ia_gov_sa · guide · processed · 127 chunks
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السمات
Ministry of Health
SAUDI STROKE PATHWAY
STANDARDS
11. March. 2019 Version 1.7
STROKE CLINICAL ADVISORY GROUP
Vision Realization Office
[Non-Text]
احلاق
Ministry of Health
Table of Contents
Foreword 2
Contributions......4
Executive Summary 5
Purpose and Scope 7
Chapter 1. The Saudi Stroke Hospitals classification system ....9
Chapter 2. Network....19
Chapter 3. Community activation....24
QM 3.1 Early Detection....25
Chapter 4. Integrated stroke care....25
A. Components of acute stroke care....26
QM 4.1 EMS transfer 26
QM 4.2 Emergency Stroke Assessment and Care 27
QM 4.2.2 Protocol for acute stroke screening....28
QM 4.2.3 Protocol for stroke code pathway 29
QM 4.2.4 Swallow screening 30
QM 4.2.5 Intracerebral Haemorrhage 31
QM 4.2.6 Door to needle time....32
QM 4.2.7 Mechanical Thrombectomy (MT) 33
QM 4.2.8 Decompressive Hemi Craniectomy for acute ischemic stroke....33
QM 4.2.9 Cerebral Venous Thrombosis....34
QM 4.2.10 Subarachnoid hemorrhage 36
QM 4.3 Acute stroke unit 36
QM 4.4 Acute Stroke Rehabilitation 38
QM 4.5 Transfer of care 42
B. TIA 46
QM 4.6 TIA assessment 46
QM 4.7 TIA treatment....48
Chapter 5. Post stroke care....49
QM 5.1 Post-Acute Stroke Rehabilitation....50
QM 5.1.2 In-patient rehabilitation....50
QM 5.1.3 Outpatient Rehabilitation 52
QM 5.2 Psycho-social, emotional and cognitive support ....53
QM 5.3 Secondary Prevention ....54
QM 5.4 Community Assessment and Review ....57
QM 5.5 Participation in the Community....58
QM 5.6 Vocational Therapy....58
QM 5.7 Long term care 59
QM 5.8 End of Life Care 60
Chapter 6. Human resource development....61
QM 6.2 Workforce 64
Glossary 67
Appendix 1 – Key Performance Indicators....69
High Priority Key Performance Indicators: 69
Appendix 2 - Patient Selection Criteria for Rehabilitation Team....107
Version control....109
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السلام عليكم
المسح
Ministry of Health
Foreword
Stroke has been defined as a sudden interruption in the blood supply of the brain. Most strokes are caused by an abrupt blockage of arteries leading to the brain (ischemic stroke). Other strokes are cause by bleeding into brain tissue when a blood vessel bursts (hemorrhagic stroke). Because stroke occurs rapidly and requires immediate treatment, stroke is called a brain attack and sometimes referred to as ‘earthquake in the brain’. When the symptoms of a stroke last only a short time (less than 24 hours), this is called a transient ischemic attack (TIA) or mini-stroke. \( ^{1} \) There are approximately 24,000 strokes in Saudi Arabia annually. \( ^{2} \)
Inefficient use and distribution of available resources, inconsistent provision of services and sometimes lack of evidence-based urgent stroke care services impacts on patient outcomes across the Kingdom. Urgent and acute care is not the only aspect of care that needs to improve, lack of inpatient and community rehabilitation, long term care and community support services has a significant impact on the patients with non-acute phase of stroke, this also impacts on the providers of acute services who are unable to transfer the patient to a safe environment to receive appropriate care. Lack of long term and community services limits the capacity in our existing acute hospitals to treat those most in need of acute care. Yet we know that for months or even years after a stroke, there may be a need for specialized therapeutic help – for example to improve speech or mobility – and that enabling people to participate in work, leisure and education improves well-being, combats depression and often aids recovery. The input and commitment of rehabilitation services, primary care teams, of social care professionals and wider community services is absolutely critical to delivering improved outcomes for people with stroke. These standards aim to address the urgent care and wider aspects of stroke care.
Medical and technological advances have transformed our understanding of stroke, there have been advances in the treatments available for restoring blood flow and improving brain function. However, time is critical for restoring brain function following a stroke – the faster someone reaches expert help, the greater their chances of making a full recovery. We need to make use of the latest advances in stroke treatment, implement evidence-based stroke care, and improve quality, efficiency and consistency of the services to improve patient outcomes. We need to develop the rapid response systems that get people to a hospital of expertise quickly and onwards to provide appropriate treatment and stroke unit care. We need to develop stroke networks to ensure improved access of services to the patients and better utilization of resources. Working across the stroke networks, we need to deliver integrated stroke care that liberates rather than constrains the talents and energies of the doctors, nurses, therapists and their wider teams.
The stroke standards create a strong foundation, supported by expert guidance, for continued innovation and progress in stroke care. Many strokes are preventable, most are treatable, and the harm done by stroke can be greatly reduced if we act quickly on important warning signs like transient ischemic attacks or ‘minor strokes’, deploy effectively
\( ^{1} \) https://stroke.org.sa/understand-stroke/
\( ^{2} \) Based on expert opinion and available data:
https://journals.sagepub.com/doi/full/10.1177/2396987316654338
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السلام عليكم
المسجق
Ministry of Health
the power of modern imaging, and ensure all patients can benefit from expert, multidisciplinary care.
This document presents a number of quality markers outlining the features of a good service. Each quality marker is distilled into a number of standards which aim to improve the quality of service across the stroke pathway. In addition, there are several key performance indicators (KPIs) associated with the standards. Collectively, these markers set an ambitious agenda to deliver the best in class stroke services, from prevention right through to life-long support. It will take time to deliver, and stroke networks will need to work with service users to determine the early priorities for their local areas. These stroke care standards will help commissioners, stroke networks and service providers judge the quality of their local services and plan for the improvements needed.
This document is designed for all health care professionals including administrators. A panel of stroke specialist Doctors and other clinical professionals was set up to form a Clinical Advisory Group (CAG) to develop this document. A range of national and international guidelines, standards and evidence was reviewed and expert opinion from the CAG was used to develop these standards for Saudi Arabia. While the document is a great starting point, there are still areas where further recommendations are needed from a consensus of the experts. We need the research to confirm or refute these views. The work involved in developing clinical standards is enormous, and the resources to undertake the searching, critical appraisal, drafting and editing are constrained. We are very grateful to all the CAG members and others who volunteered their time outside of their day job to undertake these tasks.
