WMAS Clinical Guidelines CLN PRO - 027 I Version - 4

WMAS Clinical Guidelines CLN PRO - 027 I Version - 4 Guideline ID CLN PRO - 027 Version Version 4 Title WMAS Stroke Guidelines Approved by Clinical Steering Group Date Issued 4 May 2016 Review Date May 2019 Directorate Clinical and Quality Emergency Care Assistant X Student Paramedic X Technician X Critical Care Paramedic X Authorised Staff Advanced Technician X Nurse X Paramedic X Doctor X Specialist Paramedic - Urgent Care X Clinical Category Green Deviation permissible with application of clinical judgement 1 Statement West Midlands Ambulance Service NHS Foundation Trust is committed to providing the best possible care to patients suffering Stroke or Transient Ischaemic Attacks. The Trust recognises this is a rapidly changing speciality and will require both local and regional flexibility to adapt to the increasing weight of evidence that is changing Stoke care both locally and internationally. 2 Scope This instruction applies to all pre-hospital practitioners attending a patient with Stroke symptoms. It also applies to all staff working within the Emergency Operations Centres, NHS Trust Community First Responder Schemes and by all Voluntary Aid Societies and Private Providers deployed by West Midlands Ambulance NHS Trust. Page 1 of 15

3 Stroke and TIA, UK Ambulance Clinical Practice Guidelines 2013 3.1 Introduction Stroke is a major health problem in the UK. Improving care for patients with Stroke and transient ischaemic attack (TIA) is a key national priority, with a National Stroke Strategy published by the Department of Health in 2007 and clinical guidelines published by the National Institute for Health and Clinical Excellence (NICE) in 2008. In 2010 work carried out by the National Audit Office (NAO) showed that Stroke care had significantly improved in the 5 years since their previous review, although the NAO acknowledge that improvements still need to be made to Stroke care. 3.2 Acute Stroke Acute Stroke is a medical emergency. For patients with thrombotic Stroke, treatment with thrombolytic therapy (Alteplase) is highly timedependent. In order to determine suitability for treatment, patients must undergo a brain scan, therefore, patients need to be transferred to an appropriate hospital as rapidly as possible once the diagnosis is suspected. It is important to remember that thrombolysis is not the only clinical management strategy that has proven to benefit Stroke patients. Admission to a Stroke unit for early specialist care is known to be lifesaving and to reduce disability, even if thrombolysis is not indicated. Symptoms of Stroke include: Weakness or Paralysis Slurred Speech Numbness Severe headache Visual Field Deficit Ataxia Vertigo The most sensitive features associated with diagnosing Stroke in the prehospital setting are facial weakness, arm and leg weakness, and speech disturbance. This said, the FAST test correctly identifies approximately 75% of hyper acute Strokes, meaning that in the region of 25% (1 in 4) patients that are deemed FAST negative are diagnosed with Stroke in hospital. This patients group traditionally has worse mortality and morbidity rates and receive sub optimal care due to difficulty in diagnosing. Page 2 of 15

Stroke patients presenting FAST negative during assessment in the hyper acute phase, frequently have a range of subtle symptoms that are difficult to identify. It has been shown that patients with acute onset of ataxia and/or a Visual field deficit often with sudden onset of Vertigo and vomiting are strongly suspected to have suffered acute posterior Stroke. The Mnemonic AVVV (Ataxia, Visual Disturbances, Vertigo, Vomiting) may be helpful to support patient examination. 3.3 Transient Ischaemic Attack (TIA) Transient ischaemic attack (TIA) is defined as Stroke symptoms and signs that resolve within 24 hours. However, there are limitations to these definitions. For example, they do not include retinal symptoms (sudden onset of visual field deficit), which should be considered as part of the definition of Stroke. The symptoms of a TIA usually resolve within minutes or a few hours at most, and anyone with continuing neurological signs when first assessed should be assumed to have had a Stroke. 3.4 Incidence Each year in England, approximately 110,000 people have a first or recurrent Stroke and a further 20,000 people have a TIA. 3.5 Severity and Outcome Stroke accounted for over 56,000 deaths in England and Wales in 1999, which represents 11% of all deaths. Most people survive a first Stroke, but often have significant morbidity. More than 900,000 people in England are living with the effects of Stroke, with half of these being dependent on other people for help with everyday activities. 3.6 Pathophysiology The majority (85%) of Strokes are thrombotic (cerebral infarction) and 15% intracranial haemorrhage. Distinguishing between the two is not currently feasible in the pre-hospital setting. A TIA occurs when blood supply to part of the brain is temporarily interrupted. 4 Assessment Assess ABCD s and correct as appropriate. Further guidance can be obtained from the 2013 UK Ambulance Clinical Practice Guidelines Page 3 of 15

