Stroke: Clinical Guidelines

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Admin, Simisola Ajeyalemi, 127.0.0.1, Abiodun Adedotun, Rucha Gadgil, Amrita Patro and Lucinda hampton  

Introduction

The momentum for evidence-based healthcare has been gaining ground rapidly, motivated by clinicians, and management concerned about quality, consistency and costs of healthcare intervention. The use of Clinical Guidelines, based on standardised best practice, have been shown to be capable of supporting improvements in quality and consistency in healthcare and is considered one of the main ways that evidence-based medicine can be implemented. Clinical Practice Guidelines was defined by Field and Lohr (1990) as "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances". 

According to Woolf et al (2012) Clinical Guidelines have become one of the foundation of efforts to improve healthcare and health care management. Methods of guideline development have progressed both in terms of process and necessary procedures and the context for guideline development has changed with the emergence of Guideline Clearinghouses and large scale guideline production organisations e.g National Institute for Health and Clinical Excellence .

Purpose

Clinical guidelines provide recommendations on how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment and longer-term management and are designed to support the decision-making processes in patient care. The content of a guideline is based on a systematic review of research literature and clinical evidence - the main source for evidence-based care.

"The aim of clinical guidelines is to improve quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay out. In the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways and interprofessional agreements".

• To describe appropriate care based on the best available scientific evidence and broad consensus;
• To reduce inappropriate variation in practice;
• To provide a more rational basis for referral;
• To provide a focus for continuing professional education;
• To promote efficient use of resources;
• To act as focus for quality control, including audit;
• To highlight shortcomings of existing literature and suggest appropriate future research. 
  

Guideline Organisations

• National Institute for Health and Clinical Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Guidelines and Audit Implementation Network (GAIN)
• USA National Guideline Clearing House
• New Zealand Guidelines Group
• Guidelines International Network
  

Limitations & Controversy

But Clinical Guidelines can have their limitations and there is controversy surrounding some recommendations within some guidelines e.g. controvery around use of tPA in Acute Stroke. Not every patient or situation fits neatly into a guideline. Guidelines to not always cover every eventuality and each patient's circumstance needs to be taken into consideration when a treatment is decided upon. Recommendations should be viewed as statements that inform the clinician, the patient and any other user, and not as rigid rules.

" The problems of getting people to act on evidence based guidelines are widely recognised. An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders, and educational outreach. The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines. None of the studies used the simplest intervention-that is, changing the wording of the guidelines. We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved. ... "

For a fuller discussion on the pros and cons of Clinical Guidelines, see the original series of articles written in the British Medical Journal followed by an updated and extended series with further recent considerations in the development of Clinical Guidelines. 

Development and Use of Clinical Guidelines Series 1:

1. Potential Benefits, Limitations, and Harms of Clinical Guidelines 
2. Developing Guidelines[9]
3. Legal and Political Considerations of Clinical Practice Guidelines[10]
4. Using Clinical Guidelines[11]
   

Developing Clinical Practice Guidelines Series 2 - Updated & Extended:

1. Target Audiences, Identifying Topics for Guidelines, Guideline Group Composition and Functioning and Conflicts of Interest
2. Types of Evidence and Outcomes; Values and Economics, Synthesis, Grading, and Presentation and Deriving Recommendations
3. Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development

Stroke Clinical Guidelines

While the evidence base for stroke managament and rehabilitation is increasing substantial gaps still remain with an ongoing need for more research to improve both service delivery and more importantly patient outcomes.

Acute

Acute Clinical Guidelines fo Stroke tend to focus on the Medical Management covering interventions for Stroke or TIA during the acute phase, when the diagnosis is made, medical stability is achieved and early complications prevented, which approximates to the first 72 hours of care but in some instances extends into the rehabilitation phase when an individual has ongoing needs around their medical managament and stabilisation of Stroke. Principally it covers interventions at the level of individual patients and their family/carers with recommendations related to diagnosis and management of the underlying disease based on the WHO-ICF framework level of pathology, over the course of the first few days while clinical stability is being achieved, complications prevented and rehabilitation can begin in earnest.  

Secondary Prevention

Focuses on ong-term medical management, principally around secondary vascular prevention.

Rehabilitation

This phase of the Stroke Recovery process focuses on the common issues that people with stroke will encounter as they recover from their stroke and is focused on person-centred outcomes of activities and participation rather than interventions aimed at pathology or impairments.  

Guidelines highlight the importance of the stroke specialist multidisciplinary team but both timeframe anf pathway for this process is not restrictuied and often overlaps with the into the long-term management phase. This phase can cover a range of settings including an acute stroke units, stroke rehabilitation units, early supported discharge services and other community rehabilitation services.

Guidelines for this phase tend to focus initially on restoritive approaches then changing towards compensatory and adaptive approaches towards the end of this phase as the patient moves into the long term managament phase. Although a natural plateau should not preclude access to ongoing rehabilitation.

Recommendations during this phase include management of specific losses and limitations that arise following a stroke and include cognition, communication, continence) which contain recommendations for specific impairments (e.g. spasticity), activity limitations (e.g. driving), restricted social participation and quality of life (e.g. sex). 

Long Term

Focuses on the long-term management of people with stroke, but only in relation to stroke- specific issues. It combines long-term medical management, principally around secondary vascular prevention and the treatment of less common causes of stroke, with aspects of social participation. It is concerned with the process of care as applied to people with stroke and their family/carers.

References