Hyperacute *NEW!

4th Edition
2012-2013 UPDATE
May 23, 2013

Taking Action in Hyperacute Stroke Care

Taking Action is an imperative across stroke systems of care, healthcare providers, patients, families, and the broader community. The primary underpinnings of ‘hyperacute stroke care’ are to RECOGNIZE and MOBILIZE. This starts with recognition of stroke symptoms by patients, families and bystanders. Mobilization has to occur without delay, from emergency medical services response to a new stroke patient, transport to hospitals with specialized stroke services, rapid access to neuroimaging, stroke specialists and time-sensitive treatments, such as acute thrombolysis. A coordinated and seamless system taking all these components into account will minimize the time from stroke symptom onset (time last known well) to arrival at a hospital providing specialized stroke diagnostic and intervention services and lead to better outcomes.

Taking Action for hyperacute care requires all healthcare professionals involved in this phase to have specialized stroke training, develop knowledge and skills for competent and efficient care delivery, and function as an integrated and seamless team. The hyperacute stroke team involves a range of providers from both the community and several hospital departments. Key team members during the hyperacute phase include primary care when patients with symptoms initially present to a community physician or nurse practitioner, emergency medical service professionals, emergency department physicians and nurses, stroke neurologists, diagnostic imaging, laboratory services, pharmacists, intensive care specialists, neuroradiologists, neurosurgeons and social workers. Several other specialists may be required in the hyperacute phase to meet the needs of individual patients and their unique clinical presentations. Communication among these professionals and departments are paramount to coordinated hyperacute care, and protocols and agreements should be in place for high priority rapid access to all specialists, departments and services required for each stroke patient to optimize outcomes and meet patient and family needs in the immediate post stroke time frame.

The Quality of Stroke Care in Canada (2011), which reported current levels of performance on key quality stroke indicators, found that more than one-third of stroke patients do not contact emergency medical services for transport to hospital, and only just over 30% of stroke patients arrived at hospital within the 3.5 hour time frame to be eligible for acute thrombolysis. Time to brain imaging was prolonged, and on average the time from arrival at hospital to tPA administration was greater than 60 minutes; exceeding the current one hour target for door-to-needle time. Taking Action in hyperacute stroke care going forward aims to improve performance in these areas and thereby improve outcomes and reduces morbidity and long-term disability for all stroke patients.

Highlights of the Hyperacute Stroke Care Update 2013

The 2013 update of the Hyperacute Stroke Care Chapter of the Canadian Best Practice Recommendations for Stroke Care reinforces the growing and changing body of research evidence available to guide assessment, diagnosis and management in the first hours following a stroke.

Key messages for 2013 and significant changes to previous recommendations include:

strong emphasis on educating the public to call 911 or local emergency number to access emergency services for on-site assessment, management and transport to appropriate facilities providing advanced stroke services;
clarity on the critical role emergency medical services personnel play in all aspects of pre-hospital stroke care and communication with receiving hospital during transport;
need for essential coordination among all hospital departments and services involved in hyperacute care to reduce process delays to acute thrombolysis;
integration of the findings from the International Stroke Trial 3 (IST3) into thrombolysis recommendations and eligibility criteria;
new recommendations on the management of seizures in the hyperacute phase of care;
moderate updates to management of subarachnoid hemorrhage and Intracerebral hemorrhage patients in the first hours after onset, with stronger emphasis on the need for communication and coordination between the emergency department, stroke experts and neurosurgery services;
update on the management of blood pressure in the hyperacute phase of care for ischemic stroke, subarachnoid hemorrhage and Intracerebral hemorrhage;
new recommendations on the identification and evaluation of patients who may be candidates for hemicraniectomy;
new guidance on addressing palliative care issues in patients with severe stroke;
development of a Taking Action Towards Optimal Stroke Care resource kit including stroke care information, educational modules, summary tables and resource links.

Hyperacute Stroke Care Update 2013 Resource Package Includes:

Stroke Best Practice Recommendations for Hyperacute Stroke Care
Taking Action Towards Optimal Stroke Care resource kit, with implementation materials and educational slide decks for all topic areas
Hyperacute Stroke Care Assessment Tools Summary Tables
Links to implementation tools for all topic areas

Hyperacute and Acute Inpatient Stroke Care Definitions

Hyperacute and Acute Stroke care involves all direct care, service delivery and interactions from first contact with the healthcare system after the onset of an acute stroke to discharge from an emergency department or acute inpatient care, and moving on to the next stage of care or return to the community.

