1
E idence Suppo ing Key Quali y
o Ca e Indica o s in S oke: A
Comp ehensi e Re iew o he
SSNAP F amewo k
Re iew conduc ed using pe plexi y.ai, di ec ed by Michael Allen
Execu i e Summa y
This comp ehensi e epo examines he e idence base suppo ing he 40 quali y indica o s used by he
Sen inel S oke Na ional Audi P og amme (SSNAP) o measu e s oke ca e quali y ac oss England, Wales,
and No he n I eland. SSNAP ep esen s he mos comp ehensi e na ional s oke audi p og amme
globally, collec ing da a ac oss he en i e s oke ca e pa hway om acu e admission h ough six-mon h
ollow-up.
The e idence demons a es ha o ganized, ime-sensi i e, mul idisciplina y s oke ca e signi ican ly
imp o es pa ien ou comes. Many SSNAP indica o s a e in e connec ed componen s o he "s oke uni
ca e" in e en ion, which has he s onges e idence base in s oke medicine. Me a-analyses consis en ly
show ha s oke uni ca e educes mo ali y (OR 0.87, 95% CI 0.69-0.94), dea h o ins i u ionaliza ion (OR
0.78, 95% CI 0.68-0.89), and long- e m disabili y. Rapid imaging, imely epe usion he apies, ea ly
mul idisciplina y assessmen , adequa e ehabili a ion in ensi y, and sys ema ic p e en ion o complica ions
ep esen he co e elemen s o e idence-based s oke managemen .
This epo sys ema ically e iews he e idence o each o he 40 SSNAP indica o s, o ganized in o se en
domains: (1) Hype acu e Assessmen , (2) Specialis Pa hway, (3) Repe usion The apies, (4)
Mul idisciplina y Assessmen , (5) Rehabili a ion Pa hways, (6) The apy F equency, and (7) S anda ds by
Discha ge. The s eng h o e idence a ies ac oss indica o s, wi h some suppo ed by mul iple andomized
con olled ials and me a-analyses (s ong e idence), o he s by obse a ional s udies and subse analyses
(mode a e e idence), and some p ima ily by expe consensus and clinical guidelines (limi ed di ec
e idence).
In oduc ion
Backg ound on SSNAP
The Sen inel S oke Na ional Audi P og amme (SSNAP) was es ablished in 2013 as a na ional heal hca e
quali y imp o emen p og amme based a King's College London. SSNAP measu es bo h he p ocesses o
ca e (clinical audi ) and he s uc u e o s oke se ices (o ganisa ional audi ) agains e idence-based
s anda ds, including he Na ional Clinical Guideline o S oke. The p og amme cap u es o e 90% o
expec ed s oke hospi al admissions, ep esen ing app oxima ely 85,000 pa ien s annually ac oss England,
Wales, and No he n I eland[web:4].
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SSNAP is unique globally as he i s na ional s oke egis e o collec in o ma ion abou he en i e s oke
ca e pa hway, om hospi al admission h ough o six-mon h ollow-up. Resul s a e upda ed qua e ly and
co e all hospi als ea ing s oke pa ien s in he pa icipa ing na ions. The o e all aim o SSNAP is o
p o ide imely in o ma ion o clinicians, commissione s, pa ien s, and he public on how well s oke ca e is
being deli e ed, se ing as a ool o imp o e he quali y o ca e p o ided o pa ien s[web:3][web:4].
The Se en Domains o Quali y Measu emen
SSNAP o ganizes i s 40 key quali y indica o s in o se en domains, each co e ing dis inc aspec s o he
s oke ca e pa hway:
• Domain 1: Hype acu e Assessmen - Focuses on apid diagnosis and ini ial assessmen ,
including b ain imaging wi hin 20 minu es, CT angiog aphy on i s imaging isi , s oke-skilled
clinician assessmen wi hin 1 hou , nu se assessmen wi hin 4 hou s, and swallow sc eening wi hin
4 hou s.
• Domain 2: Specialis Pa hway - Measu es access o and ime spen on s oke uni s, including
di ec admission o s oke uni wi hin 4 hou s, spending a leas 90% o s ay on s oke uni , and
access o s oke specialis communi y ehabili a ion eams.
• Domain 3: Repe usion The apies - Assesses acu e epe usion ea men s, including
h ombolysis a es, ime om a i al o h ombolysis, h ombec omy a es, and doo -in-doo -ou
imes o h ombec omy ans e s.
• Domain 4: Mul idisciplina y Assessmen - Co e s mul idisciplina y assessmen s wi hin speci ic
ime ames, including s oke consul an e iew, swallow assessmen , and he apy assessmen s.
• Domain 5: Rehabili a ion Pa hways - E alua es comp ehensi e ehabili a ion p o ision,
including achie emen o he apy dose a ge s and coo dina ion o mul idisciplina y assessmen s.
• Domain 6: The apy F equency - Measu es he amoun and equency o di e en he apy ypes
ecei ed, including mo o , psychological, and communica ion/swallowing he apy.
• Domain 7: S anda ds by Discha ge - Includes nu i ion sc eening, in ec ion a es, mood and
cogni ion sc eening, ision sc eening, and p o ision o pos -discha ge suppo .
Pu pose and Scope o This Re iew
This comp ehensi e li e a u e e iew sys ema ically examines he e idence ha each o he 40 SSNAP
quali y indica o s a ec s ou comes a e s oke. The e iew syn hesizes da a om andomized con olled
ials, me a-analyses, obse a ional s udies, and quali y imp o emen ini ia i es o p o ide a ho ough
unde s anding o he e idence base suppo ing cu en s oke quali y measu emen p ac ices.
The impo ance o his e iew lies in unde s anding no only which indica o s a e measu ed, bu why hey
ma e o pa ien ou comes. While some indica o s ha e obus e idence om mul iple andomized
con olled ials demons a ing clea imp o emen s in mo ali y and unc ional independence, o he s a e
based on mechanis ic unde s anding, obse a ional da a, o ep esen componen s o complex
in e en ions ha collec i ely imp o e ou comes.
Domain 1: Hype acu e Assessmen
The hype acu e phase o s oke ca e encompasses he i s ew hou s a e symp om onse , when apid
diagnosis and ea men decisions a e mos c i ical. Domain 1 indica o s ocus on he speed and
comp ehensi eness o ini ial assessmen , ecognizing ha " ime is b ain" - app oxima ely 1.9 million
neu ons die pe minu e du ing un ea ed ischemic s oke[1].
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Indica o s 1.1 & 1.2: B ain Scanning Wi hin 20 Minu es
Clinical Ra ionale
Ea ly b ain imaging is undamen al o acu e s oke managemen , se ing mul iple c i ical unc ions:
di e en ia ing ischemic om hemo hagic s oke, excluding s oke mimics, assessing sui abili y o acu e
he apies, and es ablishing baseline inju y se e i y. The 20-minu e a ge e lec s he u gency equi ed o
minimize ea men delays o ime-dependen in e en ions like h ombolysis and h ombec omy.
E idence Base
While speci ic e idence o he 20-minu e h eshold is limi ed, ea lie imaging consis en ly co ela es wi h
be e ou comes h ough enabling as e ea men decisions. CT scanning enables apid exclusion o
hemo hage and assessmen o ischemic changes using alida ed sco ing sys ems like he Albe a S oke
P og am Ea ly CT Sco e (ASPECTS).
The ASPECTS sco e p edic s unc ional ou comes wi h clinical signi icance. A s udy o 1,216 ischemic s oke
pa ien s ound ha pa ien s wi h ASPECTS 8-10 we e 1.9 imes mo e likely o achie e a o able ou comes
a 90 days compa ed o hose wi h sco es 0-7 (OR 1.9, p<0.001)[1]. The sco e's p edic i e alue
demons a es he impo ance o ea ly imaging o p ognos ica ion and ea men planning.
The isibili y o ea ly ischemic changes on CT inc eases wi h ime om s oke onse . Ea ly CT signs become
mo e e iden a e 3 hou s om symp om onse , suppo ing he impo ance o apid imaging when changes
may be sub le bu ea men windows emain open[2][3]. This empo al ela ionship unde sco es why
apid imaging p o ocols a e essen ial - hey cap u e pa ien s in he ime window when imaging may s ill
appea ela i ely no mal bu ea men is mos e ec i e.
Quali y imp o emen s udies demons a e ha achie ing e y apid CT scanning is easible. Sys ems
implemen ing s eamlined p o ocols ha e achie ed median doo - o-CT imes o 10-15 minu es, wi h some
cen e s epo ing 90% o pa ien s scanned wi hin 20 minu es[4]. These sys ems u ilize p e-no i ica ion,
di ec - o-CT pa hways, and pa allel p ocessing o clinical assessmen and imaging.
Ou comes Impac
Fas e imaging enables as e ea men , which di ec ly impac s ou comes. Each 15-minu e delay om
hospi al a i al o imaging is associa ed wi h educed odds o good unc ional ou come. The ela ionship
be ween imaging speed and clinical ou comes is media ed h ough i s e ec on ea men imes a he han
imaging i sel p o iding he apeu ic bene i .
Indica o s 1.3 & 1.4: CT Angiog aphy on Fi s Imaging Visi
Clinical Ra ionale
CT angiog aphy (CTA) iden i ies la ge essel occlusions (LVO) ha a e amenable o mechanical
h ombec omy, one o he mos e ec i e acu e s oke ea men s. CTA also p o ides in o ma ion abou
essel ana omy, colla e al ci cula ion, and h ombus cha ac e is ics ha guide ea men decisions. Fo
pa ien s wi h wake-up s okes o unknown onse imes, ad anced imaging enables ea men in ex ended
ime windows by demons a ing iable issue despi e unce ain iming.
E idence o CTA in Acu e S oke
Ad anced imaging including CTA imp o es pa ien selec ion o endo ascula he apy. The in eg a ion o
CTA in o acu e s oke p o ocols has e olu ionized ca e by enabling apid iden i ica ion o h ombec omy
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candida es. S udies demons a e ha CTA-based selec ion p o ocols achie e ou comes compa able o mo e
ad anced pe usion imaging, while being as e and mo e widely a ailable[5].
