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Canadian Stroke Best Practice Recommendations: Acute Inpatient Stroke Care Guidelines, Update 2015

International Journal of Stroke 2016, Vol. 11(2) 239–252 ! 2016 World Stroke Organization Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1747493015622461 wso.sagepub.com

Leanne K Casaubon1,2, Jean-Martin Boulanger3,4, Ev Glasser5, Dylan Blacquiere6, Scott Boucher7, Kyla Brown8, Tom Goddard9,10, Jacqueline Gordon11, Myles Horton12, Jeffrey Lalonde13, Christian LaRivie`re14, Pascale Lavoie15, Paul Leslie16, Jeanne McNeill11, Bijoy K Menon17, Brian Moses18, Melanie Penn19, Jeff Perry20,21, Elizabeth Snieder21, Dawn Tymianski1,2, Norine Foley22, Eric E Smith17, Gord Gubitz8,9, Michael D Hill17 and Patrice Lindsay2,5; on behalf of the Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee Keywords Guidelines, stroke unit, acute inpatient care, complications, early mobilization, palliative care, advanced care planning Received: 6 October 2015; accepted: 11 November 2015

Canadian Stroke Best Practice Recommendations Acute Inpatient Stroke Care Guidelines, Update 2015 The 2015 update of the Canadian Stroke Best Practice Recommendations Acute Inpatient Stroke Care guideline provides further emphasis on the importance of stroke unit care. Moreover, it highlights the core elements of such care and provides tools for implementation of these elements in any institution involved in the care of patients with stroke. There is an emphasis in this update on improving response time to acute stroke in already hospitalized patients, and in reducing poststroke complications. The updated recommendations for venous thromboembolism prophylaxis incorporate

findings from the CLOTS 3 trial.1 Also in the 2015 update, recommendations for early mobilization have been revised in response to new findings from the AVERT trial showing worse outcomes in patients with very early mobilization.2 Both advance care planning and palliative care are included in these recommendations, with enhanced content. These two areas pose a challenge for front-line staff and variations in approach have been reported across Canada.3 This 2015 update also provides further tools and resources for healthcare practitioners who are involved in stroke patient care to be able to Take Action Towards Optimal Stroke Care. Resources include updated patient order set templates for the care of stroke patients in emergency departments, for patients receiving tissue 14

1

University Health Network, Toronto, Ontario, Canada 2 University of Toronto, Toronto, Ontario, Canada 3 Charles-LeMoyne Hospital, Quebec, Canada 4 Sherbrooke University, Quebec, Canada 5 Heart and Stroke Foundation, Ontario, Canada 6 Saint John Regional Hospital, New Brunswick, Canada 7 Regina Qu’Appelle Health Region, Saskatchewan, Canada 8 Halifax Infirmary, Nova Scotia, Canada 9 Dalhousie University, Nova Scotia, Canada 10 Annapolis Valley Health Region, Nova Scotia, Canada 11 Horizon Health Network, New Brunswick, Canada 12 Fraser Health Region, British Columbia, Canada 13 Kingston General Hospital, Ontario, Canada

University of Manitoba, Manitoba, Canada Laval University, Quebec, Canada 16 British Columbia Emergency Health Services, Vancouver, Canada 17 Calgary Stroke Program, Hotchkiss Brain Institute, Alberta, Canada 18 Southwest Health Region, Nova Scotia, Canada 19 Victoria General Hospital, Island Health Authority, British Columbia, Canada 20 Ottawa Hospital Research Institute, Ontario, Canada 21 Ottawa Hospital, Ontario, Canada 22 WorkHorse Consulting, Ontario, Canada 15

Corresponding author: Patrice Lindsay, Heart and Stroke Foundation of Canada, 222 Queen Street, Suite 1402, Ottawa, Ontario, Canada K1P 5V9. Email: [email protected]

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240 plasminogen activator (tPA) thrombolysis or endovascular treatment with mechanical embolectomy, for stroke patients admitted to a stroke unit, and for the management of intracerebral hemorrhage. Overall, the 2015 update highlights all aspects of in-hospital care that will optimize stroke outcomes.

Canadian Stroke Best Practice Recommendations: Acute Inpatient Stroke Care Guidelines, Update 2015

Introduction Stroke is a burden across the globe; in Canadian hospitals, one patient is treated every 9 min for a stroke or a transient ischemic attack (TIA).3 Stroke is also the third leading cause of death in Canada and a leading cause of disability.4 Every year, approximately 62,000 people with stroke and TIA are treated in Canadian hospitals. Moreover, it is estimated that for each symptomatic stroke, there are nine ‘‘silent’’ strokes that result in subtle changes in cognitive function and processes.3 The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke, and to promote optimal recovery and reintegration for people who have experienced stroke (patients, families and informal caregivers). The CSBPR are evidence-based guidelines that are updated and released every two to three years, with interim updates of specific topics when critical new evidence emerges.5 They address the continuum of stroke care from stroke symptom onset through the hyperacute and acute inpatient care periods, to rehabilitation and longer-term recovery. Acute stroke care specifically refers to the key interventions involved in the assessment, treatment or management, and early recovery in the first days after stroke onset. For these recommendations, acute care occurs within an inpatient hospital setting. This may represent initial diagnostic procedures undertaken to identify the nature and mechanism of stroke, interprofessional care on designated stroke units to prevent complications and promote early recovery, a comprehensive assessment of rehabilitation needs, initiation of an individualized secondary stroke prevention plan, discussions related to advance care planning, engagement of palliative care teams, and engagement with the stroke survivor and family to assess and plan for transition to the next level of care. The principal aims of this phase of care are to


International Journal of Stroke 11(2) optimize outcomes through investigation and treatment of the index stroke or TIA and to promote early recovery. Broadly speaking ‘‘acute care’’ refers to the first days to weeks of inpatient treatment with stroke survivors transitioning from this level of care to either inpatient rehabilitation, community-based rehabilitation services, home (with or without support services), continuing care or palliative care. This acute phase of care is usually considered to have ended either at the time of discharge from acute inpatient care or by 30 days of hospital admission. The present publication summarizes the recommendations for the acute period. Other up-to-date and comprehensive CSBPR for all stages of stroke care and recovery are freely available at www.strokebestpractices. ca, and in three recent publications in this Journal: Prevention of Stroke,6 Mood, Cognition and Fatigue Following Stroke,7 and Hyperacute Stroke Care guidelines.8 The CSBPR also provide a comprehensive set of knowledge translation and implementation resources to support guideline uptake and delivery of evidencebased stroke care. These additional resources are found on our website (www.strokebestpractices.ca), and include detailed rationales for the recommended practices, supporting evidence, system implications, performance measures, as well as patient and professional education resources.

