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Acute Stroke Management CANADIAN STROKE BEST PRACTICE RECOMMENDATIONS ACUTE STROKE MANAGEMENT: PREHOSPITAL, EMERGENCY DEPARTMENT, AND ACUTE INPATIENT STROKE CARE Update 2018 Boulanger JM, Butcher K (Writing Group Chairs), Gubitz G, Stotts G, Smith EE, Lindsay MP on Behalf of the Acute Stroke Management Best Practice Writing Group, and the Canadian Stroke Best Practices and Quality Advisory Committees; in collaboration with the Canadian Stroke Consortium and the Canadian Association of Emergency Physicians © 2018 Heart & Stroke July 2018 Heart and Stroke Foundation Acute Stroke Management Update 2018 Canadian Stroke Best Practice Recommendations Table of Contents Canadian Stroke Best Practice Recommendations ACUTE STROKE MANAGEMENT: PREHOSPITAL, EMERGENCY DEPARTMENT, AND ACUTE INPATIENT STROKE CARE, SIXTH EDITION (UPDATED JUNE 2018) Table of Contents Section Topic Page Part One: Canadian Stroke Best Practice Recommendations Introduction and Overview I. Introduction and Overview 4 II. Profile of Stroke Care in Canada 5 III. Acute Stroke Management Module Overview 5 IV. Acute Stroke Management Definitions 7 V. Notable Changes in the Acute Stroke Management Module – 2018 Update 8 VI. Guideline Development Methodology 9 VII. Acknowledgements, Funding, Citation 11 Part Two: Canadian Stroke Best Practice Recommendations ~ Prehospital and Emergency Department Stroke Care Recommendations 1. Stroke Awareness, Recognition and Response 13 Outpatient Management of Transient Ischemic Attack and Non-Disabling 2. 19 Stroke Table 2A: Summary of Canadian Stroke Best Practices 27 Recurrent Stroke Risk Levels and Initial Management Table 2B: Recommended Laboratory Investigations for Patients with Acute Stroke or Transient Ischemic Attack 28 3. Emergency Medical Services (EMS) Management of Acute Stroke Patients 29 Emergency Department Evaluation and Management of Patients with TIA 4. 38 and Acute Stroke 5. Acute Ischemic Stroke Treatment 50 6. Acute Antiplatelet Therapy 67 7. Early Management of Patients Considered for Hemicraniectomy 72 Part Three: Canadian Stroke Best Practice Recommendations Acute Inpatient Stroke Care Recommendations 8. Acute Stroke Unit Care 77 Revised FINAL (06June18) CONFIDENTIAL Page 2 of 135 9. Preventing and Managing Complications following Acute Stroke 83 10. Advanced Care Planning 97 11. Palliative and End of Life Care 101 Appendices Prehospital and Emergency Stroke Care Writing Group Members, Appendix Endovascular Thrombectomy Subgroup Members, and External 106 One Reviewers Appendix Table 2A: Standardized Acute Pre-Hospital Stroke Screening Tools 112 Two Table 2B: Additional Tools: Glasgow Coma Scale 115 Table 2C. Prehospital Stroke Severity Scales 117 Appendix Screening and Assessment Tools for Acute Stroke Severity 123 Three Appendix Selection of Validated Swallow Screening and Assessment Tools 130 Four FINAL July 2018 Page 3 of 135 Heart and Stroke Foundation Acute Stroke Management Update 2018 Canadian Stroke Best Practice Recommendations Introduction and Overview ACUTE STROKE MANAGEMENT: PREHOSPITAL, EMERGENCY DEPARTMENT, AND ACUTE INPATIENT STROKE CARE, SIXTH EDITION (UPDATED APRIL 2018) PART ONE: INTRODUCTION AND OVERVIEW I. Introduction to the Canadian Stroke Best Practice Recommendations The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke, and to promote optimal recovery and reintegration for people who have experienced stroke (patients, families and informal caregivers). The CSBPR are under the leadership of the Heart and Stroke Foundation, Canada. They are intended for use by all members of the interdisciplinary teams that together care for stroke patients across the continuum from symptom onset to long term recovery. These best practice recommendations address issues relevant to all stroke types, including acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage and subarachnoid hemorrhage. The theme of the Sixth Edition of the CSBPR is Partnerships and Collaborations. This theme stresses the importance of integration and coordination of partners across the healthcare system to ensure timely and seamless care of stroke patients to optimize recovery and outcomes. Working with people who have experienced a stroke, their family, friends and caregivers, interdisciplinary stroke experts, emergency medical services, other vascular care groups, community care providers, educators health administrators, and researchers will strengthen our ability to reduce risk factor prevalence and mortality from stroke. This theme also includes consideration of people who experience stroke who may also have other healthcare issues or conditions; known as multi-morbidities who have complex medical needs requiring collaboration