Clinical Management of Acute Stroke: The Acute Stroke Clinical Care Standard

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Published: 21 February 2021

In 2017, there were about 38,000 stroke events in Australia. That’s more than 100 strokes every day (AIHW 2020).

Stroke is a leading cause of disability and accounts for about 5.3% of deaths in Australia, making it one of the five most common underlying causes of mortality (ACSQHC 2019; AIHW 2020).

Stroke is a medical emergency. Surviving and recovering from a stroke is reliant on rapid recognition and treatment, as there is only a narrow window of time during which interventions will work effectively (ACSQHC 2019).

Despite this, data from 2015 found that only 34% of stroke patients presented to hospital within three hours of symptom onset (ACSQHC 2019).

While stroke care in Australia has been improving, there are still issues that need to be addressed. The Acute Stroke Clinical Care Standard aims to facilitate continuous improvement and ensure patients receive the most effective care possible (ACSQHC 2019).

What is a Stroke?

Read: Different Types of Strokes

Risk Factors for Stroke

There are both modifiable (able to be changed) and non-modifiable (unable to be changed) risk factors for stroke.

Modifiable risk factors include:

  • Smoking
  • Lack of exercise
  • Unhealthy diet
  • High cholesterol
  • Medical conditions such as type 2 diabetes mellitus and atrial fibrillation.

(Healthdirect 2020)

Non-modifiable risk factors include:

  • Being over 65 years of age
  • Family history of stroke
  • Being male.

(Healthdirect 2020)

acute stroke risk factors
Some risk factors for stroke, such as being male and over 65, are non-modifiable.

Acute Stroke Care in Australia

While the death rate of stroke is decreasing in Australia, there are other issues related to stroke care in Australia:

  • Less than half of stroke patients spend the majority of their acute hospital stay in a stroke unit.
  • Over 30% of stroke patients do not receive a physiotherapy assessment within 48 hours of admission.
  • Many stroke patients do not receive reperfusion therapy, which may be lifesaving.
  • Australian stroke patients receive less timely thrombolysis than patients in the United States and the United Kingdom.

(ACSQHC 2019)

What is Reperfusion Treatment?

Reperfusion treatments are used to treat ischaemic stroke by restoring blood flow and oxygen supply to the area of the brain affected by the blockage. Reperfusion treatments include:

  • Thrombolysis, where medicine (such as alteplase) is used to break up and dissolve the blood clot. The medicine is usually administered intravenously.
  • Endovascular thrombectomy (also known as endovascular clot retrieval), where the clot is surgically removed using imaging guidance. The procedure involves inserting a catheter into a large vessel, which is fed up to the blockage site in the brain. A wire stent or device is then used to remove the clot, restoring blood flow.

(ACSQHC 2019; Stroke Foundation 2017; Better Safer Care 2019)

Acute Coronary Syndromes Clinical Care Standard

In 2019, the Australia Commission on Safety and Quality in Health Care released the Acute Stroke Clinical Care Standard. This standard aims to improve stroke care in Australia, with a goal of:

  • Improving early assessment and management of acute and subacute stroke
  • Increasing survival from stroke
  • Maximising recovery from stroke
  • Decreasing the risk of future stroke.

(ACSQHC 2019)

The standard contains seven quality statements related to the recognition, assessment and management of acute stroke:

1. Early Assessment

acute stroke early assessment symptoms

Patients experiencing a suspected stroke should be assessed immediately using a validated screening tool. An example is the F.A.S.T. (Face, Arm, Speech and Time) test:

F - Face Has the patient’s mouth drooped?
A - Arm Is the patient able to lift both arms?
S - Speech Is the patient’s speech slurred? Can they understand you?
T - Time Call 000 immediately if the patient is displaying any of the above signs.