This standards document has been developed as a result of a great deal of hard work by many people, in particular, the clinical advisory group which has led on the development of this document so well to this point. It is equally important to note that many other people have been involved too - responding to the consultation and surveys and providing valuable feedback. As a result, these stroke standards are a reflection of all of the knowledge, perspectives, and efforts put forth by the group. This document marks a point in our journey, but we have a long way to go yet, it is now that the hard work begins. We look forward to working with clinicians, managers and patients to tackle the challenge of stroke.
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السلام عليك
المسح
Ministry of Health
Contributions
Contributions from diverse stakeholders to the development of this standards documents are noted with gratitude. Particularly, contributions from the CAG membership are noted. The members of the development group include:
<table><tr><td>Name</td><td>Profession</td><td>Organization(s)</td></tr><tr><td>Dr. Fahmi Al-Senani (Chair)</td><td>Consultant in Stroke, Neurology and Interventional Vascular Neurology</td><td>King Fahd Medical City</td></tr><tr><td>Dr. Ali Al Khathaami</td><td>Consultant in Stroke and Neurology</td><td>King Abdulaziz Medical City in Riyadh</td></tr><tr><td>Dr. Adel Alhazzani</td><td>Consultant in Stroke and Neurology</td><td>King Saud University</td></tr><tr><td>Dr.Bakheet Ahmed Musa</td><td>Consultant in Neurologist</td><td>Dallah Hospital</td></tr><tr><td>Dr. Bassam AlQassami</td><td>Consultant of Neurology, Interventional neurology and Neuroimaging.</td><td>Consultants sans frontiers</td></tr><tr><td>Dr. Omar A Ayoub</td><td>Assistant professor of Neurology</td><td>King Abdulaziz University</td></tr><tr><td>Dr. Abrar Alduraibi</td><td>Doctorate of Clinical Sciences (CScD) in Speech-Language Pathology</td><td>King Fahd Medical City</td></tr><tr><td>Dr. Abdullah Ahmad Alabdali</td><td>Associate Dean clinical affairs and EMS program director</td><td>King Saud Bin Abdulaziz University</td></tr><tr><td>Dr. Salwa Ahmed</td><td>Consultant in physical Medicine and Rehabilitation</td><td>King Fahd Medical City</td></tr><tr><td>Miss Maha Aljuaid</td><td>Nurse Specialist Neuro Critical Care Unit</td><td>King Abdulaziz Medical City in Riyadh</td></tr></table>
External review of the document was provided by Professor Tony Rudd Professor of Stroke Medicine, Kings College London National Clinical Director for Stroke, NHS England London Director for Stroke Consultant Stroke Physician, Guy's and St Thomas' NHS Foundation Trust.
In addition, support from Stroke team members including Amar sharma, , Mohamed Bin Saleh and Shatha Alsaidan is noted.
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السلام عليك
السلام عليك
Ministry of Health
Executive Summary
Stroke is the second leading cause of death in Saudi Arabia and a leading cause of disability in adults. The physical, emotional and financial consequences are felt by the patient, his/her family, the community and the country. Stroke is a preventable and treatable disease. The gap between evidence-based stroke medicine and care in Saudi Arabia is high. The Ministry of Health has identified stroke as a high priority disease that needs to be managed more appropriately.
We will prevent strokes by empowering the person and developing a healthy community by encouraging people to live a healthy lifestyle, free of smoking, obesity and high blood pressure. Developing healthy food choices and increasing physical activity will lower the incidence and prevalence of strokes.
We understand that when a stroke or transient ischemic attack happens, patients will require many services from the healthcare system, and we will ensure that all stroke patients get treated in the highest quality manner with minimal variability. The stroke pathway will be patient- centered and done in a timely manner to improve patient outcomes and reduce costs. We will ensure that when a stroke does happen the stroke system will react quickly and efficiently, the stroke patient will be taken to the most appropriate hospital, and admitted to an acute stroke unit, that will manage the patient according to current stroke standards. Stroke patients with disabilities will be managed and treated in rehabilitation units with the aim of returning maximum function as close to the patients' home as possible.
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الحمد لله
Ministry of Health
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السلام عليكم
السلام عليكم
Ministry of Health
Purpose and Scope
Vision 2030 has committed to improving to health and outcomes for the population of Saudi Arabia. To support this, a number of strategic programs of work were identified and are being piloted across the Kingdom. To support some of these programs of work, specifically in relation to the New Models of Care, it has been identified in some of the projects, that to achieve success for new clinical pathways, and particularly in relation to urgent care treatment in Stroke, clinical Standards would be needed. These Standards will take into account the patient journey and will work across the boundaries of ministries.
Guiding Values and Principles
Guiding values and principles are important if the new pathways are to be successful. When developing the pathway, a set of guiding principles were developed to ensure that the focus of the work was undertaken consistently.
Patient safety, outcomes, and needs should be considered at the heart of every decision.
All patients should be treated equally and receive timely, effective care regardless of status, location, or wealth.
Solutions designed and investments made should compensate institutions and staff to organize their resources to maximize improved patient outcome and financial sustainability in the short, medium and long term.
Collaboration between ministries, providers, and organizations is essential for the pathway's success.
Care provided should be standardized and based on international evidence. Data should be collected to allow for continuous improvement, knowledge sharing, auditing, and transparency across the system to ensure best practices are being applied.
Pathways should be created using innovative ideas from colleagues and patients.
Figure 1: Overarching guiding principles
In addition to the guiding principles for developing the pathway (fig. 1), with input from wider clinical colleagues, the Stroke Clinical Advisory Group (CAG), values and principles for the development of a clinical network has been developed that will help form the foundation on which the strategic clinical network for stroke should be designed, and should now guide its development and operation:
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اللغه العربيه
المسند
دليل
الطبيه
Purpose of this document
This document was developed as a part of the ‘Models of Care’ Urgent Care pilots project to support the design and implementation of a comprehensive evidence-based stroke pathway. These standards are a work in progress and are meant to be used primarily for the stroke pathway pilots, these standards will evolve as a result of the lessons learnt from implementation of the pathways and protocols. It is expected that this document will feed into a national policy document in future.
