1. Implementing NICE guidance
Stroke
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)’. This guideline has been written for healthcare professionals involved in the initial management of patients with an acute stroke or TIA.
The guideline is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on or sending an to Quote reference number N1621. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.
You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. Where necessary, the recommendation will be given in full. Please feel free to adapt, amend or remove these as you see necessary.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
2008
NICE clinical guideline 68

2. What this presentation covers
Introduction
Scope
Key priorities for implementation
Costs and savings
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing an introduction and a definition of the guideline scope and why it is important.
The NICE guideline contains six key priorities for implementation, which you can find in your quick reference guide.
Costs and savings that are likely to be incurred in implementing the guideline are summarised, followed by a suggested list of questions to help prompt discussion.
Information on how to find out more about the support provided by NICE is given at the end of this presentation.

3. Introduction Stroke is a major health problem in the UK
Each year in England:
110,000 people have a first or recurrent stroke
a further 25,000 people have a TIA
Over 900,000 people are living with the effects of stroke
Estimated annual cost of stroke is around £7 billion
NOTES FOR PRESENTERS:
Key points to raise:
Stroke is a preventable and treatable disease. Over the past two decades a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of aging that inevitably results in death or severe disability. Evidence is accumulating for more effective primary and secondary prevention strategies, better recognition of people at highest risk and interventions that are effective soon after the onset of symptoms. Understanding of the care processes that contribute to a better outcome has improved, and there is now good evidence to support interventions and care processes in stroke rehabilitation.
Stroke accounted for over 56,000 deaths in England and Wales in 1999, which represents 11% of all deaths [1]. Most people survive a first stroke, but often have significant morbidity.
Of the more than 900,000 people in England living with the effects of stroke, half are dependent on other people for help with everyday activities [2].
The estimated £7 billion per year cost to the economy comprises direct costs to the NHS of £2.8 billion, costs of informal care of £2.4 billion and costs because of lost productivity and disability of £1.8 billion [1].
Additional information:
Symptoms of stroke include numbness, weakness or paralysis, slurred speech, blurred vision, confusion and severe headache. Stroke is defined by the World Health Organization [3] as a clinical syndrome consisting of ‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin’. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. However, there are limitations to these definitions. For example, they do not include retinal symptoms (sudden onset of monocular visual loss), which should be considered as part of the definition of stroke and TIA. The symptoms of a TIA usually resolve within minutes or a few hours at most, and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke. The term ‘brain attack’ is sometimes used to describe any neurovascular event and may be a clearer and less ambiguous term to use. A non-disabling stroke is defined as a stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability.
References:
[1] Mant J, Wade DT, Winner S (2004) Health care needs assessment: stroke. In: Stevens A, Raftery J, Mant J et al., editors, Health care needs assessment: the epidemiologically based needs assessment reviews, First series, 2nd edition. Oxford: Radcliffe Medical Press, p141–244.
[2] National Audit Office (2005) Reducing brain damage: faster access to better stroke care. (HC 452 Session 2005–2006). London: The Stationery Office.
[3] Hatano S (1976) Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organization 54: 541–53.

4. Scope The guideline covers the initial care of people over
16 years with TIA or completed stroke
It gives recommendations for:
primary and secondary healthcare settings, including referral to tertiary care
pre-hospital emergency care settings, including ambulance services
NOTES FOR PRESENTERS:
Key points to raise:
This guideline covers interventions in the acute stage of a stroke (‘acute stroke’) or TIA aimed at reducing the ischaemic brain damage, and in the case of TIA, preventing subsequent stroke.
Most of the recommendations relate to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered.
The Intercollegiate Stroke Working Party (ICSWP) National Clinical Guidelines for Stroke (published July 2008), which is an update of the 2004 edition, includes all of the recommendations from the NICE guideline.
This NICE guideline should also be read alongside the Department of Health National Stroke Strategy [1]. There are some differences between the recommendations made in the NICE guideline and those in the National Stroke Strategy. However, the NICE Guideline Development Group (GDG) feel that their recommendations are based on evidence derived from all of the relevant literature as identified by systematic methodology.
Additional information:
The guideline cross-refers to: Clopidogrel and modified-release dipyridamole in the prevention of occlusive vascular events. NICE technology appraisal guidance 90 (2005).
The guideline includes the following recommendation from ‘Alteplase for the treatment of acute ischaemic stroke’ (NICE technology appraisal guidance 122, 2007):
[1] Department of Health (2007) National Stroke Strategy. London: Department of Health.
[2] See NHS Data Dictionary, ‘Critical care level’ [online]. Available from:
[3] In accordance with its marketing authorisation.

