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Implementation of this guideline

6.0 Introduction

Clinical guidelines usually focus on how an individual patient should be treated, and draw upon evidence concerning the efficacy, effectiveness and costs of interventions.  This ch...

6.1 Overall structure of stroke services

The provision of a well-led, appropriately trained and skilled workforce providing holistic and compassionate care to patients and their families is one of the principal implicatio...


Comprehensive stroke services should include the whole stroke pathway from prevention (including neurovascular services) through pre-hospital and acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, palliative care and long-term support. [2023]


Comprehensive stroke services should be provided based on an estimate of the needs of the population served, and derived from the best available evidence locally and nationally. [2016]


Comprehensive stroke services should ensure that:

  • people with suspected stroke or TIA are diagnosed and treated urgently, using evidence-based treatments;
  • sufficient provision is made for people with stroke with long-term disability covering the full range of their needs (e.g. nursing, therapy, emotional support, practical support, family/carer support);
  • people with stroke who live in care homes or are unable to leave their own home have equivalent access to specialist stroke services;
  • people with stroke can re-access specialist stroke services when necessary;
  • people dying with stroke receive end-of-life (palliative) care from the acute stroke service and whenever possible in their own homes. [2023]

A public education and professional training strategy should be developed and implemented to ensure that the public and emergency personnel (e.g. staff in emergency call centres) can recognise when a person has a suspected stroke or TIA and respond appropriately.  This should be implemented in such a way that it can be formally evaluated. [2016]


All those caring for people with stroke should have the knowledge, skills and attitudes to provide safe, compassionate and effective care, especially for vulnerable people with restricted mobility, sensory loss, impaired communication and cognition and neuropsychological problems. [2016]


People with stroke and their family/carers should be provided with sufficient information about which services are available and how to access them at all stages of the pathway of care.  All information should be provided in a format accessible to those with communication disability. [2016]


Along the pathway of stroke care, there should be:

  • protocols between healthcare providers and social services that enable seamless and safe transfers of care without delay;
  • protocols in place that enable rapid assessment and provision of all equipment, aids (including communication aids) and structural adaptations needed by people with disabilities after stroke. [2016]

The process of care, the patient experience and person-centred outcomes of hospital and community-based stroke services should be monitored and evaluated regularly through participation in national comparative audit. [2023]


All stroke services should regularly seek the views of those who use their services, and use the findings to design services around the needs of the person with stroke. [2016]

Sources, evidence to recommendations, implications

6.2 Acute stroke services

This section covers aspects of the implementation of high quality acute care that will be of particular relevance to service planners/commissioners for acute hospital services. [20...


Ambulance services, including call handlers, should respond to every person with a suspected acute stroke as a medical emergency. [2016]


Acute stroke services should provide:

  • urgent brain imaging for patients with suspected acute stroke, including the 24/7 provision of CT angiography and perfusion;
    treatment with thrombolysis for eligible patients with acute ischaemic stroke;
  • an endovascular service for eligible patients with acute ischaemic stroke;
    a neuroscience service to admit, investigate and manage patients referred with subarachnoid haemorrhage, both surgically and with interventional radiology;
  • a neuroscience service delivering neurosurgical interventions for patients with intracerebral haemorrhage, malignant cerebral oedema, and hydrocephalus;
  • direct admission of patients with acute stroke to a hyperacute stroke unit providing active management of physiological status and homeostasis within 4 hours of arrival at hospital;
  • an acute neurovascular service for the diagnosis and treatment of people with suspected TIA and minor stroke;
    an acute vascular surgical service to investigate and manage patients with TIA and stroke due to carotid artery stenosis. [2023]

Acute stroke services should involve the active participation of people with stroke and their family/carers in the planning and evaluation of their services. [2016]

Sources, evidence to recommendations, implications

6.3 Secondary prevention services

At least one quarter of all strokes are recurrences, and people who have already suffered a stroke or TIA have a 5-year risk of a further vascular event as high as 22.4%, even with...