What’s new for 2015? In the 2015 update of the Canadian Stroke Best Practice Recommendations Acute Stroke Care guideline, the definition of a stroke unit and specific performance indicators to measure optimal stroke unit care are included (Section 1). Furthermore, emphasis is placed on the various core elements required for centers providing acute stroke care, particularly in light of the new evidence to support endovascular treatment with mechanical embolectomy for patients with acute ischemic stroke. The guideline also highlights the importance of stroke protocols to be in place at institutions that provide stroke care and at institutions that transfer patients to stroke centers. Regarding investigations for stroke etiology, Section 2.1 of this guideline includes updated recommendations regarding prolonged cardiac rhythm monitoring based on the EMBRACE and CRYSTAL AF trials.9,10 The new recommendation is for prolonged ECG monitoring for up to 30 days duration for patients with embolic stroke or TIA of undetermined source and where atrial fibrillation is suspected but not noted on initial ECG, telemetry, or 48-h cardiac monitoring. System implications of this updated recommendation include access to

Casaubon et al. prolonged ambulatory ECG monitoring at all institutions providing care to patients with stroke/TIA. Another focus of this guideline is on updated recommendations for venous thromboembolism prophylaxis (Section 2.2). With the results of the CLOTS 3 trial,1 recommendations were added for the use of thigh-high intermittent pneumatic compression (IPC) devices within the first 24 h of hospital admission, particularly for immobilized stroke patients at high risk of deep vein thrombosis that have a contraindication to pharmacological venous thromboembolism prophylaxis (e.g. in a patient with primary intracerebral hemorrhage). It should be noted that there have been no trials directly comparing IPC to pharmacological venous thromboembolism prophylaxis with low-molecular weight heparin (i.e. enoxaparin). When IPC are used, if they are not applied in the first 24 h of hospital admission, it is recommended that lower limb venous Doppler ultrasound studies be completed to rule out a deep vein thrombosis. As in the previous Canadian Stroke Best Practice Recommendations update, there is a strong recommendation against the use of anti-embolism stockings for venous thromboembolism prophylaxis. Similarly, the latest results of the AVERT trial2 for very early, frequent, out-of-bed mobilization within the first 24 h following a stroke became available during this update process, and the findings have been carefully reviewed. A broad consultation took place within Canada on the findings, and revised recommendations for very early mobilization have been incorporated into this edition (Section 2.4). Finally, the updated recommendations for palliative and end-of-life care emphasize the importance of stroke centers having a dedicated healthcare team with expertise in palliative care (Section 4.0). It is recommended that early and frequent communication with families take place when patients present with a catastrophic stroke so that their concerns can be addressed and support be provided in addition to providing care for the patient. Specific attention is paid to easing symptoms such as pain, delirium, respiratory distress and secretions, gastrointestinal symptoms, seizures, anxiety and depression. Overall, the 2015 update of the Canadian Stroke Best Practice Recommendations Acute Stroke Care guideline highlights the elements of optimal stroke care, including stroke unit care, stroke protocols and standardized order sets, enhanced investigations to evaluate for occult paroxysmal atrial fibrillation, updated recommendations for venous thromboembolism prophylaxis and a holistic approach to end-of-life care. All centers that provide stroke patient care should work to ensure that these recommendations are implemented to demonstrate evidence-based care delivery and strive for improved patient outcomes.

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Guideline development methodology The CSBPR have been developed and undergo routine review and updates using a rigorous and transparent methodology which is described in the CSBPR Methodology Manual5 and available online at www.strokebestpractices.ca. The Canadian Stroke Best Practice Recommendations development and update process follows a framework adapted from the Practice Guideline Evaluation and Adaptation Cycle.11 An interprofessional group of stroke experts was convened to participate in reviewing, drafting and revising all recommendation statements. These experts have extensive experience in the topic areas covered in this acute inpatient stroke care module, are considered leaders and experts in their field, have been involved in clinical trials or publications on the topics addressed in this module, and have experience appraising the quality of research evidence. People who have experienced a stroke or their family members are also included as group members and/or external reviewers. The interprofessional writing group and reviewers included stroke neurologists, emergency department physicians, neurosurgeons, radiologists, family physicians, paramedics, nurses, stroke program managers, physiotherapists, occupational therapists, a speech language pathologist, a social worker and a stroke survivor. This interprofessional approach ensures that the perspectives and nuances of all relevant health disciplines are considered in the development of the recommendations, and mitigates the risk of potential or real conflicts of interest from individual members. Other experts outside the writing group were consulted for very specific issues such as neuroimaging. A systematic literature search was conducted to identify research evidence for each topic area addressed in the acute inpatient stroke care module. All literature searches are conducted by individuals with expertise performing systematic literature reviews that are not directly involved in active research or the writing group to ensure objective selection of evidence. Literature searches include set time frames which overlap the previous search time frame by six months to ensure high catchment of key articles within that time frame. The literature searches included all published literature up to 31 July 2015. The writing group was provided with comprehensive evidence tables that include summaries of all high-quality evidence identified through the literature search and appraisal process. The writing group discussed and debated the value of the evidence and through consensus developed a final set of proposed recommendations. Through their discussions, additional research had been identified and added to the evidence tables if consensus on the value of the research was achieved.


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Table 1. Summary of Criteria for Levels of Evidence Reported in the Canadian Stroke Best Practice Recommendations (Update 2015) Level of evidence

Criteriaa

A

Evidence from a meta-analysis of randomized controlled trials or consistent findings from two or more randomized controlled trials. Desirable effects clearly outweigh undesirable effects or undesirable effects clearly outweigh desirable effects.

B

Evidence from a single randomized controlled trial or consistent findings from two or more welldesigned non-randomized and/or non-controlled trials, and large observational studies. Desirable effects outweigh or are closely balanced with undesirable effects or undesirable effects outweigh or are closely balanced with desirable effects.

C

Writing group consensus and/or supported by limited research evidence. Desirable effects outweigh or are closely balanced with undesirable effects or undesirable effects outweigh or are closely balanced with desirable effects, as determined by writing group consensus. Recommendations assigned a Level C evidence may be key system drivers supporting other recommendations, and some may be expert opinion based on common, new or emerging evidence or practice patterns.

