SAUDI STROKE PATHWAY

STANDARDS

11. March. 2019 Version 1.7

STROKE CLINICAL ADVISORY GROUP
Vision Realization Office
Table of Contents
Foreword ................................................................................................................................... 2
Contributions............................................................................................................................. 4
Executive Summary .................................................................................................................. 5
Purpose and Scope .................................................................................................................... 7
Chapter 1. The Saudi Stroke Hospitals classification system ................................................. 9
Chapter 2. Network ................................................................................................................. 19
Chapter 3. Community activation ........................................................................................... 24
QM 3.1 Early Detection ............................................................................................................................ 25
Chapter 4. Integrated stroke care ........................................................................................... 25
A. Components of acute stroke care.......................................................................................... 26
QM 4.1 EMS transfer ............................................................................................................................... 26
QM 4.2 Emergency Stroke Assessment and Care .................................................................................. 27
QM 4.2.2 Protocol for acute stroke screening ......................................................................................... 28
QM 4.2.3 Protocol for stroke code pathway ........................................................................................... 29
QM 4.2.4 Swallow screening .................................................................................................................... 30
QM 4.2.5 Intracerebral Haemorrhage .................................................................................................... 31
QM 4.2.6 Door to needle time................................................................................................................... 32
QM 4.2.7 Mechanical Thrombectomy (MT) ........................................................................................... 33
QM 4.2.8 Decompressive Hemi Craniectomy for acute ischemic stroke .............................................. 33
QM 4.2.9 Cerebral Venous Thrombosis .................................................................................................. 34
QM 4.2.10 Subarachnoid hemorrhage .................................................................................................... 36
QM 4.3 Acute stroke unit ......................................................................................................................... 36
QM 4.4 Acute Stroke Rehabilitation ....................................................................................................... 38
QM 4.5 Transfer of care ........................................................................................................................... 42
B. TIA .......................................................................................................................................... 46
QM 4.6 TIA assessment ............................................................................................................................ 46
QM 4.7 TIA treatment .............................................................................................................................. 48
Chapter 5. Post stroke care ..................................................................................................... 49
QM 5.1 Post-Acute Stroke Rehabilitation ............................................................................................... 50
QM 5.1.2 In-patient rehabilitation........................................................................................................... 50
QM 5.1.3 Outpatient Rehabilitation ........................................................................................................ 52
QM 5.2 Psycho-social, emotional and cognitive support ....................................................................... 53
QM 5.3 Secondary Prevention ................................................................................................................. 54
QM 5.4 Community Assessment and Review ......................................................................................... 57
QM 5.5 Participation in the Community................................................................................................. 58
QM 5.6 Vocational Therapy ..................................................................................................................... 58
QM 5.7 Long term care ............................................................................................................................ 59
QM 5.8 End of Life Care .......................................................................................................................... 60
Chapter 6. Human resource development .............................................................................. 61
QM 6.2 Workforce .................................................................................................................................... 64
Glossary ................................................................................................................................... 67
Appendix 1 – Key Performance Indicators ............................................................................ 69
High Priority Key Performance Indicators: ........................................................................................... 69
Appendix 2 - Patient Selection Criteria for Rehabilitation Team ....................................... 107
Version control ...................................................................................................................... 109

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Foreword
Stroke has been defined as a sudden interruption in the blood supply of the brain. Most
strokes are caused by an abrupt blockage of arteries leading to the brain (ischemic stroke).
Other strokes are cause by bleeding into brain tissue when a blood vessel bursts
(hemorrhagic stroke). Because stroke occurs rapidly and requires immediate treatment,
stroke is called a brain attack and sometimes referred to as ‘earthquake in the brain’. When
the symptoms of a stroke last only a short time (less than 24 hours), this is called a transient
ischemic attack (TIA) or mini-stroke.1 There are approximately 24,000 strokes in Saudi
Arabia annually.2

Inefficient use and distribution of available resources, inconsistent provision of services and
sometimes lack of evidence-based urgent stroke care services impacts on patient outcomes
across the Kingdom. Urgent and acute care is not the only aspect of care that needs to
improve, lack of inpatient and community rehabilitation, long term care and community
support services has a significant impact on the patients with non-acute phase of stroke,
this also impacts on the providers of acute services who are unable to transfer the patient
to a safe environment to receive appropriate care. Lack of long term and community
services limits the capacity in our existing acute hospitals to treat those most in need of
acute care. Yet we know that for months or even years after a stroke, there may be a need
for specialized therapeutic help – for example to improve speech or mobility – and that
enabling people to participate in work, leisure and education improves well-being, combats
depression and often aids recovery. The input and commitment of rehabilitation services,
primary care teams, of social care professionals and wider community services is absolutely
critical to delivering improved outcomes for people with stroke. These standards aim to
address the urgent care and wider aspects of stroke care.
Medical and technological advances have transformed our understanding of stroke, there
have been advances in the treatments available for restoring blood flow and improving
brain function. However, time is critical for restoring brain function following a stroke – the
faster someone reaches expert help, the greater their chances of making a full recovery. We
need to make use of the latest advances in stroke treatment, implement evidence-based
stroke care, and improve quality, efficiency and consistency of the services to improve
patient outcomes. We need to develop the rapid response systems that get people to a
hospital of expertise quickly and onwards to provide appropriate treatment and stroke unit
care. We need to develop stroke networks to ensure improved access of services to the
patients and better utilization of resources. Working across the stroke networks, we need to
deliver integrated stroke care that liberates rather than constrains the talents and energies
of the doctors, nurses, therapists and their wider teams.

The stroke standards create a strong foundation, supported by expert guidance, for
continued innovation and progress in stroke care. Many strokes are preventable, most are
treatable, and the harm done by stroke can be greatly reduced if we act quickly on
important warning signs like transient ischemic attacks or ‘minor strokes’, deploy effectively

1
https://stroke.org.sa/understand-stroke/
2
Based on expert opinion and available data:
https://journals.sagepub.com/doi/full/10.1177/2396987316654338

2
the power of modern imaging, and ensure all patients can benefit from expert,
multidisciplinary care.

This document presents a number of quality markers outlining the features of a good
service. Each quality marker is distilled into a number of standards which aim to improve
the quality of service across the stroke pathway. In addition, there are several key
performance indicators (KPIs) associated with the standards. Collectively, these markers set
an ambitious agenda to deliver the best in class stroke services, from prevention right
through to life-long support. It will take time to deliver, and stroke networks will need to
work with service users to determine the early priorities for their local areas. These stroke
care standards will help commissioners, stroke networks and service providers judge the
quality of their local services and plan for the improvements needed.

This document is designed for all health care professionals including administrators. A panel
of stroke specialist Doctors and other clinical professionals was set up to form a Clinical
Advisory Group (CAG) to develop this document. A range of national and international
guidelines, standards and evidence was reviewed and expert opinion from the CAG was
used to develop these standards for Saudi Arabia. While the document is a great starting
point, there are still areas where further recommendations are needed from a consensus of
the experts. We need the research to confirm or refute these views. The work involved in
developing clinical standards is enormous, and the resources to undertake the searching,
critical appraisal, drafting and editing are constrained. We are very grateful to all the CAG
members and others who volunteered their time outside of their day job to undertake these
tasks.

This standards document has been developed as a result of a great deal of hard work by
many people, in particular, the clinical advisory group which has led on the development of
this document so well to this point. It is equally important to note that many other people
have been involved too - responding to the consultation and surveys and providing valuable
feedback. As a result, these stroke standards are a reflection of all of the knowledge,
perspectives, and efforts put forth by the group. This document marks a point in our
journey, but we have a long way to go yet, it is now that the hard work begins. We look
forward to working with clinicians, managers and patients to tackle the challenge of stroke.

3
Contributions
Contributions from diverse stakeholders to the development of this standards documents
are noted with gratitude. Particularly, contributions from the CAG membership are noted.
The members of the development group include:

Name Profession Organization(s)

Dr. Fahmi Al-Senani (Chair) Consultant in Stroke, Neurology King Fahd Medical City
and Interventional Vascular
Neurology

Dr. Ali Al Khathaami Consultant in Stroke and King Abdulaziz Medical City in Riyadh
Neurology

Dr.Adel Alhazzani Consultant in Stroke and King Saud University

Neurology

Dr.Bakheet Ahmed Musa Consultant in Neurologist Dallah Hospital

Dr. Bassam AlQassami Consultant of Neurology, Consultants sans frontiers

Interventional neurology
and Neuroimaging.

Dr. Omar A Ayoub Assistant professor of King Abdulaziz University

Neurology

Dr. Abrar Alduraibi Doctorate of Clinical Sciences King Fahd Medical City
(CScD) in Speech-Language
Pathology

Dr. Abdullah Ahmad Alabdali Associate Dean clinical affairs King Saud Bin Abdulaziz University
and EMS program director

Dr. Salwa Ahmed Consultant in physical Medicine King Fahd Medical City
and Rehabilitation
Miss Maha Aljuaid Nurse Specialist Neuro Critical King Abdulaziz Medical City in Riyadh
Care Unit

External review of the document was provided by Professor Tony Rudd Professor of Stroke
Medicine, Kings College London National Clinical Director for Stroke, NHS England London
Director for Stroke Consultant Stroke Physician, Guy’s and St Thomas’ NHS Foundation
Trust.

In addition, support from Stroke team members including Amar sharma, , Mohamed Bin
Saleh and Shatha Alsaidan is noted.

4
Executive Summary
Stroke is the second leading cause of death in Saudi Arabia and a leading cause of disability
in adults. The physical, emotional and financial consequences are felt by the patient, his/
her family, the community and the country. Stroke is a preventable and treatable disease.
The gap between evidence-based stroke medicine and care in Saudi Arabia is high. The
Ministry of Health has identified stroke as a high priority disease that needs to be managed
more appropriately.
We will prevent strokes by empowering the person and developing a healthy community by
encouraging people to live a healthy lifestyle, free of smoking, obesity and high blood
pressure. Developing healthy food choices and increasing physical activity will lower the
incidence and prevalence of strokes.
We understand that when a stroke or transient ischemic attack happens, patients will
require many services from the healthcare system, and we will ensure that all stroke
patients get treated in the highest quality manner with minimal variability. The stroke
pathway will be patient- centered and done in a timely manner to improve patient
outcomes and reduce costs. We will ensure that when a stroke does happen the stroke
system will react quickly and efficiently, the stroke patient will be taken to the most
appropriate hospital, and admitted to an acute stroke unit, that will manage the patient
according to current stroke standards. Stroke patients with disabilities will be managed and
treated in rehabilitation units with the aim of returning maximum function as close to the
patients’ home as possible.

5
6
Purpose and Scope
Vision 2030 has committed to improving to health and outcomes for the population of Saudi
Arabia. To support this, a number of strategic programs of work were identified and are
being piloted across the Kingdom. To support some of these programs of work, specifically
in relation to the New Models of Care, it has been identified in some of the projects, that to
achieve success for new clinical pathways, and particularly in relation to urgent care
treatment in Stroke, clinical Standards would be needed. These Standards will take into
account the patient journey and will work across the boundaries of ministries.

Guiding Values and Principles

Guiding values and principles are important if the new pathways are to be successful. When
developing the pathway, a set of guiding principles were developed to ensure that the focus
of the work was undertaken consistently.

Figure 1: Overarching guiding principles

In addition to the guiding principles for developing the pathway (fig. 1), with input from
wider clinical colleagues, the Stroke Clinical Advisory Group (CAG), values and principles for
the development of a clinical network has been developed that will help form the
foundation on which the strategic clinical network for stroke should be designed, and
should now guide its development and operation:

7
Purpose of this document
This document was developed as a part of the ‘Models of Care’ Urgent Care pilots project to
support the design and implementation of a comprehensive evidence-based stroke
pathway. These standards are a work in progress and are meant to be used primarily for the
stroke pathway pilots, these standards will evolve as a result of the lessons learnt from
implementation of the pathways and protocols. It is expected that this document will feed
into a national policy document in future.

The stroke standards are intended to:

 Provide a guide against which providers and commissioners of services can secure
improvements to stroke services and address health inequalities relating to stroke;
 Provide advice, guidance and support for clusters, and other commissioners of
health and care services, in the planning, development and monitoring of services;
and
 Inform the expectations of stroke patients and their families, by providing a guide to
high-quality health and social care services.

How this document is structured

Chapter 1 describes the different types of stroke hospitals based on the level of complexity
of stroke care provided.
Chapter 2 sets out the principles and components of a stroke network.
Chapters 3 to 5 set out a number of quality markers, which outline the features of a good
service. Under each marker are a number of standards and indicators.
Chapter 6 sets out standards and actions needed to develop leadership and workforce and
to ensure capacity and capability is built for providing a high-quality stroke care.
Appendix 1 includes the Key Performance Measures which are linked to each of the six
chapters in the document.
Appendix 2 sets out the patient selection criteria for rehabilitation. It is intended that this
will be moved to an implementation guide at a later stage.

8
Chapter 1. The Saudi Stroke Hospitals classification system
A network of hospitals may be needed to adequately manage acute stroke patients. Since
80% of Saudi stroke patients self-refer to emergency rooms3, therefore all hospitals within
the stroke network will be classified according to their ability to acutely manage and treat
acute stroke patients. This classification system will allow acute stroke patients to be
treated adequately according to the best evidence-based standards. The classification
system allows hospitals within stroke networks to be developed, where urgent identification
of acute stroke patients occur and urgent transfers to appropriate stroke hospitals are
pivotal to properly manage these patients.

Individual hospitals and stroke networks will be able to properly allocate resources and
develop high quality, value-based improvement initiatives.

Table 1: Proposed hospital classification

Comprehensive Primary Stroke Acute Stroke Ready
Stroke Hospital Hospital (PSH) Hospital (ASRH)
(CSH)
Typical bed size >300 beds 100-400 beds <200 beds
Typical acute More than 1,000 More than 200 Less than 100
stroke
admissions per
year
Stroke program Yes, Stroke trained Yes, Physician with Yes, a physician with
director physician stroke expertise sufficient knowledge on
acute stroke
management
Acute stroke Yes, usually stroke Yes, usually stroke Yes, usually ED or IM
team neurology, nurse neurology consultant & nurse
and multi- consultant, nurse and
disciplinary therapy multi-disciplinary
team therapy team
EMS Yes Yes Yes, to divert to a PSH
collaboration or CSH
Stroke Unit Yes Yes No
Initial Triage nurse & ED Triage nurse & ED Triage nurse & ED
assessment of consultant consultant physician
patient
Diagnostic CAT, CTA, MRI, CAT, CTA, MRI, MRA, CAT (optional CTA &
testing MRA, penumbral penumbral imaging penumbral imaging
capabilities imaging (CTP &/or (CTP &/or MRP) & preferred to assess LVO
MRP) & DSA 24/7. TTE, Holter & labs. transfer destination)
TTE, TEE, TCD, labs,
pathology

3
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5966841/

9
 DSA 24/7 if IA
thrombolysis
capabilities available.
Strokologist Yes, 24/7 Yes, maybe by Available by
availability telemedicine 24/7* telemedicine 24/7*
Neurosurgical Yes, 24/7 Yes, within 2 hours Yes, within 2 hours by
availability by transfer transfer
Telemedicine Provide Yes, if needed Yes**
telemedicine to
other
centers/hospitals
Treatment IV & IA IV r-tPA & probably IV thrombolytics
capabilities thrombolytics, IA thrombolytics
aneurysmal clipping
& coiling, ICA
stenting & CEA,
neurosurgical
procedures
Transfer Yes, accepting from Yes, for neurosurgical Yes, with PSH & CSH.
protocols other consults & MT if not Diversion protocol to
centers/hospitals available PSH/CSH if within 60km
Staff stroke Yes Yes Yes
education
requirements
Clinical Yes Yes Yes
performance
measures

* If stroke physician consultation is needed.

**In rural areas, if the distance from the nearest Primary or Comprehensive Stroke Hospital
is more than 60 Km. Within city limits, tele-stroke should be available if IV r-tPA may be
delayed for more than 20 minutes.

Acute Stroke Ready Hospitals

Acute stroke ready hospitals (ASRH) are usually smaller hospitals without acute stroke units
and without the capability of performing mechanical thrombectomy. Since acute stroke
patients can self-refer to any hospital the ASRH should develop a stroke code system to
rapidly identify acute stroke patients and manage them appropriately. An acute stroke code
team should be available 24 hours, that has sufficient knowledge on acute stroke symptoms
and follows and pre-approved stroke code protocol.

The stroke code team

A team consisting of a physician and nurse with sufficient acute stroke management
knowledge should be available 24 hours a day and should assess an acute stroke patient

10
within 15 minutes of arrival in an emergency room and within the hospital, as an inpatient.
All team members should be trained in using the National Institute of Health Stroke Scale
(NIHSS) for all acute ischemic stroke patients. Members of the stroke code team should
receive at least 4 hours of stroke training every year.

The protocol

A written stroke protocol will be developed to standardize acute stroke management in the
emergency department and hospital, which should be revised yearly. Protocols should
include management of acute ischemic stroke, intracerebral hemorrhage and subarachnoid
hemorrhage. Specific aims of the protocols should include medical stabilization of the stroke
patient in terms of airway and blood pressure management, decisions on the acute use of IV
r-tPA for selected acute ischemic stroke patients and transfer protocols with PSHs and CSHs.
Predetermined acute management and transfer protocols should be established based on
many factors including distance between the ASRH and the PSH/CSH, and current
transportation condition.

