood pressure in their adult patients regularly, and 63% use a cutoff of 140/90 mm Hg to start antihypertensive therapy in routine clinical practice; 90% ask their patients about cigarette smoking or tobacco use, but only 64% regularly advise their patients to quit smoking; 75% do not routinely check cholesterol levels in their patients; 36% treat patients with stroke by themselves, whereas 64% prefer to refer these patients to a specialist or hospital; 57% use intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure >160/100 mm Hg; and 95% use antiplatelet agents for stroke prevention, with 70% using aspirin and 28% using clopidogrel as first-line antiplatelet therapy. These data indicate a substantial gap between international guidelines and Pakistani family physicians' management of stroke patients. There is an urgent need for stroke-related continuing medical education to propagate stroke management guidelines.

Postpublication External Review of the Japanese Guidelines for the Management of Stroke 2004

Many guidelines for management of stroke have been published throughout the world, but no postpublication external review of any set of stroke guidelines by users, using standard checklists, has been reported. The purpose of this article is to present the results of an external review of the Japanese Guidelines for the Management of Stroke 2004, conducted several months postpublication. Forty-one evaluators, who had not been involved in developing the guidelines, were selected from representative stroke centers and institutions in Japan. They consisted of 30 physicians including 22 stroke specialists, and 11 nurse practitioners. Three standard checklists, ie, Appraisal of Guidelines for Research and Evaluation (AGREE) instrument, checklist by Shaneyfelt et al, and the Conference on Guideline Standardization (COGS) checklist, were used. Confidence ratios according to the AGREE checklist were 75%, 77%, and 86% for stroke specialists, physicians other than stroke specialists, and nurse practitioners, respectively. The average scores were 2.98, 3.13, and 3.29, [corrected] respectively. The confidence ratios according to the checklist by Shaneyfelt et al were 72%, 73% and 86% respectively, and those for the COGS checklist were 66%, 74%, and 91%, respectively. Although it is impossible to compare our results with those for other stroke guidelines, because none of them has been externally reviewed by users postpublication, our results seem better than those for published guidelines for treatment of other diseases in Japan. These results should be helpful in the process of updating stroke guidelines in Japan and elsewhere.

脳卒中予防と降圧治療の実際―ガイドラインと実際間のｄｉｓｃｒｅｐａｎｃｙ―

Recommended measures for control of blood pressure in stroke patients at the superacute, acute and chronic stages were presented in two guidelines in 2004 (The Guideline for the Management of Hypertension and The Guideline for the Management of Stroke). We have investigated the discrepancy between actual clinical practice and the above recommendations.We examined the clinical outcome and the incidence of symptomatic hemorrhage in patients with and without antihypertensive drug treatment before the administration of rt-PA in superacute stroke patients. We analyzed 47 patients with acute stroke treated within 3 hours after onset. According to the guideline, antihypertensive agents are indicated in patients with hypertension over 180mmHg systolic or 105mmHg diastolic pressure. Six patients showed the indication for antihypertensive therapy. There was no significant difference in prognosis measured in terms of mRS (0–1) at 3 months and the incidence of symptomatic hemorrhage between two groups. The recommended level of blood pressure in the guidelines is therefore considered appropriate for these patients.Anti-hypertensive therapy in the acute phase within one or two weeks after onset has not been done in principle, except in special circumstances as described in the guidelines. We chose to examine the propriety of early anti-hypertensive therapy for patients with lacunar stroke, based on the tendency for shorter duration of hospitalization in acute hospitals, and because of the introduction of the seamless stroke collaboration system for treating stroke patients and the results of the ACCESS study, which showed that early intervention with ARB had a favorable effect on prognosis. We divided 100 patients with lacunar stroke into two groups according to the level of blood pressure. We prescribed anti-hypertensive agents (ARB or Ca channel blocker) in patients with over 180mmHg systolic or 105mmHg diastolic pressure within 2 weeks after onset. There was no significant difference in clinical outcome at 3 months or in the recurrence rate of stroke at one year between the two groups. The results suggested that early intervention with antihypertensive agents could be safe and appropriate in patients with lacunar stroke. However, this should be confirmed with more patients and a clinical trial.As regards the goal for blood pressure in the chronic stage for the secondary prevention of stroke, the Japanese Guideline for Treatment of Hypertension recommended that the final goal should be under 140/90mmHg. Recent subanalysis of the PROGRESS study suggested that lowering the level to 120mmHg systolic pressure might be preferrable. However, Japanese and American Guidelines for Stroke Management have not given a precise goal for blood pressure, because of individual differences among patients. We think a new guideline recommending a lower level of blood pressure in certain kinds of stroke types and clinical situations is needed.