a

Adapted from Guyatt et al.12

All recommendations were assigned a level of evidence ranging from A to C, according to the criteria defined in Table 1. When developing and including ‘‘C-level’’ recommendations, consensus was obtained among the writing group and validated through the internal and external review process. This level of evidence is used cautiously, and only when there is a lack of stronger evidence for topics considered important system drivers for stroke care (e.g. obtaining a CT scan or access to some screening practices). Recommendations with this level of evidence may also be made in response to requests from a range of healthcare professionals who seek guidance and direction from the experts in the absence of strong evidence on certain topics that are faced on a regular basis. In some sections, the expert writing group felt there was additional information that should be included within the documentation, but these statements did not meet the criteria to be stated as recommendations. Therefore, such information was included as clinical considerations with the goal of providing additional guidance or clarity in the absence of evidence. After completion of the draft update of the recommendations, the acute inpatient stroke care module underwent an internal review by the Canadian Stroke Best Practices Advisory Committee, and an external review by 10 Canadian and international experts in acute inpatient stroke care who were not involved in any aspects of the guideline development. All feedback was reviewed and addressed by the writing group members and the advisory committee to ensure a balanced approach to addressing suggested edits. All recommendations in this guideline are accompanied by additional supporting information, including a rationale for inclusion of the topics, system


implications to ensure the structural elements and resources are available to achieve the recommended levels of care, performance measures to monitor care delivery and patient outcomes, implementation resources and a summary of the evidence to which the recommendations were based. The detailed evidence tables are also available online. These recommendations undergo full scientific review every two to three years. A process is also in place for continuous monitoring of the research literature between scheduled updates to detect new emerging evidence that may impact the ongoing validity and/or relevance of recommendations within this module. If new compelling evidence arises, it is reviewed by the writing group and the CSBPR advisory committee. A decision is then made as to whether an interim review process is warranted to develop a timely update to a specific topic area off-cycle. For a more detailed description of the methodology on the development and dissemination of the CSBPR, please refer to the CSBPR Overview and Methodology documentation available on the website at http://www.strokebestpractices.ca/wp-content/uploads/2014/08/CSBPR2014_ Overview_Methodology_ENG.pdf.5 For full French translation of this manuscript and the recommendations, refer to Appendix One online.

Canadian Stroke Best Practice Recommendations: Acute Inpatient Stroke Care Update 2015 This section provides detailed recommendations for several aspects of acute inpatient stroke care. These include stroke unit care; inpatient investigations and management, including cardiac investigations, venous

Casaubon et al. thromboembolism prophylaxis, temperature management, mobilization, bladder and bowel continence, nutrition and dysphagia, oral care, seizure management; prevention of complications; advance care planning and palliative care. All recommendations are assigned a level of evidence which reflects the strength and quality of the evidence available to support the recommendations as of 31 July 2015. For more details on the rationale for the recommendations, health system implications, suggested performance measures, implementation resources, and detailed evidence summaries and evidence tables, visit http://www.strokebestpractices.ca/index.php/acute-stroke-management.

Section 1: Acute Stroke Unit Care It is now well-established that patients who receive stroke unit care are more likely to survive, return home and regain independence compared to patients who receive less organized forms of care. Stroke unit care is characterized by an experienced interprofessional stroke team, including physicians, nurses, physiotherapists, occupational therapists, speech language pathologists, among others, dedicated to the management of stroke patients and located within a geographically defined space. Other features of stroke units include staff members who have an interest in stroke, routine team meetings, continuing education/ training and early engagement in the rehabilitation process. In an updated Cochrane Review, the Stroke Unit Trialists’ Collaboration identified 28 randomized and quasi-randomized trials (n ¼ 5855) comparing stroke unit care with alternative, less organized care (e.g. an acute medical ward).13 Compared to less organized forms of care, stroke unit care was associated with a significant reduction in the odds of death (OR ¼ 0.81, 95% CI 0.69 to 0.94, p ¼ 0.005), death or institutionalization (OR ¼ 0.78, 95% CI 0.68 to 0.89, p ¼ 0.0003) and death or dependency (OR ¼ 0.79, 95% CI 0.68 to 0.90, p ¼ 0.0007) at a median follow-up period of one year. Based on the results from a small number of trials, the authors also reported that the benefits of stroke unit care are maintained for periods up to 5 and 10 years poststroke. Moreover, subgroup analyses demonstrated benefits of stroke unit care regardless of sex, age or stroke severity. Saposnik et al.14 investigated the differential impact of stroke unit care on four subtypes of ischemic stroke (cardioembolic, large artery disease, small vessel disease or other) and reported that stroke unit care was associated with reduced 30-day mortality across all subtypes. A conundrum in acute stroke care is that there is evidence to suggest that patients who experience a stroke while already in hospital for other conditions,

243 compared with persons who suffer a stroke in the community, have more severe strokes, worse outcomes and do not receive care in as timely a fashion. Estimates of persons who experience a stroke while already hospitalized for other conditions range from 4% to 17%.15 Many of these patients have pre-existing stroke risk factors including hypertension, diabetes, cardiac disease and dyslipidemia.16 These in-hospital strokes often occur following cardiac and orthopedic procedures, usually within seven days of surgery. These findings on in-hospital acute stroke emphasize the need for all healthcare providers to be educated in symptom recognition, using guidelines and tools such as the Heart and Stroke Foundation of Canada’s FAST (Face, Arm, Speech, Time) approach.17 Also, protocols for rapid recognition and management of patients who experience stroke while in hospital, as well as protocols for stroke unit care, are required universally to address the reported discrepancies in outcomes compared to community-onset stroke.

Stroke unit care recommendations 1.1. Patients admitted to hospital with an acute stroke or TIA should be treated on an inpatient stroke unit (Evidence Level A) as soon as possible; ideally within 6 h of hospital arrival (Evidence Level C). i. Patients should be admitted to a stroke unit which is a specialized, geographically defined hospital unit dedicated to the management of stroke patients (Evidence Level A). a. For facilities without a dedicated stroke unit, the facility must strive to focus care on the priority elements identified for comprehensive stroke care delivery (including clustering patients, interprofessional team, access to early rehabilitation, stroke care protocols, case rounds, patient education). Refer to FIGURE 1: Optimal Acute Stroke Care for further information. ii. The core interprofessional team on the stroke unit should consist of healthcare professionals with stroke expertise including physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers and clinical nutritionists (dietitians) (Evidence Level A). a. All stroke teams should include hospital pharmacists to promote patient safety, medication reconciliation, provide education to the team and patients/family regarding medication(s) (especially side effects, adverse effects, interactions), discussions regarding adherence, and discharge planning (such as special needs for patients, e.g. individual dosing packages) (Evidence Level B).