among different specialty areas. As well, this theme emphasizes the critical need for partnerships to support and improve access to quality stroke care in rural and remote settings. The goal of disseminating and implementing these recommendations is to optimize stroke care across Canada, reduce practice variations in the care of stroke patients, and reduce the gap between current knowledge and clinical practice. Heart & Stroke works closely with national, provincial and regional stakeholders and partners to develop and implement a coordinated and integrated approach to stroke prevention, treatment, rehabilitation, and community reintegration in every province and territory in Canada. The CSBPR provides a common set of guiding principles and objectives for stroke care delivery, and describes the resources and infrastructure necessary at a system level, and the clinical protocols and processes that are needed to achieve and enhance integrated, high-quality, and efficient stroke services for all Canadians. Through the innovations embodied within the stroke best practices, these guidelines contribute to health system reform in Canada and internationally. The Canadian Stroke Best Practice Recommendations are developed and presented within a continuous improvement model and are written for health system planners, funders, administrators, and healthcare professionals, all of whom have important roles in the optimization of stroke prevention and care and who are accountable for results. A strong stroke research literature base is drawn upon to guide the optimization of stroke prevention and care delivery. Several implementation tools are provided to facilitate uptake into practice, and are used in combination with active professional development programs. By monitoring performance, the impact of adherence to best practices is assessed and results then used to direct ongoing improvement. Recent stroke quality monitoring activities have compelling results which continue to support the value of adopting evidence-based best practices in organizing and delivering stroke care in Canada. FINAL July 2018 Page 4 of 135 Heart and Stroke Foundation Acute Stroke Management Update 2018 Canadian Stroke Best Practice Recommendations Introduction and Overview II. Profile of Stroke Care in Canada • Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. Moreover, it is estimated that for each symptomatic stroke, there are approximately nine covert strokes that result in subtle changes in cognitive function and processes (Quality of Stroke Care in Canada Technical Report 2017, Heart and Stroke, based on CIHI DAD and NACRS data). • Approximately 50,000 patients are admitted to acute care hospitals each year in Canada. (Quality of Stroke Care in Canada Technical Report 2017, Heart and Stroke, based on CIHI DAD and NACRS data). • Stroke is the third leading cause of death in Canada and the second leading cause of death globally (CANSIM Table 2014, GBD 2017). • Stroke is a leading cause of adult disability, with over 400,000 people in Canada living with the effects of stroke (Krueger 2015). • The annual cost of stroke is approximately $3.6 billion, taking into account both healthcare costs and lost economic output (Krueger 2012). • The human cost of stroke on families and communities is immeasurable.(Cameron 2017, Anderson 2017) III. Acute Stroke Management Module Overview The Acute Stroke Management module provides guidance to healthcare providers caring for people who present to the healthcare system with current or very recent symptoms of acute stroke or transient ischemic attack (TIA). This module also addresses the issue of public and healthcare provider’s recognition of the signs of stroke and immediate actions to take, including contacting emergency medical services, arriving at a stroke – enabled emergency department, and launching local healthcare institution code stroke protocols. It represents care at the outset and in the middle of the stroke continuum (Figure 1). Stroke patients may move back and forth between different stages of care as their healthcare needs and situation changes. Figure 1: Stroke Continuum of Care, 2018 FINAL July 2018 Page 5 of 135 Heart and Stroke Foundation Acute Stroke Management Update 2018 Canadian Stroke Best Practice Recommendations Introduction and Overview The Acute Stroke Management module provides guidance to healthcare providers caring for people who present to the healthcare system with current or very recent symptoms of acute stroke or transient ischemic attack (TIA). This module also addresses the issue of public and healthcare provider’s recognition of the signs of stroke and immediate actions to take, including
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