Scope of the guidelines
These National Clinical Guidelines for stroke cover the management of patients with acute stroke and the secondary prevention of stroke. Primary prevention of stroke, rehabilitation and subarachnoid hemorrhage are excluded from the scope of these guidelines. These guidelines cover the management of stroke in adults (over 18 years) from onset to chronic care and focus on patients with a new clinical event (first stroke or recurrent stroke).
Goal and objectives of the guidelines
The primary goal of the guidelines is to continuously improve the quality of care in patients with stroke nationally. Our intention is closing the gap between best practice and actual practice.
The objective of the guidelines is to provide clinicians and administrators with explicit statements, where evidence is available, on the best way to manage specific problems. Local health service facilities (e.g. hospitals, nursing homes, etc.) will need to add detail.
The guidelines are directed primarily at practising clinicians involved in management of patients with stroke. Their aim is to help clinicians, at any level – primary, secondary or tertiary - to make the best decisions for each patient, using the evidence currently available. The focus is on the more common clinical questions faced in day-to-day practice. The guidelines may be used by all health professionals or health care planners involved in the management of the patients with stroke.
The secondary objectives of the guidelines are to identify areas where gaps in knowledge or lack of evidence exist and to stimulate research in each area.
The guidelines are concerned with the management of patients who present with a new clinical event that might be stroke. Stroke in this context is defined as ‘a clinical syndrome characterized by rapidly developing signs and symptoms of focal or at times global loss (as in subarachnoid hemorrhage or brain stem involvement) of cerebral brain functions, lasting more than 24 hours or leading to death, with no apparent cause other than of vascular origin.’
While appraisal of evidence forms the basis of the development of these guidelines, we wish to clarify some points:
- Evidence related to drugs is generally stronger, because it is methodologically easier to study each intervention in contrast to studying complex intervention like occupational therapy, health education or nursing care. These do not necessarily mean that interventions with so called strong evidence are more important than those where the evidence is weak.
- We believe that highest level of evidence is not always required to make strong recommendation. If the intervention is safe, logic is strong and effect is obvious, the level of evidence desirable to make strong recommendation may be lower than the highest.
- We recognize that many areas of clinical importance may not have evidence available to construct guidelines, and the recommendations represent a consensus from the working group on such areas.
The working group is aware of recent developments in evaluating levels of evidence and strength of recommendations, and also that the GRADE methodology has been adopted by more than 25 organizations around the world including the WHO. The group endorses the use of GRADE methodology (Guyatt and Oxman) for this purpose and will incorporate this in the next version of the guidelines.
Context and use
These guidelines should be taken as statements to inform the clinician, not as rigid rules. Practitioners may need to deviate from the guidelines in individual cases but such deviations should be justifiable and justified.
The guidelines may be used to inform decisions on standards of good practice and are likely to be used for audit of stroke services. Before the guidelines are used as ‘standards’, it is important to ensure that the relevance and appropriateness of the guidelines are discussed in the context proposed.
These guidelines do not cover specific management of associated illnesses like diabetes mellitus, cardiac problems and others as these may addressed by guidelines from related organizations or are generally expected from a physician.