Improving Adherence to Guidelines for Acute Stroke Management

In recent years, many medical professional organizations such as the European Society of Cardiology, the American Heart Association, the American College of Cardiology, and the American Stroke Association have promoted guideline-based therapy for different groups of patients. These guidelines are based in part on large clinical trials and, when such are not available, on so-called expert opinion. Article p 107 Some argue that pursuing adherence to guidelines is a worthy effort by itself, just to bring order into diversity. For others, it seems obvious that use of guidelines leads to improved quality of medical care and improved health outcomes. Yet a few wonder whether the chain of evidence from guideline development and implementation, adherence to guidelines, and improved process of care through improved quality and functional outcomes is everywhere as solid as it should be. It has become quite clear that in order to improve healthcare quality, merely introducing guidelines is not sufficient, not even after creating a solid framework of evidence-based recommendations. The guidelines should be incorporated in a quality-assurance cycle with education programs and feedback from registries or surveys of clinical practice (Figure 1), such as the Get with the Guidelines program (GWTG). Figure 1. The quality assurance cycle: relationship between guideline development, education programs, and feedback from registries or surveys of clinical practice. Several large surveys in Europe and the United States have indicated that adherence to guidelines for the clinical management of stroke and cardiovascular disease needs improvement.1,2 For example, treatment with oral anticoagulants to prevent recurrent stroke in patients with symptomatic atrial fibrillation has been recommended in clinical guidelines for more than a decade. Undertreatment is associated with an increased stroke rate.3 Treatment with anticoagulants should be tailored to estimated stroke risk, yet in the EuroHeartSurvey program several other factors were associated with …

Does a higher 'quality points' score mean better care in stroke? An audit of general practice medical records

The Royal College of Physicians (RCP) have produced guidelines for stroke management in primary care; this guidance is taken to be the gold standard for the care of people with stroke. UK general practitioners now have a quality-based contract which includes a Quality and Outcomes Framework (QOF). This consists of financially remunerated 'quality points' for specific disease areas, including stroke. Achievement of these quality points is measured by extracting a limited list of computer codes from practice computer systems. To investigate whether a high stroke quality score is associated with adherence to RCP guidelines. Examination of computer and written medical records of all patients with a diagnosis of stroke. Two general practices, one in southwest London, one in Surrey, with a combined practice population of over 20 000. Both practices had a similar age-sex profile and prevalence of stroke. One practice scored 93.5% (29/31) of the available stroke quality points. The other practice achieved 73.4% (22.75/31), and only did better in one stroke quality target. However, the practice scoring fewer quality points had much better adherence to RCP guidance: 96% of patients were assessed in secondary care compared with 79% (P=0.001); 64% of stroke patients were seen the same day, compared with 44%; 56% received rehabilitation compared with 37%. Higher quality points did not reflect better adherence to RCP guidance. This audit highlights a gap between relatively simplistic measures of quality in the QOF, dependent on the recording of a narrow range of computer codes, and the actual standard of care being delivered. Research is needed to see whether this finding is generalisable and how the Quality and Outcomes Framework might be better aligned with delivering best practice.

Updated ischaemic stroke management guidelines released

Updated ischaemic stroke management guidelines released

A multidisciplinary guideline for the acute phase of stroke: barriers perceived by Dutch neurologists.

Guidelines for stroke management should improve quality of care. Dissemination of guidelines, however, does not guarantee guideline adherence. The aim of this paper is to investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies. Questionnaire survey among all Dutch neurologists working on neurology wards in general hospitals during the year 2000 in The Netherlands. The neurologists expressed a high degree of agreement with the diagnostic and preventive recommendations, but expressed doubts with regard to the therapeutic recommendations, especially for the recombinant tissue plasminogen activator therapy. In general, barriers at the organizational and the multidisciplinary team level were most prominent. Active implementation of the guidelines seems necessary. Implementation strategies should be focused on the different sources of barriers: the caregiver, the patient and the organization of care.

The uptake and costs of guidelines for stroke in a district of southern England.

STUDY OBJECTIVE: To assess the impact of guidelines for stroke management on the utilisation of services by patients and the cost consequences of implementation. DESIGN: Prospective audit. SETTING: District health...

Cooperative stroke management project by a peer-review organization

To improve the care of patients in Mississippi through increased adherence to nationally accepted ischemic stroke management guidelines, patterns for ischemic stroke services were determined from hospital chart review. Hospital-specific education and data feedback were performed to encourage international systems improvements. The Mississippi Foundation for Medical Care, Inc, reviewed records of Medicare beneficiaries discharged with the principal diagnosis of acute ischemic stroke from four hospitals over a 1-year period. Records were analyzed for compliance with stroke management guidelines. Hospital-specific and aggregate data were presented to the staffs of each hospital and the hospitals were encouraged to develop internal quality improvement projects. The Foundation reviewed 427 records of acute stroke patients, of whom 375 (87.8%) had ischemic stroke. Among the 427 stroke patients, there were 76 (17.8%) in-hospital deaths. Notable variances from the ischemic stroke management guidelines included those for emergent hypertension management, deep vein thrombosis prophylaxis, evaluation for cause of ischemic stroke, and use of antithrombotic therapy on discharge of ischemic stroke patients. Thus, the management of acute stroke patients in these four regional hospitals in Mississippi often differed from nationally accepted guidelines. We hope to improve the care of stroke patients by using the expertise of academic stroke physicians and hospital-specific analyses that are personally meaningful but not personally threatening to treating physicians.