5. Key priorities for implementation
Rapid recognition of symptoms and diagnosis
Specialist care for people with acute stroke
Nutrition and hydration
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into three areas of key priority and within these there are six recommendations that we will consider in turn.

6. Rapid recognition of symptoms and diagnosis
Use the FAST tool to screen for stroke or TIA outside hospital
NOTES FOR PRESENTERS:
Key points to raise:
There is evidence that rapid treatment improves outcome after stroke or TIA.
Additional information:
Hypoglycaemia should be excluded as the cause of sudden-onset neurological symptoms.
The diagnosis in people who are admitted to accident and emergency (A&E) with a suspected stroke or TIA should be rapidly established using a validated tool such as ROSIER (Recognition of Stroke in the Emergency Room).
Recommendation in full:
In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA.
Reproduced with permission from The Stroke Association

7. Rapid recognition of symptoms and diagnosis
Ensure that people who have had a suspected TIA who are at high risk of stroke (ABCD2 score of 4 or above) have:
aspirin (300 mg) started immediately
specialist assessment and investigation within 24 hours of symptom onset
measures for secondary prevention introduced
Treat all people with crescendo TIA as being at high risk of stroke
NOTES FOR PRESENTERS:
Recommendations in full:
People who have had a suspected TIA who are at high risk of stroke (that is, with an ABCD2 score of 4 or above) should have:
aspirin (300 mg daily) started immediately
specialist assessment [1] and investigation within 24 hours of onset of symptoms
measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors.
People with crescendo TIA (two or more TIAs in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.
[1] Specialist assessment includes exclusion of stroke mimics, identification of vascular treatment, identification of likely causes, and appropriate investigation and treatment.
Additional Information:
Other recommendations that relate to this point of the guidance are:
People with a suspected TIA should be assessed for their risk of subsequent stroke using a validated scoring system, such as ABCD2. ( )
People with a suspected TIA who are at low risk of stroke (e.g. an ABCD2 score of less than 4) should receive:
• immediate initiation of aspirin
• specialist assessment as soon as possible, but definitely within 1
week of onset of symptoms
• commencement of secondary prevention as soon as the
diagnosis is confirmed. ( )

8. Specialist care for people with acute stroke (1)
Admit anyone with a suspected stroke directly to a specialist acute stroke unit following initial assessment, from the community or from A&E
NOTES FOR PRESENTERS:
Key points to raise:
An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting.
Recommendation in full:
All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment, either from the community or from the A&E department.

9. Specialist care for people with acute stroke (2)
Perform brain imaging immediately if any of these apply:
- indications for thrombolysis or early anticoagulation treatment
- on anticoagulant treatment
- a known bleeding tendency
- a depressed level of consciousness
- unexplained progressive or fluctuating symptoms
- papilloedema, neck stiffness or fever
- severe headache at onset of stroke symptoms
Otherwise brain imaging should be performed as soon as possible
NOTES FOR PRESENTERS:
Key points to raise:
The GDG felt that ‘immediately’ is defined as ‘ideally the next slot and definitely within 1 hour, whichever is sooner’, in line with the National Stroke Strategy.
Additional information:
For all people with acute stroke without indications for immediate brain imaging, scanning should be performed as soon as possible.
The GDG felt that ‘as soon as possible’ is defined as ‘within a maximum of 24 hours after onset of symptoms’.
Recommendation in full:
Brain imaging should be performed immediately for people with acute stroke if any of the
following apply:
indications for thrombolysis or early anticoagulation treatment
on anticoagulant treatment
a known bleeding tendency
a depressed level of consciousness (Glasgow Coma Score below 13)
unexplained progressive or fluctuating symptoms
papilloedema, neck stiffness or fever
severe headache at onset of stroke symptoms.