Fo wake-up s okes and s okes wi h unknown onse ime, ad anced imaging (CTA, CTP, o MRI) enables
ea men in ex ended ime windows. A mul icen e s udy ound ha a ailabili y o ad anced imaging
esul ed in an 11.7% inc ease in h ombolysis a es and 44% inc ease in h ombec omy a es o pa ien s
wi h unknown onse imes[6]. This ansla es o ea ing signi ican ly mo e pa ien s who would o he wise
be excluded om acu e he apies.
The WAKE-UP ial demons a ed ha MRI-based selec ion using DWI-FLAIR misma ch enabled sa e and
e ec i e h ombolysis in wake-up s oke pa ien s, wi h imp o ed unc ional independence (OR 1.61, 95% CI
1.09-2.36)[7]. While his ial used MRI, he p inciple o ad anced imaging enabling ex ended window
ea men applies o CTA and CTP p o ocols as well.
Impac on Th ombec omy Access
CTA is he co ne s one o h ombec omy pa ien iden i ica ion. Wi hou CTA, la ge essel occlusions may
be missed, denying pa ien s access o highly e ec i e ea men . A sys ema ic e iew ound ha CTA has
95% sensi i i y and 98% speci ici y o de ec ing in ac anial a e ial occlusion[8]. This excellen diagnos ic
accu acy makes CTA an essen ial componen o acu e s oke p o ocols.
Implemen a ion o ou ine CTA p o ocols has been associa ed wi h inc eased h ombec omy a es.
Hospi als ha adop ed CTA as pa o i s imaging saw h ombec omy a es inc ease om 2-3% o 5-8% o
all s oke pa ien s, e lec ing imp o ed iden i ica ion o eligible candida es[6].
Indica o 1.5: S oke-Skilled Clinician Assessmen Wi hin
1 Hou
Clinical Ra ionale
Ea ly specialis assessmen ensu es accu a e diagnosis, app op ia e ea men decisions, and imely
ini ia ion o acu e he apies. S oke-skilled clinicians ha e expe ise in ecognizing s oke synd omes,
assessing se e i y using s anda dized scales (NIHSS), iden i ying con aindica ions o ea men , and
managing acu e complica ions.
E idence Base
S udies demons a e ha o ganized s oke sys ems wi h immedia e specialis in ol emen educe doo - o-
ea men imes and imp o e ou comes. While di ec e idence on he 1-hou h eshold speci ically is
limi ed, as e clinical assessmen is a c i ical componen o success ul s oke p o ocols ha achie e doo -
o-needle imes unde 30 minu es[7][8].
The Ge Wi h The Guidelines-S oke egis y analysis o 71,169 pa ien s ound ha hospi als wi h as e
doo - o-physician assessmen imes had signi ican ly be e doo - o-needle imes o h ombolysis. Each
15-minu e educ ion in assessmen ime was associa ed wi h p opo ional educ ions in ea men ime[29].
Telemedicine-based specialis assessmen has eme ged as an e idence-based solu ion o hospi als wi hou
on-si e s oke specialis s. Mul iple andomized con olled ials demons a e ha elemedicine consul a ion
achie es ou comes equi alen o on-si e specialis assessmen , wi hou inc easing doo - o-needle imes[41].
The TRUST ial andomized pa ien s o elemedicine e sus elephone consul a ion and ound no
di e ence in 90-day ou comes, alida ing emo e specialis assessmen as e ec i e[41].
Quali y Imp o emen E idence
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Sys ems ha implemen p o ocols ensu ing apid specialis assessmen consis en ly achie e be e me ics
ac oss he acu e s oke pa hway. The Ta ge : S oke bes p ac ice ini ia i e iden i ied immedia e specialis
in ol emen as one o en key s a egies o achie ing doo - o-needle imes unde 30 minu es[30]. Cen e s
adop ing his comp ehensi e app oach educed median doo - o-needle imes om 77 o 67 minu es
na ionally.
Indica o 1.6: Nu se Assessmen Wi hin 4 Hou s
Clinical Ra ionale
S oke- ained nu sing assessmen is a co e componen o o ganized s oke uni ca e. Specialized nu ses
pe o m de ailed neu ological moni o ing, implemen s oke p o ocols, manage complica ions, coo dina e
ca e, and educa e pa ien s and amilies. Ea ly nu sing assessmen enables imely ini ia ion o e idence-
based ca e p ocesses ha ex end beyond he hype acu e window.
E idence om S oke Uni T ials
S oke- ained nu sing is in eg al o s oke uni ca e, which has been shown in mul iple andomized ials
o educe mo ali y (OR 0.87, 95% CI 0.69-0.94) and dea h o ins i u ionaliza ion (OR 0.78, 95% CI 0.68-
0.89)[9][10]. The Coch ane sys ema ic e iew o s oke uni ca e, which included 28 ials wi h 5,855
pa icipan s, iden i ied specialized nu sing as one o he key componen s con ibu ing o imp o ed
ou comes[15].
The mechanisms h ough which nu sing ca e imp o es ou comes include: ea ly iden i ica ion o
neu ological de e io a ion, p e en ion o complica ions (aspi a ion, p essu e ulce s, alls), implemen a ion
o e idence-based p o ocols (dysphagia sc eening, ea ly mobiliza ion), and coo dina ion o
mul idisciplina y ca e[10].
Dose-Response Rela ionships
S udies examining he componen s o s oke uni ca e sugges dose- esponse ela ionships, whe e g ea e
exposu e o specialized nu sing ca e is associa ed wi h be e ou comes. A s udy o 3,033 s oke pa ien s
ound ha highe nu se- o-pa ien a ios on s oke uni s we e independen ly associa ed wi h educed
mo ali y and leng h o s ay[16].
Indica o 1.7: Swallow Sc eening Wi hin 4 Hou s
Clinical Ra ionale
Dysphagia a ec s app oxima ely 50% o acu e s oke pa ien s and is he p ima y isk ac o o aspi a ion
pneumonia, a leading cause o s oke- ela ed mo ali y. Ea ly iden i ica ion o dysphagia p e en s o al
in ake in a - isk pa ien s, educing pneumonia incidence and associa ed complica ions. Swallow sc eening
is a simple, bedside assessmen pe o med by ained nu ses o iden i y pa ien s equi ing o mal dysphagia
assessmen .
S ong E idence Base
Ea ly dysphagia sc eening has one o he s onges e idence bases o any s oke quali y indica o . Mul iple
me a-analyses demons a e signi ican educ ions in pneumonia, mo ali y, and disabili y:
• A me a-analysis o dysphagia sc eening p og ams ound pneumonia educ ion wi h OR 0.52 (95% CI
0.35-0.77), mo ali y educ ion wi h OR 0.54 (95% CI 0.35-0.85), and dependency educ ion wi h
OR 0.54 (95% CI 0.35-0.85)[11].
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• Pa ien s who ail dysphagia sc eening ha e 3- old highe isk o pneumonia (adjus ed OR 3.00, 95%
CI 2.18-4.10) and 1.66- old highe isk o dea h o disabili y compa ed o hose who pass
sc eening[12].
• A la ge obse a ional s udy o 5,738 pa ien s ound ha ailu e o sc een o dysphagia was
independen ly associa ed wi h inc eased odds o pneumonia (OR 2.5), inc eased hospi al leng h o
s ay, and wo se unc ional ou comes a discha ge[13].
Compa a i e E ec i eness o Sc eening Me hods
Di e en sc eening p o ocols show a ying e ec i eness. The GLOBE-3S sc eening me hod, which includes
assessmen o consciousness, speech, and swallowing, p e en ed pneumonia in 100% o sc eened pa ien s
compa ed o a 31.82% pneumonia a e wi h he wa e swallow es alone in one s udy[14]. This highligh s
he impo ance o no jus whe he sc eening occu s, bu he quali y o he sc eening p o ocol used.
The iming o sc eening also ma e s. Sc eening wi hin 4 hou s ensu es ha pa ien s a e iden i ied be o e
ecei ing o al in ake, maximizing p e en ion o aspi a ion e en s. Delayed sc eening o lack o sc eening is
consis en ly associa ed wi h inc eased pneumonia a es ac oss mul iple s udies[11][12][13].
Implemen a ion and Ou comes
Quali y imp o emen s udies demons a e ha implemen ing sys ema ic dysphagia sc eening p og ams
educes pneumonia a es by 50-60% and sho ens hospi al leng h o s ay by 2-3 days on a e age[13]. The
e ec is mos p onounced when sc eening is combined wi h s ic nil-by-mou h p o ocols o pa ien s who
ail sc eening, ollowed by o mal speech and language he apy assessmen wi hin 24 hou s.
Domain 2: Specialis Pa hway
Domain 2 indica o s measu e access o o ganized s oke uni ca e and specialized ehabili a ion se ices.
S oke uni ca e ep esen s one o he mos e idence-based in e en ions in all o medicine, wi h bene i s
documen ed ac oss mul iple decades and heal hca e sys ems.
Indica o s 2.1 & 2.2: Di ec Admission o S oke Uni
Wi hin 4 Hou s
The S oke Uni E idence Base
S oke uni ca e is one o he mos igo ously e alua ed in e en ions in s oke medicine. The e idence base
has been sys ema ically e iewed and upda ed mul iple imes, consis en ly demons a ing bene i . The
la es Coch ane sys ema ic e iew (2020) inco po a ed 29 ials wi h 5,902 pa icipan s and u ilized
ne wo k me a-analysis o assess di e en ypes o s oke uni ca e[web:11][web:14].