(ACSQHC 2019)

Other screening tools include:

  • National Institutes of Health Stroke Scale (NIHSS)-8
  • The Modified Rankin Scale (mRS)

(QAS 2020)

Other potential symptoms of stroke include:

  • Weakness or paralysis (one or both sides of the body)
  • Loss of sensation (usually on one side of the body only)
  • Loss of vision or blurred vision (one or both eyes)
  • Severe, sudden headache
  • Dizziness, loss of balance or unexplained fall
  • Swallowing difficulties.

(Healthdirect 2020)

Be aware that the symptoms of stroke may mimic:

  • Drug or alcohol-related symptoms
  • Brain tumour
  • Seizure or post-seizure
  • Migraine
  • Syncope
  • Middle ear disorder.

(Ambulance Victoria 2019)

2. Time-Critical Therapy

Patients experiencing suspected ischaemic stroke are offered reperfusion treatment as soon as possible if:

(ACSQHC 2019)

When considering reperfusion, the following factors should be taken into account:

  • Comorbidities
  • The patient’s circumstances and preferences
  • Potential risks and benefits.

(ACSQHC 2019)

Reperfusion treatment is time-critical (ACSQHC 2019). It is therefore essential to note the time of symptom onset (Ambulance Victoria 2019). Refer to Chapter 3 of the Clinical Guidelines for Stroke Management for specific treatment timeframes.

3. Stroke Unit Care

Patients experiencing stroke should be treated in a specialised stroke unit by an interprofessional team. This may comprise:

  • Doctors
  • Nurses
  • Physiotherapists
  • Speech pathologists
  • Occupational therapists
  • Dietitians
  • Social workers
  • Pharmacists.

(ACSQHC 2019)

Ideally, patients should be admitted to the unit within three hours of symptom onset (ACSQHC 2019).

4. Early Rehabilitation

Read: Post-Stroke Management and Care

Patients’ individual rehabilitation needs should be assessed within 24 to 48 hours of hospital admission. This assessment should be performed using an assessment tool such as the Australian Stroke Coalition’s Assessment for Rehabilitation: Pathway and Decision-Making Tool (ACSQHC 2019).

Assessment should help determine when discharge is appropriate and whether the patient needs to be referred onwards (ACSQHC 2019).

Patient rehabilitation should be commenced during acute care, when clinically appropriate. Avoid intensive mobilisation within 24 hours of stroke onset (ACSQHC 2019).

acute stroke rehabilitation

5. Minimising Risk of Another Stroke

It is estimated that 40% of people who have had a stroke will go on to experience another within the next 10 years, with the first year after a stroke being the most high-risk timeframe. However, over 80% of strokes are preventable (Stroke Foundation 2018; Ausmed 2020).

Patients should be advised on how to reduce modifiable risk factors. This may involve:

  • Smoking cessation
  • Maintaining a balanced diet
  • Regular physical activity
  • Weight loss
  • Limiting alcohol consumption.

(Stroke Foundation 2017)

Patients may also be prescribed medicines such as antihypertensives, antithrombotics or lipid-modifying therapy (ACSQHC 2019).

Refer to Chapter 4 of the Clinical Guidelines for Stroke Management for a comprehensive overview of medicines and treatments for secondary prevention.

6. Carer Training and Support

Carers should receive education and practical training on how to care for patients who have experienced a stroke. This may comprise:

  • Personal care techniques
  • Communicating with the patient
  • Physical handling
  • Swallowing assistance
  • Dietary modifications
  • Emotional wellbeing.

(ACSQHC 2019)

Carers should also be given contact information for relevant support services prior to patient discharge (ACSQHC 2019).

7. Transition From Hospital Care

Prior to discharge, patients who have experienced a stroke should work with clinicians to develop an individualised care plan containing:

  • The patient’s goals
  • Lifestyle changes to manage risk factors
  • Medicines to manage risk factors
  • Required equipment
  • Follow-up appointments
  • Referral to rehabilitation services, prevention services and other community support services.

(ACSQHC 2019)

Within 48 hours of discharge, a copy of this plan should be forwarded to the patient and their general practitioner or ongoing clinical provider (ACSQHC 2019).

Additional Resources


References

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