244 b. Additional members of the interprofessional team may include discharge planners or case managers, (neuro) psychologists, palliative care specialists, recreation and vocational therapists, spiritual care providers, peer supporters and stroke recovery group liaisons (Evidence Level B). iii. The interprofessional team should assess patients within 48 h of admission to hospital and formulate a management plan (Evidence Level B). a. Clinicians should use standardized, valid assessment tools to evaluate the patient’s strokerelated impairments and functional status (Evidence Level B). b. Assessment components should include dysphagia, mood and cognition, mobility, functional assessment, temperature, nutrition, bowel and bladder function, skin breakdown, discharge planning, prevention therapies, venous thromboembolism prophylaxis (Evidence Level B). Refer to Section 2 of this module for further information. c. Alongside the initial and ongoing clinical assessments regarding functional status, a formal and individualized assessment to determine the type of ongoing post-acute rehabilitation services required should occur as soon as the status of the patient has stabilized, and within the first 72 h post-stroke, using a standardized protocol (including tools such as the alpha-FIMTM) (Evidence Level B). iv. Any child admitted to hospital with stroke should be managed in a center with paediatric stroke expertise when available. If there is no access to specialized paediatric services, children with stroke should be managed using standardized paediatric stroke protocols (Evidence Level B). 1.2. In-hospital stroke Hospital inpatients who have a diagnosis of a new stroke confirmed, should be assessed in a timely fashion and receive appropriate access to acute inpatient stroke care dependent upon their level of stroke-related impairment and other presenting medical/surgical conditions (Evidence Level B).

Section 2: Inpatient stroke management and prevention of complications Acute stroke is responsible for prolonged lengths of stay compared to other causes of hospitalization,4 and the burden on inpatient resources increases further when complications arise. In 2014, the median length of stay in Canada for an acute stroke was six days with an inter-quartile range of 3 to 15 days.3 Acute stroke patients are at risk for complications during this early phase of recovery. The priorities for inpatient care are


International Journal of Stroke 11(2) management of stroke sequelae to optimize recovery, prevention of post-stroke complications that may interfere with the recovery process and prevention of stroke recurrence. A significant challenge in the guideline development process is the weaker to moderate levels of evidence available for some of the interventions identified to accomplish these goals; however, that does not minimize their importance or their contribution to patient outcomes, including length of stay, complications, as well as cognitive and functional ability. Therefore, some recommendations with weaker evidence bases were included to provide some guidance for consideration by clinicians.

Inpatient stroke management and prevention of complications recommendations 2.0. Appropriate investigations and management strategies should be implemented for all hospitalized stroke and TIA patients to optimize recovery, avoid complications, prevent stroke recurrence, and provide palliative care when required. i. During acute inpatient care, stroke patients should undergo appropriate investigations to determine stroke mechanism and guide stroke prevention and management decisions (Evidence Level B). ii. Individualized care plans should address nutrition, oral care, mobilization and incontinence, and reduce the risk of complications such as urinary tract infection, aspiration pneumonia and venous thromboembolism (Evidence Level B). iii. Discharge planning should begin as a component of the initial admission assessment and continue throughout hospitalization as part of ongoing care of hospitalized acute stroke patients (Evidence Level B). iv. All patients, family members and informal caregivers should receive timely and comprehensive information, education and skills training by all interprofessional team members (Evidence Level A). v. A past history of depression should be identified for all acute stroke inpatients (Evidence Level C). vi. Patients should undergo an initial screening for vascular cognitive impairment when indicated (Evidence Level C).

2.1. Cardiovascular investigations i. In cases where the electrocardiogram or initial cardiac rhythm monitoring (e.g. 24 or 48 h ECG monitoring) does not show atrial fibrillation but a cardioembolic mechanism is suspected,

Casaubon et al.

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Figure 1. Core Elements of Comprehensive Stroke and Neurovascular Care. (Based on Stroke Unit Trialists’ Collaboration 2013) [13] DEFINTION: A stroke unit is a specialized, geographically defined hospital unit dedicated to the management of stroke patients and staffed by an experienced interprofessional stroke team. Refer to the resource Taking Action Towards Optimal Inpatient Stroke Care for detailed information about stroke unit criteria, found at www.strokebestpractices.ca. Alternate Stroke Care Models: It is recognized that many models of acute stroke care exist across Canada. Many organizations do not have the official administrative designation as an ‘acute stroke unit’; however they have most or all of the stroke unit criteria in place and should be recognized as attempting to meet optimal stroke care in the face of administrative/structural resource challenges. These models are sometimes referred to as clustered acute stroke care, or purposeful grouping of stroke patients. Core Elements: •

It is recognized that not all hospitals are able to deliver all of the stroke unit elements, and every hospital should be Taking Action to establish protocols and processes of care to implement as many elements as possible to achieve optimal stroke care delivery within their geographic location, hospital volumes and resource availability (human, equipment, funding).

•

Specialized care for patients with ischemic stroke, intracerebral hemorrhage (ICH), and transient ischemic attack (TIA) (care may be expanded in some institutions to include patients with subarachnoid hemorrhage [SAH] and other neurovascular conditions);

•

Dedicated stroke team with broad expertise – including neurology, nursing, neurosurgery, physiatry, rehabilitation professionals, pharmacists, and others;

•

Consistent model where all stroke patients are cared for on the same hospital unit with dedicated stroke beds by trained and experienced staff, including rehabilitation professionals;

•

Access to 24/7 brain and neurovascular imaging and interventional neuroradiology expertise;

•

Emergent neurovascular surgery access;

•

Protocols in place for hyperacute and acute stroke management, and seamless transitions between stages of care (including pre-hospital, Emergency Department and inpatient care);

•

Dysphagia screening protocols in place to assess all stroke patients without prolonged time delays prior to commencing oral nutrition and oral medications;

•

Access to rehabilitation services, including inpatient, community-based, and/or early supported discharge (ESD) therapy;

•

Discharge planning starting as soon as possible after admission, and anticipating discharge needs to facilitate smooth and timely transitions;

•

Daily/bi-weekly patient care rounds with interprofessional stroke team to conduct case reviews, discuss patient management issues, family concerns or needs, and discharge planning (discharge or transition to the next step in their care, timing, and transition requirements);

•

Patient and family education that is formal, coordinated, and addresses learning needs and responds to patient and family readiness;

•

Provision of palliative care when required, ideally by a specialized palliative care team;

•

Ongoing professional development for all staff – stroke knowledge, evidence-based best practices, skill building, and orientation of trainees;

•

Involvement in clinical research for stroke care.

prolonged ECG monitoring, up to 30 days duration, is recommended in selected patients for detection of paroxysmal atrial fibrillation (Evidence Level B). ii. Echocardiography, either 2D or transesophageal, should be considered for patients with suspected embolic stroke and normal neurovascular imaging (Evidence Level B), as well as no contraindications

for anticoagulant therapy. This is particularly relevant for younger adults with stroke or TIA and unknown etiology. iii. Children with stroke should undergo a comprehensive cardiac evaluation including echocardiography, as well as detailed rhythm monitoring if clinically indicated (Evidence Level B).


