National Stroke Service Model: Integrated Stroke Delivery Networks in Secondary Care

Overview

This specialist Guidelines summary covers elements of NHS England and NHS Improvement guidance on integrated stroke delivery networks (ISDNs). It offers best practice guidance in caring for adult (more than 16 years of age) stroke patients, including acute and hyper-acute stroke care, transient ischaemic attack (TIA) services, early supported discharge (ESD), and rehabilitation.

This summary is for secondary care cardiology professionals. For further information, refer to the full guideline.

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Hyper-Acute Stroke Care

• Hyper-acute care typically covers the first 72 hours after admission
• Every patient with acute stroke should gain rapid access to a stroke unit (in less than 4 hours) and receive an early multidisciplinary assessment
• The recommendations detailed in the section Acute Stroke Care also apply to hyper-acute care, unless stated otherwise.

Neurovascular Imaging

• ISDNs should ensure that there is a networked agreement to the pivotal role of rapid imaging using the most appropriate modality, and that this aligns with up-to-date evidence and national guidance
• The use of artificial intelligence (AI) in stroke care should be encouraged and deployed in line with its certified and pre-specified use, or within a research environment
• Image sharing between centres within and external to each ISDN should be optimised to provide timely patient-centred decisions, and to align with the integrated care system (ICS) imaging networks
• A national optimal stroke imaging pathway has been developed (Figure 1).

Figure 1: National Optimal Stroke Imaging Pathway

Clinical Assessment

• All patients (including self/GP/ambulance referrals) with suspected stroke are to be admitted to a hospital with an acute stroke centre (ASC) or comprehensive stroke centre (CSC) service
• There, appropriately trained staff in a consultant-led stroke team will provide immediate, structured assessment to determine diagnosis, suitability for thrombolysis or thrombectomy, rehabilitation, and ongoing care needs
• All patients with suspected acute stroke should receive the most appropriate brain imaging and interpretation as soon as possible and within 60 minutes of arrival, with immediate networked arrangements for image sharing and review by relevant specialists.

On Diagnosis of Stroke

• All patients presenting with acute stroke should be treated as the highest priority of medical emergency, with emergency protocols in place
• To optimise treatment, all patients must be admitted directly to a stroke unit and receive early multidisciplinary assessment that involves, as a minimum, stroke specialist nursing input, stroke specialist medical input, and swallow screening within 4 hours
• All patients should be seen by a stroke specialist clinician within 60 minutes of arrival
• Patients should be assessed by all specialist therapists (physiotherapist, occupational therapist, speech and language therapist) within 24 hours of admission
• Patients presenting with stroke may be under specialist medical care for other significant co-morbidities, so careful and early collaboration between the hyper-acute stroke team and specialist teams is needed to determine the correct treatment plan. 

Thrombolysis

• Intravenous thrombolysis should be provided 24/7 to stroke patients deemed suitable for this, with an appropriate protocol in place to screen patients against the medical criteria for thrombolysis
• Stroke patients should be scanned, assessed by a stroke specialist and, if appropriate, receive thrombolysis within 60 minutes, and ideally within 20 minutes of admission (door to needle time)
• 24/7 access to perfusion brain imaging (magnetic resonance perfusion or computed tomographic perfusion [CTP]) should be available, with rapid interpretation to support decision-making. AI and off-site expertise can support this where appropriate
• Thrombolysis should be provided to all appropriate patients. Up to 20% of stroke admissions across the ISDN may be amenable to this.

Thrombectomy

• Thrombectomy must be provided as soon as possible to all appropriate patients, in line with NICE guidance to maximise patient benefit
• 24/7 emergency intra-hospital thrombectomy transfer pathways must be in place for all ASC. Repatriation flows must also be established, agreed, and supported by the whole system
• All potential thrombectomy patients should have a computed tomography angiogram (CTA) as part of their initial brain scan, with image interpretation for thrombectomy referral completed by the referring team, supported by AI and off-site expertise, as required
• Thrombectomy should be provided to all appropriate patients. Up to 10% of stroke admissions across the ISDN may be amenable to this.

Intracerebral Haemorrhage

• Rapid medical management of intracerebral haemorrhage (ICH) must be available 24/7, with evidence-based interventions initiated within the first hour of a patient reaching hospital:
  • reversal of anticoagulation therapy where appropriate
  • lowering of blood pressure in line with current guidance (ISDN annual review)
  • referral to a neurosurgical centre for consideration of intervention, considering location and calculation of intracerebral volume. Clear referral protocols in line with current guidance (ISDN annual review) should be in place, and routine referral avoided
  • consideration of referral to intensive therapy units to support cardiorespiratory and renal systems while the definitive treatment plan is finalised
  • consideration of end-of-life care where appropriate, for example, for catastrophic events
• Regular neurological observation is needed, with 24/7 access to repeat brain imaging within one hour of any further deterioration.