The stroke standards are intended to:
- Provide a guide against which providers and commissioners of services can secure improvements to stroke services and address health inequalities relating to stroke;
- Provide advice, guidance and support for clusters, and other commissioners of health and care services, in the planning, development and monitoring of services; and
- Inform the expectations of stroke patients and their families, by providing a guide to high-quality health and social care services.
How this document is structured
Chapter 1 describes the different types of stroke hospitals based on the level of complexity of stroke care provided.
Chapter 2 sets out the principles and components of a stroke network.
Chapters 3 to 5 set out a number of quality markers, which outline the features of a good service. Under each marker are a number of standards and indicators.
Chapter 6 sets out standards and actions needed to develop leadership and workforce and to ensure capacity and capability is built for providing a high-quality stroke care.
Appendix 1 includes the Key Performance Measures which are linked to each of the six chapters in the document.
Appendix 2 sets out the patient selection criteria for rehabilitation. It is intended that this will be moved to an implementation guide at a later stage.
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adl aljg
Ministry of Health
Chapter 1. The Saudi Stroke Hospitals classification system
A network of hospitals may be needed to adequately manage acute stroke patients. Since 80% of Saudi stroke patients self-refer to emergency rooms \( ^{3} \) , therefore all hospitals within the stroke network will be classified according to their ability to acutely manage and treat acute stroke patients. This classification system will allow acute stroke patients to be treated adequately according to the best evidence-based standards. The classification system allows hospitals within stroke networks to be developed, where urgent identification of acute stroke patients occur and urgent transfers to appropriate stroke hospitals are pivotal to properly manage these patients.
Individual hospitals and stroke networks will be able to properly allocate resources and develop high quality, value-based improvement initiatives.
Table 1: Proposed hospital classification
<table><tr><td></td><td>Comprehensive Stroke Hospital (CSH)</td><td>Primary Stroke Hospital (PSH)</td><td>Acute Stroke Ready Hospital (ASRH)</td></tr><tr><td>Typical bed size</td><td>>300 beds</td><td>100-400 beds</td><td><200 beds</td></tr><tr><td>Typical acute stroke admissions per year</td><td>More than 1,000</td><td>More than 200</td><td>Less than 100</td></tr><tr><td>Stroke program director</td><td>Yes, Stroke trained physician</td><td>Yes, Physician with stroke expertise</td><td>Yes, a physician with sufficient knowledge on acute stroke management</td></tr><tr><td>Acute stroke team</td><td>Yes, usually stroke neurology, nurse and multi-disciplinary therapy team</td><td>Yes, usually stroke neurology consultant, nurse and multi-disciplinary therapy team</td><td>Yes, usually ED or IM consultant & nurse</td></tr><tr><td>EMS collaboration</td><td>Yes</td><td>Yes</td><td>Yes, to divert to a PSH or CSH</td></tr><tr><td>Stroke Unit</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>Initial assessment of patient</td><td>Triage nurse & ED consultant</td><td>Triage nurse & ED consultant</td><td>Triage nurse & ED physician</td></tr><tr><td>Diagnostic testing capabilities</td><td>CAT, CTA, MRI, MRA, penumbral imaging (CTP &/or MRP) & DSA 24/7. TTE, TEE, TCD, labs, pathology</td><td>CAT, CTA, MRI, MRA, penumbral imaging (CTP &/or MRP) & TTE, Holter & labs.</td><td>CAT (optional CTA & penumbral imaging preferred to assess LVO transfer destination)</td></tr></table>
3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5966841/
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[Non-Text]
احمد الجلج
Ministry of Health
<table><tr><td></td><td></td><td>DSA 24/7 if IA
thrombolysis
capabilities available.</td><td></td></tr><tr><td>Strokologist availability</td><td>Yes, 24/7</td><td>Yes, maybe by telemedicine 24/7*</td><td>Available by telemedicine 24/7*</td></tr><tr><td>Neurosurgical availability</td><td>Yes, 24/7</td><td>Yes, within 2 hours by transfer</td><td>Yes, within 2 hours by transfer</td></tr><tr><td>Telemedicine</td><td>Provide telemedicine to other centers/hospitals</td><td>Yes, if needed</td><td>Yes**</td></tr><tr><td>Treatment capabilities</td><td>IV & IA thrombolytics, aneurysmal clipping & coiling, ICA stenting & CEA, neurosurgical procedures</td><td>IV r-tPA & probably IA thrombolytics</td><td>IV thrombolytics</td></tr><tr><td>Transfer protocols</td><td>Yes, accepting from other centers/hospitals</td><td>Yes, for neurosurgical consults & MT if not available</td><td>Yes, with PSH & CSH. Diversion protocol to PSH/CSH if within 60km</td></tr><tr><td>Staff stroke education requirements</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Clinical performance measures</td><td>Yes</td><td>Yes</td><td>Yes</td></tr></table>
* If stroke physician consultation is needed.
**In rural areas, if the distance from the nearest Primary or Comprehensive Stroke Hospital is more than 60 Km. Within city limits, tele-stroke should be available if IV r-tPA may be delayed for more than 20 minutes.
Acute Stroke Ready Hospitals
Acute stroke ready hospitals (ASRH) are usually smaller hospitals without acute stroke units and without the capability of performing mechanical thrombectomy. Since acute stroke patients can self-refer to any hospital the ASRH should develop a stroke code system to rapidly identify acute stroke patients and manage them appropriately. An acute stroke code team should be available 24 hours, that has sufficient knowledge on acute stroke symptoms and follows and pre-approved stroke code protocol.
The stroke code team
A team consisting of a physician and nurse with sufficient acute stroke management knowledge should be available 24 hours a day and should assess an acute stroke patient
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dawld aljg
Ministry of Health
within 15 minutes of arrival in an emergency room and within the hospital, as an inpatient. All team members should be trained in using the National Institute of Health Stroke Scale (NIHSS) for all acute ischemic stroke patients. Members of the stroke code team should receive at least 4 hours of stroke training every year.