Airway and Breathing Management, Section 2 Pages 33-35 Medical Emergencies, Section 3 Pages 93-97 & Pages 100-104 Altered level of Consciousness, Section 3, pages 78-81 Evaluate if the patient has any TIME CRITICAL features these may include: any major ABC problem altered level of consciousness any unilateral neurological deficit including paraesthesia and visual field deficit. positive FAST test positive AVVV examination All patients presenting with Stroke symptoms should have their Blood Pressure, Blood Glucose and Glasgow Coma Scale recorded. FAST Test A deficit in any one of the three criteria is sufficient for the patient to be identified as FAST positive. There is no requirement for all 3 FAST criteria to be present for the patient to be deemed FAST positive, a positive FAST test should be considered a TIME CRITICAL condition. FACE Does the patient have unilateral drooping or an inability to smile? ARMS Ask the patient to raise their arms to 90 if sitting or 45 if lying and hold for 5 seconds with their eyes closed. Does one arm fall or slowly drift away indicating a unilateral weakness? o In the absence of arm weakness, sudden onset of unilateral leg weakness can be considered to be a FAST positive sign SPEECH Is there a new onset of slurred speech or incorrect use of words during conversation? Show the patient some everyday objects and ask them to name them i.e. pens, watch, cup is a correct response given? TIME Record the onset time of symptoms, when was the patient last seen well or if the patient has woken up with Stroke symptoms document wake-up Stroke. Page 4 of 15

AVVV When assessing a patient with potential symptoms of posterior circulation Stroke, the mnemonic AVVV can provide a framework for examination. Posterior circulation Stroke primarily affects the Cerebellum, the area of brain responsible for motor control and cognition. Injury to the cerebellum can cause a change to a patients gait, induce ataxia, impact upon the fourth cranial nerve, prompt symptoms of vertigo and cause sudden vomiting. In order for a patient to be deemed to have a positive AVVV assessment, the patient must have an; Acute, sudden onset of Ataxia and/or Acute, sudden onset of Visual field deficit There is no requirement for all four of the AVVV symptoms, however Ataxia and/or visual field deficit must be present. Association with the symptoms of sudden onset of Vertigo and/or Vomiting should increase suspicion of Posterior Stroke. However it is worth noting that without the presence of ataxia and/or visual field deficit, Stroke is unlikely to be the primary differential diagnosis and further investigation is required. Ataxia Ataxia, a lack of co-ordination of muscles commonly affects balance, coordination and speech. Ascertaining patients with ataxia often involves thorough clinical examination and detailed history taking. Patients will frequently report falls since onset of symptoms, stumbling when mobilising or collision with objects. There are several appropriate neurological assessments that help to evaluate a patients co-ordination, offering a potential indication of ataxia. Strong consideration must be made around the appropriateness of mobilising a patient with suspected ataxia to assist examination, and this should only be undertaken if deemed safe to do so following a dynamic risk assessment which must be documented. Visual Field Deficit To ascertain a visual field deficit the patient may require a detailed history taking with symptoms often described as a barrier in vision or commonly, report the misjudging of proximity of everyday objects such as doorways or furniture. An example of a simple examination can be undertaken to aid identification of a visual field deficit: Page 5 of 15

1. Ask the patient to raise both arms out to the side to the height of their shoulders (picture 1) 2. Ask the patient to look straight ahead 3. Ask the patient to wriggle their fingers, moving their arms forward to close the arc (picture 2) 4. Ask the patient to stop moving their arms when the wriggling fingers can be detected in their peripheral vision. (Picture 1) (Picture 2) A positive visual field deficit is when the peripheral vision differs greatly from one side to another or when the arc has closed sufficiently for the wriggling fingers to be seen in the central line of vision. The below picture (picture 3) shows an example of how left sided peripheral visual field deficit, may appear. Page 6 of 15