Hyperacute Stroke Care

Hyperacute care refers to the key interventions involved in the assessment, stabilization and treatment in the first hours after stroke onset. This represents all pre-hospital and initial emergency care for TIA, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and acute venous sinus thrombosis. This includes thrombolysis or endovascular interventions for acute ischemic stroke, emergency neurosurgical procedures, and same-day TIA diagnostic and risk stratification evaluation.

The principal aim of this phase of care is to diagnose the stroke type, and to coordinate and execute the treatment plan as rapidly as possible.

Hyperacute care is time-sensitive by nature, minutes for disabling stroke and hours for TIA, but specific interventions are associated with their own individual treatment windows. Broadly speaking ”hyperacute” refers to care offered in the first 24 hours after stroke (ischemic and hemorrhagic) and the first 48 hours after TIA.

Acute Stroke Care

Acute care refers to the key interventions involved in the assessment, treatment or management, and early recovery in the first days after stroke onset. This will represent all of the initial diagnostic procedures undertaken to identify the nature and mechanism of stroke, interprofessional care to prevent complications and promote early recovery, institution of an individualized secondary prevention plan, and engagement with the stroke survivor and family to assess and plan for transition to the next level of care (including a comprehensive assessment of rehabilitation needs). New models of acute ambulatory care such as rapid assessment TIA and minor stroke clinics or day-units are also starting to emerge.

The principal aims of this phase of care are to identify the nature and mechanism of stroke, prevent further stroke complications, promote early recovery, and (in the case of severest strokes) provide palliation or end-of-life care.

Broadly speaking “acute care” refers to the first days to weeks of inpatient treatment with stroke survivors transitioning from this level of care to either inpatient rehabilitation, community based rehabilitation services, home (with or without support services), continuing care, or palliative care. This acute phase of care is usually considered to have ended either at the time of acute unit discharge or by 30 days of hospital admission.

Canadian Stroke Best Practices Framework for Optimal Stroke Services Delivery

There are variations in the levels of stroke care service provided within the Canadian healthcare system. These services can be arranged along a continuum from minimal, non-specialized services provided in facilities that offer general medical and surgical care, to more advanced and comprehensive stroke care centres (See Figure 1). The goal for each organization involved in the delivery of stroke care services is to continue to develop the expertise and processes needed to provide optimal patient care, taking into consideration that organization’s geographic location, patient population, structural resources, and relationship to other centres within their healthcare region or system. Once a level of stroke services has been achieved, the organization should strive to develop and incorporate components of the next higher level for ongoing growth of stroke services where appropriate, as well as continuous quality improvement within the level of service currently provided.

Figure 1: Canadian Stroke Best Practices Framework for Optimal Stroke Services Delivery

For additional information and details about the Stroke Services Framework, please refer to the “Taking Action Towards Optimal Stroke Care” Resource.

Development of the Canadian Best Practice Recommendations for Stroke Care

For detailed methodology on the development and dissemination of the Canadian Best Practice Recommendations for Stroke Care please refer to the stroke best practices website at http://www.strokebestpractices.ca/index.php/methods/.

Acknowledgements

The Canadian Stroke Best Practices Team, Heart and Stroke Foundation and the Canadian Stroke Network gratefully acknowledge the writing group leaders and members, the external reviewers, all of who have volunteered their time and expertise to this update. We thank the Canadian Stroke Quality and Performance Advisory Group for their work in updating and confirming the performance measures that accompany each recommendation. We acknowledge Norine Foley and Katherine Salter for their work on implementation tool development. We are grateful to Dr. Robert Teasell, Andrew McClure and their team for work on the systematic reviews of the literature and evidence tables; and, we thank Marie-France Saint-Cyr and Jan Carbon for their work on the French translations. All participants complete a Conflict of Interest form and these are reviewed by the CSN privacy officer for risk assessment.

Funding

The development of these Canadian stroke care guidelines is funded in its entirety by the Canadian Stroke Network and the Heart and Stroke Foundation. No funds for the development of these guidelines come from commercial interests, including pharmaceutical companies. All members of the recommendation writing groups and external reviewers are volunteers and do not receive any remuneration for participation in guideline development, updates and reviews.

Citing the Hyperacute Stroke Care Update 2013

Casaubon LK, Suddes M, on behalf of the Acute Stroke Care Writing Group. Chapter 3: Hyperacute Stroke Care.

In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke Best Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care: 2013; Ottawa, Ontario Canada: Canadian Stroke Network and Heart and Stroke Foundation of Canada.

Comments

We invite comments, suggestions, and inquiries on the development and application of the Canadian Best Practice Recommendations for Stroke Care and ongoing updates.

Please forward comments to the Heart and Stroke Foundation Stroke Best Practices and Performance team at strokebestpractices@hsf.ca