Mo ali y and Disabili y Ou comes
The me a-analy ic e idence demons a es ha o ganized s oke uni ca e educes:
• Dea h: OR 0.87 (95% CI 0.69-0.94), ep esen ing a 13% ela i e isk educ ion
• Dea h o ins i u ionaliza ion: OR 0.78 (95% CI 0.68-0.89), ep esen ing a 22% ela i e isk educ ion
• Dea h o dependency: OR 0.82 (95% CI 0.73-0.92), wi h bene i s main ained a 1-yea ollow-up[9]
[15]
These bene i s pe sis a 10-yea ollow-up, demons a ing ha s oke uni ca e p oduces las ing
imp o emen s in su i al and independence[16]. A 10-yea ollow-up s udy o s oke uni ial pa icipan s
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ound sus ained mo ali y educ ion (OR 0.86, 95% CI 0.74-0.99) and inc eased likelihood o li ing a
home (OR 1.21, 95% CI 1.01-1.47)[16].
Bene i s Ac oss S oke Types
While mos e idence ocuses on ischemic s oke, s oke uni bene i s ex end o hemo hagic s oke. A
sys ema ic e iew speci ic o in ace eb al hemo hage ound ha s oke uni admission educed 30-day
mo ali y by 17 pe cen age poin s and 1-yea mo ali y by 17 pe cen age poin s compa ed o gene al wa d
ca e[17]. This consis en bene i ac oss s oke ypes unde sco es he uni e sal applicabili y o o ganized
s oke ca e p inciples.
Mechanisms o Bene i
The s oke uni model achie es supe io ou comes h ough mul iple mechanisms:
1. Ea ly assessmen and ea men - Rapid implemen a ion o e idence-based he apies
including aspi in, DVT p ophylaxis, and ea ly ehabili a ion
2. Physiological moni o ing - Regula obse a ions de ec ing and enabling ea men o
complica ions like hype ension, hypo ension, hypoxia, and hype glycemia
3. P e en ion o complica ions - Sys ema ic p o ocols educing pneumonia, u ina y ac
in ec ions, p essu e ulce s, and deep ein h ombosis
4. Coo dina ed mul idisciplina y ca e - Regula eam mee ings, sha ed goal-se ing, and
in eg a ed ea men plans
5. Specialized nu sing ca e - Nu ses ained in s oke-speci ic assessmen , moni o ing, and
managemen
6. Ea ly mobiliza ion and ehabili a ion - The apy assessmen and ea men beginning wi hin
24-48 hou s
7. Family in ol emen and educa ion - S uc u ed p og ams suppo ing ca egi e s and
p epa ing o discha ge
Compa ison wi h Al e na i e Ca e Models
Ne wo k me a-analysis compa ing di e en s oke uni ypes ound ha dedica ed s oke wa ds showed
supe io ou comes compa ed o gene al medical wa ds, mobile s oke eams, and mixed ehabili a ion
wa ds[web:11]. The absolu e educ ion in poo ou comes anged om 3-5% o dea h and 7-9% o
combined dea h o dependency, ep esen ing subs an ial clinical bene i when applied a popula ion le el.
Time o S oke Uni Admission
The 4-hou a ge o s oke uni admission ecognizes he impo ance o ea ly access o specialized ca e.
While mos s oke uni ials did no speci ically analyze admission iming, obse a ional s udies
demons a e dose- esponse ela ionships. A s udy o 10,977 pa ien s ound ha each hou o delay o s oke
uni admission was associa ed wi h inc eased odds o poo ou come (OR 1.03 pe hou , 95% CI 1.01-1.05)
[18].
Admission o s oke uni s was associa ed wi h a 43% educ ion in p olonged hospi aliza ion (>30 days) in
one la ge obse a ional s udy[18]. This educ ion in ex ended s ays e lec s bo h imp o ed ou comes and
mo e e icien ca e pa hways.
Indica o 2.3: Spending ≥90% o S ay on S oke Uni
Ra ionale o Con inuous Ca e
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The 90% h eshold ecognizes ha s oke pa ien s may equi e empo a y ans e o o he uni s (ICU,
ca diac ca he e iza ion labo a o y, in e en ional adiology) while ensu ing hey ecei e he as majo i y o
hei ca e in a specialized s oke en i onmen . Con inuous s oke uni ca e maximizes exposu e o
specialized moni o ing, ea ly complica ion de ec ion, coo dina ed mul idisciplina y managemen , and
ehabili a ion.
E idence om S oke Uni T ials
The s oke uni ials ha demons a ed mo ali y and disabili y bene i s p o ided con inuous ca e on
specialized uni s h oughou he acu e and ea ly ehabili a ion phases. The p o ocol in mos ials speci ied
ha pa ien s emain on he s oke uni o he majo i y o hei hospi aliza ion, wi h o ganized ca e om
admission h ough discha ge planning[9][15].
Dose-Response Rela ionships
S udies examining he dose- esponse ela ionship be ween s oke uni exposu e and ou comes consis en ly
show ha g ea e ime in s oke uni s is associa ed wi h be e ou comes. A Swedish na ional egis y s udy
o 54,876 pa ien s ound ha each addi ional day on a s oke uni (as opposed o gene al wa d) was
associa ed wi h educed mo ali y and imp o ed unc ional ou comes[19].
Con e sely, pa ien s who a e admi ed o s oke uni s bu hen ans e ed o gene al wa ds o ex ended
pe iods lose he bene i s o specialized ca e. Analysis om he SSNAP da abase ound ha pa ien s
spending <50% o hei s ay on s oke uni s had ou comes simila o hose ne e admi ed o s oke uni s,
while hose spending >90% o s ay on s oke uni s had he bes ou comes[20].
Implemen a ion Challenges
Achie ing he 90% a ge equi es su icien s oke uni capaci y ela i e o pa ien olumes and leng hs o
s ay. Ba ie s include: inadequa e s oke uni beds leading o "boa ding" o pa ien s on gene al wa ds,
p olonged s ays o pa ien s awai ing ehabili a ion o long- e m ca e placemen , and compe ing demands
o beds du ing pe iods o high hospi al occupancy[21].
Quali y imp o emen ini ia i es add essing hese ba ie s ha e success ully inc eased he p opo ion o
pa ien s mee ing he 90% h eshold om 60-70% o 80-90% h ough in e en ions including: expansion o
s oke uni capaci y, implemen a ion o ea ly suppo ed discha ge p og ams o educe a e age leng h o
s ay, and enhanced discha ge planning[21].
Indica o 2.4: S oke Specialis Communi y Rehabili a ion
(ESD/CRT)
Ea ly Suppo ed Discha ge Se ices
Ea ly Suppo ed Discha ge (ESD) se ices p o ide hospi al-le el mul idisciplina y ehabili a ion in
pa ien s' homes, enabling ea lie hospi al discha ge while main aining in ensi e he apy. ESD se ices
ypically include: assessmen and goal-se ing in hospi al, ea ly discha ge when medically s able, home
isi s by a mul idisciplina y s oke eam (physio he apy, occupa ional he apy, speech and language
he apy, nu sing), and coo dina ion wi h p ima y ca e and communi y se ices[22].
E idence om Randomized Con olled T ials
A Coch ane sys ema ic e iew o 17 ials wi h 2,422 pa icipan s demons a ed ha ESD se ices:
• Reduce hospi al leng h o s ay by app oxima ely 6 days (MD -5.5 days, 95% CI -3 o -8 days)
• Imp o e independence in ac i i ies o daily li ing (OR 1.44, 95% CI 1.08-1.91)
9
• Reduce odds o poo ou come (dea h o dependency) a 6 mon hs (OR 0.78, 95% CI 0.65-0.94)
• Achie e hese bene i s wi hou inc easing mo ali y o eadmission a es[22][23]
Func ional Bene i s
ESD se ices p oduce speci ic imp o emen s in unc ional domains including mobili y, ba hing, oile ing,
and d essing. E ec sizes ange om OR 1.23 o 1.60 o di e en ac i i ies o daily li ing[24]. These gains
e lec he bene i s o p ac icing unc ional ac i i ies in he home en i onmen whe e hey will be pe o med
long- e m.
A me a-analysis examining pa ien -le el da a om ESD ials ound ha bene i s we e g ea es o pa ien s
wi h mode a e disabili y (equi alen o modi ied Rankin Scale 2-3). Pa ien s wi h se e e disabili y equi ed
mo e in ensi e suppo , while hose wi h mild disabili y eco e ed well ega dless o se ing[25].
Cos -E ec i eness
ESD se ices demons a e cos -e ec i eness while main aining o imp o ing ou comes. Economic analyses
om mul iple coun ies show ha ESD se ices educe o al heal hca e cos s h ough sho e hospi al
s ays, while main aining quali y o li e and unc ional ou comes[26]. The UK Na ional Ins i u e o Heal h
and Ca e Excellence (NICE) ecommends ESD se ices based on clinical and cos -e ec i eness e idence.
Requi emen s o E ec i e ESD
E idence sugges s ha ESD se ices mus mee ce ain c i e ia o be e ec i e:
• Adequa e s a ing le els o p o ide in ensi e he apy ( ypically 1-2 hou s daily ini ially)
• A ailabili y o all co e disciplines (physio he apy, occupa ional he apy, speech and language he apy)
• Rapid esponse capabili y (able o ini ia e home isi s wi hin 24 hou s o discha ge)
• Coo dina ion wi h hospi al eams and p ima y ca e
• Du a ion o se ice ( ypically 6-12 weeks)
• Clea eligibili y c i e ia ocusing on pa ien s likely o bene i [22][23]
ESD se ices wi h pa ial implemen a ion o hese componen s show a enua ed bene i s compa ed o ully-
esou ced se ices, emphasizing he impo ance o adequa e in as uc u e and s a ing[25].
Domain 3: Repe usion The apies
Repe usion he apies—in a enous h ombolysis and mechanical h ombec omy— ep esen he mos
ime-sensi i e and po en ially ans o ma i e acu e s oke ea men s. Domain 3 indica o s measu e bo h
he a es o epe usion he apy deli e y and he speed wi h which hese ea men s a e adminis e ed.
Indica o s 3.1-3.3: Th ombolysis Ra es
E idence o In a enous Th ombolysis
In a enous h ombolysis wi h issue plasminogen ac i a o ( PA) o enec eplase signi ican ly imp o es
unc ional independence a e ischemic s oke. The e idence base has e ol ed o e h ee decades, om
ini ial ials demons a ing e icacy wi hin 3 hou s, o ex ended ime window ials, o ecen inno a ions
wi h enec eplase.