The protocol
A written stroke protocol will be developed to standardize acute stroke management in the emergency department and hospital, which should be revised yearly. Protocols should include management of acute ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. Specific aims of the protocols should include medical stabilization of the stroke patient in terms of airway and blood pressure management, decisions on the acute use of IV r-tPA for selected acute ischemic stroke patients and transfer protocols with PSHs and CSHs. Predetermined acute management and transfer protocols should be established based on many factors including distance between the ASRH and the PSH/CSH, and current transportation condition.
Safe and fast transportation before or after giving IV r-tPA for selected acute ischemic stroke patients is further discussed elsewhere (
Stroke Rehabilitation Care Pathway
QM 4.5 Transfer of care).
Stroke physician consultation via tele-stroke.
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adil aljg
Ministry of Health
Different levels of stroke expertise may be needed at the ASRH ranging from diagnosis to management. Live, synchronous videoconferencing with access to the ASRH picture archiving system (PACS) is standard practice. The use or tele-stroke and decision for IV r-tPA for selected acute ischemic stroke patients, should be standardized and be part of the protocol.
In rural areas, if the distance from the nearest Primary or Comprehensive Stroke Hospital is more than 60 km, the use of tele-stroke and the ship and drip method is preferred. Within city limits, tele-stroke should be available if IV r-tPA may be delayed for more than 20 minutes.
Emergency management services (EMS)
EMS should be available 24 hours a day for immediate transfer of acute stroke patients to PSHs or CSHs. Acute management protocols during the transfer should be available and will include communication strategies, acute blood pressure management, oxygenation, hydration and swallowing protocols.
Laboratory services
Basic laboratory testing, including blood glucose, complete blood count, chemistry studies, coagulation profile, pregnancy testing, toxicology, and ECG will be available in the ASRH on an immediate basis and reported within 45 minutes.
Radiology
Emergency CAT scan of the brain should be available and done within 20 minutes of arrival in the emergency room. CAT scans should be read within 10 minutes of completion of the CAT scan. If indicated, CT angiogram (arch to vertex) should be performed on selected acute ischemic stroke patients after IV r-tPA is given. CT perfusion scanning may be considered in selected acute ischemic stroke patients within 24 hours of symptom onset.
MRI and MRA may be used as a substitute for CAT and CTA, if they can be done in a timely fashion.
Pharmacy
Medications for the acute management of hypertension, hyperglycemia, hypoglycemia, seizures and coagulopathies should be readily available in the emergency department. Intravenous thrombolytics (IV r-tPA) should be quickly available. Sublingual nifedipine should NOT be given to manage acute hypertension in stroke patients.
Transfers
Predetermined written transfer protocols to PSHs and CSHs should be available and based on written agreements. Repatriation agreements should also be included.
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السلام عليكم
السلام عليكم
Ministry of Health
Data collection
In addition to participating in the Saudi stroke registry, the ASRH may choose to collect data for continuous quality improvement measures. The stroke team should meet at least quarterly to discuss its KPIs and improvement measures.
Primary Stroke Hospitals
Primary stroke hospitals are located in medium sized hospitals and are able to treat 70-80% of acute stroke patients, excluding subarachnoid hemorrhages. PSHs are able to acutely diagnose and manage acute stroke patients in the emergency room, give IV r-tPA for selected acute stroke patients and admit patients to a dedicated acute stroke unit (ASU). PSHs are able to determine stroke pathophysiology and start secondary stroke prevention measures. ASUs in PSHs are able to prevent stroke complications. PSHs are able to provide all needed rehabilitation services including physical therapy medicine consultation, physical therapy, occupational therapy and speech therapy consultation.
The stroke code team
A team consisting of a physician and nurse with significant acute stroke management knowledge, should be available 24 hours a day and should assess an acute stroke patient within 15 minutes of arrival in an emergency room and within the hospital, as an inpatient. The physician leader is usually a neurologist with significant training in managing acute ischemic strokes. A reliable notification system (pager, mobile phone, overhead page) must be implemented in each PSH. The stroke team may be used to assist ASRH's manage acute stroke patients, which may include diagnosis, recommendation to give IV r-tPA, perform further tests, and transfer patients to PSH or CSH as needed. The team will be able to decide which patients should be transferred to CSHs and be able to stabilize and make transfer arrangements as needed; examples may include patients with large vessel occlusion, eligible for mechanical thrombectomy, patients needing urgent neurosurgical consultation or neuro-intensive care management.
All team members should be trained in using the National Institute of Health Stroke Scale (NIHSS) for all acute ischemic stroke patients. Members of the stroke code team should provide and receive stroke training every year. A code stroke policy should be available in each PSH designating the duties of the code stroke team and a log of each stroke code KPI should be collected and shared with all departments involved in the stroke code (mainly emergency department, neurology, radiology and administration).
The protocol
A written stroke protocol will be available to standardize acute stroke management in the emergency department and hospital, which should be revised yearly. Protocols should include management of acute ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. Specific aims of the protocols should include medical stabilization of the stroke patient in terms of airway and blood pressure management, decisions on the acute use of IV r-tPA for selected acute ischemic stroke patients and transfer protocols with CSHs.
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[Non-Text]
adallajlg
Ministry of Health
Predetermined acute management and transfer protocols should be established based on many factors including distance between the PSH and the CSH, and current transportation condition, with the aim of fast and safe transport to a CSH. Transportation after giving IV r-tPA for selected acute ischemic stroke patients is further discussed elsewhere (
Stroke Rehabilitation Care Pathway
QM 4.5 Transfer of care).
Stroke physician consultation via tele-stroke.
Different levels of stroke expertise may be needed at ASRH ranging from diagnosis to management. PSH physicians may be able to provide consultations to ASRH with respect to diagnosis, acute management (including drip and ship), and transfer decisions. Live, synchronous videoconferencing with access to the ASRH picture archiving system (PACS) is standard practice. The use or tele-stroke and decision for IV r-tPA for selected acute ischemic stroke patients should be standardized and be part of the protocol.
PSH physicians may also connect to CSH stroke experts by tele-stroke for urgent consultations and transfer decisions to CSH for selected patients, like mechanical thrombectomy, neurosurgical procedures or neuro-ICU transfers.
Emergency management services (EMS)
EMS should be available 24 hours a day for immediate transfer of acute stroke patients to CSHs. Acute management protocols during the transfer should be available and will include communication strategies, acute blood pressure management, oxygenation, hydration and swallowing protocols.