Safe and fast transportation before or after giving IV r-tPA for selected acute ischemic
stroke patients is further discussed elsewhere (

Stroke Rehabilitation Care Pathway

Hospital setting
Acute Stroke Inpatient
Unit Stroke
Acute Stroke Rehabilitation
Rehabilitation

Stroke Rehabilitation
OPD

Spasticity
management OPD

Day care or OPD

(PT, OT, SLP) Community setting
Acute Stroke
Care in Community services and Rehabilitation.
Community Social Re-integration, Education, Vocational
and family support

QM 4.5 Transfer of care).

Stroke physician consultation via tele-stroke.

11
Different levels of stroke expertise may be needed at the ASRH ranging from diagnosis to
management. Live, synchronous videoconferencing with access to the ASRH picture
archiving system (PACS) is standard practice. The use or tele-stroke and decision for IV r-tPA
for selected acute ischemic stroke patients, should be standardized and be part of the
protocol.
In rural areas, if the distance from the nearest Primary or Comprehensive Stroke Hospital is
more than 60 km, the use of tele-stroke and the ship and drip method is preferred. Within
city limits, tele-stroke should be available if IV r-tPA may be delayed for more than 20
minutes.

Emergency management services (EMS)

EMS should be available 24 hours a day for immediate transfer of acute stroke patients to
PSHs or CSHs. Acute management protocols during the transfer should be available and will
include communication strategies, acute blood pressure management, oxygenation,
hydration and swallowing protocols.

Laboratory services

Basic laboratory testing, including blood glucose, complete blood count, chemistry studies,
coagulation profile, pregnancy testing, toxicology, and ECG will be available in the ASRH on
an immediate basis and reported within 45 minutes.

Radiology

Emergency CAT scan of the brain should be available and done within 20 minutes of arrival
in the emergency room. CAT scans should be read within 10 minutes of completion of the
CAT scan. If indicated, CT angiogram (arch to vertex) should be performed on selected acute
ischemic stroke patients after IV r-tPA is given. CT perfusion scanning may be considered in
selected acute ischemic stroke patients within 24 hours of symptom onset.
MRI and MRA may be used as a substitute for CAT and CTA, if they can be done in a timely
fashion.

Pharmacy

Medications for the acute management of hypertension, hyperglycemia, hypoglycemia,

seizures and coagulopathies should be readily available in the emergency department.
Intravenous thrombolytics (IV r-tPA) should be quickly available. Sublingual nifedipine
should NOT be given to manage acute hypertension in stroke patients.

Transfers

Predetermined written transfer protocols to PSHs and CSHs should be available and based
on written agreements. Repatriation agreements should also be included.

12
Data collection

In addition to participating in the Saudi stroke registry, the ASRH may choose to collect data
for continuous quality improvement measures. The stroke team should meet at least
quarterly to discuss its KPIs and improvement measures.

Primary Stroke Hospitals

Primary stroke hospitals are located in medium sized hospitals and are able to treat 70-80%
of acute stroke patients, excluding subarachnoid hemorrhages. PSHs are able to acutely
diagnose and manage acute stroke patients in the emergency room, give IV r-tPA for
selected acute stroke patients and admit patients to a dedicated acute stroke unit (ASU).
PSHs are able to determine stroke pathophysiology and start secondary stroke prevention
measures. ASUs in PSHs are able to prevent stroke complications. PSHs are able to provide
all needed rehabilitation services including physical therapy medicine consultation, physical
therapy, occupational therapy and speech therapy consultation.

The stroke code team

A team consisting of a physician and nurse with significant acute stroke management
knowledge, should be available 24 hours a day and should assess an acute stroke patient
within 15 minutes of arrival in an emergency room and within the hospital, as an inpatient.
The physician leader is usually a neurologist with significant training in managing acute
ischemic strokes. A reliable notification system (pager, mobile phone, overhead page) must
be implemented in each PSH. The stroke team may be used to assist ASRH’s manage acute
stroke patients, which may include diagnosis, recommendation to give IV r-tPA, perform
further tests, and transfer patients to PSH or CSH as needed. The team will be able to decide
which patients should be transferred to CSHs and be able to stabilize and make transfer
arrangements as needed; examples may include patients with large vessel occlusion, eligible
for mechanical thrombectomy, patients needing urgent neurosurgical consultation or
neuro-intensive care management.
All team members should be trained in using the National Institute of Health Stroke Scale
(NIHSS) for all acute ischemic stroke patients. Members of the stroke code team should
provide and receive stroke training every year. A code stroke policy should be available in
each PSH designating the duties of the code stroke team and a log of each stroke code KPI
should be collected and shared with all departments involved in the stroke code (mainly
emergency department, neurology, radiology and administration).

The protocol

A written stroke protocol will be available to standardize acute stroke management in the
emergency department and hospital, which should be revised yearly. Protocols should
include management of acute ischemic stroke, intracerebral hemorrhage and subarachnoid
hemorrhage. Specific aims of the protocols should include medical stabilization of the stroke
patient in terms of airway and blood pressure management, decisions on the acute use of IV
r-tPA for selected acute ischemic stroke patients and transfer protocols with CSHs.

13
Predetermined acute management and transfer protocols should be established based on
many factors including distance between the PSH and the CSH, and current transportation
condition, with the aim of fast and safe transport to a CSH. Transportation after giving IV r-
tPA for selected acute ischemic stroke patients is further discussed elsewhere (

Stroke Rehabilitation Care Pathway

Hospital setting
Acute Stroke Inpatient
Unit Stroke
Acute Stroke Rehabilitation
Rehabilitation

Stroke Rehabilitation
OPD

Spasticity
management OPD

Day care or OPD

(PT, OT, SLP) Community setting
Acute Stroke
Care in Community services and Rehabilitation.
Community Social Re-integration, Education, Vocational
and family support

QM 4.5 Transfer of care).

Stroke physician consultation via tele-stroke.

Different levels of stroke expertise may be needed at ASRH ranging from diagnosis to
management. PSH physicians may be able to provide consultations to ASRH with respect to
diagnosis, acute management (including drip and ship), and transfer decisions. Live,
synchronous videoconferencing with access to the ASRH picture archiving system (PACS) is
standard practice. The use or tele-stroke and decision for IV r-tPA for selected acute
ischemic stroke patients should be standardized and be part of the protocol.
PSH physicians may also connect to CSH stroke experts by tele-stroke for urgent
consultations and transfer decisions to CSH for selected patients, like mechanical
thrombectomy, neurosurgical procedures or neuro-ICU transfers.

Emergency management services (EMS)

EMS should be available 24 hours a day for immediate transfer of acute stroke patients to
CSHs. Acute management protocols during the transfer should be available and will include
communication strategies, acute blood pressure management, oxygenation, hydration and
swallowing protocols.

14
Laboratory services

Basic and advanced laboratory testing, including autoimmune and hypercoagulable disease
testing and toxicology will be available in the PSH. Basic laboratory testing, like CBC,
electrolytes, coagulation profile and glucose will be available on an immediate basis and
reported within 45 minutes.
EKG and long term Holter monitoring testing will be available.
Transthoracic echocardiography will be available. Transesophageal echocardiography (TEE)
and cardiac MRI will be available for selected stroke patients, either in house of by urgent
referral to another facility.

Radiology

Emergency CAT scan of the brain should be available and done within 20 minutes of arrival
in the emergency department. CAT scans should be read within 10 minutes of completion of
the CAT scan. If indicated, CT angiogram (arch to vertex) should be performed on selected
acute ischemic stroke patients after IV r-tPA is given. CT perfusion scanning will be available
and may be done in selected acute ischemic stroke patients, within 24 hours of symptom
onset.
Emergency MRI and MRA may be used as a substitute for CAT and CTA, if they can be done
in a timely fashion.
Diagnostic cerebral angiography may be present in PSHs.

The Acute Stroke Unit

The ASU is a dedicated, geographically distinct area in the hospital that admits the vast
majority of stable stroke patients. It is staffed by stroke trained personnel (physicians,
nurses, rehabilitation staff and others). Continuous telemetry recording is needed for the
first few days of admission, including pulse rate, blood pressure, temperature, oxygenation
and respiratory rate.
Hospital policies documenting the ASU admission, transfer and discharge policy will be
available. The policies should also document the interaction with other needed specialties,
mainly the emergency department, radiology, rehabilitation services, case manager, social
services and others. Hospital policies will also be available for acute stroke unit
management of the stroke patient which will include prevention of deep venous
thrombosis, pressure ulcers, aspiration pneumonia and urinary tract infections. A policy
documenting the management strategy for any changes in patients neurological and
cardiovascular status will be available.
The ASU is commonly referred to as a step-down unit, but higher levels of management may
be considered, such as arterial blood pressure monitoring, vasoactive medication use or
mechanical ventilation, which will need appropriate manpower, competencies and training.

Pharmacy

15
Medications for the acute management of hypertension, hyperglycemia, hypoglycemia,
seizures and coagulopathies should be readily available in the emergency department and
the inpatient area. Intravenous thrombolytics (IV r-tPA) and vasoactive medications (like IV
labetalol) should be readily available, preferably in the emergency room. Sublingual
nifedipine should NOT be given to manage acute hypertension in stroke patients.

Neurosurgical care should be available within 2 hours of consultation either inhouse or by

rapid transfer to another hospital. Pre-written agreements should be in place to avoid ad
hoc decisions in urgent situations.

Rehabilitation services

PSHs will be able to perform a rehabilitation assessment and start most rehabilitation
services. Well trained staff in rehabilitation are a requirement for all PSH and will include a
physical medicine and rehabilitation doctor (physiatrist), a speech therapist, a swallow
therapist, a physical therapist and an occupational therapist.

Transfers

Predetermined written transfer protocols to CSHs should be available and based on written
agreements. Repatriation agreements should also be included.

Data collection

In addition to participating in the Saudi stroke registry, the PSH may choose to collect data
for continuous quality improvement measures. The stroke team should meet at least
quarterly to discuss its KPIs and improvement measures.

Comprehensive Stroke Hospitals

Comprehensive Stroke Hospitals (CSH) are located in medium to large sized hospitals and
are able to treat all acute and subacute stroke patients. Significant differences between
CSHs and PSHs is the availability of stroke trained experts able to perform invasive
interventional vascular procedures, the ability to perform all cerebrovascular neurosurgical
procedures, the ability to perform vascular surgical procedures and the availability of an
intensive care unit with advanced neuroscience competencies.
CSHs are able to acutely diagnose and manage all acute stroke patients in the emergency
room, give IV r-tPA for selected acute stroke patients, perform CTA and CT perfusion scans,
provide mechanical thrombectomies for ischemic strokes with large vessel occlusions (LVO)
and admit patients to a dedicated acute stroke unit (ASU). CSHs are able to determine
stroke pathophysiology and start secondary stroke prevention measures. ASUs in CSHs are
able to prevent stroke complications. CSH are able to provide all needed rehabilitation
services including Physical Medicine and Rehabilitation consultation, physical therapy,
occupational therapy and speech therapy consultation.
CSH are frequently the hub of the stroke network that accept referrals from PSHs and
ASRHs. Frequently the stroke network is administered from the CSH.

16
CSH are typically hospitals were stroke education is provided to all healthcare staff,
including nurses, physicians and the public. CSH are typically hospitals undertaking research
at many disciplines (clinical, preclinical and administrative).

The stroke code team

A team of stroke trained physicians and nurses should be available 24 hours a day and
should assess an acute stroke patient within 15 minutes of arrival in an emergency room
and within the hospital as an inpatient. The physician leader is usually a neurologist with 1-2
years of dedicated stroke training in managing acute ischemic strokes. A reliable notification
system (pager, mobile phone, overhead page) must be implemented in each CSH. The
stroke team may be used to assist PSH and ASRHs to manage acute stroke patients, which
may include diagnosis, recommendation to give IV r-tPA, perform further tests, and transfer
patients to CSH, as needed. The team will be able to decide which patients should be
transferred to CSHs and be able to stabilize and make transfer arrangements as needed;
examples may include patients with large vessel occlusion, eligible for mechanical
thrombectomy, patients needing urgent neurosurgical consultation or neuro-intensive care
management.
All team members should be trained in using the National Institute of Health Stroke Scale
(NIHSS), the modified Rankin score and the Barthel index for all acute ischemic stroke
patients. Members of the stroke code team should provide and receive stroke training every
year. A code stroke policy should be available in each CSH designating the duties of the code
stroke team, and a log of each stroke code KPI should be collected and shared with all
departments involved in the stroke code (mainly emergency department, neurology,
radiology and administration).

The protocol

A written stroke protocol will be available to standardize acute stroke management in the
emergency department and hospital, which should be revised yearly. Protocols should
include management of acute ischemic stroke, intracerebral hemorrhage and subarachnoid
hemorrhage. Specific aims of the protocols should include medical stabilization of the stroke
patient in terms of airway and blood pressure management, decisions on the acute use of IV
r-tPA for selected acute ischemic stroke patients and transfer protocols with CSHs.
Predetermined acute management and transfer protocols should be established based on
many factors including distance between the PSH and the CSH, and current transportation
condition, with the aim of fast and safe transport to a CSH. Transportation after giving IV r-
tPA for selected acute ischemic stroke patients is further discussed elsewhere (

17
 Stroke Rehabilitation Care Pathway

Hospital setting
Acute Stroke Inpatient
Unit Stroke
Acute Stroke Rehabilitation
Rehabilitation

Stroke Rehabilitation
OPD

Spasticity
management OPD

Day care or OPD

(PT, OT, SLP) Community setting
Acute Stroke
Care in Community services and Rehabilitation.
Community Social Re-integration, Education, Vocational
and family support

QM 4.5 Transfer of care).

Stroke physician consultation via tele-stroke

Different levels of stroke expertise may be needed at PSHs and ASRHs ranging from
diagnosis to management. CSH physicians will be able to provide consultations to PSHs and
ASRHs with respect to diagnosis, acute management (including drip and ship), and transfer
decisions. Live, synchronous videoconferencing with access to the PSHs and ASRHs picture
archiving system (PACS) is standard practice. The use or tele-stroke and decision for IV r-tPA
for selected acute ischemic stroke patients should be standardized and be part of the
protocol between the 2 hospitals.
PSH physicians may also consult CSH stroke physicians by tele-stroke for urgent
consultations and transfer decisions to CSH for selected patients, like mechanical
thrombectomy, neurosurgical procedures or neuro-ICU transfers.

Laboratory services

Basic and advanced laboratory testing, including autoimmune and hypercoagulable disease
testing and toxicology will be available in the CSH. CBC, electrolytes, coagulation profile and
glucose will be available on an immediate basis and reported within 45 minutes.
Pathology testing for vasculitis will be available either inhouse or outsourced.

Cardiac testing

18
EKG and long term Holter monitoring testing will be available.
Transthoracic (TTE) and transesophageal echocardiography (TEE) and cardiac MRI will be
available for selected stroke patients.
Long term cardiac monitoring should be available (loop recorders) for detecting cardiac
arrhythmias in cryptogenic strokes.

Radiology

Emergency CAT scan of the brain should be available and done within 20 minutes of arrival
in the emergency room. CAT scans should be read within 10 minutes of completion of the
CAT scan. If indicated, CT angiogram (arch to vertex) should be performed on selected acute
ischemic stroke patients after IV r-tPA is given. CT perfusion scanning will be available and
may be done in selected acute ischemic stroke patients within 24 hours of symptom onset.
Emergency MRI and MRA may be used as a substitute for CAT and CTA, if they can be done
in a timely fashion.
Diagnostic cerebral angiography will be available. A Comprehensive Stroke Hospital will be
able to provide mechanical thrombectomies urgently 24 hours a day. The ability to perform
all urgent neuro-endovascular procedures will be available urgently, like coiling of cerebral
aneurysms. Endovascular angioplasty and stenting of carotid stenosis will be available.
Management of arteriovenous malformations will be available, including endovascular
embolization, radiation therapy and surgical management.

Pharmacy

Medications for the acute management of hypertension, hyperglycemia, hypoglycemia,

seizures and coagulopathies should be readily available in the emergency department and
the inpatient area. Intravenous thrombolytics (IV r-tPA) and vasoactive medications (like IV
labetalol) should be quickly available, preferably in the emergency room. Sublingual
nifedipine should NOT be given to manage acute hypertension in stroke patients.

Transfers

Predetermined written transfer protocols between stroke Hospitals should be available and
based on written agreements with prespecified transfer criteria. Repatriation agreements
should also be included.

Surgical procedures

Surgical expertise should be available immediately upon consultation. The surgical team will
be able to provide care for all cerebrovascular neurosurgical disorders, including clipping of
cerebral aneurysms, surgical management of AVMs, insertion of ventricular drains,
hematoma removal and drainage, and carotid endarterectomies.

Data collection

19
In addition to participating in the Saudi stroke registry, the CSH may choose to collect data
for continuous quality improvement measures. The stroke team should meet at least
quarterly to discuss its KPIs and improvement measures.