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2.2. Venous thromboembolism prophylaxis All stroke patients should be assessed for their risk of developing venous thromboembolism (deep vein thrombosis and pulmonary embolism). Patients at high risk include those who are unable to move one or both lower limbs; those who are unable to mobilize independently; a previous history of venous thromboembolism; dehydration; and comorbidities such as cancer. i. Patients at high risk of venous thromboembolism should be started on thigh-high IPCdevices or pharmacological venous thromboembolism prophylaxis immediately if there is no contraindication (e.g. systemic or intracranial hemorrhage) (Evidence Level A). At present, there is no direct evidence to suggest the superiority of one approach over the other. a. If IPC is selected, it should be applied as soon as possible and within the first 24 h after admission. IPC should be taken off when the patient becomes independently mobile, at discharge from hospital, if the patient develops any adverse effects, or by 30 days (whichever comes first) (Evidence Level B). 1. For patients wearing IPC devices, skin integrity should be assessed daily (Evidence Level B). 2. Consultation with a wound care specialist is recommended if skin breakdown begins during IPC therapy (Evidence Level C). 3. If IPC is considered after the first 24 h of admission, venous leg Doppler studies should be considered (Evidence Level C). b. Low-molecular weight heparin (i.e. enoxaparin) should be considered for patients with acute ischemic stroke at high risk of venous thromboembolism; or unfractionated heparin for patients with renal failure (Evidence Level A). c. For stroke patients admitted to hospital and remaining immobile for longer than 30 days, the use of ongoing venous thromboembolism prophylaxis (e.g. with pharmacological venous thromboembolism prophylaxis) is recommended (Evidence Level C). ii. The use of anti-embolism stockings alone for poststroke venous thromboembolism prophylaxis is not recommended (Evidence Level A). iii. Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent venous thromboembolism (Evidence Level C). iv. There is some evidence regarding the safety and efficacy of anticoagulant therapy for deep vein thrombosis prophylaxis after intracerebral hemorrhage. Antiplatelet agents and anticoagulants


International Journal of Stroke 11(2) should be avoided for at least 48 h after onset (Evidence Level C). a. Patients with intracerebral hemorrhage who are judged to be at high risk of venous thromboembolism may be treated after 48 h post-stroke onset after careful risk assessment and following repeat brain imaging that demonstrates stability of the hematoma (Evidence Level C).

2.3. Temperature management i. Temperature should be monitored as part of vital sign assessments; ideally every four h for the first 48 h, and then as per ward routine or based on clinical judgment (Evidence Level C). ii. For temperature greater than 37.5 C, increase frequency of monitoring, initiate temperature-reducing care measures, investigate possible infection such as pneumonia or urinary tract infection (Evidence Level C), and initiate antipyretic and antimicrobial therapy as required (Evidence Level B).

2.4. Mobilization Mobilization is defined as ‘‘the process of getting a patient to move in the bed, sit up, stand, and eventually walk.’’ i. All patients admitted to hospital with acute stroke should be assessed by rehabilitation professionals (Evidence Level A), ideally within the first 48 h of admission (Evidence Level C). ii. Frequent, out-of-bed activity in the very early time frame (within 24 h of stroke onset) is not recommended (Evidence Level B). Mobilization may be reasonable for some patients with acute stroke in the very early time frame and clinical judgment should be used (Evidence Level C). iii. All patients admitted to hospital with acute stroke should start to be mobilized early (between 24 h and 48 h of stroke onset) if there are no contraindications (Evidence Level B). a. Contraindications to early mobilization include, but are not restricted to, patients who have had an arterial puncture for an interventional procedure, unstable medical conditions, low oxygen saturation and lower limb fracture or injury.

2.5. Continence i. The use of indwelling catheters should be avoided due to the risk of urinary tract infection (Evidence

Casaubon et al.

ii.

iii.

iv.

v.

vi.

vii.

viii.

Level A). If used, indwelling catheters should be assessed daily and removed as soon as possible (Evidence Level A). Excellent pericare and infection prevention strategies should be implemented to minimize the risk of infections (Evidence Level B). All stroke patients should be screened for urinary incontinence and retention (with or without overflow), fecal incontinence and constipation (Evidence Level C). The use of a portable ultrasound machine is recommended as the preferred non-invasive painless method for assessing post-void residual (Evidence Level C). Possible contributing factors surrounding continence management should be assessed, including urinary tract infection, medications, nutrition, diet, mobility, activity, cognition, environment and communication (Evidence Level C). Stroke patients with urinary incontinence should be assessed by trained personnel using a structured functional assessment to determine cause and develop an individualized management plan (Evidence Level B). A bladder-training program should be implemented in patients who are incontinent of urine (Evidence Level C), including timed and prompted toileting on a consistent schedule (Evidence Level B). Appropriate intermittent catheterization schedules should be established based on amount of postvoid residual (Evidence Level B). A bowel management program should be implemented for stroke patients with persistent constipation or bowel incontinence (Evidence Level A).

2.6. Nutrition and dysphagia i. Interprofessional team members should be trained to complete initial swallowing screening for all stroke patients to ensure patients are screened in a timely manner (Evidence Level C). ii. The swallowing, nutritional and hydration status of stroke patients should be screened as early as possible, ideally on the day of admission, using validated screening tools (Evidence Level B). Refer to www.strokebestpractices.ca for a list of Validated Swallow Screening and Assessment Tools. iii. Abnormal results from the initial or ongoing swallowing screens should prompt referral to a speechlanguage pathologist, occupational therapist and/ or dietitian for more detailed assessment and management of swallowing, nutritional and hydration

247 status (Evidence Level C). An individualized management plan should be developed to address therapy for dysphagia, nutrition needs and specialized nutrition plans (Evidence Level C). iv. Stroke patients with suspected nutritional concerns, hydration deficits, dysphagia or other comorbidities that may affect nutrition (such as diabetes) should be referred to a dietitian for recommendations: a. to meet nutrient and fluid needs orally while supporting alterations in food texture and fluid consistency recommended by a speech-language pathologist or other trained professional (Evidence Level B); b. for enteral nutrition support (nasogastric tube feeding) in patients who cannot safely swallow or meet their nutrient and fluid needs orally. The decision to proceed with tube feeding should be made as early as possible after admission, usually within the first three days of admission in collaboration with the patient, family (or substitute decision maker) and interprofessional team (Evidence Level B).

2.7. Oral care i. Upon or soon after admission, all stroke patients should have an oral/dental assessment, including screening for signs of dental disease, level of oral care and appliances (Evidence Level C). ii. For patients wearing a full or partial denture, it should be determined if they have the neuromotor skills to safely wear and use the appliance(s) (Evidence Level C). iii. An appropriate oral care protocol should be used for every patient with stroke, including those who use dentures (Evidence Level C). The oral care protocol should be consistent with the Canadian Dental Association recommendations (Evidence Level B), and should address areas such as frequency of oral care (ideally after meals and before bedtime); types of oral care products (toothpaste, floss, and mouthwash); and management for patients with dysphagia. iv. If concerns with implementing an oral care protocol are identified, consider consulting a dentist, occupational therapist, speech-language pathologist and/or a dental hygienist (Evidence Level C). v. If concerns are identified with oral health and/or appliances, patients should be referred to a dentist for consultation and management as soon as possible (Evidence Level C).