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السلام عليكم
السلام عليكم
Ministry of Health
Laboratory services
Basic and advanced laboratory testing, including autoimmune and hypercoagulable disease testing and toxicology will be available in the PSH. Basic laboratory testing, like CBC, electrolytes, coagulation profile and glucose will be available on an immediate basis and reported within 45 minutes.
EKG and long term Holter monitoring testing will be available.
Transthoracic echocardiography will be available. Transesophageal echocardiography (TEE) and cardiac MRI will be available for selected stroke patients, either in house of by urgent referral to another facility.
Radiology
Emergency CAT scan of the brain should be available and done within 20 minutes of arrival in the emergency department. CAT scans should be read within 10 minutes of completion of the CAT scan. If indicated, CT angiogram (arch to vertex) should be performed on selected acute ischemic stroke patients after IV r-tPA is given. CT perfusion scanning will be available and may be done in selected acute ischemic stroke patients, within 24 hours of symptom onset.
Emergency MRI and MRA may be used as a substitute for CAT and CTA, if they can be done in a timely fashion.
Diagnostic cerebral angiography may be present in PSHs.
The Acute Stroke Unit
The ASU is a dedicated, geographically distinct area in the hospital that admits the vast majority of stable stroke patients. It is staffed by stroke trained personnel (physicians, nurses, rehabilitation staff and others). Continuous telemetry recording is needed for the first few days of admission, including pulse rate, blood pressure, temperature, oxygenation and respiratory rate.
Hospital policies documenting the ASU admission, transfer and discharge policy will be available. The policies should also document the interaction with other needed specialties, mainly the emergency department, radiology, rehabilitation services, case manager, social services and others. Hospital policies will also be available for acute stroke unit management of the stroke patient which will include prevention of deep venous thrombosis, pressure ulcers, aspiration pneumonia and urinary tract infections. A policy documenting the management strategy for any changes in patients neurological and cardiovascular status will be available.
The ASU is commonly referred to as a step-down unit, but higher levels of management may be considered, such as arterial blood pressure monitoring, vasoactive medication use or mechanical ventilation, which will need appropriate manpower, competencies and training.
Pharmacy
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Ministry of Health
Medications for the acute management of hypertension, hyperglycemia, hypoglycemia, seizures and coagulopathies should be readily available in the emergency department and the inpatient area. Intravenous thrombolytics (IV r-tPA) and vasoactive medications (like IV labetalol) should be readily available, preferably in the emergency room. Sublingual nifedipine should NOT be given to manage acute hypertension in stroke patients.
Neurosurgical care should be available within 2 hours of consultation either inhouse or by rapid transfer to another hospital. Pre-written agreements should be in place to avoid ad hoc decisions in urgent situations.
Rehabilitation services
PSHs will be able to perform a rehabilitation assessment and start most rehabilitation services. Well trained staff in rehabilitation are a requirement for all PSH and will include a physical medicine and rehabilitation doctor (physiatrist), a speech therapist, a swallow therapist, a physical therapist and an occupational therapist.
Transfers
Predetermined written transfer protocols to CSHs should be available and based on written agreements. Repatriation agreements should also be included.
Data collection
In addition to participating in the Saudi stroke registry, the PSH may choose to collect data for continuous quality improvement measures. The stroke team should meet at least quarterly to discuss its KPIs and improvement measures.
Comprehensive Stroke Hospitals
Comprehensive Stroke Hospitals (CSH) are located in medium to large sized hospitals and are able to treat all acute and subacute stroke patients. Significant differences between CSHs and PSHs is the availability of stroke trained experts able to perform invasive interventional vascular procedures, the ability to perform all cerebrovascular neurosurgical procedures, the ability to perform vascular surgical procedures and the availability of an intensive care unit with advanced neuroscience competencies.
CSHs are able to acutely diagnose and manage all acute stroke patients in the emergency room, give IV r-tPA for selected acute stroke patients, perform CTA and CT perfusion scans, provide mechanical thrombectomies for ischemic strokes with large vessel occlusions (LVO) and admit patients to a dedicated acute stroke unit (ASU). CSHs are able to determine stroke pathophysiology and start secondary stroke prevention measures. ASUs in CSHs are able to prevent stroke complications. CSH are able to provide all needed rehabilitation services including Physical Medicine and Rehabilitation consultation, physical therapy, occupational therapy and speech therapy consultation.
CSH are frequently the hub of the stroke network that accept referrals from PSHs and ASRHs. Frequently the stroke network is administered from the CSH.
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السلام عليكم
دعيل
السلام
Ministry of Health
CSH are typically hospitals were stroke education is provided to all healthcare staff, including nurses, physicians and the public. CSH are typically hospitals undertaking research at many disciplines (clinical, preclinical and administrative).
The stroke code team
A team of stroke trained physicians and nurses should be available 24 hours a day and should assess an acute stroke patient within 15 minutes of arrival in an emergency room and within the hospital as an inpatient. The physician leader is usually a neurologist with 1-2 years of dedicated stroke training in managing acute ischemic strokes. A reliable notification system (pager, mobile phone, overhead page) must be implemented in each CSH. The stroke team may be used to assist PSH and ASRHs to manage acute stroke patients, which may include diagnosis, recommendation to give IV r-tPA, perform further tests, and transfer patients to CSH, as needed. The team will be able to decide which patients should be transferred to CSHs and be able to stabilize and make transfer arrangements as needed; examples may include patients with large vessel occlusion, eligible for mechanical thrombectomy, patients needing urgent neurosurgical consultation or neuro-intensive care management.
All team members should be trained in using the National Institute of Health Stroke Scale (NIHSS), the modified Rankin score and the Barthel index for all acute ischemic stroke patients. Members of the stroke code team should provide and receive stroke training every year. A code stroke policy should be available in each CSH designating the duties of the code stroke team, and a log of each stroke code KPI should be collected and shared with all departments involved in the stroke code (mainly emergency department, neurology, radiology and administration).
The protocol
A written stroke protocol will be available to standardize acute stroke management in the emergency department and hospital, which should be revised yearly. Protocols should include management of acute ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. Specific aims of the protocols should include medical stabilization of the stroke patient in terms of airway and blood pressure management, decisions on the acute use of IV r-tPA for selected acute ischemic stroke patients and transfer protocols with CSHs. Predetermined acute management and transfer protocols should be established based on many factors including distance between the PSH and the CSH, and current transportation condition, with the aim of fast and safe transport to a CSH. Transportation after giving IV r-tPA for selected acute ischemic stroke patients is further discussed elsewhere (
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السلام عليك
مستشفي
المطابق
Ministry of Health
Stroke Rehabilitation Care Pathway
QM 4.5 Transfer of care).