The landma k NINDS ial (1995) es ablished ha PA adminis e ed wi hin 3 hou s o symp om onse
inc eases he likelihood o minimal o no disabili y a 3 mon hs by 30-50%[27]. Subsequen ials and
16
Ea ly ehabili a ion he apy assessmen enables:
• Iden i ica ion o impai men s equi ing in e en ion
• Baseline unc ional assessmen o ou come measu emen
• Ea ly goal-se ing wi h pa ien s and amilies
• Commencemen o ehabili a ion du ing op imal plas ici y window
• P e en ion o seconda y complica ions (con ac u es, p essu e ulce s, decondi ioning)
The 24-hou ime ame e lec s e idence ha ea lie ehabili a ion imp o es ou comes, while ecognizing
p ac ical cons ain s on immedia e he apy a ailabili y[43][44].
E idence o Ea ly Rehabili a ion
Mul iple s udies examine he iming and in ensi y o ehabili a ion ini ia ion:
A Coch ane sys ema ic e iew o e y ea ly mobiliza ion (wi hin 24-48 hou s) ound mixed esul s. The
AVERT ial, he la ges s udy (2,104 pa ien s), ound ha e y ea ly, equen , and in ensi e mobiliza ion
ac ually inc eased odds o poo ou come (OR 1.37, 95% CI 1.11-1.69)[43]. This su p ising esul led o
ecogni ion ha "ea lie " and "mo e in ensi e" a e no uni o mly be e , and pa ien selec ion and
app op ia e in ensi y ma e .
Subsequen analyses cla i ied ha ea ly assessmen and goal-se ing di e om e y ea ly in ensi e
mobiliza ion. Ea ly assessmen (wi hin 24 hou s) ollowed by indi idualized ehabili a ion ailo ed o
pa ien capabili ies imp o es ou comes[44]. The key is a oiding bo h p olonged inac i i y and o e ly
agg essi e ea ly mobiliza ion.
A me a-analysis o ea ly ehabili a ion (de ined as beginning wi hin 7 days) ound imp o emen s in:
• Ac i i ies o daily li ing: s anda dized mean di e ence 6.90 (95% CI 0.22-13.57)
• Mo o unc ion: s anda dized mean di e ence 5.02 (95% CI 1.63-8.40)
• Walking abili y and balance[45]
Occupa ional The apy Speci ic E idence
Occupa ional he apy ocuses on ac i i ies o daily li ing, uppe ex emi y unc ion, cogni i e assessmen ,
and en i onmen al adap a ion. A sys ema ic e iew o occupa ional he apy in e en ions ound ha :
• Task-o ien ed aining imp o es ADL pe o mance (SMD 0.28, 95% CI 0.08-0.49)
• Uppe limb aining imp o es a m unc ion (SMD 0.35, 95% CI 0.17-0.53)
• Cogni i e ehabili a ion imp o es execu i e unc ion and memo y
• En i onmen al modi ica ions educe alls and imp o e independence[44]
Physio he apy Speci ic E idence
Physio he apy add esses mobili y, balance, mo o con ol, and ca dio ascula i ness. E idence suppo s:
• Ea ly physio he apy assessmen and in e en ion educes complica ions including DVT, pneumonia,
and p essu e ulce s
• Task-speci ic aining imp o es walking speed and endu ance
• Balance aining educes alls isk
17
• Ca dio ascula i ness aining imp o es unc ional capaci y[45]
P ac ical Implemen a ion
Achie ing 24-hou assessmen o all app op ia e pa ien s equi es adequa e he apy s a ing, weekend
a ailabili y, and e icien e e al p ocesses. S oke uni s wi h in eg a ed he apy eams achie e his a ge
mo e consis en ly han uni s elying on e e al o sepa a e he apy depa men s[10].
Indica o 4.5: Speech and Language The apy Wi hin 72
Hou s
Roles o Speech and Language The apis s
Speech and language he apis s (SLTs) assess and ea :
• Dysphagia (swallowing diso de s)
• Aphasia (language diso de s)
• Dysa h ia (speech mo o diso de s)
• Cogni i e-communica ion diso de s
• Voice diso de s
The 72-hou ime ame o SLT assessmen (compa ed o 24 hou s o OT/PT) e lec s wo conside a ions:
p io i iza ion o immedia e dysphagia assessmen o pa ien s ailing swallow sc eening (co e ed unde
Indica o 4.2), and ecogni ion ha comp ehensi e communica ion assessmen may equi e pa ien o be
medically s able and ale enough o pa icipa e[46].
E idence o Speech and Language The apy
The e idence base o SLT in e en ions has g own subs an ially, wi h sys ema ic e iews demons a ing
e icacy ac oss mul iple domains:
Fo Aphasia:
A Coch ane e iew o speech and language he apy o aphasia ound:
• SLT imp o es unc ional communica ion compa ed o no he apy (SMD 0.28, 95% CI 0.06-0.49)
• SLT imp o es eading (SMD 0.29, 95% CI 0.08-0.50) and w i ing (SMD 0.22, 95% CI 0.01-0.44)
• Mo e in ensi e he apy p oduces g ea e gains (dose- esponse ela ionship)
• The apy begun wi hin 3 mon hs o s oke is mos e ec i e[46][47]
Dosage and In ensi y:
Op imal he apy in ensi y emains an ac i e esea ch a ea. S udies demons a e:
• F equen he apy (4-5 imes pe week) supe io o in equen he apy (1-2 imes pe week)
• Highe cumula i e dose (40-60 hou s o al) p oduces la ge e ec sizes han lowe dose (<20 hou s)
• Combina ion o he apis -deli e ed and p ac ice-based in e en ions maximizes gains
• Technology-assis ed he apy can augmen adi ional he apy o inc ease dose[47][48]
Fo Dysa h ia:
18
SLT in e en ions o dysa h ia (speech mo o diso de s) include:
• A icula ion exe cises imp o ing speech in elligibili y
• Ra e con ol s a egies enhancing comp ehensibili y
• Respi a o y exe cises suppo ing speech p oduc ion
• Augmen a i e communica ion o se e ely a ec ed indi iduals[46]
Timing Conside a ions
The 72-hou ime ame balances mul iple ac o s:
• Immedia e needs: Pa ien s wi h dysphagia equi e assessmen wi hin 24 hou s (Indica o 4.2)
• Communica ion assessmen : Comp ehensi e language assessmen equi es pa ien ale ness and
coope a ion, which may ake 48-72 hou s o achie e in d owsy o medically uns able pa ien s
• Resou ce alloca ion: Mos s oke uni s ha e limi ed SLT s a ing, necessi a ing p io i iza ion
• P ognos ic assessmen : Ea ly aphasia se e i y p edic s eco e y ajec o y, enabling goal-se ing and
amily counseling[47]
Domain 5: Rehabili a ion Pa hways
Domain 5 indica o s measu e he comp ehensi eness and coo dina ion o ehabili a ion p o ision,
ecognizing ha s oke eco e y equi es o ganized, goal-di ec ed, mul idisciplina y in e en ion o e
weeks o mon hs. These indica o s e lec he in ensi y and in eg a ion o ehabili a ion se ices.
Indica o 5.1: Coo dina ed Mul idisciplina y Assessmen
Composi e Indica o Componen s
This indica o combines mul iple assessmen ime ames:
• Nu se assessmen wi hin 4 hou s (also Indica o 1.6)
• Occupa ional he apy and physio he apy wi hin 24 hou s (also Indica o s 4.3 and 4.4)
• Speech and language he apy wi hin 72 hou s (also Indica o 4.5)
• Rehabili a ion goals ag eed wi hin 5 days
The composi e na u e e lec s he in eg a ed, eam-based app oach ha cha ac e izes e ec i e s oke uni
ca e. Each componen is necessa y bu no su icien ; he coo dina ed deli e y o all componen s ep esen s
op imal p ac ice[10].
E idence o Mul idisciplina y Team App oach
Mul idisciplina y eam wo king is a de ining cha ac e is ic o s oke uni ca e. The mechanisms h ough
which coo dina ed ca e imp o es ou comes include:
1. Comp ehensi e needs assessmen - Each discipline iden i ies impai men s and unc ional
limi a ions om hei specialized pe spec i e
2. In eg a ed goal-se ing - Team de elops sha ed unde s anding o pa ien p io i ies and ealis ic
sho /medium- e m goals
19
3. Coo dina ed in e en ions - The apy p og ams complemen a he han duplica e, wi h
consis en app oaches ac oss disciplines
4. Regula communica ion - Team mee ings ensu e in o ma ion sha ing and ca e plan adjus men
5. Family in ol emen - Coo dina ed amily educa ion and aining in echniques o suppo ing
pa ien
S udies examining componen s o s oke uni ca e iden i y coo dina ed mul idisciplina y eam mee ings as
a key ac i e ing edien [10]. A sys ema ic e iew ound ha s oke uni s wi h weekly o mo e equen
mul idisciplina y mee ings had supe io ou comes compa ed o hose wi h less coo dina ed ca e[15].
Goal-Se ing E idence
The equi emen o ehabili a ion goals o be ag eed wi hin 5 days e lec s e idence ha s uc u ed goal-
se ing imp o es ou comes. S udies o collabo a i e goal-se ing demons a e:
• Imp o ed pa ien mo i a ion and ehabili a ion engagemen
• Be e unc ional ou comes when goals a e speci ic, measu able, and challenging
• Enhanced pa ien and amily sa is ac ion
• Mo e e icien esou ce u iliza ion h ough ocused in e en ions[49]
The SMART amewo k (Speci ic, Measu able, Achie able, Rele an , Time-bound) o goal-se ing is widely
ecommended and inco po a ed in o s oke ehabili a ion guidelines[50].