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2.8. Seizure management i. New-onset seizures in admitted patients with acute stroke should be treated using appropriate shortacting medications (e.g. lorazepam IV) if they are not self-limiting (Evidence Level C). a. A single, self-limiting seizure occurring at the onset or within 24 h after an ischemic stroke (considered an ‘‘immediate’’ post-stroke seizure) should not be treated with long-term anticonvulsant medications (Evidence Level C). b. Patients that have an immediate post-stroke seizure should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status. Recurrent seizures in patients with ischemic stroke should be treated as per treatment recommendations for seizures in other neurological conditions (Evidence Level C). . Seizures are a common presentation with stroke in neonates and children. Consider enhanced or increased seizure/electroencephalogram (EEG) monitoring in at risk populations such as neonates, children with stroke and adults with otherwise unexplained reduced level of consciousness (Evidence Level C). b. Patients with one or more seizures in the early (defined as occurring up to four weeks postindex stroke) or late (occurring beyond four weeks) post-stroke period should be treated as per treatment recommendations for seizures in other neurological conditions (Evidence Level C). Other investigations may include EEG and tests to rule out other precipitating factors of seizures (e.g. infections) and may be warranted in these patients. c. Prophylactic use of anticonvulsant medications in patients with ischemic stroke is not recommended (Evidence Level B). There is no evidence to support the prophylactic use of anticonvulsant medications in patients with ischemic stroke, and there is some evidence to suggest possible harm with negative effects on neural recovery.

Section 3: Advance Care Planning Advance care planning is an important educational aspect of any patient encounter when a serious or chronic condition is involved, where the risks of a recurrent event and/or a poor outcome are increased, such as with stroke. It is a process through which a patient, in consultation with healthcare providers and family members, makes pre-determined decisions


International Journal of Stroke 11(2) regarding their healthcare in the event they should become incapable of participating in decision making at a later time. Often in patients with stroke, the direction of these decisions is unclear for the family when the patient is unable to participate in decision making. Elements of advance care planning include the patients’ treatment options, prognosis, goals of care, and the identification and documentation of end-of-life wishes.18 Evidence suggests that interventions aimed at increasing advance care planning have been successful in significantly increasing the likelihood that end-oflife wishes are known and respected.18–21

Advance Care Planning Recommendations 3.0 Patients surviving a stroke, as well as their families and informal caregivers, should be approached by the stroke healthcare team to participate in advance care planning (Evidence Level C). i. The primary goal of advance care planning conversations is to determine the individual’s goals of care (Evidence Level B). a. Advance care planning may include identifying a substitute decision-maker (proxy or agent), implementing a personal directive (Evidence Level C), and discussion of the patient’s preferences and the medical appropriateness of therapies such as feeding tubes, hydration, treatment of the current illness, admission to intensive care, ventilation, cardio-pulmonary resuscitation, and place of care (Evidence Level B). b. Advance care planning discussions should be documented in the patient’s chart and any relevant hospital-specific forms should be completed and signed by the patient or decision-maker and a member of the healthcare team (Evidence Level C). ii. The patient’s goals of care and advance care planning decisions should be revisited periodically, such as when there is a change in the patient’s health status (Evidence Level B). iii. The interprofessional team should have the appropriate communication skills and knowledge to address the physical, spiritual, psychological, ethical and social needs of stroke patients, their families and informal caregivers (Evidence Level C). a. Respectful discussion of patient’s values and wishes should be balanced with information regarding medically appropriate treatment related to ongoing stroke management and future medical care (Evidence Level C).

Casaubon et al.

Section 4: Palliative care The CSBPR defines palliative care as a comprehensive approach that focuses on comfort and quality of life for those affected by life-limiting illness, such as large hemispheric strokes and severe hemorrhagic stroke. It aims to prevent and relieve physical, social, psychological, or spiritual suffering of stroke patients, their families and informal caregivers. Palliative care can complement life-prolonging or disease-modifying therapies poststroke and need not be reserved for those whose death is imminent. End-of-life care or terminal care, is part of the palliative approach and is the management and treatment of dying patients, as well as their families and informal caregivers. The end-of-life period often involves a period of change (e.g. worsening clinical condition) rather than an acute event. Several studies have examined the characteristics of patients who are transferred to palliative care units. San Luis et al.22included data retrieved from chart review of 236 patients admitted to hospital with a confirmed diagnosis of stroke. There were 97 patients transitioned to palliative care. These patients were more likely to be older, have atrial fibrillation, more severe dysphagia on the first swallowing evaluation, left hemispheric stroke, higher initial stroke severity, received tPA, and been admitted on a weekday. Gott et al.23reported that the diagnosis of stroke was a strong predictor of transfer to palliative care among a mixed diagnosis group of 514 patients with palliative care needs (OR ¼ 8.0, 95% CI 2.5–25.9, p ¼ 0.001).23 In studies of family satisfaction with palliative care for stroke patients, higher ratings were associated with adequate nursing assistance, family involvement with decision making, respecting patient dignity and being told when death was imminent.24 Symptom control and addressing the needs of the family during the final days were identified as weaker and opportunities for improvement.24,25

Palliative care recommendations 4.0. Palliative and end-of-life care The palliative approach should be used when there has been a catastrophic stroke or a stroke in the setting of significant pre-existing comorbidity, to optimize care for these patients, their families and caregivers (Evidence Level B). i. Communication with patients, families and caregivers should provide, on an ongoing basis, information and counseling regarding diagnosis, prognosis and management, including:

249 a. the appropriateness of life-sustaining measures including mechanical ventilation, enteral/intravenous feeding and intravenous fluids (Evidence Level B); b. reassessment of all medications and recommendations for cessation of medications no longer necessary when the goals of care shift to comfort measures only (e.g. antiplatelets, anticoagulants, statins, hypoglycemics) (Evidence Level C); c. oral care (Evidence Level C); d. assessment and management of pain (Evidence Level B); e. assessment and management of delirium (Evidence Level C); f. assessment and management of respiratory distress and secretions (Evidence Level B); g. assessment and management of incontinence, nausea, vomiting, constipation, and skin and wound care (Evidence Level C); h. assessment and management of seizures (Evidence Level C); i. assessment and management of anxiety and depression (Evidence Level C). ii. Patients, families, caregivers and the healthcare team should have access to palliative care specialists, particularly for consultation regarding patients with difficult-to-control symptoms, complex or conflicted end-of-life decision making or complex psycho-social family issues (Evidence Level C). iii. The interprofessional team should have the appropriate communication skills and knowledge to address the physical, spiritual, psychological, and social needs of patients, families and caregivers who are receiving end-of-life care. There should be regular communication with the patient, family and caregivers to ensure that these needs are being met (Evidence Level C). iv. Formalized palliative care processes and a team experienced in providing end-of-life care for stroke patients (especially nursing staff) should be considered to introduce and monitor standards of care provided to patients at the end-of-life (Evidence Level B). v. Organ donation should be discussed with families and caregivers as appropriate (Evidence Level C).