Stroke physician consultation via tele-stroke
Different levels of stroke expertise may be needed at PSHs and ASRHs ranging from diagnosis to management. CSH physicians will be able to provide consultations to PSHs and ASRHs with respect to diagnosis, acute management (including drip and ship), and transfer decisions. Live, synchronous videoconferencing with access to the PSHs and ASRHs picture archiving system (PACS) is standard practice. The use or tele-stroke and decision for IV r-tPA for selected acute ischemic stroke patients should be standardized and be part of the protocol between the 2 hospitals.
PSH physicians may also consult CSH stroke physicians by tele-stroke for urgent consultations and transfer decisions to CSH for selected patients, like mechanical thrombectomy, neurosurgical procedures or neuro-ICU transfers.
Laboratory services
Basic and advanced laboratory testing, including autoimmune and hypercoagulable disease testing and toxicology will be available in the CSH. CBC, electrolytes, coagulation profile and glucose will be available on an immediate basis and reported within 45 minutes.
Pathology testing for vasculitis will be available either inhouse or outsourced.
Cardiac testing
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EKG and long term Holter monitoring testing will be available.
Transthoracic (TTE) and transesophageal echocardiography (TEE) and cardiac MRI will be available for selected stroke patients.
Long term cardiac monitoring should be available (loop recorders) for detecting cardiac arrhythmias in cryptogenic strokes.
Radiology
Emergency CAT scan of the brain should be available and done within 20 minutes of arrival in the emergency room. CAT scans should be read within 10 minutes of completion of the CAT scan. If indicated, CT angiogram (arch to vertex) should be performed on selected acute ischemic stroke patients after IV r-tPA is given. CT perfusion scanning will be available and may be done in selected acute ischemic stroke patients within 24 hours of symptom onset. Emergency MRI and MRA may be used as a substitute for CAT and CTA, if they can be done in a timely fashion.
Diagnostic cerebral angiography will be available. A Comprehensive Stroke Hospital will be able to provide mechanical thrombectomies urgently 24 hours a day. The ability to perform all urgent neuro-endovascular procedures will be available urgently, like coiling of cerebral aneurysms. Endovascular angioplasty and stenting of carotid stenosis will be available.
Management of arteriovenous malformations will be available, including endovascular embolization, radiation therapy and surgical management.
Pharmacy
Medications for the acute management of hypertension, hyperglycemia, hypoglycemia, seizures and coagulopathies should be readily available in the emergency department and the inpatient area. Intravenous thrombolytics (IV r-tPA) and vasoactive medications (like IV labetalol) should be quickly available, preferably in the emergency room. Sublingual nifedipine should NOT be given to manage acute hypertension in stroke patients.
Transfers
Predetermined written transfer protocols between stroke Hospitals should be available and based on written agreements with prespecified transfer criteria. Repatriation agreements should also be included.
Surgical procedures
Surgical expertise should be available immediately upon consultation. The surgical team will be able to provide care for all cerebrovascular neurosurgical disorders, including clipping of cerebral aneurysms, surgical management of AVMs, insertion of ventricular drains, hematoma removal and drainage, and carotid endarterectomies.
Data collection
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In addition to participating in the Saudi stroke registry, the CSH may choose to collect data for continuous quality improvement measures. The stroke team should meet at least quarterly to discuss its KPIs and improvement measures.
The Acute Stroke Unit (ASU)
The ASU is a dedicated, geographically distinct area in the hospital that admits the vast majority of stable stroke patients. It is staffed by stroke trained personnel (physicians, nurses, rehabilitation staff and others). Continuous telemetry recording is needed for the first few days of admission, including pulse rate, blood pressure, temperature, oxygenation and respiratory rate.
Hospital policies documenting the ASU admission, transfer and discharge policy will be available. The policies should also document the interaction with other needed specialties, mainly the emergency department, radiology, rehabilitation services, case manager, social services and others. Hospital policies will also be available for acute stroke unit management of the stroke patient which will include prevention of deep venous thrombosis, pressure ulcers, aspiration pneumonia and urinary tract infections. A policy documenting the management strategy for any changes in patients neurological and cardiovascular status will be available.
The ASU is commonly referred to as a step-down unit, but higher levels of management may be considered, such as arterial blood pressure monitoring, vasoactive medication use or mechanical ventilation, which will need appropriate manpower, competencies and training.
Intensive Care Management
Some stroke patients will require a higher level of medical care that may be unavailable in the ASU, requiring patients to be admitted to Intensive Care Units (ICUs) or neuro-ICUs. Both units should follow a unified hospital stroke management protocol.
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المسا
Chapter 2. Network
Introduction
Stroke is the \( 2^{nd} \) leading cause of death in Saudi Arabia and a leading cause of adult disability. Managed well, stroke treatment results in better patient outcomes and is cost-saving. Stroke and transient ischemic attacks (TIA) are complex diseases that are treated by a multidisciplinary stroke team sometimes in multiple sites according to each stroke patients' specific journey in a pre-specified stroke pathway.
The Saudi stroke pathway is a patient-centered, value-based initiative that has been developed to set standards for appropriate stroke treatment methods that will result in better patient outcomes.
The stroke network is a group of institutions and individuals (an integrated stroke care network) that seamlessly deliver the objectives of the stroke pathway to all stroke patients within that catchment area.
The stroke network is responsible for delivering the objectives of the National Stroke Pathway to all patients within its prespecified catchment area, throughout the journey of the patient through the stroke pathway, in an integrated care approach.
The network is ultimately responsible for all stroke patient outcomes within its catchment area.
The stroke patients' journey through the stroke pathway
Excluding primordial and primary prevention, the stroke patients journey starts with the onset of stroke/ TIA symptoms. The ability of the patient and bystanders to recognize stroke symptoms and activate the stroke pathway is paramount in reducing the delay to treatment; stroke management is time-dependent, where patients treated earlier have better outcomes, and cost less to the stroke network.
