8.1 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

8.2 Key points for audit

• Was the patient managed in an acute Stroke Unit or a Rehabilitation Unit?
• Was the patient under the care of a physician with an interest in stroke?
• Has discharge information been sent to the GP including details of the stroke, functional abilities and services (or care package) set up for home?
• Was the patient and/or carer given information about their stroke?
• What was the patient’s perspective of the treatment and information they received?
• What were the levels of stroke specialist education available to the various disciplines?

Example audit forms are given at the end of this section.

8.3 Recommendations for research

Further research should be of high methodological quality, relying on randomised controlled trials whenever possible.

Key components of the Stroke Unit

Further research is required into which components of the multidisciplinary team stroke unit care are effective, cost-effective and the most beneficial to patient outcome (unpacking the black box of rehabilitation). Primary research should investigate different therapy interventions, different therapy approaches, the optimum intensity of therapy, the optimum timing of such interventions and attempt to identify which patients benefit most from which interventions.

In addition, research is required in the following specific areas:

Therapy (covering all disciplines)

Further research is required into therapy provided out-with stroke units, for example community and domiciliary services as well as their long term effects following stroke.

Additionally, specific interventions such as therapeutic positioning, continence management, treatments for shoulder pain and pre-discharge home visits need to be evaluated.

Standardised methods to describe and define interventions need to be developed in order to facilitate the interpretation and implementation of research findings.

Stroke Liaison Nurse/Co-ordinator

Further research is required to review and define the optimum role and service characteristics of the Stroke Liaison Nurse/Co-ordinator, and to demonstrate their effectiveness.

Aphasia

Future research into the treatment of aphasia should employ larger subject groups and evaluate outcome in terms of functional communication and quality of life. Evaluation of the benefits of management approaches such as augmentative communication, counselling and carer training should be undertaken, employing suitably robust methodology.

Dysarthria

There is an urgent need for large-scale funded research into the effectiveness of interventions for dysarthria following stroke.

Mood disturbance

Research is required to identify a standardised screening measure for mood disturbance in stroke patients. There has been some indication from other areas of neurological rehabilitation that ‘illness’ specific mood scales might add to sensitivity and specificity. Further research may clarify this.

Further research is required to assess the impact of psychosocial interventions to treat anxiety and depression in stroke patients.

Cognitive rehabilitation

High quality trials are required to assess the efficacy of cognitive rehabilitation. Controlled comparisons with placebo or no treatment are required.

Outcome trials should include tests of both cognition and broader functioning in daily life. However, it is unlikely that current activity of daily living tests will be sensitive enough to assess the functional effects of cognitive rehabilitation/training. Cognitive disability measures will need to be validated for reliability. It should be noted that self-report of functioning in daily life may not be accurate if the patient has difficulties such as severe memory problems or poor awareness of their deficits.

Graduated elastic compression stockings

Clinicians are encouraged to participate in RCTs for patients participating in prolonged stroke rehabilitation in order to assess the efficacy of graduated compression stockings. One such trial is currently ongoing (more information is available on the internet at http://www.dcn.ed.ac.uk/CLOTS).

Feeding after stroke

The dilemmas of feeding patients after a stroke are currently the focus of a major international multicentre trial, the FOOD trial, co-ordinated in Scotland. At the time of writing the FOOD trial is still recruiting patients (and centres) and results from this research will help guide future advice. The evidence relating to artificial feeding after stroke is reviewed in the FOOD trial protocol (available on the internet at http://www.dcn.ed.ac.uk/food/).

Incontinence

There is a dearth of good quality research into improving continence after stroke.

Lothian Stroke Care Audit Form - available to download in Acrobat format (info). (374K)