Indica o s 5.2 & 5.3: NICE Ta ge o To al The apy Dose
NICE Rehabili a ion Guidelines
The 2023 NICE guidelines o s oke ehabili a ion ecommend ha pa ien s should ecei e a minimum o
3 hou s o mul idisciplina y he apy pe day, 5 days pe week ( o al 15 hou s pe week)[49]. This ep esen s
cumula i e ime ac oss physio he apy, occupa ional he apy, and speech and language he apy. The
ecommenda ion e lec s e idence o dose- esponse ela ionships in s oke ehabili a ion.
E idence o High-In ensi y Rehabili a ion
Mul iple s udies demons a e ha mo e in ensi e ehabili a ion p oduces be e ou comes:
DOSE T ial:
This p agma ic andomized con olled ial (218 pa ien s) compa ed h ee doses o ehabili a ion:
• Con ol: usual ca e (app oxima ely 30 minu es daily)
• DOSE1: double usual ca e in ensi y (app oxima ely 1 hou daily)
• DOSE2: quad uple usual ca e in ensi y (app oxima ely 2 hou s daily)
Resul s showed dose-dependen imp o emen s in walking endu ance:
• Con ol g oup: 29-me e imp o emen in 6-minu e walk dis ance
• DOSE1 g oup: 61-me e imp o emen (95% CI 27-95 me e s be e han con ol)
• DOSE2 g oup: 58-me e imp o emen (95% CI 24-92 me e s be e han con ol)[51]
Bene i s pe sis ed a 12-mon h ollow-up, demons a ing sus ained e ec s o highe in ensi y
ehabili a ion[51].
20
Me a-Analyses o Rehabili a ion In ensi y:
A sys ema ic e iew examining ehabili a ion in ensi y (90-180 minu es daily) ac oss mul iple ials ound:
• Highe in ensi y associa ed wi h g ea e imp o emen s in ADL (Ba hel Index mean di e ence 5.2
poin s, 95% CI 0.7-9.7)
• Imp o emen s in mo o unc ion (Fugl-Meye sco e mean di e ence 3.8 poin s, 95% CI 0.8-6.8)
• No inc ease in ad e se e en s wi h highe in ensi y
• Bene i s mos p onounced in i s 6 mon hs pos -s oke[52][53]
The apy Time Dis ibu ion:
S udies examining ac ual he apy deli e y on s oke uni s ind wide a ia ion:
•Median o al he apy ime: 45-90 minu es pe day ac oss disciplines
•Only 20-40% o pa ien s ecei e he ecommended 3 hou s daily
•Va ia ion d i en by pa ien ac o s (se e i y, a igue, medical s abili y) and sys em ac o s (s a ing,
weekend co e age)[52]
SSNAP da a demons a e ha hospi als achie ing highe he apy doses ha e be e unc ional ou comes
and sho e leng hs o s ay[web:3].
Ba ie s o Achie ing The apy Ta ge s:
Quali y imp o emen s udies iden i y ba ie s o deli e ing ecommended he apy in ensi y:
• Inadequa e he apy s a ing le els
• Limi ed weekend and e ening he apy co e age
• Medical ins abili y o a igue limi ing pa ien pa icipa ion
• Compe ing demands (medical p ocedu es, in es iga ions, appoin men s)
• Lack o space o equipmen o concu en he apy sessions
• Adminis a i e and documen a ion bu den educing di ec pa ien con ac ime[53]
Success ul s a egies o inc easing he apy dose include: enhanced s a ing models, sel -di ec ed p ac ice
p og ams be ween supe ised sessions, echnology-augmen ed he apy, g oup he apy sessions, and
amily-assis ed p ac ice[52][53].
Domain 6: The apy F equency
While Domain 5 measu es o al he apy dose, Domain 6 examines he dis ibu ion and equency o he apy
ac oss di e en modali ies. These indica o s ecognize ha di e en impai men s equi e a ge ed
in e en ions deli e ed wi h app op ia e in ensi y and equency.
Indica o s 6.1 & 6.2: Mo o The apy In ensi y (3
Hou s/Day)
Ra ionale o High-In ensi y Mo o The apy
21
Mo o impai men s a ec 80% o s oke su i o s and ep esen p ima y de e minan s o unc ional
independence. E idence om animal models and human s udies demons a es ha mo o eco e y
depends on:
• Repe i i e ask-speci ic p ac ice
• Adequa e in ensi y and du a ion o p ac ice
• Challenge ma ched o cu en abili ies (shaping)
• Feedback on pe o mance
• T ans e o skills o eal-wo ld ac i i ies[54]
The 3-hou daily a ge o mo o he apy e lec s e idence ha highe doses p oduce g ea e mo o
eco e y[51][54].
E idence om High-In ensi y T aining S udies
Task-Speci ic T aining:
S udies o ask-speci ic aining ( epe i i e p ac ice o unc ional ac i i ies) demons a e dose- esponse
ela ionships:
• In e en ions p o iding >20 hou s o ask-speci ic p ac ice p oduce clinically meaning ul
imp o emen s in mo o unc ion (mean 6-poin imp o emen on Fugl-Meye scale)
• Highe epe i ion coun s (>300 epe i ions pe session) associa ed wi h g ea e gains
• Func ional asks (e.g., eaching o objec s, s epping p ac ice) show be e ans e o ADL han
impai men - ocused exe cises[54]
Cons ain -Induced Mo emen The apy (CIMT):
CIMT, which in ol es in ensi e p ac ice wi h he a ec ed a m (6 hou s daily) while cons aining he
una ec ed a m, p oduces la ge e ec sizes:
• Me a-analyses show SMD 0.45 (95% CI 0.25-0.65) o uppe ex emi y unc ion
• Modi ied p o ocols wi h educed in ensi y (2-3 hou s daily) e ain subs an ial bene i s while
imp o ing easibili y
• Bene i s main ained a long- e m ollow-up (1-2 yea s)[55]
Ae obic Exe cise T aining:
Ca dio ascula i ness aining imp o es walking endu ance, gai speed, and unc ional mobili y:
• High-in ensi y in e al aining p oduces g ea e imp o emen s han mode a e-in ensi y con inuous
aining in walking speed and endu ance
• Typical p o ocols: 20-40 minu es pe session, 3-5 imes weekly, o 8-12 weeks
• Imp o emen s in ca dio ascula i ness co ela e wi h unc ional gains[51]
F equency o Mo o The apy:
Indica o 6.2 measu es he pe cen age o inpa ien days on which mo o he apy is ecei ed. E idence
suppo s:
• Daily he apy (5-7 days pe week) supe io o 2-3 days pe week
22
• Dis ibu ed p ac ice (mul iple sessions pe day) may be mo e e ec i e han massed p ac ice (single
long session)
• Weekend he apy p o ision educes leng h o s ay and imp o es ou comes[55]
Indica o s 6.3 & 6.4: Psychological The apy (45
Minu es/Day)
P e alence and Impac o Pos -S oke Dep ession
Pos -s oke dep ession (PSD) a ec s 20-50% o s oke su i o s and signi ican ly impac s ou comes:
• Inc eased mo ali y: HR 1.61 (95% CI 1.33-1.96)[56]
• Wo se unc ional ou comes: OR 1.64 (95% CI 1.36-1.99)[57]
• Reduced ehabili a ion pa icipa ion and slowe eco e y
• Lowe quali y o li e
• Inc eased ca egi e bu den[58]
PSD di e s om dep ession in o he con ex s, wi h unique ea u es including: sudden onse ollowing
s oke e en , po en ial associa ion wi h lesion loca ion, coexis ence wi h cogni i e impai men and aphasia,
and in e ac ion wi h physical disabili y[56].
E idence o Dep ession Sc eening and In e en ion
Sc eening:
Sys ema ic dep ession sc eening using alida ed ools (e.g., Pa ien Heal h Ques ionnai e-9, Hospi al
Anxie y and Dep ession Scale) inc eases de ec ion a es om 20-30% o 40-50%, iden i ying pa ien s who
migh o he wise go un ecognized[58]. Ea ly iden i ica ion enables imely in e en ion.
Pha macological T ea men :
Me a-analyses o an idep essan ea men o PSD demons a e:
• E icacy in educing dep ession symp oms (SMD -0.92, 95% CI -1.29 o -0.54)
• Po en ial bene i s o unc ional eco e y independen o dep ession imp o emen
• Bes e idence o selec i e se o onin eup ake inhibi o s (SSRIs)
• P ophylac ic an idep essan s do no p e en PSD in unselec ed pa ien s[59]
Psychological In e en ions:
Non-pha macological ea men s o PSD include:
• Cogni i e-beha io al he apy (CBT): adap ed o s oke pa ien s, add esses nega i e hough s and
beha io al ac i a ion
• P oblem-sol ing he apy: helps pa ien s de elop coping s a egies o s oke- ela ed challenges
• Mo i a ional in e iewing: enhances engagemen in ehabili a ion
• Beha io al ac i a ion: s uc u ed ac i i y scheduling o coun e ac wi hd awal[59]
A me a-analysis o psychological in e en ions ound mode a e e ec sizes (SMD -0.50, 95% CI -0.83 o
-0.17) o educing dep essi e symp oms[57].
23
Op imal In ensi y o Psychological The apy:
The 45-minu e daily ecommenda ion e lec s clinical guidelines, hough e idence speci ically alida ing
his dose is limi ed. Mos e icacy ials o psychological in e en ions used:
• 30-60 minu e sessions
• 1-2 imes weekly equency
• 8-12 week du a ion
• To al cumula i e dose o 6-12 hou s[58][59]
Fo hospi alized pa ien s wi h mo e se e e dep ession, daily b ie in e en ions may be app op ia e, while
ou pa ien s ypically ecei e weekly longe sessions.
Indica o s 6.5 & 6.6: Communica ion/Swallowing The apy
(45 Minu es/Day)
Na ional Guidelines o SLT In ensi y
UK na ional guidelines ecommend 45 minu es o speech and language he apy daily, i e days pe week,
o pa ien s wi h communica ion o swallowing de ici s[60]. This e lec s e idence ha SLT in ensi y
ma e s o ou comes, wi h dose- esponse ela ionships demons a ed ac oss mul iple s udies.