Figure 2: Stroke patient's journey, through the acute phase of the stroke pathway
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The end to end journey of a stroke patient would include:
1. Community education of stroke symptoms and how to activate the stroke pathway e.g. calling the ambulance service
2. Ambulance transfer
3. Emergency room care
4. Neuroradiology care
5. Inpatient care
6. Out-patient care (including TIA clinics)
7. Rehabilitation
8. Reintegration into the society
The components of the stroke network
A stroke network will consist of all the components of stroke care from stroke onset, through to reintegration into society for a period of 4 months. The objectives of the stroke network are to ensure access to high quality, value-based stroke care to all patients in the network.
It is in the best interest of the patient and the network providers for all stroke care to be provided by one network. The network should ensure that all patients who suffer a stroke within its catchment area, follow a prespecified “stroke patient journey” in the stroke pathway; this should result in less variability and better patient outcomes. Service level agreements between departments within a hospital, between hospitals within a network and between outsourced service providers ensure seamless provision and transfer of care, reduce fragmentation of care, results in less variability of care and high quality, value-based stroke care.
Pre-specified agreements between networks will ensure that patients entering another network will receive the highest possible care and be safely repatriated.
Component 1. Community Education Services
The network should educate its catchment area on stroke/TIA symptoms and methods to immediately activate the stroke pathway since stroke/TIA is a time dependent disease. The network should also work closely with EMS services to educate them on acute stroke diagnosis and the networks' method of acute stroke patient transfer to the appropriate emergency room.
Component 2. Emergency Medical Services (ambulance services)
Ideally all acute stroke patients should activate the EMS system; this usually ensures timely diagnosis and transfer to the appropriate stroke hospital, and thus to better stroke outcomes. EMS staff should evaluate all potential stroke patients using a unified pre-hospital stroke screening tool (like FAST, LAPSS etc). Using a pre-written algorithm to recognize patients that will benefit from comprehensive or primary stroke hospital care, EMS staff can triage patients to identify which would be the best hospital to transfer the patient to, depending on their symptoms and transfer times to the appropriate hospital. All stroke patients should be quickly assessed by a stroke trained team for their eligibility for urgent reperfusion therapies (intravenous R-TPA and endovascular mechanical
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thrombectomy). These therapies are usually done in primary or comprehensive stroke hospitals. An urgent communication system should be developed between EMS personal and stroke experts to triage the patients to the appropriate stroke hospital.
Component 3. Emergency Department and Neuroradiological Services
Emergency departments should be accepting all patients that come pre-triaged through EMS and be capable of triaging all patients that self-present with stroke symptoms in a timely fashion. A stroke triage screening tool should be used (like FAST or ROSIER). An emergency department stroke code pathway should be developed. A stroke-code system should be in place to activate the stroke team. The stroke team's responsibility is to quickly assess patients with stroke symptoms, rule out stroke mimics, and clinically manage patients.
Neuroradiological expertise is central to clinical decision making. For all strokes (ischemic and hemorrhagic) an urgent non-contrast CAT scan of the brain is needed. For ischemic strokes, urgent brain imaging (usually non-contrast CAT scan or MRI) is needed for IV r-tPA decision making. Urgent neurovascular imaging (usually CTA or MRA) is needed for endovascular mechanical thrombectomy decision making. Penumbral imaging will be needed for specific ischemic stroke patients, especially those presenting between 6 to 24 hours after stroke symptom onset.
An urgent decision for IV r-tPA or endovascular mechanical thrombolysis should be made and initiated quickly.
For subarachnoid hemorrhages an urgent CTA usually confirms the cause of the bleed and subsequent conventional angiography would be needed.
Component 4. Inpatient care
The Stroke Network Provider should classify all hospitals in its system, based on their ability to manage stroke patients into Comprehensive Stroke Hospitals, Primary Stroke Hospital and Acute Stroke Ready Hospitals. The Saudi Stroke Hospital classification system will be used. Most strokes and some TIA patients should be admitted to an acute stroke unit; others may require ICU admission. Acute stroke units are located in primary or comprehensive stroke hospitals. Each stroke network should develop a system of acute stroke care so that most stroke and some TIA patients are admitted to a stroke unit for the first few days after their stroke (usually 72 hours). The immediate stay of most stroke patients and some TIAs will be in Acute Stroke Units (ASU). Patients usually spend less than 5 days in ASUs. Some patients may require further medical care requiring daily physician assessments and management, usually not by a neurologist, these patients may be transferred to a Skilled Medical Unit (SMU). SMUs may be a general medical or neurological ward and stroke patients are treated by internists or neurologists with expertise in subacute stroke care. SMUs will also provide subacute rehabilitation services as needed.
Prewritten admission and transfer criteria between ASUs and SMUs should be available and seamless.
A stroke network may consist of one comprehensive stroke hospital and a few primary stroke hospital and/or ASRHs. All other hospitals should be classified, and a triaging and transportation system should be in place for timely transfers to and from hospitals according to the stroke patient's requirements.
The appropriate inpatient rehabilitation services will be discussed in component 6.
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Ministry of Health
The organization of the acute inpatient hospital stay may differ from network to network, depending on available resources, geographical issues and transport times within the networks. Some networks may prefer to develop a single CSH, where all patients in the network are admitted to one CSH. Others may prefer a more multifaceted approach of hub and spoke model (figure 2).
Figure 3: Hub and spoke model of stroke hospitals
Component 5. Outpatient care (including TIA clinics)
All networks will develop an outpatient care program to follow-up acute strokes and TIAs according to the National Stroke Standards. Most stroke patients care can be transferred to his/her family medicine physician within 6 months of his 1 \( ^{st} \) diagnosis of stroke/TIA. Some TIA patients will require emergency workup for carotid stenosis or atrial fibrillation within 24 hours and thus weekend coverage should be available.
Component 6. Rehabilitation
The network should make available appropriate rehabilitation services for all stroke patients according to their disability. Acute inpatient care, acute outpatient care, subacute rehabilitation and long-term rehabilitation requirements should be developed and integrated into the stroke patient's pathway. Early supported discharge (ESD) is a method of
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discharging stroke patients earlier than usual to complete their nursing and rehabilitation requirements at their home.
