Acute Stroke

Hyper-acute stroke care

Hyper-acute care typically covers the first 24 hours after admission.

Every person with acute stroke should gain rapid access to a stroke unit (<4 hours) and receive an early multidisciplinary assessment. Hyper-acute stroke services provide expert specialist clinical assessment and rapid multi-modal brain imaging, and the ability to deliver intravenous thrombolysis 24/7 transfer or treatment for thrombectomy.

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.

Acute Service Specifications

NZ Organised Acute Stroke Service Specifications

Prepared by the National Stroke Network to outline minimal standards and strongly recommended standards for DHBs. Date: August 2014.

Organised Acute Stroke Services are provided by a coordinated specialised interdisciplinary team (IDT) and consist of early and ongoing comprehensive assessments and treatment which is guided by best practice. This is reflected in the use of stroke specific protocols. The IDT meets regularly to discuss, formulate and implement patient management and optimise rehabilitation and patient function. Ideally care is provided in a geographically discrete unit, but depending on DHB size this may not always be feasible.

Organisation of systems that incorporate the ambulance service, emergency department, radiology department and stroke teams is therefore paramount to improving access to thrombolytic therapy. (NZ Clinical Guidelines for Stroke Management 2010)

The NSN have developed a set of acute service specifications for New Zealand DHBs to follow when designing their stroke services.

Accreditation is a process whereby health services can demonstrate that their patients are receiving a level of care consistent with recognised standards.

The NSN has developed process documents for Acute stroke centre accreditation - secondary level.

Download: Acute Stroke Centre Accreditation - secondary level - PDF, 273 KB

Accreditation allows health services to show that their patient care meets recognised standards.

Download: Acute Stroke Centre Accreditation table - PDF, 43 KB

Resources

F.A.S.T

F.A.S.T. is a really simple way to remember the signs of stroke. It stands for:

Face drooping
Arm weakness
Speech difficulties
Take action - call 111

To order New Zealand F.A.S.T awareness resources (external link) contact the New Zealand Stroke Foundation.

ACT F.A.S.T. is a community-led initiative to improve stroke outcomes. presented at the Long-Term Conditions Virtual Forum 2022.

Presentation: Models of Care Across the Motu: Sharing Innovation (external link).

Thrombolysis

The purpose of this National Working Group is to develop and implement a strategy that supports provision of a stroke thrombolysis service in all large and medium sized DHBs using clearly documented protocols and quality assurance measures.

For small DHBs it is expected a thrombolysis service is provided or a timely, effective pathway to access a service elsewhere.

Transient Ischaemic Attacks (TIA)

TIA stands for transient ischaemic attack.

A TIA is the same as a stroke, except that the signs last for a short amount of time and no longer than 24 hours.

Although the signs do not last long, a TIA is very serious. It means there is a problem linked with a high risk of stroke. More than one in 12 people will have a stroke within a week after a TIA.Transient Ischaemic Attacks or TIAs (warning strokes or mini-strokes)

A TIA is the same as a stroke, except that the signs last for a short amount of time and no longer than 24 hours.

Although the signs do not last long, a TIA is very serious. It means there is a problem linked with a high risk of stroke. More than one in 12 people will have a stroke within a week after a TIA.

Because of this, a TIA is often called a warning stroke or mini-stroke. It shouldn’t be ignored.

More information available on info.health website (external link)

Members of an Acute Stroke Team

Designated to stroke (not necessarily designated to stroke exclusively):

A stroke physician*
A stroke nurse*
Physiotherapist
Occupational Therapist
Speech and Language Therapist
Social worker

Clinicians that add significant value to stroke care, but are not mandatory designated members of the acute stroke team:

Dietician
Clinical Psychologist
Pharmacist

* Each centre should have a designated lead stroke physician and lead stroke nurse. However, for daily clinical activities several clinicians can share patient responsibilities on a rotating basis.

Education

Baseline qualifications yet to be defined.
Ongoing education should include a minimum of 8 hours of annual formal stroke education for each designated acute stroke team member
Provision of education to other staff working with stroke

Meetings/collaboration

Minimum IDT meeting once a week to discuss ongoing management, goal setting, and discharge planning

Offering key components of stroke management utilising protocols with specified time frames

Thrombolysis, TIA, stroke care guidelines (medical, nursing, dysphagia, early mobilisation, functional assessments, education of patients and family)

Quality Assurance and audit

If providing stroke thrombolysis maintenance of a thrombolysis registry is mandatory; additional stroke registry data is desirable although regular stroke relevant audits are an acceptable alternative. All serious adverse events should be fully investigated and discussed as a team.

Research/Advocacy

There should be some evidence that the service engages in clinical stroke research or stroke audits and patient advocacy relating to stroke.

Geographical area

Hospitals designated as providing an ‘Organised Acute Stroke Service’ should have a designated geographical area with stroke patients spending the majority of their acute hospital stay in this ‘unit.’

Ideally beds are dedicated to stroke patients, but this is not mandatory.

In small hospitals where a dedicated ‘unit’ may not be feasible due to low patient volumes patients may be admitted to a single general medical ward if all other components of an organised stroke services are provided.

Alternatively, if organised acute stroke services are not available patients should be transferred to a larger centre using a defined pathway.

Formalised remote support from a larger service may in some instances be a further option.

Staffing Levels

Exact FTE allocation for interdisciplinary stroke team member staffing levels has not been firmly established at this point in time.

However, as a general guide staffing levels should be sufficient to enable care of patients in accordance with NZ Stroke Guidelines.

All designated members of the stroke team should have some dedicated time (part- or fulltime depending on patient volumes) specifically allocated to stroke care and maintenance of stroke care competencies.

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