E idence o Aphasia The apy In ensi y
Dose-Response S udies:
Mul iple s udies examine he ela ionship be ween aphasia he apy in ensi y and ou comes:
• A sys ema ic e iew ound ha in e en ions p o iding >5 hou s pe week p oduced la ge e ec sizes
(SMD 0.69) han in e en ions p o iding <2 hou s pe week (SMD 0.25)[47]
• Ve y high in ensi y (>15 hou s weekly) may no p oduce p opo ionally g ea e gains, sugges ing an
op imal in ensi y ange o 5-15 hou s weekly
• Cumula i e dose ma e s: o al he apy hou s o e weeks/mon hs p edic ou comes be e han
in ensi y alone[61]
Compa a i e E ec i eness:
The Big CACTUS ial compa ed wo aphasia he apy app oaches:
• Aphasia Compu e T ea men (ACT): sel -di ec ed compu e p ac ice, 20-30 minu es daily
• Usual ca e: he apis -deli e ed he apy, 1-2 sessions weekly
Resul s showed ha compu e -based he apy (deli e ing highe cumula i e dose h ough daily p ac ice)
was non-in e io o he apis -deli e ed he apy, wi h some ad an ages in wo d- inding[62]. This suppo s
he p inciple ha cumula i e p ac ice dose d i es ou comes, whe he deli e ed by he apis s o h ough
s uc u ed sel -p ac ice.
Dysphagia The apy E idence:
Fo swallowing diso de s, e idence suppo s:
24
• Swallowing exe cises (e.g., e o ul swallow, Mendelsohn maneu e ) imp o e swallow sa e y and
e iciency
• In ensi e he apy (daily sessions) educes ime o o al die ad ancemen
• Elec ical s imula ion and bio eedback may augmen adi ional he apy
• Adequa e he apy dose (>3 hou s weekly) associa ed wi h be e ou comes[61]
F equency o The apy:
Indica o 6.6 measu es he pe cen age o inpa ien days on which communica ion/swallowing he apy is
ecei ed. E idence suppo s:
•Daily p ac ice (wi h o wi hou di ec he apis supe ision) supe io o 2-3 imes weekly
•Dis ibu ed p ac ice (mul iple b ie sessions) may be mo e e ec i e han single long sessions,
pa icula ly o swallowing exe cises
•Home p ac ice p og ams be ween he apis sessions inc ease cumula i e dose[62]
Technology-Enhanced The apy Deli e y:
Inno a i e app oaches o deli e ing adequa e he apy dose include:
• Compu e -based aphasia he apy p og ams enabling in ensi e p ac ice
• Telep ac ice deli e ing he apy o ou pa ien s and u al popula ions
• Vi ual eali y and gaming pla o ms engaging pa ien s in speech p ac ice
• Mobile apps suppo ing home p ac ice wi h au oma ed eedback[47][62]
These echnologies add ess he challenge o limi ed he apis a ailabili y by augmen ing, hough no
eplacing, adi ional he apy.
Domain 7: S anda ds by Discha ge
Domain 7 indica o s add ess impo an ca e p ocesses and sc eening ac i i ies ha should occu du ing he
inpa ien s ay o op imize long- e m ou comes and p e en complica ions. These indica o s e lec
comp ehensi e, pa ien -cen e ed ca e add essing medical, unc ional, cogni i e, and psychosocial needs.
Indica o 7.1: Nu i ion Sc eening and Die i ian
In ol emen
P e alence o Malnu i ion A e S oke
Malnu i ion and nu i ional isk a ec 10-30% o s oke pa ien s a hospi al admission and up o 35-50%
du ing hospi aliza ion. Risk ac o s include:
• Dysphagia limi ing o al in ake
• Reduced consciousness o al e ed men al s a us
• P e-exis ing malnu i ion in ail elde ly pa ien s
• Inc eased me abolic demands o acu e illness
• Dep ession and educed appe i e
25
• En i onmen al ba ie s o ea ing (un amilia hospi al ood, assis ance needed)[63]
E idence Linking Nu i ion o Ou comes
Nu i ional s a us p edic s s oke ou comes:
The P ognos ic Nu i ional Index (PNI), calcula ed om se um albumin and lymphocy e coun ,
independen ly p edic s ou comes:
• Low PNI (<40) associa ed wi h pos -s oke cogni i e impai men (OR 2.158, 95% CI 1.205-3.863)
• Low PNI p edic s poo unc ional ou comes (mRS 3-6) a 3 mon hs
• Malnu i ion independen ly associa ed wi h inc eased mo ali y, longe leng h o s ay, and highe
complica ion a es[63]
Nu i ional Sc eening and In e en ion
Sys ema ic nu i ional sc eening iden i ies pa ien s equi ing de ailed assessmen and in e en ion.
Valida ed ools include:
• Malnu i ion Uni e sal Sc eening Tool (MUST)
• Nu i ional Risk Sc eening 2002 (NRS-2002)
• Mini Nu i ional Assessmen (MNA)
Pa ien s iden i ied as a nu i ional isk equi e die i ian assessmen and indi idualized nu i ion ca e
plans, which may include:
• Tex u e-modi ied die s o dysphagia
• Nu i ional supplemen a ion (o al supplemen s, o i ied oods)
• Feeding assis ance and en i onmen al modi ica ions
•En e al nu i ion (nasogas ic o gas os omy eeding) o se e e dysphagia
•Moni o ing o in ake and weigh ends[63]
Ou comes o Nu i ion In e en ions:
S udies o sys ema ic nu i ional sc eening and in e en ion demons a e:
• P e en ion o weigh loss du ing hospi aliza ion
• Reduced p essu e ulce incidence
• Imp o ed unc ional eco e y (con lic ing e idence, may depend on in e en ion ype)
• Reduced leng h o s ay in pa ien s wi h iden i ied nu i ional isk who ecei e in e en ion[63]
Indica o 7.2: In ec ion Ra es (UTI and Pneumonia)
S oke-Associa ed In ec ions
In ec ions ep esen majo complica ions a ec ing 20-30% o s oke pa ien s, wi h pneumonia and u ina y
ac in ec ions accoun ing o mos cases[64]. S oke-associa ed in ec ions d ama ically wo sen ou comes
h ough:
• Inc eased mo ali y (OR 2.3-3.0)
• P olonged hospi aliza ion (mean 5-10 addi ional days)
32
Ea ly Suppo ed Discha ge:
ESD p og ams inco po a ing ongoing suppo and ollow-up (discussed unde Indica o 2.4) demons a e
be e ou comes han discha ge wi hou s uc u ed ollow-up. Key componen s include:
• Designa ed ca e coo dina o known o pa ien and amily
• Regula con ac (phone o in-pe son) du ing ansi ion pe iod
• A ailabili y o add ess ques ions and conce ns
• Facili a ion o communi y se ice access[22][25]
Ca e T ansi ions In e en ions:
S udies o ca e ansi ions in e en ions (no s oke-speci ic) demons a e ha p o iding:
• Named con ac pe son educes 30-day eadmission a es
• Ca e coo dina ion imp o es medica ion adhe ence
• S uc u ed ollow-up educes eme gency depa men isi s
• Pa ien educa ion and ac i a ion imp o es sel -managemen [78]
Pa ien and Ca egi e Pe spec i es:
Quali a i e esea ch wi h s oke su i o s and ca egi e s consis en ly iden i ies pos -discha ge suppo as a
majo unme need. Pa ien s epo :
• Unce ain y abou who o con ac wi h ques ions
• Di icul y na iga ing agmen ed se ices
• Feeling "abandoned" a e in ensi e hospi al ca e
• Lack o in o ma ion abou eco e y ajec o y and a ailable esou ces
P o ision o a named con ac add esses hese conce ns by p o iding a clea poin o en y o he heal hca e
sys em[79].
Implemen a ion Models:
Di e en se ice models p o ide pos -discha ge suppo con ac :
• S oke nu se specialis : p o ides elephone ollow-up and clinic appoin men s
• Ea ly suppo ed discha ge eam: ca e coo dina o ole
• P ima y ca e s oke liaison: GP-based suppo
• Pee suppo p og ams: connec ing wi h expe ienced s oke su i o s
• Volun a y sec o : s oke associa ion suppo wo ke s[22][79]
The op imal model likely depends on local se ice con igu a ion, bu he key p inciple is ensu ing pa ien s
ha e a known, accessible con ac o pos -discha ge needs.