Component 7. Reintegration to society and end of life care
Depending on the physical or mental disability, the stroke/TIA patient will need assistance in returning to become an active member of society. Vocational training/retraining, social work support, financial support, disability assistance for the family and/or caregiver may be needed. Approximately 25-35% of all stroke patients will require some form of assistance 1 year after their stroke \( ^{4} \) ; this may be as simple as assistance with shopping for food or as severe as complete dependence of a bedbound patient requiring full care. Chronic long-term facilities, nursing homes or home health care measures should be implemented according to the patient’s need. Palliative care and end of life care should be an integral part of the acute stroke care for appropriate patients.
QM 2.1 Networked care delivery
Purpose: To deliver integrated stroke care for standardized, seamless and cost effective stroke care to patients within a specific catchment area.
Rationale:
- Evidence from other countries suggests networked delivery of care is cost effective and improves patient outcomes
- Networks can improve the utilization of resources and reduce unwarranted variation in care
Standards:
1. Each network should establish at least one Comprehensive Stroke Hospital along with a network of either Primary or Acute Stroke Ready Hospitals or both.
2. Each network should develop a public and patient education campaign to help improve timely diagnosis and transfer to appropriate stroke hospitals.
3. Each network should develop links with out of hospital services such as Primary care, EMS (ambulance services), Rehabilitation, Long Term and Palliative care services to ensure consistent use of standards and sharing of patient data.
4. Each network should set up a multi-disciplinary clinical committee, to oversee the delivery of stroke care, this committee should include professionals from all appropriate stroke care facilities, including hospitals and other relevant facilities.
\( ^{4} \) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751976/
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دجله الاربق
Ministry of Health
Chapter 3. Community activation
Objectives
1. To improve public and professional awareness of the risk factors and symptoms of a stroke, and what action to take.
2. To ensure that people who experience a stroke are at the center of decisions about their treatment and are involved in the design of services.
Key facts
• Stroke is the second largest cause of deaths in the Kingdom of Saudi Arabia.
- Based on expert opinion, it is estimated that the 2018 incidence of stroke is (75/100,000) in Saudi Arabia.
- There are approximately 24,000 strokes per year in Saudi Arabia.
- There has been a 103% increase in the incidence of stroke between 1990 and 2018.
- High blood pressure (26.1%) and Diabetes (13.1%) are the biggest preventable risk factors for stroke.
Introduction
Lack of awareness of stroke is a significant problem. People do not know what a stroke is, what the symptoms are, or that it is a treatable condition that warrants the same response as a heart attack. Additionally, people are unaware of the potential risk of themselves having a stroke, how to reduce that risk, or that stroke is largely preventable. Knowledge about stroke is also low among health and social care professionals. A study into ‘Knowledge and Attitude of Stroke Among Saudi Population in Riyadh’, suggested that cultural and educational strategies to improve knowledge about stroke in Riyadh community was needed. Considerable efforts should be planned to increase awareness about stroke, especially with low income and low-educated population. \( ^{5} \)
To initiate an emergency response to a suspected stroke, it is crucial that staff who have contact with the public (including GP receptionists, EMS call handlers, hospital triage staff, social care staff and allied health professionals) are able to recognize the symptoms of stroke or TIA, even when they cannot see the individual, and that they all share a common understanding of the importance of dealing with stroke as rapidly as possible.
\( ^{5} \) http://www.ijasrjournal.org/wp-content/uploads/2017/03/MS36xx-17.pdf
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دهل الارج
Ministry of Health
QM 3.1 Early Detection
Purpose
To ensure that signs and symptoms of stroke are recognized by the public and healthcare professionals to facilitate rapid detection of stroke and enable quick initiation of treatment in an appropriate setting.
Rationale
- Fast response to stroke reduces the risk of death and disability.
- Both public and professional awareness of stroke are crucial for patients to receive appropriate care.
Standards
1. Public and professional (including physicians, healthcare facilities personnel, and EMS personnel) stroke education campaigns should be regular and frequent to increase awareness of stroke and the need for urgent diagnosis and treatment.
2. Networks should ensure that people who have had a stroke, and their families and care givers, are informed and empowered, by providing information, advice and support and ensuring that services are in place to support people.
3. All healthcare professionals should be trained to recognize signs and symptoms of stroke indicating an acute stroke as an emergency, requiring immediate transfer to a stroke unit.
4. Patients seen by community-based healthcare professionals with the sudden onset of focal neurological deficit should be screened for hypoglycemia with a capillary blood glucose and for stroke or TIA using a validated tool such as FAST, as soon as possible.
5. Patients with an acute focal neurological deficit suspected to be a stroke should be moved directly to an appropriate stroke hospital.
6. EMS should be activated as soon as possible to ensure that patients with a positive stroke screen and/or a strong suspicion of stroke are transported rapidly to the closest stroke care unit that can administer IV Alteplase.
7. Standardized written protocol and standing orders for the emergency evaluation of patients with suspected stroke is recommended.
8. Telemedicine services can be used appropriately where necessary to ensure urgent management.
9. Patients who have had a suspected TIA should be assessed as soon as possible for their risk of subsequent stroke using a validated scoring system such as ABCD2.
Chapter 4. Integrated stroke care
Objectives
- To improve speed, accuracy and consistency of stroke assessment and treatment for all patients.
- To improve the speed of patient transfer to an appropriate stroke facility so that patients can receive rapid diagnosis and treatment.
- To treat people with suspected stroke as a medical emergency in order to provide optimal treatment and maximize the chances of independent living after stroke.
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- To assess people experiencing a transient ischemic attack (TIA) or minor stroke rapidly in order to minimize the chances of a full stroke occurring.
- To ensure that all the patients that can benefit from reperfusion therapy are identified as soon as possible and appropriate therapy is administered in an evidence-based manner.
Key facts
- There is a 20 per cent risk of a full stroke within the first four weeks after a TIA.\(^{6}\)
- Approximately 69% of the strokes are ischemic strokes and IV r-tPA rates are 0.5%.
- Stroke is a common emergency seen in the Kingdom of Saudi Arabia.
- Most stroke patients are transferred by private mode such as private car.
- EMS transferred around 20% of stroke patients between 2017-2018.
Introduction
A more urgent response to both stroke and TIA will save lives and reduce long-term disability. Intensive physiological and neurological monitoring in the early phase of a stroke supports early treatment that stops or slows stroke progression and prevents more brain cells being dama
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