Monitoring and Mobilisation

• Protocols must be in place to ensure appropriate monitoring of all patients by stroke-trained staff during the entire hyper-acute phase. This includes daily senior stroke specialist medical ward rounds
• Early mobilisation must only be offered, if at all, within 24 hours to patients who require minimal support to mobilise.

Exclusion Criteria

• While all patients should be offered emergency assessment and scanning, with due consideration of recurrent stroke risk and benefit of hyper-acute stroke care, patients who are more than 24 hours after onset of symptoms may benefit less from some elements of hyper-acute care.

Access to and Interdependence with Other Services/Providers

• Hyper-acute services must have on-site access to the following support services and clinical interpretation:
  • urgent brain imaging, with patients scanned in the next scan slot (ideally within 20 minutes and a maximum of 60 minutes) and skilled interpretation available 24/7, supported where necessary and appropriate by AI
  • vessel imaging and assessment of salvageable penumbra, for example CTA/CTP, should be considered in line with symptoms, and ideally as part of the first brain scan on admission (see Figure 1). All other patients should be able, where clinically appropriate, to access extracranial vessel imaging within 24 hours of admission, alternatives being ultrasound of the carotids or magnetic resonance angiography 
• Effective and timely referrals to specialist neurosurgical and vascular procedures are sometimes necessary to prevent further damage following a stroke or a second stroke. Networks must ensure that images are immediately available to these services
• Where appropriate, neurosurgical services must be provided as early as possible, with rapid recognition of the need for surgical intervention.

Neurovascular Surgical Services

• All patients with a suspected non-disabling stroke or TIA must have urgent access to neurovascular surgical services, including carotid intervention (for example, carotid endarterectomy):
  • for recently symptomatic significant carotid stenosis (according to validated criteria), carotid intervention should be regarded as an urgent procedure and performed within 7 days of symptom onset, where the patient is neurologically stable and it is clinically appropriate
  • patients with a non-disabling stroke or TIA who require carotid endarterectomy should be admitted for urgent investigation and, if appropriate, carotid surgery should be available within 48 hours and at least 7 days of radiological confirmed diagnosis
  • access to tertiary services on-site or off-site. For off-site services, clear protocols must be in place for a commissioned pathway of care.

Neurosurgical Services

• There are relatively few indications for neurosurgical intervention in patients with stroke, however some specific stroke patients may require urgent management
• In particular, arrangements for the monitoring and transfer of patients with ICH and those at risk of malignant middle cerebral artery syndrome should be in place across the ISDN and delivered in line with current national guidelines (ISDN annual review).

Acute Stroke Care

• Acute stroke care immediately follows the hyper-acute phase, usually 72 hours after admission. Acute stroke care services provide continuous specialist input, with daily multidisciplinary care and continued access to stroke-trained consultant care, physiological monitoring, and urgent imaging, as required
• The following recommendations also apply to hyper-acute stroke care, unless otherwise stated
• All stroke patients should have access to high-quality stroke care, and for most of their time in hospital should be under specialist stroke care, with access to:
  • early and regular communication with them and their nominated relative or carer about diagnosis, interventions, prognosis, and transfer of care plans
  • stroke inpatient rehabilitation (see below)
  • stroke-trained nursing at all times
  • daily senior decision-making capable ward rounds at consultant or equivalent level at least 5 days a week, and within 24 hours of repatriation or admission to a new unit or team
  • protocols for timely receipt and discharge of patients 7 days a week
  • a stroke trained multidisciplinary team (MDT) available 7 days a week
  • a venous thromboembolism (VTE) risk assessment with appropriate prescription and administration of intermittent pneumatic compression where justified in accordance with NICE recommendations, and regular review of VTE risk and management based on changes in mobility and time since the stroke event, using a stroke-specific decision support aid
  • assessment or treatment by all appropriate specialist therapists (physiotherapist, occupational therapist, speech and language therapist) within 24 hours of admission, and others (for example, dietitian, orthoptist) within 72 hours
  • protocols for the promotion of bladder and bowel continence, including a policy to avoid use of urinary catheters and a policy for prevention of pressure sores
  • reassessment if loss of bladder control continues 2 weeks after diagnosis, and by week 3 for an ongoing treatment plan that has involved patients and carers to be jointly agreed
  • comprehensive secondary prevention advice and treatment with interventions to improve adherence and persistence with medication and lifestyle modification
  • a dysphagia management service, including best interest meetings, where appropriate, and access to services to insert a gastrostomy tube, where indicated, within 72 hours of decision
  • a formal discharge summary report must be shared with the referrer, GP, and patient, with a named contact (if requested) for the day of transfer of care
  • 6-week follow-up; for most patients this need not be from a medically qualified individual, but must include the capability to confirm the diagnosis, interventions received, prognosis, secondary prevention investigations undertaken and measures instituted, and medication adherence, along with an understanding of the condition and patient reported outcomes.