The Acute Stroke Unit (ASU)

The ASU is a dedicated, geographically distinct area in the hospital that admits the vast
majority of stable stroke patients. It is staffed by stroke trained personnel (physicians,
nurses, rehabilitation staff and others). Continuous telemetry recording is needed for the
first few days of admission, including pulse rate, blood pressure, temperature, oxygenation
and respiratory rate.
Hospital policies documenting the ASU admission, transfer and discharge policy will be
available. The policies should also document the interaction with other needed specialties,
mainly the emergency department, radiology, rehabilitation services, case manager, social
services and others. Hospital policies will also be available for acute stroke unit
management of the stroke patient which will include prevention of deep venous
thrombosis, pressure ulcers, aspiration pneumonia and urinary tract infections. A policy
documenting the management strategy for any changes in patients neurological and
cardiovascular status will be available.
The ASU is commonly referred to as a step-down unit, but higher levels of management may
be considered, such as arterial blood pressure monitoring, vasoactive medication use or
mechanical ventilation, which will need appropriate manpower, competencies and training.

Intensive Care Management

Some stroke patients will require a higher level of medical care that may be unavailable in
the ASU, requiring patients to be admitted to Intensive Care Units (ICUs) or neuro-ICUs.
Both units should follow a unified hospital stroke management protocol.

20
Chapter 2. Network
Introduction

Stroke is the 2nd leading cause of death in Saudi Arabia and a leading cause of adult
disability. Managed well, stroke treatment results in better patient outcomes and is cost-
saving. Stroke and transient ischemic attacks (TIA) are complex diseases that are treated by
a multidisciplinary stroke team sometimes in multiple sites according to each stroke
patients’ specific journey in a pre-specified stroke pathway.

The Saudi stroke pathway is a patient-centered, value-based initiative that has been
developed to set standards for appropriate stroke treatment methods that will result in
better patient outcomes.

The stroke network is a group of institutions and individuals (an integrated stroke care
network) that seamlessly deliver the objectives of the stroke pathway to all stroke patients
within that catchment area.

The stroke network is responsible for delivering the objectives of the National Stroke
Pathway to all patients within its prespecified catchment area, throughout the journey of
the patient through the stroke pathway, in an integrated care approach.

The network is ultimately responsible for all stroke patient outcomes within its catchment
area.

The stroke patients’ journey through the stroke pathway

Excluding primordial and primary prevention, the stroke patients journey starts with the
onset of stroke/ TIA symptoms. The ability of the patient and bystanders to recognize stroke
symptoms and activate the stroke pathway is paramount in reducing the delay to
treatment; stroke management is time-dependent, where patients treated earlier have
better outcomes, and cost less to the stroke network.

2. 3. 4.
1. 5.
Ambulance Emergency Neuro-
Early detection In-patient care
transfer room care radiology care

Figure 2: Stroke patient's journey, through the acute phase of the stroke pathway

21
The end to end journey of a stroke patient would include:
1. Community education of stroke symptoms and how to activate the stroke pathway
e.g. calling the ambulance service
2. Ambulance transfer
3. Emergency room care
4. Neuroradiology care
5. Inpatient care
6. Out-patient care (including TIA clinics)
7. Rehabilitation
8. Reintegration into the society

The components of the stroke network

A stroke network will consist of all the components of stroke care from stroke onset,
through to reintegration into society for a period of 4 months. The objectives of the stroke
network are to ensure access to high quality, value-based stroke care to all patients in the
network.

It is in the best interest of the patient and the network providers for all stroke care to be
provided by one network. The network should ensure that all patients who suffer a stroke
within its catchment area, follow a prespecified “stroke patient journey” in the stroke
pathway; this should result in less variability and better patient outcomes. Service level
agreements between departments within a hospital, between hospitals within a network
and between outsourced service providers ensure seamless provision and transfer of care,
reduce fragmentation of care, results in less variability of care and high quality, value-based
stroke care.
Pre-specified agreements between networks will ensure that patients entering another
network will receive the highest possible care and be safely repatriated.

Component 1. Community Education Services

The network should educate its catchment area on stroke/TIA symptoms and methods to
immediately activate the stroke pathway since stroke/TIA is a time dependent disease. The
network should also work closely with EMS services to educate them on acute stroke
diagnosis and the networks’ method of acute stroke patient transfer to the appropriate
emergency room.

Component 2. Emergency Medical Services (ambulance services)

Ideally all acute stroke patients should activate the EMS system; this usually ensures timely
diagnosis and transfer to the appropriate stroke hospital, and thus to better stroke
outcomes. EMS staff should evaluate all potential stroke patients using a unified pre-
hospital stroke screening tool (like FAST, LAPSS etc). Using a pre-written algorithm to
recognize patients that will benefit from comprehensive or primary stroke hospital care,
EMS staff can triage patients to identify which would be the best hospital to transfer the
patient to, depending on their symptoms and transfer times to the appropriate hospital.
All stroke patients should be quickly assessed by a stroke trained team for their eligibility for
urgent reperfusion therapies (intravenous R-TPA and endovascular mechanical

22
thrombectomy). These therapies are usually done in primary or comprehensive stroke
hospitals. An urgent communication system should be developed between EMS personal
and stroke experts to triage the patients to the appropriate stroke hospital.

Component 3. Emergency Department and Neuroradiological Services

Emergency departments should be accepting all patients that come pre-triaged through
EMS and be capable of triaging all patients that self-present with stroke symptoms in a
timely fashion. A stroke triage screening tool should be used (like FAST or ROSIER). An
emergency department stroke code pathway should be developed. A stroke-code system
should be in place to activate the stroke team. The stroke team’s responsibility is to quickly
assess patients with stroke symptoms, rule out stroke mimics, and clinically manage
patients.
Neuroradiological expertise is central to clinical decision making. For all strokes (ischemic
and hemorrhagic) an urgent non-contrast CAT scan of the brain is needed. For ischemic
strokes, urgent brain imaging (usually non-contrast CAT scan or MRI) is needed for IV r-tPA
decision making. Urgent neurovascular imaging (usually CTA or MRA) is needed for
endovascular mechanical thrombectomy decision making. Penumbral imaging will be
needed for specific ischemic stroke patients, especially those presenting between 6 to 24
hours after stroke symptom onset.
An urgent decision for IV r-tPA or endovascular mechanical thrombolysis should be made
and initiated quickly.
For subarachnoid hemorrhages an urgent CTA usually confirms the cause of the bleed and
subsequent conventional angiography would be needed.

Component 4. Inpatient care

The Stroke Network Provider should classify all hospitals in its system, based on their ability
to manage stroke patients into Comprehensive Stroke Hospitals, Primary Stroke Hospital
and Acute Stroke Ready Hospitals. The Saudi Stroke Hospital classification system will be
used. Most strokes and some TIA patients should be admitted to an acute stroke unit;
others may require ICU admission. Acute stroke units are located in primary or
comprehensive stroke hospitals. Each stroke network should develop a system of acute
stroke care so that most stroke and some TIA patients are admitted to a stroke unit for the
first few days after their stroke (usually 72 hours). The immediate stay of most stroke
patients and some TIAs will be in Acute Stroke Units (ASU). Patients usually spend less than
5 days in ASUs. Some patients may require further medical care requiring daily physician
assessments and management, usually not by a neurologist, these patients may be
transferred to a Skilled Medical Unit (SMU). SMUs may be a general medical or neurological
ward and stroke patients are treated by internists or neurologists with expertise in subacute
stroke care. SMUs will also provide subacute rehabilitation services as needed.
Prewritten admission and transfer criteria between ASUs and SMUs should be available and
seamless.

A stroke network may consist of one comprehensive stroke hospital and a few primary
stroke hospital and/or ASRHs. All other hospitals should be classified, and a triaging and
transportation system should be in place for timely transfers to and from hospitals
according to the stroke patient’s requirements.
The appropriate inpatient rehabilitation services will be discussed in component 6.

23
 The organization of the acute inpatient hospital stay may differ from network to network,
depending on available resources, geographical issues and transport times within the
networks. Some networks may prefer to develop a single CSH, where all patients in the
network are admitted to one CSH. Others may prefer a more multifaceted approach of hub
and spoke model (figure 2).

PSH
ASRH

PSH CSH PSH

ASRH
PSH
Figure 3: Hub and spoke model of stroke hospitals

Component 5. Outpatient care (including TIA clinics)

All networks will develop an outpatient care program to follow-up acute strokes and TIAs
according to the National Stroke Standards. Most stroke patients care can be transferred to
his/her family medicine physician within 6 months of his 1st diagnosis of stroke/TIA. Some
TIA patients will require emergency workup for carotid stenosis or atrial fibrillation within
24 hours and thus weekend coverage should be available.

Component 6. Rehabilitation
The network should make available appropriate rehabilitation services for all stroke patients
according to their disability. Acute inpatient care, acute outpatient care, subacute
rehabilitation and long-term rehabilitation requirements should be developed and
integrated into the stroke patient’s pathway. Early supported discharge (ESD) is a method of

24
discharging stroke patients earlier than usual to complete their nursing and rehabilitation
requirements at their home.

Component 7. Reintegration to society and end of life care

Depending on the physical or mental disability, the stroke/TIA patient will need assistance in
returning to become an active member of society. Vocational training/retraining, social
work support, financial support, disability assistance for the family and/or caregiver may be
needed. Approximately 25-35% of all stroke patients will require some form of assistance 1
year after their stroke4; this may be as simple as assistance with shopping for food or as
severe as complete dependence of a bedbound patient requiring full care. Chronic long-
term facilities, nursing homes or home health care measures should be implemented
according to the patient’s need. Palliative care and end of life care should be an integral part
of the acute stroke care for appropriate patients.

QM 2.1 Networked care delivery

Purpose: To deliver integrated stroke care for standardized, seamless and cost effective
stroke care to patients within a specific catchment area.

Rationale:
 Evidence from other countries suggests networked delivery of care is cost effective
and improves patient outcomes
 Networks can improve the utilization of resources and reduce unwarranted variation
in care

Standards:
1. Each network should establish at least one Comprehensive Stroke Hospital along
with a network of either Primary or Acute Stroke Ready Hospitals or both.
2. Each network should develop a public and patient education campaign to help
improve timely diagnosis and transfer to appropriate stroke hospitals.
3. Each network should develop links with out of hospital services such as Primary care,
EMS (ambulance services), Rehabilitation, Long Term and Palliative care services to
ensure consistent use of standards and sharing of patient data.
4. Each network should set up a multi-disciplinary clinical committee, to oversee the
delivery of stroke care, this committee should include professionals from all
appropriate stroke care facilities, including hospitals and other relevant facilities.

4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751976/

25
Chapter 3. Community activation
Objectives

1. To improve public and professional awareness of the risk factors and symptoms of a
stroke, and what action to take.
2. To ensure that people who experience a stroke are at the center of decisions about their
treatment and are involved in the design of services.

Key facts
 Stroke is the second largest cause of deaths in the Kingdom of Saudi Arabia.
 Based on expert opinion, it is estimated that the 2018 incidence of stroke is
(75/100,000) in Saudi Arabia.
 There are approximately 24,000 strokes per year in Saudi Arabia.
 There has been a 103% increase in the incidence of stroke between 1990 and 2018.
 High blood pressure (26.1%) and Diabetes (13.1%) are the biggest preventable risk
factors for stroke.

Introduction
Lack of awareness of stroke is a significant problem. People do not know what a stroke is,
what the symptoms are, or that it is a treatable condition that warrants the same response
as a heart attack. Additionally, people are unaware of the potential risk of themselves
having a stroke, how to reduce that risk, or that stroke is largely preventable. Knowledge
about stroke is also low among health and social care professionals. A study into
‘Knowledge and Attitude of Stroke Among Saudi Population in Riyadh’, suggested that
cultural and educational strategies to improve knowledge about stroke in Riyadh
community was needed. Considerable efforts should be planned to increase awareness
about stroke, especially with low income and low-educated population.5
To initiate an emergency response to a suspected stroke, it is crucial that staff who have
contact with the public (including GP receptionists, EMS call handlers, hospital triage staff,
social care staff and allied health professionals) are able to recognize the symptoms of
stroke or TIA, even when they cannot see the individual, and that they all share a common
understanding of the importance of dealing with stroke as rapidly as possible.

5
http://www.ijasrjournal.org/wp-content/uploads/2017/03/MS36xx-17.pdf

26
QM 3.1 Early Detection
Purpose
To ensure that signs and symptoms of stroke are recognized by the public and healthcare
professionals to facilitate rapid detection of stroke and enable quick initiation of treatment
in an appropriate setting.

Rationale
 Fast response to stroke reduces the risk of death and disability.
 Both public and professional awareness of stroke are crucial for patients to receive
appropriate care.

Standards
1. Public and professional (including physicians, healthcare facilities personnel, and
EMS personnel) stroke education campaigns should be regular and frequent to
increase awareness of stroke and the need for urgent diagnosis and treatment.
2. Networks should ensure that people who have had a stroke, and their families and
care givers, are informed and empowered, by providing information, advice and
support and ensuring that services are in place to support people.
3. All healthcare professionals should be trained to recognize signs and symptoms of
stroke indicating an acute stroke as an emergency, requiring immediate transfer to a
stroke unit.
4. Patients seen by community-based healthcare professionals with the sudden onset
of focal neurological deficit should be screened for hypoglycemia with a capillary
blood glucose and for stroke or TIA using a validated tool such as FAST, as soon as
possible.
5. Patients with an acute focal neurological deficit suspected to be a stroke should be
moved directly to an appropriate stroke hospital.
6. EMS should be activated as soon as possible to ensure that patients with a positive
stroke screen and/or a strong suspicion of stroke are transported rapidly to the
closest stroke care unit that can administer IV Alteplase.
7. Standardized written protocol and standing orders for the emergency evaluation of
patients with suspected stroke is recommended.
8. Telemedicine services can be used appropriately where necessary to ensure urgent
management.
9. Patients who have had a suspected TIA should be assessed as soon as possible for
their risk of subsequent stroke using a validated scoring system such as ABCD2.

Chapter 4. Integrated stroke care

Objectives
 To improve speed, accuracy and consistency of stroke assessment and treatment for
all patients.
 To improve the speed of patient transfer to an appropriate stroke facility so that
patients can receive rapid diagnosis and treatment.
 To treat people with suspected stroke as a medical emergency in order to provide
optimal treatment and maximize the chances of independent living after stroke.

27
  To assess people experiencing a transient ischemic attack (TIA) or minor stroke
rapidly in order to minimize the chances of a full stroke occurring.
 To ensure that all the patients that can benefit from reperfusion therapy are
identified as soon as possible and appropriate therapy is administered in an
evidence-based manner.

Key facts
 There is a 20 per cent risk of a full stroke within the first four weeks after a TIA. 6
 Approximately 69% of the strokes are ischemic strokes and IV r-tPA rates are 0.5%.
 Stroke is a common emergency seen in the Kingdom of Saudi Arabia.
 Most stroke patients are transferred by private mode such as private car.
 EMS transferred around 20% of stroke patients between 2017-2018.

Introduction
A more urgent response to both stroke and TIA will save lives and reduce long-term
disability. Intensive physiological and neurological monitoring in the early phase of a stroke
supports early treatment that stops or slows stroke progression and prevents more brain
cells being damaged. Investigating and treating high-risk patients with TIA within 24 hours
could produce a significant reduction in the number of people who go on to have a full
stroke.7

A. Components of acute stroke care

QM 4.1 EMS transfer

Purpose
To improve EMS transfer of stroke patients in terms of speed of response, consistency of
assessment and intervention and conveyance to the appropriate facility in a timely manner.

Rationale
 Stroke is a major emergency seen in prehospital care. EMS stroke performance
indicators have not been established. This document is designed to standardize the
care and EMS response to all stroke patients.
 Urgent detection and treatment of stroke is crucial to the final outcomes. Typically,
1.9 million neurons are lost for each minute a stroke goes untreated.
 The first steps to accessing emergency treatment is a rapid response to an EMS call
or ED conveyance for suspected acute stroke; rapid assessment utilizing a pre-
hospital assessment tool (e.g. FAST) by the ambulance crew and emergency transfer
with pre-alert to a receiving hospital able to offer hyper-acute services with
appropriate 24-hour expertise for all those who are likely to benefit from immediate
treatment, including intravenous thrombolysis.

6
Ibid
7
Rothwell PM, et al., 2007, ‘Effect of urgent treatment of transient ischemic attack and minor stroke on early
recurrent stroke (EXPRESS study): a prospective population-based sequential comparison’, Lancet 370, 1432–
42

28
  Ambulance services should work on proposals for improving the ability of ambulance
medical dispatch systems to determine stroke calls that meet the FAST criteria and
allow ambulance control staff to make a more appropriate response, which might be
a category A response, within 15 minutes, where indicated.
 Thrombolysis for treatment of stroke must be started as soon as possible and within
4 ½ hours of the onset of the stroke symptoms at the latest and after prior exclusion
of intracranial hemorrhage by means of appropriate imaging techniques.
 For ischemic stroke patient’s thrombolysis can be an effective treatment where it
can be delivered within 4 ½ hours; the patient should be triaged to a hospital which
can deliver the drug. If the 4 ½ hour window has passed, it may be more appropriate
to transfer to the nearest hospital with an acute stroke unit. (This time window may
change as the evidence base increases.)

Standards
1. All stroke patients are recommended to be transferred via the EMS system.
2. EMS dispatchers should make stroke a priority, dispatch and transport times should
be minimized.
3. EMS personnel should provide prehospital notification to the receiving hospital that
a suspected stroke patient is on-route so that the appropriate hospital resource is
mobilized prior to the patient arrival.
4. Stroke patients should be attended by the highest level of care available (If highest
level of care will delay response, available EMS unit should be dispatched).
5. EMS response time should be < 15 minutes, and ambulance response should be code
1 (with lights and sirens).