E idence S eng h Summa y and Quali y
G ading
33
S ong E idence (Mul iple RCTs and Me a-Analyses)
The ollowing indica o s ha e he s onges e idence base, wi h mul iple andomized con olled ials and
sys ema ic e iews demons a ing clea imp o emen s in mo ali y, disabili y, o o he pa ien -impo an
ou comes:
S oke Uni Ca e (Indica o s 2.1, 2.2, 2.3):
29 RCTs wi h 5,902 pa icipan s
OR 0.87 o dea h (95% CI 0.69-0.94)
OR 0.78 o dea h o ins i u ionaliza ion (95% CI 0.68-0.89)
Coch ane e iews consis en ly upda ed since 1997
Bene i s sus ained a 10-yea ollow-up[9][10][15][16][web:11][web:14]
Dysphagia Sc eening and Assessmen (Indica o s 1.7, 4.2):
Mul iple me a-analyses demons a ing consis en bene i s
OR 0.52 o pneumonia (95% CI 0.35-0.77)
OR 0.54 o mo ali y (95% CI 0.35-0.85)
S ong mechanis ic a ionale and biological plausibili y[11][12][13][14]
Th ombolysis (Indica o s 3.1-3.3):
Nine majo RCTs wi h 6,756 pa icipan s
OR 1.64 o a o able ou come (95% CI 1.47-1.82)
Time-dependen bene i s well-documen ed
Ex ended ime window bene i s p o en in imaging-selec ed pa ien s[27][28][29]
Th ombec omy (Indica o s 3.5-3.7):
Mul iple landma k RCTs (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT)
HERMES me a-analysis: OR 2.39 o unc ional independence (95% CI 1.88-3.04)
Bene i s demons a ed ac oss mul iple ime windows and pa ien subg oups[33][34][35][36][37]
[38]
Ea ly Suppo ed Discha ge (Indica o 2.4):
Coch ane e iew o 17 ials wi h 2,422 pa icipan s
OR 0.78 o dea h o dependency (95% CI 0.65-0.94)
5.5-day educ ion in hospi al leng h o s ay (95% CI -3 o -8 days)
Cos -e ec i eness demons a ed[22][23][24][25]
The apy Dose and In ensi y (Indica o s 5.2, 5.3, 6.1, 6.2):
Mul iple RCTs demons a ing dose- esponse ela ionships
DOSE ial showing sus ained bene i s o highe in ensi y
Me a-analyses consis en ly a o ing highe doses
E idence ac oss mul iple he apy ypes (PT, OT, SLT)[51][52][53][54]
34
Mode a e E idence (Obse a ional S udies and Subse
Analyses)
Ea ly Imaging (Indica o s 1.1, 1.2):
No RCTs speci ically es ing imaging ime a ge s
Obse a ional s udies showing co ela ions wi h ou comes
ASPECTS alida ion s udies demons a ing p ognos ic alue
Mechanism h ough enabling as e ea men [1][2][3][4]
CTA Use (Indica o s 1.3, 1.4):
No RCTs o CTA s. no CTA (would be une hical gi en cu en knowledge)
Obse a ional s udies showing imp o ed h ombec omy a es
Diagnos ic accu acy s udies (95% sensi i i y, 98% speci ici y)
Ex ended window ea men enabled by ad anced imaging[5][6][7][8]
Doo - o-Needle Time Reduc ion (Indica o 3.4):
La ge obse a ional s udies (58,353 pa ien s)
Quali y imp o emen s udies demons a ing easibili y
Clea ime-ou come ela ionships
No RCT andomizing pa ien s o di e en doo - o-needle imes (une hical)[8][30][31][32]
Ea ly Mul idisciplina y Assessmen (Indica o s 4.1-4.5, 5.1):
Componen o s oke uni ca e bu speci ic iming h esholds no di ec ly es ed
Obse a ional da a suppo ing ea lie assessmen
AVERT ial cau iona y ega ding e y ea ly in ensi e mobiliza ion
Mechanism plausible and consis en wi h s oke uni bene i [43][44][45][46]
Cogni ion Sc eening (Indica o 7.4):
P ognos ic alue es ablished
No RCTs es ing ou comes o sc eening s. no sc eening
Logical link o cogni i e ehabili a ion which has mode a e e idence
Ox o d Cogni i e Sc een alida ion s udies[69][70][71]
SLT In ensi y (Indica o s 6.5, 6.6):
Mul iple s udies showing dose- esponse ela ionships o aphasia he apy
Fewe s udies speci ically es ing daily he apy s. less equen
S ong e idence o cumula i e dose impo ance
Limi ed e idence o swallowing he apy in ensi y[47][61][62]
35
Limi ed Di ec E idence (Expe Consensus and
Guidelines)
Speci ic Time Th esholds:
Many ime-based indica o s (1 hou o clinician assessmen , 14 hou s o consul an , 4 hou s o
a ious assessmen s) ep esen expe consensus a ge s
E idence suppo s he gene al p inciple o ea ly assessmen
Speci ic h esholds chosen based on easibili y and clinical wo k low a he han explici ials[9]
[10][41]
Vision Sc eening P o ocols (Indica o s 7.6, 7.7):
High p e alence and impac o isual de ici s es ablished
E idence o speci ic in e en ions mode a e
Limi ed di ec e idence ha sys ema ic sc eening imp o es ou comes
Recommended in guidelines based on expe consensus[72][73][74][75][76][77]
Named Con ac P o ision (Indica o 7.8):
Componen o success ul ESD p og ams
Pa ien - epo ed impo ance in quali a i e s udies
No RCTs speci ically es ing named con ac p o ision s. none
Suppo ed by ca e ansi ions li e a u e om o he condi ions[22][25][78][79]
Nu i ion Sc eening (Indica o 7.1):
Malnu i ion clea ly p edic s poo ou comes
Sc eening iden i ies a - isk pa ien s
Limi ed e idence ha sc eening i sel (as opposed o subsequen in e en ions) imp o es ou comes
Nu i ional in e en ions ha e mixed e idence[63]
Quali y o E idence Conside a ions
Se e al ac o s a ec he s eng h o e idence o SSNAP indica o s:
1. Clus e s. Indi idual E ec s: Many indica o s ep esen componen s o complex in e en ions
(s oke uni ca e) whe e he bene i a ises om he combina ion a he han indi idual elemen s.
Isola ing e ec s o speci ic componen s is challenging.
2. E hical Cons ain s: Fo in e en ions now conside ed s anda d o ca e (e.g., dysphagia
sc eening, b ain imaging, s oke uni admission), conduc ing RCTs wi hholding in e en ion would
be une hical, limi ing e idence o obse a ional s udies and his o ical con ols.
3. Time-Based Indica o s: Speci ic ime h esholds (20 minu es o imaging, 1 hou o
assessmen ) o en ep esen expe consensus a ge s based on wo k low easibili y a he han
empi ically- es ed h esholds. E idence suppo s he gene al p inciple o as e is be e , bu
op imal speci ic imes a e less ce ain.
36
4. Measu emen Challenges: Some ou comes (pa ien sa is ac ion, con idence, knowledge) a e
di icul o measu e igo ously, limi ing e idence gene a ion despi e clinical impo ance.
5. Sys em-Le el Implemen a ion: Quali y imp o emen s udies demons a e easibili y and
associa ion wi h ou comes bu lack andomiza ion and con ol g oups, limi ing causal in e ence.
Na ional Quali y Imp o emen and SSNAP
Impac
SSNAP as a Quali y Imp o emen Tool
Beyond measu ing quali y, SSNAP unc ions as a powe ul quali y imp o emen ool h ough se e al
mechanisms:
1. Benchma king: Hospi als can compa e hei pe o mance agains egional and na ional a e ages,
iden i ying a eas o ela i e weakness equi ing imp o emen e o s[web:13].
2. T anspa ency: Public epo ing c ea es accoun abili y and incen i izes imp o emen . Hospi als
pe o ming poo ly ace sc u iny om commissione s and pa ien s[web:4].
3. Bes P ac ice Sha ing: High-pe o ming cen e s se e as models, wi h hei p o ocols and
sys ems s udied and adap ed by o he cen e s[web:16].
4. Resea ch Pla o m: The comp ehensi e na ional da ase enables esea ch iden i ying ac o s
associa ed wi h be e ou comes and es ing imp o emen in e en ions[web:6].
E idence o SSNAP E ec i eness
Mul iple s udies ha e examined SSNAP's impac on s oke ca e quali y:
Imp o emen s in P ocess Measu es:
Analysis o SSNAP da a o e ime demons a es sus ained imp o emen s in mul iple domains:
• B ain scanning wi hin 1 hou : inc eased om 38% (2013) o 55% (2019)
• Di ec admission o s oke uni wi hin 4 hou s: inc eased om 46% (2013) o 58% (2019)
• Th ombolysis a es: inc eased om 10.2% (2013) o 11.8% (2019)
• Doo - o-needle imes: median educed om 60 minu es (2013) o 43 minu es (2019)[web:7]
Quali y Imp o emen Collabo a i e Success:
A ecen s udy examining a quali y imp o emen collabo a i e ac oss a na ional s oke ne wo k ound ha
s uc u ed QI e o s using SSNAP da a signi ican ly imp o ed ca e pa hway e iciency[web:9]:
• Doo o Decision ime educed by 15.97% (SE 4.29%, p<0.001)
• Doo o CT ime signi ican ly imp o ed (p=0.002 and p=0.004 in wo phases)
• Imp o emen s sus ained o e 2-yea ollow-up pe iod
• Bo om-up collabo a i e app oach mo e e ec i e han op-down manda es[web:9]
Associa ion wi h Ou comes:
37
S udies linking SSNAP p ocess measu es o ou comes demons a e:
• Highe SSNAP sco es (agg ega e pe o mance) associa ed wi h lowe mo ali y
• Speci ic quali y indica o s (di ec s oke uni admission, dysphagia sc eening, ea ly he apy
assessmen ) independen ly p edic be e unc ional ou comes
• Hospi als imp o ing SSNAP pe o mance show co esponding ou come imp o emen s[web:12]
[web:18]
In e na ional Pe spec i e and Compa ison
Global Adop ion o S oke Quali y Measu emen
Mul iple coun ies ha e de eloped na ional s oke audi p og ammes inspi ed by o modeled a e SSNAP:
Aus alia:
The Aus alian S oke Clinical Regis y (AuSCR) collec s da a on o e 90% o s oke admissions ac oss
app oxima ely 125 hospi als. Quali y indica o s o e lap subs an ially wi h SSNAP, demons a ing
in e na ional consensus on key quali y measu es. Aus alia has shown simila quali y imp o emen s o e
ime associa ed wi h egis y implemen a ion[80].
Uni ed S a es:
The Ge Wi h The Guidelines-S oke p og am ope a ed by he Ame ican Hea Associa ion collec s da a
om o e 2,300 hospi als. While olun a y (unlike SSNAP's nea -uni e sal co e age), GWTG-S oke has
demons a ed quali y imp o emen s in pa icipa ing hospi als, pa icula ly in doo - o-needle imes and
e idence-based medica ion use[8][81].
Canada:
The Canadian S oke Bes P ac ices p og am p o ides guidelines and quali y indica o s aligned wi h
in e na ional s anda ds. P o incial egis ies collec da a, hough na ional coo dina ion is less
comp ehensi e han SSNAP. Regional a ia ion in pe o mance emains subs an ial[82].
Eu opean Coun ies:
Many Eu opean na ions ha e de eloped na ional o egional s oke egis ies, wi h a ying co e age and
indica o se s. The Eu opean S oke O ganisa ion has wo ked o ha monize quali y indica o s ac oss
coun ies o enable in e na ional compa isons and collabo a i e imp o emen e o s[83].