(Picture 3) Vertigo Vertigo is commonly described as the feeling of objects or the room spinning around the patient or spinning motions occurring within the patients head. Often vertigo has a simple and/or benign origin, however suspicion must be applied in patients presenting with multiple symptoms associated with Stroke. Vomiting Vomiting is clearly a common symptom across many disease pathologies and is likely to be the least useful of the AVVV symptoms, particularly if used in isolation. It is important to note that vomiting is more sensitive than a feeling of nausea when consideration is made to posterior Stroke. If any of these features are present, start correcting A and B problems then transport to the nearest suitable receiving hospital. Where possible attempts should be made to transport patients to a specialist Stroke facility, ideally those with a Hyper Acute Stroke Unit (HASU) Appendix 1). The following patient management should be initiated. Provide a Hospital Alert Message stating clearly that the patient is FAST positive/suspected acute Stroke, ensuring the inclusion of symptom onset time or wake-up Stroke is included (when patients awake with Stroke symptoms, however an exact onset time is unknown) En-route continue patient management (see below). Assess blood glucose level, as hypoglycaemia may mimic a Stroke Assess blood pressure, as hypotension may mimic a Stroke Perform a brief secondary survey but do not allow this to delay transport to hospital: Page 7 of 15

5.1 Management Follow medical emergencies guideline, remembering to start correcting: AIRWAY BREATHING CIRCULATION DISABILITY (mini neurological examination) Oxygen therapy is not recommended unless the patient is hypoxic (refer to UK Ambulance Clinical Practice Guidelines). Consider recording 12-lead ECG en route to hospital, but do not delay transport for this test. Intravenous access is not essential unless the patient requires specific interventions, and may delay transport to hospital. 5.2 Documentation Both West Midlands Ambulance Service NHS Foundation Trust and the Health Care Profession Council (HCPC) offers clear guidance on documentation and record keeping within the documents, Patient Clinical Record Policy and Procedure and Standards of Conduct, Performance and Ethics accessible internally at https://wmas365.sharepoint.com/pps/patient%20clinical%20record%20policy%2 0and%20Procedure.pdf As with all other aspects of pre-hospital care, clear concise and accurate documentation is imperative to ensuring patient safety and providing a clearly defined picture of events when called upon. Documentation surrounding Stroke/TIA care is hugely important as symptoms change and resolve over time. Failure to inadequately record events may result in missed symptoms and diagnosis when the patient is reviewed within the hospital setting. One major recommendation from the Collaboration for Learning in Applied Health Research and Care (CLARHC) Theme 7: Optimisation of the management of Stroke and transient ischaemic attack, at Birmingham University emphasises the importance of documentation and communication of symptom onset time from ambulance practitioners and hospital staff. Patients that have known onset of symptom times conveyed to hospital with a pre-alert, receive prompter brain imagery and definitive care. Page 8 of 15

6 Definitions 6.1 Hyperacute Stroke Currently within the West Midlands, Hyper Acute Stroke is defined as onset of symptoms within 5 hours. This allows Stroke thrombolysis (with Alteplase) to be administered when patients present to appropriate facilities with a 6 hour time frame. It is worth noting that some Stroke facilities within the region are taking part in several Stroke related research trials, some of which offer extended thrombolysis window. N.B Mechanical thrombectomy (surgical removal of the clot) is also being practiced within the region, although this practice is not widespread and still in its infancy when compared to other procedures. 6.2 Acute Stroke Acute Stroke is defined as onset of Stroke symptoms within 5 72 hours, where Symptoms have not resolved. 6.3 Transient Ischaemic Attack A Transient Ischaemic Attack (TIA) is defined as Stroke symptoms that resolve within 24hours of onset of symptoms. 6.4 Hyper Acute Stroke Unit A Hyper Acute Stroke Unit (HASU) is a specialist in hospital Stroke service that provide global patient care during the hyper acute phase of Stroke. The NHS Midland and East Stroke Service Specification (2013) defines this as an expert specialist clinical assessment, rapid imaging and the ability to deliver intravenous thrombolysis 24/7, typically for no longer than 72 hours after admission. At least 600 Stroke patient admissions per year are typically required to provide sufficient patient volumes to make a hyper acute Stroke service clinically sustainable, to maintain expertise and to ensure good clinical outcomes. People with acute Stroke will receive an early multidisciplinary assessment, including swallow screening and, or for those that continue to need it, have prompt access to high-quality Stroke care. 7 Monitoring the Compliance and the Effectiveness of the Policy 7.1 The Head of Cardiac and Stroke Management will monitor the implementation of this Policy, including the minimum requirements of the Page 9 of 15