6. EMS scene time should be ≤ 10 minutes.

7. EMS personnel must use a validated tool to detect stroke patients (i.e. FAST).
8. EMS should evaluate for the presence of stroke mimics
a. Hypoglycemia
b. Seizure
c. Sepsis
d. Migraine
e. Intoxication
9. EMS unit should bypass acute stroke ready hospitals if a Primary Stroke Hospital or
Comprehensive Stroke Hospital is available within 45 minutes or 60 km.

QM 4.2 Emergency Stroke Assessment and Care

QM 4.2.1 ED assessment

Purpose
To ensure that immediate assessment is carried out in the ED to diagnose stroke and TIA, to
enable urgent and accurate treatment. To standardize the stroke pathway that reflects up
to date clinical practice guidelines; and to shorten the duration for obtaining timely brain
imaging-based decisions for management of stroke patients.

Rationale

29
  Acute Stroke Protocol (stroke identification, ED evaluation, stroke team activation,
stroke decision of care, post stroke care) can be used to improve outcomes.
 Hypoglycemia can mimic stroke symptoms and early identification of hypoglycemia
can help to provide appropriate management.
 Effective clinical assessment of the patient with acute stroke, and decision making
for timely appropriate therapy, is paramount for improving patient outcomes.
 Rapid and standardized ED assessment is important to provide safe and appropriate
treatment.
 NIHSS is a standardized scale that quantifies the degree of neurological deficit,
facilitates communication between different groups of healthcare providers, assists
the decision for reperfusion therapy, and is an objective measure of clinical
outcome.
 Immediate ED assessment of stroke related swallowing problems can help reduce
the risk of aspiration in an acute stroke patient.
 It is important to increase staff knowledge and improve the quality of stroke care.

Standards
1. All hospitals must implement a protocol for acute stroke care assessment.
2. All hospitals must have an immediate triage process in ED for patients with acute
stroke symptoms.
3. All patients with acute stroke symptoms must have blood glucose checked.
4. All hospitals must have a designated stroke team to assess and manage acute stroke.
5. Every patient with FAST positive results must have urgent access to neurological
expertise.
6. All patients with stroke symptoms must be evaluated by using a standardized
evaluation for stroke assessment tool (FAST).
7. National Institution of Health Stroke Scale (NIHSS) should be used by all hospitals to
determine the severity of the stroke.
8. All patients with acute stroke symptoms will be restricted from having oral intake
until they pass the swallowing assessment. See
9.
10. QM 4.2.4 Swallow screening .
11. ED staff must be trained to detect acute stroke symptoms. For example, in
neurological assessment - STARS competencies:
(http://www.strokecorecompetencies.org/node.asp?id=home)

QM 4.2.2 Protocol for acute stroke screening

Purpose
Acute stroke symptoms are frequently missed in the ED or inpatient area; standardized
tools used for screening suspected stroke patients ensures patients enter the stroke
pathway quickly and receive appropriate treatment in a timely manner. To ensure that all
hospitals have implemented a protocol for acute stroke screening. . To ensure patient safety
and accuracy in the treatment plan

Rationale

30
 Timely assessment of suspected stroke patients is crucial to enable timely and
appropriate therapy.
 The duration for obtaining timely brain imaging is crucial for making timely decision for
management of stroke patients.
 Identification of hypoglycemia that may mimic stroke symptoms, is key to ensure that
the patients receive appropriate timely treatment.

Standards
1. All hospitals must implement a protocol for acute stroke screening in the ED and
inpatient areas.
2. All hospitals must have an immediate triage processes in ED for patients with acute
stroke symptoms.
3. Use of a standardized scale for screening and quantifying the impact of stroke is
recommended. All patients with stroke symptoms must be evaluated by using a
standardized evaluation for stroke assessment tool (FAST).
4. Every patient with FAST positive results must have urgent access to neurological
expertise.
5. All patients with acute stroke symptoms must have blood glucose checked.
6. All hospitals treating stroke patients must have a designated stroke team to assess
and manage acute stroke.
7. NIHSS is such a standardize scale which quantifies the degree of neurological deficit,
facilitates communication between different groups of healthcare providers, assists
the decision for reperfusion therapy, and it is an objective measure of clinical
outcome. The NIHSS will be used in all hospitals.
8. All patients with acute stroke symptoms will be restricted from having oral intake
until they pass the swallowing assessment. See section QM 4.2.4 Swallow screening .
9. ED staff must be trained to detect acute stroke symptoms.
10. IV r-tPA will be given where clinically indicated unless the patient refuses it.

QM 4.2.3 Protocol for stroke code pathway

Purpose
a. To ensure standardization of acute stroke patient care
b. Have protocols with facilities for transfers to more specialized centers when needed.
c. Have facilities for telemedicine when necessary.

Rationale
 Standardized medical care results in better outcomes and less variability in healthcare
provision.
 To standardize the acute stroke imaging protocol.
 Utilization of tele-stroke allows early and effective clinical assessment and support
treatment decision for reperfusion therapy.
 Acute stroke management is time dependent, it is useful to provide initial emergency
stroke care in ED and initiate the decision for transfer.
 Evidence for utilization of tele-stroke is well established in acute stroke management.

31
Standards
1. An acute code stroke pathway will be developed in all hospitals, which will include
recognition of acute stroke symptoms, urgent diagnosis, treatment and transfer.
2. Non-contrast CT imaging should be used to determine the decision about acute
stroke management.
3. All patients with suspected acute stroke must have con-contrast CAT scan of the
brain completed as soon as possible and within 25 minutes maximum on arrival.
4. Patient must have brain imaging obtained and interpreted as soon as possible and
within 45 minutes of arrival into the hospital.
5. Brain imaging must support the decision for timely appropriate therapy. The aim of
early CT imaging is to shorten the duration for decision of treatment.
6. Brain imaging to exclude ICH is recommended as part of initial evaluation for stroke
patients who are potentially eligible for reperfusion therapy.
7. Using tele-stroke is recommended for hospitals with limited in-house expertise for
diagnosis and treatment of stroke patients.
8. All hospitals must have a transfer protocol if advanced stroke care is not available.

QM 4.2.4 Swallow screening

Purpose
The purpose of dysphagia screening is to identify patients potentially at risk of aspiration.
Delays in screening for and assessing dysphagia after stroke, are associated with higher risk
of stroke-associated aspiration pneumonia. Swallow screening may help identify dysphagia
early, thereby ensuring timely referrals to speech and language therapy and dietetics,
thereby minimising the impact on the patient. Since stroke-associated aspiration
pneumonia is one of the main causes of mortality after acute stroke, an early dysphagia
assessment may contribute to preventing deaths from acute stroke and could be
implemented even in settings without access to high-technology specialist stroke care.8
Rationale

 Dysphagia is a common consequence of stroke, affecting approximately 37% to 78%

of patients with acute stroke and is associated with increased risk of aspiration,
pneumonia, prolonged hospital stay, disability, and death
 Evidence supports that early identification of dysphagia reduces the risk for
aspiration pneumonia, and there is also emerging evidence of an association
between a failed screening and severe disability, discharge to long-term care, and 1-
year mortality. Stroke patients with dysphagia therefore may experience a
combination of these possible negative health complications. Accurate and early
identification of dysphagia is critical and can facilitate a better recovery.

8
Bray, B. D., Smith, C. J., Cloud, G. C., Enderby, P., James, M., Paley, L., ... & Rudd, A. G. (2017). The association
between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated
pneumonia. J Neurol Neurosurg Psychiatry, 88(1), 25-30.

32
  Patients with dysphagia often do not receive sufficient caloric intake, which may
result in poorer outcomes as a result of malnutrition.

Standards
1) All acute stroke patients should be nil per oral until swallow screening is completed.
2) All acute stroke patients should have a swallow screen test within 4 hours by an
appropriately trained clinician (typically a trained nurse).
3) Patients should be screened for swallowing deficits as soon as they are alert and
ready for trialing oral intake, using a valid screening tool, by an appropriately trained
professional.
4) Patients who fail the swallowing screening should be kept nil per oral (NPO) and
referred to a speech pathologist for a comprehensive assessment.
5) Comprehensive assessment by a speech language pathologist should be done within
72 hours of referral. An instrumental evaluation is required to verify the
presence/absence of aspiration and to determine the biomechanical swallowing
function to guide the treatment plan.9
6) The choice of instrumental evaluation may be based on instrument availability or
other considerations (i.e. fibreoptic endoscopic evaluation of swallowing, video
fluoroscopy.10
7) For stroke survivors with swallowing difficulties, behavioral approaches such as
swallowing exercises, environmental modifications, safe swallowing advice, and
appropriate dietary modifications should be used early.
8) Until a safe swallowing method is established for oral intake, patients with dysphagia
should have their nutrition and hydration managed with early consideration of
alternative non-oral routes.
9) Swallow screening may be repeated if medical status changes.

QM 4.2.5 Intracerebral Haemorrhage

Purpose To ensure that immediate, appropriate assessment is carried out for hemorrhagic
stroke to ensure that the patient can receive the required treatment.

Rationale
Approximately 15-20% percentage of total strokes are due to hemorrhage. Timely
management of hemorrhagic stroke improves patient outcomes.

Standards

9
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... & Jauch, E. C.
(2018). 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for
healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3),
e46-e99.

10
Powers, W. J., et al., (2018).

33
 1. All adult patients with suspected hemorrhagic stroke must have immediate
assessment and investigations to establish a diagnosis, initiate treatment and
determine eligibility for surgical interventions.
2. All health care facilities caring for patients with primary intracerebral hemorrhage
should have an evidence-based protocol outlining blood pressure control, reversal of
coagulopathy and indication for neurosurgical intervention.
3. All Patients with spontaneous bleed should be managed using standardized
guidelines and protocols.
4. All Patients with intracerebral hemorrhage related to anticoagulation use should
have their coagulation profile checked immediately and correction of coagulopathy
should be initiated rapidly, as per the established guidelines and protocols.
5. All patient with primary intracerebral hemorrhage must have urgent access to
neurological expertise when needed.
6. All patients with acute spontaneous intra-cranial hemorrhage should be admitted to
a stroke unit or equivalent.

QM 4.2.6 Door to needle time

Purpose
To ensure that timely intravenous thrombolytic therapy is delivered to those stroke patients
who can benefit from it. To ensure that intravenous thrombolytic therapy is delivered in an
evidence-based manner by qualified staff in appropriately equipped facilities.
Rationale
Evidence shows that intravenous thrombolytic therapy (recombinant tissue plasminogen
activator [rt PA]) is beneficial for selected patients with ischemic stroke. It should be
delivered in well-equipped centers/hospitals with adequate expertise and infrastructure for
monitoring, rapid assessment and investigation of acute stroke patients.

Standards
1. All adult patients with suspected ischemic stroke must have immediate assessment
and investigations to establish a diagnosis, rule out stroke mimics, determine
eligibility for reperfusion therapy within 24 hours (IV thrombolysis within 4.5 hours;
mechanical thrombectomy within 24 hours) from last time patient known to be
normal.
2. All hospitals capable of administrating thrombolysis should have an evidence-based
driven protocol outlining indications, contraindication, post thrombolysis care, and
complication management.
3. Laboratory investigation should be conducted as part of the initial evaluation which
includes: random glucose, coagulation status (INR, aPTT), complete blood count
(CBC), electrolyte and creatinine. IV r-tPA should not be delayed due to pending lab
results unless there is a clinical suspicion of a contraindication such as (patient on
warfarin or a history of leukaemia with possible low platelets).
4. If clinically indicated additional investigations such as Cardiac enzymes, ECG and
chest X ray should be considered.

34
 5. Point of care testing is recommended for Glucose, Direct Oral Anti-Coagulants
(DOACs) and INR.
6. All patients with suspected acute stroke should get brain imaging with CT or MRI as
soon as possible.
7. Within 4.5 hours of the onset of stroke symptoms, all eligible patients with disabling
ischemic stroke should receive intravenous Alteplase.
8. For patients considered for mechanical thrombectomy, a noninvasive craniocervical
vascular study is recommended, however, it should not delay IV thrombolysis if
indicated. R-tPA and TNK are the only thrombolytic agents currently approved for IV
thrombolysis.
9. All patient who had reperfusion therapy should be admitted to a stroke unit for at
least 24 hours

QM 4.2.7 Mechanical Thrombectomy (MT)

Purpose
To quickly identify ischemic stroke patients with large vessel occlusion (LVO) appropriate for
recanalization procedure. To quickly recanalize an occluded cerebral large vessel by quickly
activating the interventional neuroradiology team.

Rationale
 Timely mechanical thrombectomy is associated with improved patient outcomes for
large vessel occlusion11.
 Emergency assessment of suspected stroke patients upon arrival in ED can facilitate
timely mechanical thrombectomy.

Standards
1. All hospitals will develop a protocol for identifying ischemic stroke patients with LVO.
2. All ischemic stroke patients presenting within 24 hours will be screened for LVO.
3. All hospitals will develop a protocol to treat appropriate patients with LVO or to
transfer them as soon as possible to a MT capable center/hospital.
4. All ambulances are encouraged to have a screening protocol for LVO (NIHSS of 11 or
more, or another scale such as C-STAT etc.) and transfer them to a MT capable
center/hospital.

QM 4.2.8 Decompressive Hemi Craniectomy for acute ischemic stroke

Purpose
To treat brain swelling and mass effect secondary to a middle cerebral artery (MCA)
territory infarction by decompressive hemicraniectomy.

Rationale

11
https://www.strokeassociation.org/idc/groups/stroke-
public/@wcm/@hcm/@sta/documents/downloadable/ucm_499252.pdf

35
  In patients <60 years of age with unilateral MCA infarctions that deteriorate
neurologically within 48 hours despite maximal medical therapy, decompressive
craniectomy with dural expansion is effective.12
 Although the optimal trigger for decompressive craniectomy is unknown, it is
reasonable to use a decrease in level of consciousness and its attribution to brain
swelling as selection criteria.
 The efficacy of decompressive craniectomy in patients older than 60 years of age
and the optimal timing of surgery are uncertain.
 Clinicians may discuss with family members that a third of the patients with massive
hemispheric infarctions, even after decompressive craniectomy, are severely
disabled and fully dependent on care.13
 Decompressive craniectomy reduces mortality from avoiding the progression to
brain death.

Standards

1. Identification of patients with or at high risk for infarction and swelling should be
made using clinical data, including vessel occlusion status.
2. Patients with large MCA infarcts and potential herniation should be referred for
neurosurgery urgently.
3. Patients with middle cerebral artery infarction who meet all of the criteria below
should be considered for decompressive hemicraniectomy.

 Patients aged 60 years or under.

 Clinical deficits suggestive of infarction in the territory of the middle cerebral
artery, with a score on the NIHSS of above 15.
 Decrease in the level of consciousness to give a score of 1 or more on item 1a
of the NIHSS.
 Signs on CT of an infarct of at least 50% of the middle cerebral artery
territory, with or without additional infarction in the territory of the anterior
or posterior cerebral artery on the same side, or infarct volume greater than
145 cm3 as shown on diffusion-weighted MRI.

4. Patients who are referred for decompressive hemicraniectomy should be monitored

by appropriately trained professionals skilled in neurological assessment.

QM 4.2.9 Cerebral Venous Thrombosis

Purpose
To ensure that patients presenting with suspected Cerebral venous thrombosis (CVT) are
diagnosed and treated promptly to improve their prognosis.

12
https://professional.heart.org/idc/groups/ahamah-
public/@wcm/@sop/@smd/documents/downloadable/ucm_460163.pdf
13
https://www.ncbi.nlm.nih.gov/pubmed?term=3975967

36
Rationale
 CVT is an uncommon and frequently unrecognized type of stroke, it is more common
in younger stroke patients14.
 In a series of intracerebral hemorrhage (ICH) in young people, CVT explained 5% of
all cases15.
 Neurologic worsening may occur in 23% of the patients, even several days after
diagnosis

Standards
1. Routine blood studies consisting of a complete blood count, chemistry panel,
prothrombin time and activated partial thromboplastin time should be performed
for patients presenting with suspected CVT.
2. In patients with lobar intracerebral hemorrhage of otherwise unclear etiology or
with cerebral infarction crossing typical arterial boundaries, imaging of the cerebral
venous system should be performed.
3. In patients with the clinical features of idiopathic intracranial hypertension, imaging
of the cerebral venous system should be performed.
4. A venographic study (either CT or MR venogram) should be performed in suspected
CVT if the plain CT or MRI is negative, or, to define the extent of CVT if the plain CT
or MRI suggests CVT. A plan CT or MRI does not rule out CVT.
5. Repeat CT or MR venogram should be performed in patients presenting with
recurrent symptoms of CVT.
6. In patients with CVT and a single seizure with parenchymal lesions, early initiation of
anti-epileptic drugs for a defined duration should be performed.
7. Patients with CVT and a suspected bacterial infection should receive appropriate
antibiotics and surgical drainage of purulent collections of infectious sources
associated with CVT when appropriate.
8. In patients with CVT, visual fields should be monitored for progressive deterioration
and when this is observed, increased intracranial pressure should be urgently
treated.
9. In patients with a past history of CVT who complain of new, persisting or severe
headache, evaluation for CVT recurrence and intracranial hypertension should be
considered.
10. For patients with CVT, initial anticoagulation with adjusted-dose unfractionated
heparin or weight-based low molecular weight heparin in full anticoagulant doses
should be considered, followed by vitamin K antagonists, regardless of the presence
of intracerebral hemorrhage.
11. For women with CVT during pregnancy, LMWH in full anticoagulant doses should be
continued throughout pregnancy, and LMWH or vitamin K antagonist with a target
INR 2.0-3.0 should be continued for at least 6 weeks post-partum (for a total
minimum duration of therapy of 6 months).