Summary The 2015 update of the Canadian Stroke Best Practice Recommendations Acute Inpatient Stroke Care guideline provides a common set of guiding principles and


250 evidence-based actions from the first days after stroke onset and throughout inpatient care. This period is crucial for patient recovery, the prevention of common post-stroke complications, secondary prevention and transitions to the next stage of care. The 2015 update of the CSBPR Acute Inpatient Stroke Care module reinforces the growing and changing body of research evidence available to guide assessment, diagnosis, interventions and ongoing management of stroke patients following hospital admission. The 2015 update accentuates the positive impact of organized stroke units with interprofessional stroke teams on patient outcomes following stroke. It also advocates for rapid actions. For example, the update highlights the importance of in-hospital stroke protocols and mechanisms to enable the rapid transfer of stroke patients from the emergency department to a specialized stroke unit as soon as possible after hospital arrival, ideally within the first 6 h. Furthermore, it is imperative that comprehensive and advanced stroke care centers also have leadership roles within their geographic regions to ensure access to specialized stroke care is available to patients who may first appear at general healthcare facilities (usually remote or rural centers) and facilities with basic stroke services only. Access to stroke units remains problematic in many Canadian regions, and there is ongoing advocacy for systems change and improvement to ensure the most effective and efficient flow of patients so that they are cared for in the most appropriate setting for their individual needs. In the meantime, elements of the CSBPR should be implemented as fully as possible within the resource capability at all centers, regardless of geographic location. Many elements can be implemented with process changes that do not require an influx of new money to accomplish. Important updates were also included in this module on investigations for stroke etiology and for reducing complications. These recommendations include performing prolonged ECG monitoring (up to 30 days) in selected patients for the detection of paroxysmal atrial fibrillation, the timing before starting frequent mobilization, and using IPC devices for venous thromboembolism prophylaxis, particularly for stroke patients with contraindications to pharmacological venous thromboembolism prophylaxis. Implementation considerations across the healthcare system are related to access to the resources required for these recommendations, including IPC devices, extended coverage by rehabilitation therapists during weekend hours and prolonged ambulatory cardiac monitoring devices. The CSBPR are developed and presented within a continuous quality improvement model and are written for healthcare system planners, funders, administrators


International Journal of Stroke 11(2) and healthcare professionals, all of whom have important roles in the optimization of stroke prevention and care, and who are accountable for results. Several implementation tools are provided to facilitate uptake into clinical practice (available at www.strokebestpractices.ca), and are used in combination with active professional development programs. By monitoring performance, the impact of adherence to best practices is assessed and results are then used to direct ongoing improvement. The recommendations are targeted to healthcare professionals throughout the healthcare system who care for those affected by stroke. Healthcare system policy makers, planners, funders, senior managers and administrators who are responsible for the coordination and delivery of stroke services should also be concerned and involved in the implementation of the recommendations. The upfront investment in acute stroke care and rehabilitation services may lead to significant savings on long-term care and healthcare burden, and lead stroke patients to improved recovery and, with their families, participatory contributions to their lives. Acknowledgements The authors wish to acknowledge and thank the many people who provided internal and external review and feedback on earlier drafts of the Canadian Stroke Best Practice Recommendations Acute Inpatient Stroke Care guideline update 2015, including members of the Canadian Stroke Best Practices and Quality Advisory Committees: Dr. Robert Cote, Dr. Mark Bayley, Dr. Dariush Dowlatshahi, Dr. Alexandre Poppe, Dr. Sam Yip, Dr. Sean Dukelow, Dr. Eddy Lang, Katie Lafferty, Dr. Ian Graham Dr. Maureen Markle-Reid, Dr. Theresa Green, Dr. Michael Kelly, Barbara Ansley, Dr, Stephen Phillips, Dr. Moira Kapral and Dr. Janusz Kaczorowski, Dr. Michael Sharma, Dr. Andrew Demchuk, Dr. Mayank Goyal, Dr. Cheemun Lum, Dr. David Gladstone, Dr. Robert Teasell, Debbie Hebert; external reviewers for the 2015 update of the Acute Inpatient Stroke Care recommendations: Dr. Ken Butcher, Dr. Thalia Field, Maryse Godin, Dr. Robert Hart, Cindy Hartley, Dr. Markku Kaste, Dr. Peter Langhorne, Dr. Manu Mehdiratta, Dr. Cian O’Kelly, and Jacqueline Willems; and, the stroke team and communications team at the Heart and Stroke Foundation, including Ev Glasser, Stephanie Lawrence, Bev Powell-Vinden, Lesley James and Mary Elizabeth Harriman.

Authors’ contributions Leanne K Casaubon (first author) and Jean-Martin Boulanger (co-primary author) are chairs of the Acute Inpatient Stroke Care expert writing group and lead authors contributing to all aspects of the development, data analysis, writing, editing and final approval of this manuscript; M Patrice Lindsay is corresponding author, senior editor of the guidelines and this manuscript, coordinated the external review process, and is a writer of supplementary

Casaubon et al. documentation (supplementary material can be found online with this article at http://wso.sagepub.com and at http://strokebestpractices.ca). Ev Glasser provided support to the writing group during the development process. Dylan Blacquiere, Scott Boucher, Kyla Brown, Tom Goddard, Jacqueline Gordon, Myles Horton, Colette Lachaıˆ ne, Jeffrey Lalonde, Christian LaRivie`re Pasacale Lavoie, Paul Leslie, Jeanne McNeill, Bijoy K. Menon, Brian Moses, Melanie Penn, Jeff Perry, Elizabeth Snieder, and Dawn Tymianski are all members of the Acute Inpatient Stroke Care expert writing group and contributed by reviewing, analyzing and discussing the evidence and collectively finalizing the wording of all included recommendations. Gord Gubitz and Eric E Smith are senior advisors to the writing group and contributed significantly to the methodology and recommendation development and provided review and edits to the overall documents. Michael D Hill chairs the Heart and Stroke Foundation’s Quality and Performance committee and provided extensive review and feedback on the recommendations, performance measures and this manuscript; Norine Foley conducted the evidence searches and completed the evidence tables and evidence summaries supporting this guideline update.