Healthcare providers should enact all the secondary stroke prevention measures recommended in this guideline.  Effective secondary prevention should be assured through a process of regular audit and monitoring. [2016]


Comprehensive stroke services should:

  • identify and treat people’s modifiable vascular risk factors, including symptomatic carotid artery stenosis, as soon as possible;
  • provide all people with stroke or TIA and their family/carers with information and support for treatments and lifestyle changes to reduce their risk of stroke, tailored to their individual needs;
  • liaise with and support general practitioners in the long-term management of risk factors in people with stroke or TIA. [2023]

The lifestyle recommendations for stroke prevention made in this guideline should be implemented through:

  • promoting increased physical activity and a reduction in sedentary behaviour;
  • providing smoking cessation services;
  • working with other organisations to make it easier for people with disabilities to participate in exercise;
  • promoting healthy eating;
  • supporting people who drink alcohol in excess to abstain or maintain their intake within recommended limits. [2023]
Sources, evidence to recommendations, implications

6.4 Stroke rehabilitation services

Stroke rehabilitation services should be provided to reduce limitation in activities, increase participation and improve the quality of life of people with stroke using therapeutic...


Stroke rehabilitation services should provide:

  • an inpatient stroke unit capable of providing stroke rehabilitation for all people with stroke admitted to hospital;
  • community-based specialist rehabilitation services capable of meeting the specific health, social and vocational needs of people with stroke of all ages, including provision of early supported discharge to enable people with stroke to receive intensive rehabilitation within 24 hours of returning home or moving into a care home;
  • services capable of delivering specialist rehabilitation, which best meets the person’s needs in a variety of community settings including their own home, gyms or community centres, or outpatient clinics;
  • for the ongoing information needs of people with stroke, including those with aphasia and other communication disabilities.

Such services should be integrated to provide seamless specialist care that is not time-limited. [2023]


Stroke rehabilitation services should be capable (from within the service or by referral if the need is particularly complex) of meeting all the needs of people with stroke (e.g. orthotics, specialist seating,, equipment provision, management of physical effects such as continence and spasticity, vocational rehabilitation, emotional/psychological support, social care, assistance with benefits). [2023]


People with stroke whose mental capacity is impaired should have access to independent specialist advice and support in relation to advocacy. [2016]


Stroke rehabilitation services should ensure they have adequate equipment, including the technology requirements for providing telerehabilitation, to enable provision of all the treatments recommended within this guideline. [2023]


Stroke rehabilitation services should regularly review their skill mix and methods of delivering rehabilitation to ensure optimisation of resources and clinical effectiveness. [2023]


Community stroke teams should deliver levels 1 and 2 vocational rehabilitation and ensure referral to specialist regional services for those requiring level 3 support for everyone with anything other than complex vocational rehabilitation needs. [2023]

Sources, evidence to recommendations, implications

6.5 Long-term support services

Stroke is only one of many causes of long-term neurological disability including other conditions such as head injury, dementia and multiple sclerosis.  Furthermore, many of the ne...


Long-term support services should provide:

  • routine follow-up of people with stroke six months after hospital discharge and annually thereafter;
  • reassessment and further treatment of people with stroke who are no longer receiving rehabilitation. Services should be accessible from primary or secondary care, social services or by self-referral. [2016]

Between health and social services and other agencies, people with stroke should be able to:

  • receive the practical and emotional support they need to live with long-term disability (e.g. housing, employment);
  • access suitable social and leisure activities outside their homes;
  • receive maintenance interventions (e.g. provision of exercise programmes and peer support) to enhance and maintain health and well-being. [2016]

Long-term support services should ensure that the family/carers of people with stroke:

  • are aware that their needs can be assessed separately;
  • are able to access the advice, support and help they need;
  • are provided with information, equipment and appropriate training (e.g. manual handling) to enable them to care for a person with stroke;
  • have their need for information and support reassessed whenever there is a significant change in circumstances (e.g. if the health of the family member/carer or the person with stroke changes). [2016]

Advance care planning and community palliative care services should be available for people with stroke with limited life expectancy, and their family/carers, where appropriate. [2016]

Sources, evidence to recommendations, implications