14
https://www.ncbi.nlm.nih.gov/pubmed/14976332
15
https://www.ahajournals.org/doi/full/10.1161/01.STR.0000117571.76197.26

37
QM 4.2.10 Subarachnoid hemorrhage

Purpose
To ensure that immediate, appropriate assessment is carried out for spontaneous
subarachnoid hemorrhage to ensure that the patient can receive the required treatment.

Rationale
Spontaneous subarachnoid hemorrhage, which is usually attributable to rupture of an
intracranial aneurysm, is accountable for 3% of all strokes.16 There is some evidence that the
mortality associated with SAH may have decreased during the past few decades, but it is still
>25%.17 Immediate treatment for spontaneous subarachnoid hemorrhage patients can
improve patient outcomes. The longer the patients are left without any treatment, the
higher the chance he/she may get re-rupture from the vascular lesion or develop
complications from the initial bleed (e.g. hydrocephalus, seizers, vasospasm, etc.) leading to
mortality or long-term permanent damage.

Standards
1. All adult patients with suspected spontaneous (non-traumatic) subarachnoid
hemorrhage must have immediate assessment and investigations to establish a
diagnosis, initiate treatment and determine eligibility for surgical or endovascular
interventions.
2. All health care facilities will have a protocol outlining initial assessment,
management and transfer protocols for SAH.
3. All patients with spontaneous subarachnoid hemorrhage should be managed using
standardized guidelines and protocols in a comprehensive stroke hospital.
4. All patient with spontaneous subarachnoid hemorrhage must have immediate access
to neuro-surgical expertise.
5. All patients with spontaneous subarachnoid hemorrhage should have rapid access to
neurological imaging including vascular imaging and timely access to neuro-vascular
expertise.
6. All patients with spontaneous subarachnoid hemorrhage should be admitted to a
neurocritical care unit or equivalent.
7. All patients with spontaneous subarachnoid hemorrhage –regardless of their clinical
status- should be immediately assessed then transferred to a comprehensive stroke
hospital, where established guidelines and protocols are used to manage these
patients in a multi-disciplinary therapy team.

QM 4.3 Acute stroke unit

Purpose

16
Lloyd Jones D et al, Circulation. 2010

17 Lovelock CE et al, Neurology. 2010.

38
To improve stroke patient’s outcomes & reduce mortality by providing multi-disciplinary
treatment by specialist clinicians and professionals in the acute phase of stroke.

Rationale
 Acute stroke and some TIA patients admitted to stroke units have less morbidity and
mortality, better functional outcomes and better quality of life.
 Acute medical management, discovering the pathophysiology of the stroke and
starting secondary stroke prevention measures occurs in the acute stroke unit.
 Common comorbidities are prevented by following unified stroke protocols.
 Co-ordinated multidisciplinary acute rehabilitation is started in the stroke unit and
connects the patient and family to further short- and long-term stroke services.
 A multidisciplinary team that consists of physicians, nurses and rehabilitation staff
(physiotherapy, occupational therapy, speech therapy), social work, nutrition,
psychology and other staff with stroke expertise, manage the patients in a holistic
manner.

Standards
1. All primary and comprehensive stroke hospitals will have an acute stroke unit (ASU).
a. Acute stroke unit is a dedicated location within a hospital where stroke specialist,
multidisciplinary management of stroke patients is provided by a dedicated
team.
b. During the ASU admission:
i. An understanding of the stroke patient’s pathophysiology will be
established
a. Carotid imaging will be performed for anterior circulation strokes
in a timely fashion
ii. Appropriate acute medical management documented
iii. Secondary stroke prevention advice given
c. Prewritten protocols and policies will be followed for all stroke and TIA patients
i. To prevent deep venous thrombosis
ii. For acute antiplatelet/anticoagulant use
iii. Discharge medications for antiplatelet/anticoagulants, statins and
hypertensive medications
iv. Stroke education
v. Connection with smoking cessation program
vi. Management of blood pressure
d. Daily clinical reviews are performed by stroke trained consultants.
2. The majority of stroke and some TIA patients will be admitted to ASUs unless other
conditions requiring immediate specialist care elsewhere, dominate.
3. The patient will be assessed by appropriate rehabilitation specialties within 48 hours,
and a long-term rehabilitation plan will be developed.
4. All medical staff caring for stroke patients shall be competent in stroke medicine,
stroke rehabilitation and stroke nursing (see guidance on staff training - Chapter 6.
Human resource development).

39
 5. Appropriate staffing ratios shall be met (see guidance on types of stroke units -
Chapter 2. Network).
6. Some stroke units may choose to further divide their unit into acute stroke units,
skilled nursing units and rehabilitation stroke units. (see guidance on types of stroke
units).
7. Continuous physiological monitoring will be done during the acute phase.
8. All patients admitted with suspected acute stroke have a swallow screening
assessment performed on admission, by appropriately trained and competent staff,
and a protocol for short- and long-term management of swallowing will be made.
9. All stroke patients should have a nutritional screening assessment performed within
24 hours of admission. A protocol for short- and long-term management of nutrition
will be made.
10. Conscious patients admitted with suspected acute stroke are mobilized out of bed
on the day of admission. A protocol for early mobilization will be followed.
11. A protocol for the promotion of bladder and bowel continence including a policy to
avoid urinary catheters.
12. Multidisciplinary team meeting occurs at least weekly to discuss progress and plan
goals for patients as well as timely and appropriate transfers of care.

QM 4.4 Acute Stroke Rehabilitation

Purpose
The purpose of acute stroke rehabilitation is to improve the overall function of patients in
the acute stroke unit since the initial three months is the period when the most recovery is
expected after stroke. In addition, it will minimize complications of bed rest and
psychosocial distress which potentially decreases the length of stay in the acute and/or sub-
acute units18.
To minimize complications of bed rest and psychosocial distress of hospitalization, to ensure
safe discharge with better utilization of outpatient rehabilitation, and inpatient
rehabilitation.

Rationale
 The quality of life of stroke patient in Saudi Arabia is generally low compared with other
developed countries. Stroke rehabilitation standards are aimed at improving patient
function and encourage independence.
 The functional level of stroke patients has a strong influence on Health-related quality of
life among stroke survivors.
 Improving acute stroke rehabilitation can help to prevent complication
 Improving acute stroke rehabilitation will prepare the stroke patient to transfer from
stroke unit to inpatient rehabilitation or discharge home with outpatient rehabilitation
program, Early Supported Discharge Team or community rehabilitation.

18
http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/ForFamilyCaregivers/CaringforYourLovedOne/15-Things-
Caregivers-Should-Know-After-a-Loved-One-Has-Had-a-Stroke_UCM_310762_Article.jsp#.XDxkO88zaqA

40
 Development of Stroke Rehabilitation Standards is to provide timely rehabilitation
intervention to stroke patients to improve their outcomes, function and enhance their
independence.

 Currently the provision on acute inpatients rehabilitation is very limited to very few
centres in the Kingdom of Saudi Arabia.
 Rehabilitation is a holistic process that should begin the first day after stroke with an aim
to maximize participation of the patient in the community. To achieve this tailored
intervention that focus on impairment, activity and participation levels (based on WHO
classification of functioning model should be considered).19

Standards
1. A specialist and dedicated rehabilitation team for providing acute rehabilitation to
stroke patients should consist of the following disciplines:
i. Medical lead
ii. Speech and Language Pathologist
iii. Physical therapist
iv. Occupational therapist
v. Social worker
vi. Clinical pharmacist
vii. Dietician
viii. Orthotist
ix. Nurse
x. Clinical Psychology (competent in managing stroke patients)
xi. Orthoptist
2. The stroke rehabilitation Pathway starts in the stroke unit with 24-48 hours of
admission to the stroke unit by comprehensive assessment of all patient physical,
cognitive, swallowing and communication functions. (For post-acute inpatient and
outpatient stroke rehabilitation please see QM 5.1 Post-Acute Stroke
Rehabilitation)
3. All patients who are medically stable should receive rehabilitation therapy within 48
hours of admission
4. Stroke patients who were identified by the stroke multidisciplinary team to have
complex rehabilitation needs should be immediately referred to inpatient
rehabilitation and transfer for inpatient rehab when they are medically stable
5. Each patient diagnosed with acute stroke and admitted to acute stroke unit should
be screened for speech and language, physical, functional and cognitive functions by
a multidisciplinary rehabilitation team within 24 to 48 hours, to identify the cases
eligible for the rehabilitation services.
6. Stroke patients should receive the acute rehabilitation management carried by the
specialist multi-disciplinary team when the patient meets the inclusion criteria
(please see the suggested inclusion criteria in appendix 2).20

19
https://www.who.int/classifications/drafticfpracticalmanual2.pdf?ua=1
20
https://www.clinicalguidelines.gov.au/portal/2585/clinical-guidelines-stroke-management-2017

41
7. A valid and reliable tool must be used to assess the disability level of the stroke
patient by the multidisciplinary rehabilitation team in the acute stage (i.e. within 24
to 48 hours post onset).
8. The multidisciplinary rehabilitation team should set specific recovery goals to meet
the expected outcomes for each patient as early as possible, and update it on a
regular basis, based on the prognosis of the stroke patient.
9. Stroke patients suffering from muscle spasticity need to have access to specialised
treatment for management of symptoms including Botulinum Toxin for treatment of
spasticity.
10. When the stroke patient is medically stable, the multidisciplinary rehabilitation team
should create an evidence-based comprehensive management plan.
11. The multidisciplinary rehabilitation team should regularly reassess the stroke patient
to identify the effectiveness of the rehabilitation plan.
12. Each stroke patient should be reassessed before discharge to identify his or her
disability level and the need for follow-up support services.
13. The multidisciplinary rehabilitation team should prepare a transfer plan prior to
discharge of the stroke patient from the stroke unit (e.g. home with outpatient
rehabilitation, admission to a rehabilitation center/hospital, long term or palliative
care) based on certain eligibility criteria for each facility.
14. The multidisciplinary rehabilitation team should report the continuity of care
recommended for the stroke patient, this should be communicated to the stroke
patient, patient’s family members and receiving clinicians.
15. The multidisciplinary rehabilitation team should have an agreed-upon method to
maintain communication between its team members.
16. The multidisciplinary rehabilitation team should involve the stroke patient and/or
their family in setting goals, expected outcomes, medication management and
discharge plan.
17. All patients should be assessed for Physiotherapy within 24 hours of admission,
unless contraindicated, for example, due to being medically unstable. Rehabilitation
management should begin within 24/48 hours. This should include:
I. early mobilization
II. prescribing the right amount of exercise
III. prescribing the right assistive device
IV. educating the staff, patients and caregiver to regular turning, provide special
mattresses and cushions to prevent skin breakdown
V. educating the staff, patients and caregiver to transfer the patient safely to
prevent shoulder dislocation.
VI. determining whether the orthosis was appropriate to the patient
VII. stroke patient should receive therapy for one hour, 5 days per week as
tolerated
VIII. following up on patient’s functional level within 30 days post discharge.
1) All patients must receive swallowing screening from a qualified professional upon
emergency room admission prior to receiving any oral intake (medication or
nutrition).
I. All patients who pass the screening to monitor safety and tolerance of
regular diet and refer to SLP if concerns arise.

42
 II. All patients that fails the screening, NGT must be inserted and referral to SLP
for swallowing bedside assessment within 24 hours of admission to
determine the candidacy/safety of oral feeding.
18. All patients who fail the swallowing screening should receive a full swallowing
assessment by speech pathologist prior to starting any oral intake (oral medication/
feeding).
19. Instrumental/ diagnostic swallowing evaluation should be carried out following the
bedside evaluation as needed.
20. Swallowing and speech and language intervention should begin within 72 hours post
assessment or once the patient is medically stable. This should Include:
I. Conducting swallow instrumental evaluation to assess oropharyngeal
biomechanical function and dysfunction, determine swallowing safety and
efficiency, identify effectiveness of compensatory strategies, establish an
appropriate diet, and construct an evidence-based rehabilitation plan.
II. Increasing awareness about communication severity level and its effect on
patient’s current communication skills.
III. Increasing awareness about patient’s strengths and weakness in communicating
his/her needs by educating patient/family.
IV. Increasing patient’s orientation skills to self, place, situation and time.
V. Initiating treatment focusing on patient’s ability to effectively communicate
his/her basic needs via various communication modalities (gesture,
communication board, writing) Train patient/family to use communicative
strategies to assist patient in meeting his/her goals
VI. Educating the medical staff about strategies to support patient’s cognitive
communication skills in routine situations (e.g., medication, bathroom).
VII. Follow unified standardized measures to document the disability level start from
the acute stage and progress over the recovery phase.
VIII. Providing therapy to the stroke patient for 20-30 minutes daily as tolerated.
IX. Discharge report should include recommendations on aspiration precautions,
diet modifications, communication facilitation strategies, needed swallowing
and/or speech follow-up at discharge destination.
21. All stroke patients should be screened for cognitive and perceptual deficits by a
trained person (e.g. neuropsychologist, occupational therapist or speech pathologist)
using validated and reliable screening tools, ideally prior to discharge from hospital.
22. Stroke patients identified during screening as having cognitive deficits should be
considered for comprehensive clinical neuropsychological investigations.
23. The multidisciplinary rehabilitation team prepare the transfer plan for discharge of
the stroke patient from stroke unit to home without patient rehabilitation, admitted
to rehabilitation center/hospital, long term or palliative care, based on certain
eligibility criteria for each facility.
24. Patients who are deemed unsafe or dependent in personal activities of daily living
after stroke should be referred to an occupational therapist with experience in
neurological disability; patients should be assessed within 72 hours of referral and be
offered treatment for identified problems (e.g. feeding, toileting) by the
occupational therapist.

43
25. Stroke multidisciplinary team should refer stroke patients who were assessed to be
safe and appropriate to day care, to outpatient and to community rehabilitation
services after discharge from stroke unit
26. All acute stroke patients should be offered, as needed, specific treatments that
include:
dressing practice for people with residual problems with dressing as many
opportunities as appropriate to practice self-care; assessment, provision and training
in the use of equipment and adaptations that increase safe independence; training
of family/care givers in how to help the person with stroke.
27. Patient’s home environment should be assessed by a visit with an occupational
therapist. If a home visit is not considered appropriate, they should be offered a visit
and advice on how to adapt the home environment to improve patient’s functional
independence and safety in the home environment, this could include equipment for
the care givers and family members, to support the patient e.g. moving and handling
equipment.
28. Acute stroke patients who are dependent in personal activities (e.g. dressing,
toileting) should be offered support before being transferred home that includes:
a. visits/leave at home prior to the final transfer of care with or without
occupational therapist or care staff
b. training and education for their care givers specific to their needs
c. telephone advice and support for three months.

Stroke Rehabilitation Care Pathway

Hospital setting
Acute Stroke Inpatient
Unit Stroke
Acute Stroke Rehabilitation
Rehabilitation

Stroke Rehabilitation
OPD

Spasticity
management OPD

Day care or OPD

(PT, OT, SLP) Community setting
Acute Stroke
Care in Community services and Rehabilitation.
Community Social Re-integration, Education, Vocational
and family support

44
QM 4.5 Transfer of care
4.5.1 QM ToC1: Interfacility transfer

Purpose
To ensure that every patient has timely access to reperfusion therapy regardless of which
health care facility they visit.

Rationale
 Reperfusion therapies for ischemic stroke have been proven effective and safe in
several randomized controlled trials and metanalysis and endorsed by several
international guidelines to improve stroke outcomes.
 The efficacy and safety of IV r-tPA for ischemic stroke are well established within 4.5
hours of stroke onset.
 Thrombectomy has been proven effective and safe for acute ischemic stroke with
large vessel occlusion, salvageable brain tissues, within the first 24 hrs of symptoms
onset.
 Time to reperfusion therapy is a crucial determinant of patient outcome (the earlier
the intervention, the better the outcome).
 Timely administration of such therapies requires robust systems in place, and stroke
expertise which may not be available in each hospital due to financial constraints,
limited distribution and availability of neurological, neurosurgical, and radiological
expertise, or other reasons. Therefore, establishment of interfacility timely transfer
agreement, protocols and reimbursement mechanism can overcome such limitations
and ensure every patient receives equal standards of care.

Standards
In the event a stroke patient is received by a hospital without current capacity or
appropriate resources to provide reperfusion therapies, the patient should be transferred to
a hospital with increased level of stroke capabilities that can provide such therapies.