Transient Ischaemic Attack Services

• TIA services should provide a full and rapid diagnostic assessment urgently, without risk stratification and within 24 hours of referral
• This applies only to patients who through triage are deemed likely to have had a TIA; other patients who require review should be seen within 1 week or signposted to more appropriate clinics
• After specialist assessment in the TIA clinic, consider magnetic resonance imaging (MRI), including diffusion-weighted and blood-sensitive sequences, to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies. If MRI is done, perform it on the same day as the assessment
• Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could detect
• Referrers should discontinue the use of risk stratification tools, for example, ABCD2, to triage patients. All patients with suspected TIA must be assessed, diagnosed, and treated urgently, and within 24 hours of initial contact, via a 365-day service
• Patients with non-disabling stroke or TIA should receive treatment for secondary prevention in line with best practice (ISDN annual review), as soon as the diagnosis is confirmed
• Some who have had a TIA may have care and support needs beyond secondary prevention; it is the TIA service’s responsibility to help them access any care, support, information, and advice they require
• Patients whose suspected TIA occurred more than 1 week ago should be assessed by a specialist clinician as soon as possible, and at least within 7 days.

Rehabilitation

• People who have had a stroke should have timely access to high quality rehabilitation appropriate to their need and desired outcomes
• Patients must have a rapid initial multidisciplinary assessment to begin building a personalised rehabilitation plan, which must then be started as soon as clinically appropriate
• The MDT must work in partnership with the stroke survivor and those important to them, so they can maximise their recovery, independence, and overall quality of life
• Inpatient rehabilitation services, ESD, and community stroke/neuro rehabilitation services should work very closely together:
  • they must ensure that their patients receive:
    • physiotherapy
    • occupational therapy
    • speech and language therapy
    • vocational rehabilitation
    • psychological rehabilitation
    • life after stroke support
  • they must also ensure that their patients can promptly access other specialist clinical services as needed, such as orthoptics and dietetics
• High quality therapy should be offered 7 days a week to all patients and by all required core clinical disciplines at an appropriate intensity to meet each individual’s rehabilitation goals
• Patients should receive patient-centred care, and be enabled and empowered to meaningfully participate in their rehabilitation
• All patients with stroke-related rehabilitation goals that can be met with greater intensity in an inpatient rehabilitation setting than in a community setting are eligible for inpatient rehabilitation
  • This includes patients who are receiving palliative and end-of-life care (including access to therapy and specialist services where appropriate)
  • When deciding whether such a patient would benefit from being offered inpatient stroke rehabilitation, this should be assessed and discussed on an individual basis and recorded in a personalised care and support plan
  • ESD must be available in all areas to facilitate early transfer of care to a community setting, where rehabilitation continues at the same intensity and with the same expertise as in the inpatient setting. 

Psychological Rehabilitation and Support

• Psychological and neuropsychological rehabilitation must be routinely available as part of the core service provision throughout the patient journey
• The entire MDT must address the psychological, emotional, cognitive, and neuropsychological effects commonly experienced by stroke survivors; these can greatly impact a person’s engagement with rehabilitation, function, ability to return to work and, ultimately, quality of life
• Throughout care planning, clinicians and providers on the patient pathway should collaborate to address the patient’s psychological needs
• When required, specialist assessments and appropriate interventions should be sought from psychology services to meet needs and personalised goals, supporting the best possible patient experience and outcomes
• High quality psychological screening, assessment, and personalised interventions should be offered and tailored appropriately for all levels of need throughout the entire patient pathway. This includes all staff at every patient contact routinely monitoring changes in cognition, behaviour, emotional state, mental health, and associated mood disorders
• Establishing clinical psychologists or clinical neuropsychologists with stroke expertise as core members of the stroke team will enhance rehabilitation outcomes and patient experience. Access to senior decision-maker support and guidance, as well as interventions, will empower the MDT to provide seamless psychological support to patients throughout their rehabilitation.