NHS Litigation Authority Risk Management Standards, and take assurance to the Clinical & Quality Governance Committee. This report will be sent to the committee on an annual basis, however if the on-going monitoring of this Policy shows that there are significant implications for the implementation of this Policy then it will be sent to the Committee sooner. 7.2 The monitoring of compliance with this Policy will be undertaken through: 7.2.1 Monthly Audit of the National Clinical Performance Indicators for Stroke. 7.2.2 The Education and Training Department will report to the Clinical Quality and Governance Committee regarding the number of staff that have attended the mandatory resuscitation training as per the Trusts ETNA. 7.2.3 Annual Clinical Audit to identify performance against current Standards for Stroke Care. 8 Education and Training 8.1 All clinicians employed by the Trust must ensure that they are up to date with regards to their clinical practice being maintained at a minimum of the guidelines contained in sections 5, 6 and 7 of this document. 8.2 Staff are reminded that registered health care professionals have a responsibility to maintain their knowledge and skills following their registered body s Policy: Doctors General Medical Council Paramedics Health Professionals Council Nurses Nursing and Midwifery Council 8.3 Technicians who feel that there knowledge and skills fall below the competencies of the IHCD should in the first instance contact their line manager. 8.4 The Trust, as part of its ongoing process, has developed a Training Needs Analysis (TNA) which identifies statutory and mandatory training. This training may be in a variety of formats (e.g. in-house, external, work-based, briefing, e-learning etc). Page 10 of 15

8.5 The Trust s TNA for statutory and mandatory training is the source document. Any requirement for training to deliver this policy will be notified to the Head of Education and Training, so as to be included in the TNA. 8.6 The Director of Nursing and Quality will ensure the provision of expert advice to inform the TNA. 8.7 The Stroke Specific Education Framework can be found at: http://www.stroke-education.org.uk/framework.htm 9 Stroke Networks and Care Pathway Development 9.1 The Trust will attend the Regional Stroke Network meetings and other Local Cardiac and Stroke Network meeting as required. 9.2 The Trust will actively support care pathway development, undertaking business plans and impact analysis, where required. 9.3 The West Regional Stroke Network is made up of the five Cardiac and Stroke Networks. The regional meeting is held at least quarterly and is attended by the Regional Head of Cardiac and Stroke Management or a nominated representative. 9.4 There is a Regional Stroke Specification which identifies the requirements for the provision of care to Stroke patients by each health care organisation and is available with the current care pathways at: 10 References http://cif.ad.wmas.nhs.uk/pathway/ Association of Ambulance Chief Executives (2016) UK Ambulance Services Clinical Practice Guidelines. UK Stroke Specific Education Framework [online] available at http://www.strokeeducation.org.uk/framework.htm [Accessed 17th May 2013] National Audit Office (2010) Progress in Improving Stroke Care, National Audit Office, London Page 11 of 15

National Collaborating Centre for Chronic Conditions Stroke: national clinical guideline for diagnosis and initial management of acute Stroke and transient ischaemic attack (TIA). London: Royal College of Physicians, 2008. National Institute for Health and Clinical Excellence (2008) Stroke diagnosis and initial management of acute Stroke and transient ischaemic attack, Clinical Guideline 68, London: National Institute for Health and Clinical Excellence NHS Choices, Vertigo [online] available at http://www.nhs.uk/conditions/vertigo/pages/introduction.aspx [Accessed 01/07/2013] NHS Midlands and East Stroke Service Specification(2012),version 3.0 Page 12 of 15

Appendix One Regional Hyper Acute Stroke Management Page 13 of 15

Appendix Two Acute Pre-Alert Criteria Page 14 of 15

Change History: Date Change Authorised by/comments Dec 09 DRAFT Medical Director April 10 Amendments made following mock NHSLA assessment. June 10 Approved Staff Side Policy Group July 10 Approved Clinical Governance Committee Sept 10 May 2012 Amended following NHSLA Recommendations Amendments following NHSLA review: Update Hyper Acute Availability V13 Add NHSLA References Director of Nursing, Quality and Primary Care Agreed by Director of Nursing and Quality for escalation to approval June 2012 FINAL DRAFT Circulated to Heads of Clinical Practice and CPGMs No negative comments received. June 2012 Sent to CQGC for Approval Director of Nursing and Quality 22 June 2012 Sent to TU Policy Group for Information May 2013 Amendments following UK Ambulance Clinical Practice Guidelines 2013 Guidelines Director of Nursing and Quality 08 May 2014 Version 3 - Approved by Clinical Steering Group Director of Nursing and Quality 04 May 2016 Version 4 Approved Clinical Steering Group Page 15 of 15