1. All hospitals caring for stroke patients that are not capable to administer IV r-tPA,
mechanical thrombectomy or both should develop, adopt, and adhere to protocols
to transfer candidate patients to stroke hospitals capable to administer and perform
these therapies.
2. In order to determine the best transportation option, key factors are the geographic
location of the primary stroke hospitals and the comprehensive stroke hospitals in
relation to the patient origin, as well as regional infrastructure and available
expertise.
3. For acute stroke ready hospital not capable to administer IV t-PA, direct transfer to
stroke hospital capable of performing thrombectomy is standard of care.
4. For acute stroke ready hospitals not capable to administer IV t-PA, the time for
emergency assessment and arrangement of transfer should not exceed 20 minutes.
(the time from emergency arrival (door in) to the time when the patient physically
leaves the emergency (Door out) should be less than 20 minutes (door in-door out
time <20 minutes).
5. Hospitals that adapt the “Drip and Ship” model for a patient (that is administer IV r-
tPA then transfer thrombectomy candidate patient to thrombectomy capable

45
 hospital), should access the thrombectomy within 120 minutes from arrival to the
first emergency room. Patient safety and local circumstances should be taken into
consideration.
6. Each hospital should conduct continuous improvement initiatives to cut unnecessary
delays of transfer and benchmark with other peer hospitals.
7. Each hospital should be engaged in quality initiative and collect data for
performance measurement and benchmarking.
8. IV r-tPA should be administered to candidate patients within 60 minutes of
emergency arrivals (door-to-needle-time <60 min).
9. Thrombectomy should be performed for candidate patients within 90 minutes of
emergency arrivals (door-to-groin-time <90 min).

4.5.2 QM ToC 2: Interfacility transfer for management of non-traumatic subarachnoid

hemorrhage

Purpose
To ensure that every patient who suffers from spontaneous subarachnoid hemorrhage, has
timely access to expertise in diagnosis and management.

Rationale
 Subarachnoid hemorrhage carries a significant mortality (greater than 25%) and
morbidity.
 Prompt diagnosis, identification of source of bleeding, timely securing of the
aneurysm (by coiling or clipping), management of hydrocephalus and other
complications improve patient’s outcome.
 Management of such patients require high level of expertise which may not be
available in all hospitals. Therefore, establishment of interfacility timely transfer
agreement, protocols and reimbursement mechanism can overcome such limitations
and ensure every patient receive standard of care.

Standards
1. All hospitals should develop, adopt, and adhere to protocols to transfer SAH patients
to a comprehensive stroke hospital immediately.
2. All non-comprehensive hospitals will have transfer agreements with comprehensive
stroke hospitals for immediate transfer.

4.5.3 QM ToC 3: Transfer from a higher complexity to lower complexity stroke hospital

Purpose
 To ensure timely and safe transfer of patients from a comprehensive stroke hospital
to a primary stroke hospital and then to rehabilitation facility, long term care facility
or home.
 To ensure availability of beds in Primary and Comprehensive Stroke Hospitals
whenever needed.

Rationale

46
  For a stroke network to function effectively, a constant flow of patients out of each
designated hospital to the other, is needed.
 There is good evidence from the critical care literature that patients can get harmed
if they are not appropriately accompanied by the right personnel and if the right
procedures were not followed appropriately.
 The number of beds at any facility are limited and should be utilized appropriately.
 Seamless transfer of patients from one stroke hospital to another stroke hospital or
other facility will allow patients to be treated in the appropriate place during their
journey through the stroke pathway.

Standards
1. All hospitals should have protocols of inter-hospitals and intra-hospital transfer of
patients with the designated staffing, equipment and standards for EMS.
2. For comprehensive stroke hospital:
a. If a patient comes from acute stroke ready hospital or primary stroke hospital
for possible thrombectomy and then deemed to be not eligible for the
intervention, this patient may be transferred back to the sending hospital or
another appropriate hospital closer to patient’s home; except if medically
indicated to be kept in a higher facility.
b. The duration of stay should be determined in agreement between the two
hospitals based on clinical pathways and protocols.
c. There has to be urgent versus non-urgent protocols established within each
hospital according to best practices and local circumstances.
d. For patients who have had their intervention/thrombectomy done in the
comprehensive stroke hospital, admission to the acute stoke unit within that
facility is advised for stabilization and monitoring.
e. After stabilization and monitoring, the patient should be transferred back to
the same hospital, if his clinical condition is judged to be eligible to be
transferred, and in accordance with the agreement of hospitals within the
same network or repatriated to patient’s network.
f. If the patient is stable to be discharged home, rehabilitation facility, or to
long term care facility, then the comprehensive stroke hospital will ensure
timely transfer.
3. For primary stroke hospital:
a. All patients with acute stroke that did not need thrombectomy (hence did
not need transfer to comprehensive stroke hospital) should be transferred
from the emergency department to an acute stroke unit within the same
facility, in a timely fashion, following hospital protocols.
b. Patients who are clinically ready to be transferred to rehabilitation or long-
term facility should do so based on the protocols within the hospital.
4. For the transfer of patients from stroke facility to rehabilitation, long term care, or
home:
a. Prior to discharge home, all patients should be assessed to determine the
need for a home visit, which may be carried out to minimize safety risks and
facilitate provision of appropriate aids, support and community services.
b. Patients and families/care giver should have the opportunity to identify and
discuss their post- discharge needs (e.g. physical, emotional, social,

47
 recreational, financial and community support needs) with relevant members
of the multi-disciplinary team making decisions for discharge.
c. All medications, equipment and support services necessary for a safe
discharge should be organized and documented in the discharge summary.
d. A documented post-discharge care plan is developed in partnership with the
patient and family/care giver and a copy provided to them. This may include
relevant community services, self-management strategies (e.g., including
medications information and compliance advice, goals and therapy to
continue at home), stroke support services (e.g., Stroke Foundations if
available), any further rehabilitation or outpatient appointments, and an
appropriate contact number for any queries.
e. A discharge planner can be used to coordinate a comprehensive discharge
program for people with acute stroke.
5. Each hospital should have clearly written protocols of the patient criteria that they
can be admitted from and to another hospital within the same cluster.
6. EMS protocols have to be clear and easy to apply clinically.
7. Bed status in each hospital has to be known for both parties in each direction of
care.

B. TIA

QM 4.6 TIA assessment

Purpose
All TIA patients should be risk stratified and receive expedited care based on their risk score
to ensure prompt treatment and prevention of a stroke or other complications.

Rationale
 The risk of stroke is highest in the first few hours and days after a TIA and some of
which could be potentially fatal or disabling.
I. Two non-randomized studies supported rapid assessment and management of
TIA in order to prevent recurrent strokes.
II. Two studies in UK and France using historical controls reported an 80% risk
reduction in recurrent stroke at 90 days with establishment of rapid referral,
assessment and initiation of secondary prevention medications.
 The detection of vascular stenosis or occlusion is important to categorize patients
who are at risk of recurrent events or stroke.21 It also guides intensive secondary
prevention.22
 Urgent detection and treatment of atrial fibrillation is important in secondary
prevention.
 Delayed secondary prevention is associated with worse outcomes, including a higher
rate of early stroke recurrence.

Standards

21
(Coutts et al. 2012).
22
(Kamal et al. 2015).

48
For all patients with suspected TIA
1. All patients with suspected TIA should be assessed by a professional with
neurological expertise urgently.
2. All patients with suspected TIA should commence secondary prevention therapy
immediately.
3. All patients with suspected TIA should have detailed history and clinical examination,
prognostic (e.g. ABCD2 score) and investigative tests (e.g. basic blood tests, brain
and carotid imaging and ECG) at the initial point of healthcare contact, whether first
seen in primary or secondary care.

A) For patients with suspected TIA and high risk of subsequent stroke
Patients with suspected TIA with high risk of stroke (ABCD2 score of 4 or above) should
have:
1. Neurological expert assessment should be done within 24 hours of symptoms onset
for exclusion of stroke mimics, identification of vascular stroke treatment,
identification of likely causes, and appropriate investigation (vascular imaging) and
treatment once the diagnosis is confirmed.
2. Patients with crescendo TIA (two or more TIAs in a week) should be treated as being
at high risk of stroke and to be assessed within 24 hours, regardless of ABCD2 score.
3. Patients with high risk of stroke should have vascular imaging obtained and they
should be seen in a specialist TIA clinic within 24 hours if available
4. If urgent assessment and intervention is not available as an out-patient for high risk
patients, then they should be admitted to the hospital.

For patients with suspected TIA and low risk of subsequent stroke
Patients with suspected TIA who are at lower risk of stroke (ABCD2 score of 3 or below)
should have:
1. Neurological expert assessment can be done within one week of onset of symptoms
for exclusion of stroke mimics, identification of vascular stroke treatment,
identification of likely causes, appropriate investigation and treatment
2. Patients with TIA and presents late (more than 1 week after their clinical symptoms)
should be treated as having lower risk of stroke.
3. Vascular imaging should be carried out in 48 hours of onset of symptoms and TIA
clinic appointment should be completed within 1 week of onset of symptoms.

For all patients with confirmed TIA

1. All patients with a confirmed TIA should have ECG, brain imaging and ABCD2 scores
completed.
2. All anterior circulation TIA patients should undergo early Carotid imaging with
carotid doppler ultrasound, CT angiography, or MR angiography.
3. Carotid imaging ideally has to be done during the initial assessment in the ED but
should not be delayed more than 48 hours.
4. Imaging for other types of TIA’s is recommended when it is deemed clinically
appropriate.

49
 5. All patients with confirmed TIA should receive education and their family members
for stroke prevention via life style modification, preventative treatment and signs
and symptoms of stroke requiring emergency treatment.

QM 4.7 TIA treatment

Purpose

To assess and manage people experiencing a transient ischemic attack (TIA) or minor stroke
rapidly, in order to minimize the chances of a full stroke occurring.

Rationale

 There is a 20% risk of a full stroke within the first four weeks after a TIA.
 Stroke is a treatable and preventable when TIA is appropriately addressed and
treated
 Investigating and treating high-risk patients with TIA within 24 hours could produce
an 80 per cent reduction in the number of people who go on to have a full stroke.23

Standards

Management of TIA

Imaging

1. All patients with suspected stroke should have an urgent brain CT or MRI ( within 24
hours)
2. Echocardiography should be performed in patients with abnormal ECGs, history or
heart disease and suspected cardioembolic source
3. Long term Holter monitoring should be performed in patients with suspected
cardioembolic strokes.
4. Further, brain, cardiac or carotid imaging should be undertaken in selected patients:
when initial assessment does not identify the likely source of the ischemic event

Antithrombotic Therapy

a. Anti-platelet therapy should be given, unless contraindicated

1. A loading dose of aspirin (160-325 mg may be given as the 1st dose), followed by
81-100mg daily.
2. Clopidogrel alone can be used in a dose of 75mg once daily
3. Dual antiplatelets (aspirin and clopidogrel) may be used in high risk TIA patients
(ABCD2 score greater than 4) for 21-30 days, followed by a single antiplatelet
(initial loading dose of clopidogrel of 300mg then 75 mg daily in addition to
Aspirin)

23
https://www.thelancet.com/journals/lancet/issue/vol370no9596/PIIS0140-6736(07)X6044-6

50
b. The routine use of early anticoagulation in unselected patients following ischemic
stroke/TIA is NOT recommended.
c. A statin is recommended with a target LDL cholesterol of less than 1.7mmol/L and HDL
cholesterol of greater than 1 mmol/L.
d. Hypertension should be managed appropriately according to guidelines.
e. All vascular risk factors should be addressed and appropriately treated accordingly.

Chapter 5. Post stroke care

Objective
Patients who suffered stroke may develop a range of physical symptoms and complications
as a sequel of the stroke which will impact on their function and care provision. These
symptoms include muscle spasticity, joint contractures, pain, fatigue. For stroke patients
and their family members to achieve a good quality of life, maximize independence, well-
being and choices a holistic approach for their physical, psychological and social needs is
required.
Key facts
1. At present, provision of rehabilitation and long-term care is inconsistent across Saudi
Arabia, with lack of consistent standards of care and lack of facilities to provide
support and care to the patients and their families.
2. There is lack of support for the younger stroke patients who want to return to work.
3. A large proportion of stroke patients develop depression and long- term support
needs to account for this.
4. A large proportion of stroke patients experience language difficulties.
5. Mortality rate is high in stroke patients within three months of a stroke.
6. One out of four stroke survivors may have recurrent stroke within 5 years
7. Stroke is preventable and a treatment plan that includes dietary modification,
exercise, statin therapy, an antihypertensive medication and
antiplatelets/anticoagulants could result in a cumulative risk reduction of another
ischemic stroke by 80%.
8. Designing a stroke educational plan to improve health awareness is associated with
increase health-related self-care and healthier lifestyle.
9. Effective behavioral and motivational strategies to achieve a healthy lifestyle are
recommended for stroke secondary prevention.
10. Prevalence of spasticity after stroke ranging from 30-80% of stroke survivors and the
incidence among paretic patients is reported to be 27% and 43% 1 month and 6
months post stroke respectively.
11. Currently there is limited expertise in assessment and management of post stroke
muscle spasticity and other physical and psychosocial symptoms at a national level in
Saudi Arabia.

Introduction
The Ministry of Health, health regulators, commissioners and providers of healthcare need
to ensure delivery of appropriate level of health care and support to stroke patients and
their families, to ensure that they can achieve the best possible quality of life. Integrated
care is essential to provide continuity of care for patients who receive care from different
organizations throughout their life due to the long-term nature of their illness.

51
Stroke patients and their families need to receive good-quality, appropriate, tailored and
flexible long-term care and rehabilitation; this will affect long-term recovery and reduce
long-term disability.
Symptoms related to stroke can improve over many years, so people need both a focus on
rehabilitation to help them improve and recover and support to help them manage the
disabling factors caused by a stroke that may continue in the long term. High quality and
comprehensive non-medical services, support, and advocacy can be provided by the
voluntary sector which can be extremely useful for the stroke patients and their families.
This could include support for working age stroke patients to help them to get back to
appropriate employment, day care services to support patients and their families or advice
and support to patients to integrate back in the community.

QM 5.1 Post-Acute Stroke Rehabilitation

Purpose
Stroke patients need rehabilitation to maximize their function performance, this needs to be
provided by specialist multidisciplinary rehabilitation team in inpatient, outpatient or
community settings based on patient needs.

Rationale

 Several studies indicate that stroke rehabilitation can improve functional status in
patients who are elderly and those have severe neurologic and functional
impairment.
 Some stroke patients would benefit from early discharge from the stroke unit and
receive multidisciplinary rehabilitation at day care, at outpatient or at home. This
benefit is related to intensity of the therapy and the expertise of the
multidisciplinary team which should match the professionals in the stroke unit.
 In Saudi Arabia there is limited provision of rehabilitation therapy for stroke patients
after discharge from acute hospitals in both outpatients and in the community. Such
provision will facilitate early hospital discharge, reduce the length of stay, increase
efficiency of stroke beds and enhance community reintegration

Standards
1. Stroke patients who were assessed by the stroke unit multidisciplinary team and
identified to be suitable for early discharge should continue their rehabilitation at
outpatient, at day care or receive community rehabilitation at home
2. Health care providers should establish rehabilitation services at inpatient, outpatient
and community settings for stroke patients after discharge from strokes units in their
areas
3. Stroke patients and their carers should be well informed about their rehabilitation
plan after discharge from the stroke units

QM 5.1.2 In-patient rehabilitation

Purpose
To ensure that those patients who have complex medical needs and require ongoing
medical or nursing support can benefit from rehabilitation in an inpatient setting once their

52
acute medical management has been completed and they are able to leave the acute stroke
unit safely.
Rationale
 There are limited inpatient rehabilitation facilities to meet the rehabilitation needs
of the stroke patients in the kingdom of Saudi Arabia.
 Some stroke victims may suffer very severe stroke that may lead to multiple
impairments with more complex physical and cognitive rehabilitation needs.
 Due to the limited number of inpatient rehabilitation beds in Saudi Arabia, stroke
patients tend to wait in acute hospitals. Some of the stroke patients also develop
many preventable complications by the time they are transferred to rehabilitation.
 Stroke patients tend to have the longer hospital stay, require long term care and are
frequently discharged to long term-care facilities with added cost implications.
 Post stroke depression, fatigue and spasticity could become a problem after
discharge from acute stroke units and has a negative impact in the function and
quality of life of stroke survivors.

Standards

1. The inpatient rehabilitation should be provided in an environment in which

rehabilitation care is well coordinated
2. Inpatient rehabilitation should be delivered by skilled multidisciplinary team with
expertise in complex physical, cognitive and neurobehavioral impairments.
3. Stroke patient should receive a comprehensive assessment to determine:
I. Pre-stroke functional abilities;
II. Level of physical impairment;
III. Impairment of cognition, swallowing, communication, vision and perception,
selfcare and continence status;
IV. Symptoms related to depression, pain, spasticity, fatigue etc;
V. Activity limitations and participation restrictions;
VI. Social and environmental factors.
4. All stroke patients who are medically stable and identified to benefit from in-patient
rehabilitation should be referred to an inpatient rehabilitation facility immediately
after the assessment by the stroke team or inpatient rehabilitation program.
5. All patients who meet the criteria for a comprehensive inpatient rehabilitation
program should be transferred with in 48 hours from acceptance.
6. The inpatient rehabilitation multidisciplinary team should include the following
disciplines:
I. Consultant in Physical Medicine and Rehabilitation;
II. Rehabilitation nurses;
III. Physiotherapists;
IV. Occupational therapists;
V. Speech and language therapists;
VI. Clinical psychologists;
VII. Case managers;
VIII. Social workers;
IX. Health educators.