Declaration of conflicting interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Leanne K Casaubon: Medtronic as an independent study patient assessor for a cardiac TAVI study; NoNO Inc. as site PI for the FRONTIER study of NA-1 neuroprotective in stroke; Covidien as a past advisory board member. Jean-Martin Boulanger: conference speaker for BI Novartis, Sanofi Aventis, Merck, Merz, Allergan, Pfizer, Bayer, Boehringer Ingelheim. Gord Gubitz: speaker for Bayer, Boehringer Ingleheim, and BMS Pfizer. Dr. Michael D. Hill: Heart and Stroke Foundation of Alberta Board Chair, salary award holder; Vernalis Group Ltd and Merck Ltd Consultant; Hoffmann-LaRoche Canada, provided drug for clinical trial, consultancy and CME lecturer; Coviden, research grant holder; Servier Canada, CME lecturer (funds donated to charity); BMS Canada, consultancy (funds donated to charity); Alberta Innovates Health Solutions, program grant award; principal investigator, ESCAPE trial. Brian Moses: speaker for AstraZeneca, Bayer, Boehringer Ingelheim, Sanofi Aventis, and Servier; speaker and advisory board member for BMS, Eli Lilly, Merck, NovoNordisk, Pfizer; advisory board member for Medtronic. The following co-authors do not have any conflicts of interest to report: Patrice Lindsay, Dylan Blacquiere, Scott Boucher, Kyla Brown, Tom Goddard, Jacqueline Gordon, Myles Horton, Jeffrey Lalonde, Christian LaRivie`re, Pascale Lavoie, Paul Leslie, Jeanne McNeill, Bijoy K. Menon, Melanie Penn, Jeff Perry, Elizabeth Snieder, Dawn Tymianski, Norine Foley, Eric E. Smith and Ev Glasser. All participants complete a conflict of interest declaration prior to participation.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this

251 article: The development of the Canadian Stroke Best Practice Recommendations is funded in their entirety by the Heart and Stroke Foundation, Canada. No funds for the development of these guidelines come from commercial interests, including pharmaceutical and medical device companies. All members of the recommendation writing groups and external reviewers are volunteers and do not receive any remuneration for participation in guideline development, updates and reviews.

References 1. Dennis M, Sandercock P, Reid J, Graham C, Forbes J and Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 2013; 382: 516–524. 2. Trial Collaboration Group AVERT. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386: 46–55. 3. Heart and Stroke Foundation. Together against a rising tide: advancing stroke systems of care. Stroke Month Report 2014. Ottawa, ON, Heart and Stroke Foundation, www.heartandstroke.com. (2014, accessed 5 April 2015). 4. Public Health Agency of Canada. Tracking heart disease and stroke in Canada: stroke highlights 2011. Public Health Agency of Canada, www.phac-aspc.gc.ca/cd-mc/ cvd-mcv/sh-fs-2011/pdf/StrokeHighlights_EN.pdf (2011 accessed 6 June 2015). 5. Lindsay MP, Gubitz G, Bayley M, et al. Canadian Stroke Best Practice Recommendations Overview and Methodology (5th ed.); on behalf of the Canadian Stroke Best Practices Advisory Committee and Writing Groups. Ottawa, Ontario Canada: Heart and Stroke Foundation, Canada, 2014. 6. Coutts SB, Wein T, Lindsay MP, Buck B, et al; on behalf of Heart and Stroke Foundation Canada Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014. Int J Stroke 2015; 10: 282–291. 7. Eskes GA, Lanctot KL, Hermann N, et al. Canadian Stroke Best Practice Recommendations: mood, cognition and fatigue following stroke practice guidelines, update 2015. Int J Stroke 2015; 10: 1130–1140. 8. Casaubon LK, Boulanger JM, Blacquiere D, et al. Canadian Stroke Best Practice Recommendations: hyperacute stroke care guidelines, update 2015. Int J Stroke 2015; 10: 924–940. 9. Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370: 2467–2477. 10. Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478–2486. 11. Graham ID, Harrison MB, Brouwers M, Davies BL and Dunn S. Facilitating the use of evidence in practice: evaluating and adapting clinical practice guidelines for local


252

12.

13.

14.

15.

16.

17.

18.

International Journal of Stroke 11(2) use by health care organizations. JOGNN 2002; 3: 599–611. Guyatt GH, Cook DJ, Jaeschke R, et al. Grades of recommendation for antithrombotic agents: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed.) [published erratum in Chest 2008;134:473]. Chest 2008; 133(6 Suppl): 123S–131S. Stroke Unit Trialists’ Collaboration Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013; 11: CD000197. Saposnik G, Hassan KA, Selchen D, Fang J, Kapral MK and Smith EE. Stroke unit care: does ischemic stroke subtype matter? Int J Stroke 2011; 6: 244–250. Cumbler E, Wald H, Bhatt DL, et al. Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines-Stroke. Stroke 2014; 45: 231–238. Vera R, Lago A, Fuentes B, et al. In-hospital stroke: a multi-centre prospective registry. Eur J Neurol 2011; 18: 170–176. Wein T, Coutts S, Casaubon L, et al; on behalf of the Prevention of Stroke Writing Group. Stroke Recognition and Response Module 2014. In: Lindsay MP, Gubitz G, Bayley M, and Smith EE (eds); on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2014; Ottawa, Ontario Canada: Heart and Stroke Foundation. Accessed online July 10th, 2015 at: http://www.strokebestpractices.ca/index.php/public-awareness-of-stroke. Detering KM, Hancock AD, Reade MC and Silvester W. The impact of advance care planning on end of life care in


19.

20.

21.

22.

23.

24.

25.

elderly patients: randomised controlled trial. BMJ 2010; 340: c1345. Grimaldo DA, Wiener-Kronish JP, Jurson T, Shaughnessy TE, Curtis JR and Liu LL. A randomized, controlled trial of advanced care planning discussions during preoperative evaluations. Anesthesiology 2001; 95: 43–50. Kirchhoff KT, Hammes BJ, Kehl KA, Briggs LA and Brown RL. Effect of a disease-specific advance care planning intervention on end-of-life care. J Am Geriatr Soc 2012; 60: 946–950. Qureshi AI, Chaudhry SA, Connelly B, et al. Impact of advanced healthcare directives on treatment decisions by physicians in patients with acute stroke. Crit Care Med 2013; 41: 1468–1475. San Luis CO, Staff I, Fortunato GJ and McCullough LD. Dysphagia as a predictor of outcome and transition to palliative care among middle cerebral artery ischemic stroke patients. BMC Palliat Care 2013; 12: 21–28. Gott M, Gardiner C, Ryan T, Parker C, Noble B and Ingleton C. Prevalence and predictors of transition to a palliative care approach among hospital inpatients in England. J Palliat Care 2013; 29: 147–153. Rogers A and Addington-Hall J. Care of the dying stroke patient in the acute setting. J Res Nursing 2005; 10: 153–167. Blacquiere D, Bhimji K, Meggison H, Sinclair J and Sharma M. Satisfaction with palliative care after stroke: a prospective cohort study. Stroke 2013; 44: 2617–2619.