10. Specialist care for people with acute stroke (3)
Thrombolysis with alteplase:
– administer within a well-organised stroke service
– may be used in A&E with appropriate training and support
– protocols should be in place for delivery and management of thrombolysis
NOTES FOR PRESENTERS:
Key points to raise:
Recommendation in full:
Alteplase is recommended for the treatment of 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 [1].
The guideline also provides additional context-specific guidance, which is now more explicit:
Alteplase should be administered only within a well-organised stroke service with:
staff trained in delivering thrombolysis and in monitoring for any complications associated with thrombolysis
level 1 and level 2 nursing care staff trained in acute stroke and thrombolysis
immediate access to imaging and re-imaging, and staff trained to interpret the images.
Staff in A&E departments, if appropriately trained and supported, can administer alteplase [2] for the treatment of acute ischaemic stroke provided that patients can be managed within an acute stroke service with appropriate neuroradiological and stroke physician support.
Protocols should be in place for the delivery and management of thrombolysis, including post-thrombolysis complications.
[1] This recommendation is from NICE technology appraisal guidance 122 ‘Alteplase for the treatment of acute ischaemic stroke’.
[2] In accordance with its marketing authorisation.

11. Nutrition and hydration
Screen swallowing on admission before giving any oral food, fluid or medication
NOTES FOR PRESENTERS:
Recommendation in full:
On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication.
Additional information:
If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards.
People with suspected aspiration on specialist assessment, or who require tube feeding or dietary modification for 3 days, should be:
re-assessed and considered for instrumental examination
referred for dietary advice.
People with acute stroke who are unable to take adequate nutrition and fluids orally should:
receive tube feeding with a nasogastric tube within 24 hours of admission
be considered for a nasal bridle tube or gastrostomy if they are unable to tolerate a nasogastric tube
be referred to an appropriately trained healthcare professional for detailed nutritional assessment, individualised advice and monitoring.
All hospital inpatients on admission should be screened for malnutrition and the risk of malnutrition. Screening should be repeated weekly for inpatients [1].
All people with acute stroke should have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained.
There are a number of other recommendations about nutrition and hydration in the guideline – see pages of the quick reference guide for more details.
[1] This recommendation is adapted from ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ (NICE clinical guideline 32).

12. Costs and savings
The guideline on stroke is likely to result in a significant change in resource use in the NHS:
assessment of people who have had a suspected transient ischaemic attack (TIA), and identifying those at high risk of stroke
magnetic resonance imaging for people who have had a suspected TIA
referral for carotid endarterectomy
admission to a specialist stroke unit
performing brain imaging immediately where indicated for people with acute stroke.
NOTES FOR PRESENTERS:
NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline, and identified 5 recommendations that are likely to have significant resource consequences. However, different areas may vary from the national average and it is important to scrutinise the recommendations likely to have the most significant resource impact locally to make sure that practice matches the national average.
These recommendations are:
assessment of people who have had a suspected transient ischaemic attack (TIA), and identifying those at high risk of stroke
magnetic resonance imaging for people who have had a suspected TIA
referral for carotid endarterectomy
admission to a specialist stroke unit
performing brain imaging immediately where indicated for people with acute stroke.
The National Stroke Strategy, published by the Department of Health in December 2007, was accompanied by an ‘Impact assessment’ document, which sets out the major costs and benefits that may result from implementation of the strategy. The NICE costing report has not quantified the impact of recommendations that are consistent with the National Stroke Strategy. The NICE costing report and template only give detailed costings for carotid endarterectomy, and therefore should be used in conjunction with the Department of Health’s ‘Impact Assessment’ and not in isolation.

13. For discussion
How do you assess staff competence in the use of methods for rapid recognition of symptoms of stroke or TIA?
How can you ensure that staff are aware of the benefits of providing emergency care for a patient with a stroke or TIA?
How can you ensure that the imaging recommendations are followed 24 hours a day?
What systems do you have in place to ensure there are enough trained staff to provide a swallowing test on admission?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

14. Find out more Visit www.nice.org.uk/CG068 for: Other guideline formats
Costing report and template
Audit support
NOTES FOR PRESENTERS:
The guideline is available in a number of formats.
The quick reference guide – which summarises the guidance.
The NICE guideline – which includes all of the recommendations in full.
The full guideline – which includes all of the evidence and rationale.
‘Understanding NICE guidance’ – a version for patients and carers.
You can download these from the NICE website or order printed copies of the quick reference guide and ‘Understanding NICE guidance’ by calling NICE publications on or by sending an to Quote reference number N1621. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation.
Audit support – assists NHS trusts to determine how well they meet NICE recommendations.