53
7. The inpatient stroke rehabilitation team should have access to the following
services:
I. Dietetics;
II. Orthotics and functional electric stimulation;
III. Respiratory therapist;
IV. Continence service;
V. Wheelchair services and equipment;
VI. Assistive technology;
VII. Psychiatry support;
VIII. Podiatry.
8. All symptoms that develop after the stroke which impact on the rehabilitation e.g.
hemiplegic shoulder and neuropathic pain, muscle spasticity, fatigue and depression
should be managed appropriately. In addition, complications e.g. pressure injury,
venous thrombo-embolism and joint contractures should be prevented.
9. Inpatient rehabilitation therapy should provide a range of interventions and high-
intensity training to promote and improve motor recovery.
10. Patients should be given at least 45-60 minutes of rehabilitation by each discipline,
five days per week if they are able to tolerate this level of therapy.
11. Patients who are unable to participate in 45-60 minutes of daily therapy should
receive up to 30 minutes of therapy 5 days per week.
12. Multidisciplinary rehabilitation team should be collecting regular outcome measures
using valid tools on admission and discharge.
13. Multidisciplinary team should set agreed goals with patients and their families on
admission and update them about progress towards those goals.
14. Stroke patients and their families /carers should be provided with information
related to their condition and it is management.
15. Appropriate equipment and training should be provided for stroke patients and their
families/carer after assessing the suitability of the home environment.
16. Prior to discharge from hospital to home or long-term facilities, a follow up plan
should be agreed with stroke patients and their families in relation to their health
and social care needs.
17. Arrangements should be made to meet the educational and vocational rehabilitation
needs of young stroke patients after their discharge from inpatient rehabilitation
program.
18. Criteria for a patient’s admission to a comprehensive inpatient rehabilitation
program may include the following:

I. Medical stable;
II. Significant unresolved neurologic deficit;
III. Impairment affecting at least 2 of the following functions:
 Mobility
 self-care activities
 swallowing
 Communication
 bowel or bladder control
IV. Cognitive and communicative abilities to learn and participate in therapy;
V. Ability to tolerate the active intensive therapy program;

54
 VI. Achievable rehabilitation goals.

QM 5.1.3 Outpatient Rehabilitation

Purpose
Studies demonstrated significant functional gains with intensive outpatient therapy at 3- 6-
months post stroke. The greatest benefits were achieved in the first three months. Those
patients who are ready for discharge from inpatient facility can continue to receive
rehabilitation as outpatient to improve their functional status.

Rationale
 Stroke patients are having difficulty accessing outpatient rehabilitation clinics early
after discharge from hospital due to limited availability of these facilities. When they
get the opportunity tend to be late by then they developed multiple secondary
complication related to their stroke.
 There is no formal hospital transport system for outpatient treatment
 Limited and expensive disability assessable private vehicles

Standards
1. Stroke patients should have access to outpatient rehabilitation within two weeks of
stroke if they are medically stable. This is to maximize their functional improvement
during first six to twelve months after the stoke, when maximum recovery is
expected.
2. Patients suitable for outpatient rehabilitation should be able to be transferred to the
outpatient therapy clinic for treatment 1-3 times per week.
3. The outpatient treatment should be carried out by multidisciplinary professionals
who have expertise in stroke rehabilitation.
4. Stroke rehabilitation clinics should address secondary prevention of stroke,
management of physical, cognitive and communication difficulties as well as
changing care needs.
5. Stroke patients should have access to affordable and appropriate transport to be
able to attend outpatient rehabilitation.
6. The rehabilitation clinics should include range of specialist clinics and therapy which
include:
I. Physical therapy to improve mobility, strengthen muscles and maintain the range
of movement;
II. Occupational therapy to improve independence with self-care, as well as
assessment of educational, vocational and driving abilities;
III. Spasticity clinic for management of muscle spasticity secondary to stroke using
range of oral and focal injections like Botulinum Toxin;
IV. Stroke rehabilitation clinics to address secondary prevention of stroke and
manage other symptoms that can develop as a sequel of the stroke;
V. The need for wheelchairs, equipment and other assistive devices;
VI. Assessment of care support and carers review and training.

QM 5.2 Psycho-social, emotional and cognitive support

Purpose

55
It is well recognized in the medical literature that people who have suffered stroke
experience cognitive and neuropsychiatric issues. One of these issues is post stroke
depression which was found to be associated with lesions in the left-side of the cortex, basal
ganglia and lesions closer to the frontal lobe than on the left posterior or right frontal
lesions. Beside this, other risk factors for depression have been identified such as non-fluent
aphasia, significant motor deficit, age less than 60 years, female gender, and residency in
nursing homes. The risk of post stroke depression is found to be between 20-79% from the
first month up to 18 months post stroke. It has a negative impact on their physical
wellbeing, their rehabilitation gains, functional recovery and social reintegration. It is
imperative that stroke survivors, at various healthcare settings during their treatment
journey, are screened and assessed to identify post stroke depression so they can receive
appropriate and timely management. Furthermore, stroke can lead to behavioral and
cognitive impairment which vary in severity from amnesia to dementia, with loss of mental
capacity and inability to make decisions in life. Therefore, they will require assessment by
expert professionals.

Rationale
 The risk of neuropsychiatric manifestation is high following stroke including a range
of mood and cognitive disorders.
 Post stroke depression has been reported between 20-79% starting after the first
month and up to 18 after the stroke.
 There are risk factors associated with post stroke neuropsychiatric problems.
 Mood problems and cognitive impairment delay rehabilitation progress, reduce
functional gain and they are a hindrance for social reintegration.

Standards
1. All patients should be screened for post stoke cognitive and mental health issues
along the care pathways from hospital to community setting.
2. Patients at high risk of mood, behavioral and cognitive problems need evaluation
using validated measures, including patients with aphasia.
3. For patients with depression, severity of their depressive or cognitive symptoms
need to be identified, as well as any potential risks and impact on their functional
ability. These patients need to be referred to mental health for further evaluation
and management.
4. Patients with severe cognitive impairment affecting their mental capacity require
screening followed by expert professionals’ assessment to ensure their care & legal
rights are met.
5. Patients and their care givers/ family should be given education and should also be
provided with the information related to mood and cognitive problems post stroke,
and the support available for them.

QM 5.3 Secondary Prevention

QM 5.3.1: Counselling for lifestyle modification

Purpose
Stroke is preventable and the best defense against recurrent stroke is to increase awareness
about stroke prevention. Stroke survivors should be managed within a stroke program that

56
focuses on managing stroke symptoms, reducing risk factors, and promoting healthy
lifestyle to prevent recurrent stroke. Lifestyle modification that focuses on dietary
modification, weight reduction and increased physical activity is essential for stroke
occurrence prevention. Lifestyle modifications including daily physical activity and weight
management are associated with risk reduction in stroke and cardiovascular diseases.

Rationale
 Incidence of stroke is rising rapidly in Saudi Arabia and local data, suggests that
23.3% of all strokes were recurrent ones.
 The trend is significant; without increased prevention, the incidence of stroke will
increase. The 10-year forecast for Riyadh region is 8,00 – 9,200 per year, similar
increase in stroke prevalence is expected nationally (Unpublished data).
 Adherence to medication and lifestyle regimen is a key for stroke prevention.
 Studies show that 25% of stroke survivors stop taking one or more of
 prescribed stroke prevention medications within the first three months.
 Diet that has five serving vegetables and fruits per day may reduce the risk of stroke

Standards
1. All patients should be counselled regarding the need for lifestyle modification.
2. All patients with stroke should have identified risk factors for stroke documented
and communicated to the patients.
3. Each risk factor should be managed for effective control and prevention of recurrent
stroke (a plan for managing each risk factor should be documented).
4. The patient must be actively engaged in the plan of stroke prevention.
5. Increased physical activity with a structured exercise program should be
recommended for adult patients with stroke.
6. Technology should be incorporated into interventions and programs may offer novel
opportunities to increase physical activity and improve health fitness.
7. Counselling for lifestyle modification should be considered for all stroke patients,
this may include:
 Receiving stroke education
 Visits for nutritional specialist clinic
 Follow up visits to specialist clinic
 Referral to primary care physician
 Set up target blood glucose level 140-180 mg/dL (Normoglycemia)
 Assessment of smoking history in each follow up visit
 Counselling for smoking cessation
 Discharged on statin therapy
 Number of follow up visits to lifestyle modification clinic.

QM 5.3.2: Blood pressure management in patient with acute ischemic stroke

Purpose
Because of the high prevalence of hypertension among a patient with stroke and its
association of increased risk of CHD, recurrent stroke, and end-stage renal disease, patients

57
should receive treatment and education about blood pressure management. These
standards focus on the blood pressure management 48 hours after the onset of stroke.

Rationale
 Patients with high blood pressure can have 1.5 up to fold increase risk of stroke
 To reduce the risk of recurrent stroke and other vascular events
 To improve long-term blood pressure control
 To improve medications adherence

Standards
1. Adult patients with hypertension who experience a stroke or transient ischemic
attack should be restarted on antihypertensive treatment immediately after a stroke
event.
2. Adult patients who experience a stroke or TIA and have not been treated for
hypertension previously should have targeted blood pressure management.
3. When initiating a new or adjusted hypertensive regime patients should have follow-
up evaluation of adherence and response to treatment at monthly intervals until
target blood pressure is achieved.
4. Chronic stroke patients with normal blood pressure should have their blood pressure
monitored at least annually.

Action Needed
Stroke education that includes teaching the patient how to measure their blood pressure
and when to seek medical help.

QM 5.3.3: Prevention of future stroke among patients with stroke or

transient ischemic attack

Purpose
To prevent recurrent stroke by controlling risk factors and identify the mechanism of the
stroke and initiate effective secondary prevention to prevent future vascular events.

Rationale
 Up to 23.3% of stroke are recurrent stroke. Similarly, one out of five people with
stroke have TIA proceeding their stroke.
 Recurrent stroke caries higher mortality and morbidity.
 Up to 80% of stroke can be prevented by controlled risk factors and identifying
underling etiologic mechanism that lead to stroke and treated promptly.
 In multivariable analyses, multiple infarctions on brain imaging, large-artery
atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than
a doubling of the risk of stroke.24

Standards

24
https://www.nejm.org/doi/full/10.1056/NEJMoa1412981

58
 1. All patients with stroke or TIA should be evaluated by a health care professional with
expertise in stroke care, who can initiate appropriate investigations and
management.
2. Risk of recurrent stroke should be assessed, and stroke subtype should be classified
through prompt identification of the underlying cerebrocardiovascular cause.
3. All patients with ischemic stroke or TIA should be on an antiplatelet agent unless
there is an indication for anticoagulation:
3.1. Acetylsalicylic Acid (80 mg – 325 mg) or Clopidogrel (75 mg) are all appropriate
options and selection should depend clinical judgment and tailored according
patient characteristics.
3.2. Combined use of Acetylsalicylic Acid and Clopidogrel for short duration up to 28
days, is more effective to prevent recurrent stroke following minor stroke
(NIHSS less than 3) or transient ischemic attack.
4. All patients with ischemic stroke or TIA and non-valvular atrial fibrillation should
receive oral anticoagulation, unless contraindicated.
5. For all patients with ischemic stroke or TIA and a mechanical heart valve, warfarin is
recommended for stroke prevention with careful INR monitoring; non-vitamin-K oral
anticoagulants should not be used.
6. All patients with non-disabling ischemic stroke or TIA and an ipsilateral moderate to
severe extracranial internal carotid stenosis (50 to 99 %) should be offered carotid
revascularization:
6.1. Selection of revascularization option through carotid endarterectomy or carotid
stenting should be based depends clinical judgment and tailored according
patient anatomic or medical characteristics and technical reasons.
6.2. Revascularization should be done within two weeks.
7. All patients with ischemic stroke or TIA and a severe intracranial carotid stenosis of
70% to 99%, medical therapy is recommended. Intracranial angioplasty (with or
without stenting) is not routinely recommended.

QM 5.4 Community Assessment and Review

Purpose
Stroke patients and their family members/care givers should be offered a review from
primary care services of their health and social care status and secondary prevention needs,
typically within six weeks of discharge home or to care home, and again before six months
after leaving hospital.
This should be followed by an annual health and social care check, which facilitates a clear
pathway back to further specialist review, advice, information, support and rehabilitation,
where required.

Rationale
 Stroke patients and their family members/care givers would need information,
advice and advocacy in accessing the right kind of support.
 It will be important to bear in mind that those who have had a stroke may have
additional communication or cognitive support needs to be able to participate in the
assessment.

59
  In addition, those affected want to know how to seek further support when they
need it.

Standards
1. Stroke patients should receive a multidisciplinary person-centered assessment of the
individual’s needs and signposting to other services, such as housing or transport.
2. Family members or friends who may be taking on a caring role are entitled to an
assessment of their needs in their own right.
3. Stroke patients should be reviewed for their community living skills and support
needs upon discharge from acute hospital; these should be reviewed at least once a
year to provide appropriate support.

QM 5.5 Participation in the Community

Purpose
To enable stroke patients and their family members to live a full life in the community. Good
level of community participation by stroke sufferers will be enhanced by improving their
functional ability to be more independent and by making the community services more
accessible to them.

Rationale
 Stroke patients and their family members need support to be able to return to
varied roles they had before a stroke and to be involved in their local communities
again.
 Long-term assistance, review and rehabilitation are essential for patients to lead
independent lives and overcome physical, psychological and attitudinal barriers and
to engage and participate in community activities. To maximize emotional recovery,
people need information and advice about local opportunities and resources,
including hobbies, leisure, education and sports facilities.
 Opportunities for peer support can also enable and empower patients, especially in
relation to rebuilding the confidence that many stroke patients loose.

Standards
1. Transport authorities and local governments should undertake accessibility planning
and how they meet the needs of stroke patients, for example through their local
transport plans process.
2. Stroke networks and specialist professionals in the clusters should provide training
to providers of community services. Stroke networks should also consider providing
training on stroke to a wider range of organizations that come into contact with
individuals who have had a stroke. Allied health professionals and stroke voluntary
organizations are particularly well placed to carry out this training.
3. Clusters should ensure that there are a range of services available locally for people
to choose from when agreeing their care plan.

QM 5.6 Vocational Therapy

60
Purpose
Stroke patients and their family members should be enabled to participate in paid,
supported and voluntary employment.

Rationale
 Studies show that work is good for physical and mental health. There is a strong
inter-relationship between health, work and well-being.
 Workplaces could offer simple, reasonable adjustments to enable stroke patients to
return to work where possible.
 The workplace is also one of the best forms of rehabilitation. Many stroke patients
will not be ready to return to work in the short term but may be able to do so in the
longer term, and so can benefit from arrangements to give access to rehabilitation
and support for return to work for weeks, months or years post-stroke, as
appropriate for the individual patient. There is evidence that this can be achieved by
offering vocational rehabilitation to people after a stroke, and this may need to
begin when they are in hospital. It will also include access to government schemes
for return to work. Volunteering can also provide both a means of trialing return to
work and a satisfying alternative to paid employment for some people.
 It may also be important to offer support for employers and voluntary organizations
in adapting working conditions, especially for people with physical, communication
and cognitive difficulties. This may include offering guidance on how to educate co-
workers about the condition and what it means in practice for the individual’s role in
an organization. Alternatively, support may be needed to facilitate, for example,
reduced hours, and part-time working, initially.

Standards
1. Ensure support is offered to stroke patients and their family members to enable
them to return to work or to other opportunities such as volunteering.
2. Establish a partnership between voluntary organizations and employers to support
patients and employers to adapt to patient’s needs.

QM 5.7 Long term care

Purpose
A range of services are in place and easily accessible to support the individual long-term
needs of individuals and their care givers. This support should be at home or in long term
care facilities, when home is not an option.

Rationale
 Support for stroke patients and their family members needs to be tailored based on
the individual circumstances. A coordinated approach is needed, not just between
health and social care, but also involving housing, transport, employment, education
and leisure services, as well as the voluntary sector.

61
  Stroke patients can find that the accommodation they are in is no longer suitable.
There are a range of solutions to this: for example, simple pieces of equipment to aid
independence.
 Many stroke patients suffer from emotional difficulties, and this can have an impact
on their long-term physical recovery and lead to depression and isolation. Family
members are also vulnerable to difficulties of coping with loved ones who have
suffered a stroke, and to depression. This may make returning to activities and roles
that were part of normal life before the stroke difficult.
 Patients who find it difficult to adjust to the longer-term effects need support from
emotional support services.
 Stroke can lead to a range of pain symptoms and physical consequences like
spasticity which require monitoring and management.
 Professionals who are in charge of stroke patients need to train the paid care givers
to avoid preventable physical or emotional harm to both the patients and care
givers.

Standards

1. All stroke patients should be screened to check if they would benefit from mental
health and psychological services before discharge from the acute hospital.
2. All staff working with stroke should provide emotional and psychological support to
the patient and family/ care givers. These can range from access to good peer
support or local counselling services through to referral for psychiatric and
psychological services. Ideally, services need to develop long-term psychological and
emotional support, with coordinated programs starting with psychological support in
hospital and longer-term support involving the voluntary sector.
3. Rehabilitation teams at different settings along the stroke care pathway need to
address various physical issues related to pain, spasticity, continence, mobility,
selfcare and mental capacity.
4. All stroke patients should be assessed to check whether equipment and adaptations
can make their home environment more accessible for them, improve their
independence and make it easier for their families to look after them. Increasingly,
telecare and telehealth solutions can help people to live in their own homes for
longer.
5. Younger stroke patients may have different needs. For example, they may have a
family to support. Specific attention should be paid to the communication difficulties
experienced by many individuals and the need to commission long-term support
services from voluntary organizations that are able to meet these long-term needs.
6. Paid care givers should be trained to deal with stroke patients.
7. Stroke patients in long term facilities need to be reviewed regularly to identify their
changing needs.