Compa a i e Pe o mance
In e na ional compa isons e eal:
• Doo - o-needle imes: England/Wales median ~43 minu es, US median ~60 minu es, Aus alia
median ~72 minu es ( e lec ing di e en measu emen pe iods and sys em cha ac e is ics)[8][31]
[80]
• Th ombolysis a es: Range om 8-12% ac oss de eloped heal hca e sys ems, wi h a ia ion d i en by
popula ion cha ac e is ics and sys em o ganiza ion[80][81][82]
• S oke uni access: >80% in England/Wales, 60-70% in many o he coun ies, e lec ing SSNAP's
success in d i ing s oke uni de elopmen [web:7][83]
38
Fu u e Di ec ions and E ol ing E idence
Eme ging Quali y Indica o s
Se e al a eas ep esen po en ial u u e addi ions o s oke quali y measu emen :
A ial Fib illa ion De ec ion:
P olonged ca diac moni o ing a e c yp ogenic s oke de ec s a ial ib illa ion in 10-30% o pa ien s,
enabling an icoagula ion o p e en ecu en s oke. Quali y indica o s migh include:
• Pe cen age o pa ien s wi h c yp ogenic s oke ecei ing p olonged moni o ing
• Time o an icoagula ion ini ia ion o newly de ec ed AF
• An icoagula ion a es a discha ge o known AF[84]
Seconda y P e en ion Medica ion Op imiza ion:
While cu en indica o s ack p o ision o speci ic medica ions, u u e indica o s migh measu e:
• LDL choles e ol a ge s achie ed a ollow-up
• Blood p essu e con ol a 3 and 6 mon hs
• Medica ion adhe ence a 6 and 12 mon hs
• Li es yle modi ica ion p og am pa icipa ion[85]
Pa ien -Repo ed Ou comes:
SSNAP al eady collec s 6-mon h pa ien - epo ed ou comes in a subse o pa ien s. Fu u e di ec ions
include:
• Expanding collec ion o all pa ien s
• Inco po a ing pa ien - epo ed expe ience measu es (sa is ac ion, communica ion quali y)
• Measu ing pa icipa ion and quali y o li e beyond basic unc ional measu es
• Ca egi e bu den and quali y o li e[web:3]
Technology-Enhanced Rehabili a ion:
As ehabili a ion echnologies demons a e e icacy, quali y indica o s migh measu e:
• Access o echnology-augmen ed he apy
• Vi ual eali y ehabili a ion u iliza ion
• Tele ehabili a ion p o ision o u al/homebound pa ien s[86]
E ol ing T ea men Pa adigms
Recen clinical ials con inue expanding he e idence base and may in luence u u e quali y indica o s:
Ex ended Time Window Th ombec omy:
T ials demons a ing h ombec omy bene i up o 24 hou s wi h imaging selec ion sugges u u e indica o s
migh measu e:
39
• Ra es o pe usion imaging u iliza ion
• Th ombec omy a es in ex ended ime windows
• Awakening wi h s oke ea men a es[37][38]
Tenec eplase o Th ombolysis:
T ials demons a ing enec eplase non-in e io i y o supe io i y o al eplase may shi p ac ice. Quali y
indica o s would adap o measu e:
• Tenec eplase adop ion a es
• Single bolus adminis a ion educing ea men complexi y[87]
Di ec Th ombec omy s. B idging The apy:
T ials compa ing di ec h ombec omy o IV h ombolysis ollowed by h ombec omy in o m ea men
p o ocols. Fu u e indica o s migh measu e:
• App op ia e pa ien selec ion o di ec h ombec omy
• Time me ics o di ec h ombec omy pa hways[88]
Add essing Heal h Inequi ies
Eme ging ocus on heal h equi y sugges s u u e quali y measu emen should add ess dispa i ies:
• Pe o mance s a i ied by socioeconomic s a us, ace/e hnici y, and geog aphy
• Access o specialized se ices ( h ombec omy, ESD) ac oss popula ions
• Language-app op ia e in o ma ion and suppo p o ision
• Cul u al compe ence in s oke ca e deli e y[89]
Implemen a ion Challenges and Solu ions
Common Ba ie s o Achie ing Quali y Ta ge s
Heal hca e sys ems ace mul iple challenges in mee ing SSNAP a ge s:
Resou ce Cons ain s:
• Insu icien s oke uni beds ela i e o pa ien olumes
• Limi ed he apy s a ing p e en ing achie emen o ecommended in ensi y
• Weekend and e ening co e age gaps
• Geog aphic wo k o ce sho ages ( u al a eas, less desi able loca ions)[90]
Sys em O ganiza ion:
• F agmen ed ca e pa hways wi h delays a ansi ion poin s
• Eme gency depa men bo lenecks slowing di ec - o-s oke-uni admission
• Compe ing demands o sha ed esou ces (CT scanne s, adiology epo ing)
• Complex ans e a angemen s o h ombec omy[91]
40
Clinical Fac o s:
• Pa ien cha ac e is ics a ec ing eligibili y o in e en ions
• Medical como bidi ies limi ing he apy pa icipa ion
• Cogni i e and language impai men s a ec ing assessmen and ehabili a ion
• Family/social ac o s complica ing discha ge planning[92]
Success ul Quali y Imp o emen S a egies
E idence om quali y imp o emen ini ia i es iden i ies e ec i e s a egies:
Sys em Redesign:
• P e-no i ica ion and ac i a ion sys ems
• Di ec - o-CT and di ec - o-s oke-uni pa hways
• Pa allel p ocessing o assessmen s and in e en ions
• S anda dized p o ocols educing a ia ion[30][web:9]
Enhanced S a ing Models:
• The apy assis ance oles augmen ing p o essional he apis s
• Ex ended hou s and weekend co e age
• S oke specialis nu ses coo dina ing ca e
• Dedica ed s oke physicians educing consul an esponse imes[90][91]
Technology Solu ions:
• Telemedicine ex ending specialis expe ise
• Elec onic dashboa ds p o iding eal- ime pe o mance eedback
• Decision suppo ools embedded in elec onic eco ds
• Mobile apps coo dina ing p e-hospi al and hospi al eams[41][92]
Collabo a i e Lea ning:
• Regional ne wo ks sha ing bes p ac ices
• Lea ning collabo a i es wi h s uc u ed imp o emen me hodology
• In e -hospi al isi s and obse a ion
• Simula ion aining o a e bu c i ical scena ios[web:9][web:16]
Conclusions
Summa y o E idence Base
This comp ehensi e e iew demons a es ha he 40 SSNAP quali y indica o s es on a s ong ounda ion
o clinical e idence, hough he s eng h o e idence a ies ac oss indica o s:
41
Ve y S ong E idence: S oke uni ca e, dysphagia sc eening, h ombolysis, h ombec omy, ea ly
suppo ed discha ge, and ehabili a ion in ensi y ha e he mos obus e idence om mul iple andomized
con olled ials and me a-analyses demons a ing clea imp o emen s in mo ali y, disabili y, and quali y
o li e.
Mode a e E idence: Ea ly imaging, ad anced imaging o ea men selec ion, doo - o-needle ime
op imiza ion, and ea ly mul idisciplina y assessmen s a e suppo ed by la ge obse a ional s udies, quali y
imp o emen ini ia i es, and mechanis ic unde s anding, hough speci ic h esholds o en e lec expe
consensus a he han di ec expe imen al e idence.
Limi ed Di ec E idence: Some indica o s, pa icula ly hose ela ed o speci ic ime h esholds,
sc eening p ocesses wi hou demons a ed links o in e en ion e ec i eness, and s uc u al p ocesses
(named con ac p o ision), ely p ima ily on expe consensus and logical in e ence a he han di ec
ou come s udies.
In e connec ed Na u e o Quali y Indica o s
A c i ical insigh om his e iew is ha many SSNAP indica o s a e in e connec ed componen s o
o ganized s oke sys ems a he han independen in e en ions. The s oke uni model ha demons a es
such s ong ou come bene i s comp ises mul iple elemen s: apid assessmen , coo dina ed
mul idisciplina y ca e, specialized nu sing, ea ly ehabili a ion, complica ion p e en ion, and sys ema ic
moni o ing. A emp ing o isola e he e ec o indi idual componen s misses he syne gis ic na u e o
comp ehensi e s oke ca e.
Simila ly, achie ing apid epe usion equi es mul iple coo dina ed p ocesses: as p e-hospi al
ecogni ion and anspo , e icien eme gency depa men iage, apid imaging, quick ea men
decisions, and s eamlined medica ion o p ocedu e p epa a ion. The ime me ics measu e he e iciency
o hese sys ems wo king oge he .
Value o Comp ehensi e Quali y Measu emen
The SSNAP amewo k's comp ehensi eness is a key s eng h. By measu ing 40 indica o s ac oss se en
domains, SSNAP cap u es he mul i ace ed na u e o quali y s oke ca e. This app oach:
1. P e en s gaming o indi idual me ics a he expense o o e all ca e quali y
2. Iden i ies speci ic weaknesses equi ing a ge ed imp o emen
3. Re lec s he complexi y o s oke ca e deli e y ac oss acu e and ehabili a ion phases
4. Aligns wi h pa ien p io i ies encompassing su i al, independence, and quali y o li e
Impac on S oke Ca e Quali y
E idence demons a es ha SSNAP implemen a ion has d i en sus ained imp o emen s in s oke ca e
quali y ac oss England, Wales, and No he n I eland. P ocess measu es ha e consis en ly imp o ed yea -
o e -yea , wi h co esponding imp o emen s in pa ien ou comes. The p og amme exempli ies how
sys ema ic quali y measu emen , anspa en epo ing, and con inuous imp o emen e o s can ele a e
heal hca e deli e y a a popula ion le el[web:4][web:7][web:9].
Recommenda ions o Fu u e De elopmen
1. Con inue e idence e iew: Regula ly upda e quali y indica o s based on eme ging clinical ial
e idence and e ol ing s oke ca e pa adigms.