QM 5.8 End of Life Care

Purpose
Stroke is one of the leading causes of death and disability; 1 in 20 patients die within 72
hours following admission and 1 in 7 of stroke patients will die in hospital. Furthermore 20%

62
of stroke sufferers die within 30 days of a stroke. People who are not likely to recover from
their stroke and at risk of dying should receive care at the end of their lives in hospital or the
community. This should take account of their needs and choices and is delivered by a
workforce with appropriate skills and experience in all care settings.

Rationale
 Providing high-quality end-of-life care to stroke patients can be challenging and
requires a skilled and experienced workforce.
 Deciding when it might be more appropriate for someone who has had a stroke to
receive end-of-life care rather than active rehabilitation and providing such care
when communication is difficult is a considerable challenge and requires skilled
decision-making and interaction from an experienced workforce.
 The needs and wishes of both the patient and their family, if appropriate, should be
considered as part of this process and should be reviewed regularly to ensure that
their needs continue to be met throughout the last phase of life and into
bereavement. This includes the management of pain and other symptoms, and the
provision of psychological, social, spiritual and practical support.
 People in need of this care will often already be in hospital, but they may also be at
home, in care homes or other care settings.

Standards
1. Patients with stroke who are reaching end of life need to be identified and referred
to palliative care in the hospital or the community.
2. Holistic approach to be taken to manage the patient’s physical and psychological
symptoms and will identify family needs and support during this period.
3. Acute stroke patients should be referred to palliative care specialists if they meet
three out of the four conditions on day three of being in coma below:
i. Abnormal brainstem response
ii. Absent verbal response
iii. Absent withdrawal response to pain
iv. Serum creatinine more than 1.5gm/dl
4. Chronic stroke patients should be referred to palliative care if they meet one of the
following criteria:
i. If the rating on Karnofsky performance scale is less than 50% or,
ii. If the score of less than 40% is achieved on palliative performance
scale, or
iii. If weight loss of more than 10% is observed in the last six months or,
iv. If weight loss of more than 7.5% is observed in the last three months
or,
v. If serum albumin is less than 2.5gm/dl or,
vi. If there is current history of pulmonary aspiration not responsive to
SLP intervention or,
vii. If there is sequential calorie count documenting inadequate calorific
intake.25

25
AHA guidelines

63
 5. All the patients meeting criteria for palliative care should be transferred to palliative
care team within 24 hours of assessment.

Chapter 6. Human resource development

Objective
 To improve capacity and capability among the organizations providing stroke care
 To ensure quality and safety of patient care
 To increase productivity and efficiency
 To improve the work environment

Key facts
 Human resources development (HRD) decisions are known to be associated with
patient outcomes.
 Increased staffing or skill mix is related to key clinical outcomes, such as, lower
infection rates, increased probability of survival and better continuum of care
indicators.
 Other aspects of HRD, including strategic planning and training and development,
have been found to relate to a reduction in medical errors.
 HRD can impact on patient care by influencing how professionals apply their
technical knowledge and skills, and their relationships with patients.

Introduction
Human resources standards refer to the minimum and appropriate mix of human resources
that is required to serve the expected populations at the different levels of the system, with
the defined health services, to ensure comprehensive health service delivery in an efficient,
equitable and sustainable manner.

All of the elements of a stroke system of care will operate in a highly complex and
multidisciplinary environment, with many elements and stakeholders, each with their own
rules and regulations. In terms of the many controlling authorities, it is paramount that the
“best interests of the patient” be the primary concern and driving factor when any rules and
regulations are made and implemented.

The Acute Stroke Ready Hospitals (ASRH), Primary Stroke Hospital (PSH) and comprehensive
Stroke Hospital (CSH) should also provide education to its employees, regional healthcare
providers, EMS, and lay groups. Public education should focus on stroke risk factors
(screenings for hypertension and other risk factors), as well as the recognition of acute
stroke symptoms. A minimum of 2 professional and 2 public programs each year are
suggested. These programs should be integrated across the spectrum of care within a stroke
system.

QM 6.1 Leadership and Skills

64
Purpose
To provide care givers with the skills and knowledge on how to support and care for a
patient with stroke.

Rationale
 A stable, qualified workforce contributes effectively and efficiently to patient/family
satisfaction and positive service delivery results.
 Personnel satisfaction and retention reflect positively on outcome.
 Cluster/network wide workforce leadership supports integrated teamwork.
 There is unwarranted variation in distribution and availability of neurological,
neurosurgical, and radiological expertise.

Standards
1. All stroke patients, and those at risk of stroke should receive care from skilled,
competent and experienced doctors and other healthcare professionals.
2. Clusters, networks, cities and regions should develop an organizational
infrastructure and decision-making body to assist in addressing care issues, decision
making, implementation, and problem solving. This is typically in the form of a stroke
committee defined by a cluster, region or other overseeing body.
3. The use of telemedicine/tele-stroke resources and systems should be supported by
healthcare institutions, government, payers, and vendors as one method to ensure
adequate 24/7 coverage and care of stroke patients in a variety of settings.
4. Stroke education programs for general physicians, hospital personnel, and EMS
personnel should be planned and regularly run to increase both the number of
patients who are treated and the quality of care.
5. Multi-component quality improvement initiatives, which include ED education and
multidisciplinary teams with access to neurological expertise, are recommended to
safely increase the capacity and capability of hospitals providing stroke care.
6. The cluster should develop a uniform and fairly applied credentialing process that
assesses and confirms the qualifications of licensed professionals who provide
network services.
7. All organizations involved in stroke care should promote open communication and
collaboration among disciplines and staff levels by:
a) holding regular team, organizational, and divisional meetings, as appropriate
to the organization.
b) Providing feedback to personnel about their suggestions and
recommendations.
8. All hospitals providing stroke care should establish a program of ongoing
professional education which should include:
a) A program of interprofessional education rounds within the stroke unit.
b) Process for stroke unit staff to participate in regional, national and
international educational opportunities in the care and management of
stroke patients.
c) Networking with interprofessional stroke teams in other facilities, networks,
clusters and nationally. This will facilitate knowledge sharing, problem
solving, collaboration, and increase consistency of stroke care delivery across
clusters and nationally.

65
 9. Regular meetings should be held between stroke physicians, vascular surgeons,
vascular technologists and radiologists to monitor service performance, discuss
clinical cases and provide feedback and education.

Action needed
 For patients: If you are the care giver of a patient with stroke, you are offered
education on stroke, practical training on how to provide care, as well as contact
details of support services before the patient with stroke leaves hospital.
 For clinicians: Support care givers by offering them education on stroke, practical
training on how to provide care, contact details of support services, and other
information to support their own wellbeing before patients with stroke leave
hospital.
 For health services: Ensure processes and resources are in place to provide family
members and care givers with education about stroke, practical training on how to
provide care, access to support services (e.g. respite care), and other information to
support care givers, before patients with stroke leave hospital.
 Ministry of Health: Consider establishing the National HRD Standards Working
Group or similar as a vehicle for the implementation of these standards.
 SCFHS:
I. Monitor and evaluate training programs to ensure compliance with standards
for their respective professions
II. Establish competencies required for licensing of health care professionals
III. Grant licenses and license renewals to qualified health care professionals
IV. Maintain an inventory of health care professionals currently licensed or
certified to practice in KSA in the training databases established (database
establishment)
V. Collaborate with MOH divisions of standards & quality assurance, health
regulation & legislation and the health training institutions in the
implementation of these standards.
 Organized system of stroke care including stroke units with a critical mass of trained
staff (interprofessional team). If stroke unit not feasible, then mechanisms for
coordinating the care of stroke patients to ensure application of best practices and
optimization of outcomes.
 All patients with moderate and severe stroke should be admitted to a geographically
defined stroke rehabilitation unit that is staffed by an interprofessional team of
healthcare providers. When post-acute stroke patients receive coordinated,
interprofessional evaluation and intervention on a stroke rehabilitation unit there is
a reduction in death and disability.

QM 6.2 Workforce
Purpose
All employers should undertake a review of the current workforce and develop a plan for
development and training to create a competent and skilled workforce and define critical
cadres with shortages and develop plans for urgent attention to resolve these.

66
Additionally, to define the numbers of new health workers required to be produced for
effective service delivery over a given period of time; to define competencies required by
the team in collaboration with regulatory bodies.
To identify training needs and gaps for basic and post-basic levels by team and by location,
and to develop training plans at the facility, cluster/network and national levels.
To establish and maintain effective linkages with the health training institutions, other
relevant ministries and regulatory boards, councils, development & implementation
partners, and others as needed, for effective implementation of this standard.

Rationale
 Outstanding stroke care does not exist in a vacuum solely focused on the procedure
but instead is part of a successful multidisciplinary team.
 The stroke team comprises fully trained stroke physicians (vascular neurologists or
neurointensivists), allied professionals, and nurses that are all led by a stroke
physician with a strong background in the management of neurovascular disease.

Standards
1. All organizations involved in stroke care should assess the type and number of
personnel needed to accomplish its mission, goals, and objectives. Human resources
planning should occur in conjunction with strategic planning, budget development,
training and professional development.
2. All organizations involved in stroke care should assess its workforce as part of annual
planning and prepare for future needs by:
a. comparing the composition of its current workforce, including number of
employees, skills, and demographics, with projected workforce needs; and
b. determining how to close gaps, when possible, through recruiting, training
or outsourcing.
3. The levels of nursing staff relate directly to the provision of good stroke unit care.
Nursing staffing levels and skill mix should be appropriate to the size of the stroke
unit and dependency of the patients.
4. Stroke intervention team: each stroke hospital should ensure 24/7 on-call schedule
is available to provide acute stroke intervention. The acute stroke intervention team
should have a minimum of three clinicians with training and qualifications in Acute
Ischemic Stroke Interventions (AISI). This should include:
I. The team should organize 24/7 acute emergency large vessel occlusion
(ELVO) stroke coverage (possibly in a rotation system organized within a
cluster/network).
II. The stroke neurovascular interventionist, in collaboration with the stroke
team, should have shared responsibility for preoperative and postoperative
patient care with input from the appropriate specialties.
III. AISI should ideally be practiced in neurovascular interventional teams with
the possibility to exchange experience and knowledge. With regard to
individual procedures, each acute stroke hospital will ensure appropriate
staff coverage is available for safe and effective urgent stroke treatment.
5. Anesthesia team: there shall be 24/7 in hospital anesthesia coverage with anesthetists
who have experience in caring for patients undergoing AISI.

67
6. The core interdisciplinary stroke team should consist of clinicians with appropriate
levels of expertise in medicine, nursing, occupational therapy, physiotherapy,
speech–language pathology, social work and clinical nutrition. Additional disciplines
may include pharmacy, (neuro)psychology and recreation therapy.
7. The interdisciplinary rehabilitation team may consist of a physician, nurse, physical
therapist, occupational therapist, speech–language pathologist, psychologist,
recreation therapist, patient and family/care givers. For children, this would also
include educators and child-life workers.
8. A dedicated core interprofessional team which includes physiatry, nursing,
occupational therapy, physiotherapy, speech-language pathology, social work, and
clinical nutrition should be in place for every hospital providing stroke care. The
team may also include other disciplines such as internal medicine, pharmacy and
(neuro)psychology. The team should have a special interest in stroke and advanced
training in stroke management.
9. Stroke Unit Staffing ratio: all hospitals and other organizations providing stroke care
should ensure that they have sufficient capacity and capability among all disciplines
to provide high quality and safe patient care.

68
Glossary
ABCD2 system
The ABCD2 score is calculated using the patient’s age (A); blood pressure (B); clinical
features (C); duration of TIA symptoms (D); and presence of diabetes (2). Scores are
between 0 and 7 points. Age (>_60 years, 1 point); Blood pressure at presentation
(>_140/90 mm Hg, 1 point); Clinical features (unilateral weakness, 2 points; speech
disturbance without weakness, 1 point); Duration of symptoms (>_60 minutes, 2 points; 10–
59 minutes, 1 point); and presence of diabetes (1 point). Low risk = 0–3 points; moderate
risk = 4–5 points; high-risk = 6–7 points. Acute care – Care for a disease or illness with rapid
onset, severe symptoms and brief duration.

Acute Ischemic Stroke Interventions

Any current or future practice interventions such as IA thrombolysis, emergency carotid or
intercranial angioplasty and stenting etc.

Allied health professionals

Allied health professionals (arts therapists, chiropodists/ podiatrists, dietitians, occupational
therapists, operating department practitioners, orthoptists, physiotherapists, prosthetists
and orthotists, psychologists, psychotherapists, radiographers and speech and language
therapists) are part of a healthcare team with a range of different skills, each bringing their
particular expertise to caring for the patient. Allied health professionals have their own
caseloads of patients and are key members of a skilled multidisciplinary team.

Aphasia
Partial or total loss of the ability to articulate ideas or comprehend spoken or written
language, resulting from damage to the brain.

FAST
The Face-Arm-Speech-Test, which helps people to recognize the symptoms of a stroke or
TIA in others.

Hemorrhagic stroke
Stroke caused by the bursting of a blood vessel leading to bleeding in the brain, which
causes damage.

Ischemic stroke
Stroke caused by a clot narrowing or blocking a blood vessel so that blood cannot reach the
brain, causing brain cells in the area to die due to lack of oxygen.

Rehabilitation
Combined and coordinated use of medical, social, educational and vocational measures for
training or retraining the individual to their highest level of functional ability.

Reperfusion Therapy
IV r-r-tPA and endovascular mechanical thrombectomy (MT)

69
ROSIER
Tool to assist in the recognition of stroke in the emergency room.

Stroke
A ‘brain attack’ caused by a disturbance of the blood supply to the brain. See also ‘Ischemic
stroke’ and ‘Hemorrhagic stroke’.

Transient ischemic attack (TIA)

Sometimes also known as a minor stroke, in which symptoms of a stroke subside within 24
hours.

70
Appendix 1 – Key Performance Indicators

High Priority Key Performance Indicators:

High priority Key Performance Indicators as identified by the clinical advisory group
recommended for measuring during 2019 pilot phase:

KPI 1: Median time interval from door to CAT scan

Computation method: Median time interval from patient entry in emergency room to non-
contrast CAT scan of the brain.
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for all the time
intervals for patients arriving into ED and receiving a CAT scan.

Inclusions: All patients with a final diagnosis of stroke or TIA.

Exclusions: Nil

Reference Benchmark:
Maximum Acceptable Achievable Excellent
20 min 15-20 minutes Less than 15 minutes

KPI 2: Median time interval from door to IV r-tPA

Computation method: Median time interval from patient entry in emergency

room/department and TPA bolus time.
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for all the time
intervals for patients arriving into ED and receiving IV r-tPA.

Inclusions: Patients with a final diagnosis of ischaemic stroke that arrive within 4 hours to
the emergency department.
Exclusions: Patients with unknown time of symptom onset.
 Patients less than 18 years of age
 Patients with a documented reason for extending the initiation of IV thrombolytics
 Patients with a documented reason for not initiating IV thrombolytics 26

Reference Benchmark:
Maximum Acceptable Achievable Excellent
45-60 minutes 30-45 minutes Less than 30 minutes

KPI 3: Time from presentation to emergency care unit to stroke/TIA identification (code
activation)

Computation method: Median time from presentation to stroke/TIA identification (code

activation).
26
https://manual.jointcommission.org/releases/TJC2018B1/MIF0129.html.

71
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for all the time
intervals between patient arriving in emergency care unit and stroke/TIA code activation.

Inclusions: All patients with a final diagnosis of stroke or TIA.

Exclusions: Nil

Reference Benchmark:
Maximum Acceptable Good Excellent
15 min 15 min-10 min Less than 10 min

KPI 4: Proportion of hospitals within a network that have established ED protocol for
acute stroke management ( including IVr-tPA, swallow assess etc.)

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of hospitals with established ED protocol for acute stroke
management.
Inclusions: Hospitals admitting acute stroke patients in ED.
Exclusions: Nil

Denominator: Total number of hospitals accepting stroke patients in ED.

Inclusions: Hospitals admitting acute stroke patients in ED.
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable
100%

KPI 5: Proportion of hospitals with designated acute stroke team to manage and assess
acute stroke

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of hospitals with a designated team to assess and manage acute
stroke in ED (per cluster)
Inclusions: All hospitals admitting acute stroke patients
Exclusions: Nil

Denominator: Total number of hospitals accepting acute stroke patients in ED (per cluster).
Inclusions: All hospitals admitting acute stroke patients
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91 - 99% 100%

72
KPI 6: Swallowing screening on within 4 hours of presentation to ED

Computation method: Proportion of acute stroke patients who received swallow screening
within 4 hours on presentation to ED (Numerator ÷ Denominator) × 100.

Numerator: Total number of stroke patients who received swallowing screening within 4
hours of presentation to ED
Inclusions: All patients brought into ED with a final diagnosis of stroke.
Exclusions: Nil.

Denominator: Total number of stroke patients admitted to the hospital/ED.

Inclusions: All patients brought into ED with a final diagnosis of stroke.
Exclusions: Comatose patients.

Reference Benchmarks:
Minimum Acceptable Good Excellent
85% 86-95% 96-100%

KPI 7: Proportion of acute ischemic stroke patients who received IV-Alteplase27

Computation method: (Numerator ÷ Denominator) X 100

Numerator: Total number of patients with a final diagnosis of ischaemic stroke who
presented to hospital within 4.5 hours (i.e. within 270 minutes) of symptom onset, with
documentation that intravenous thrombolysis was administered.2829
Inclusions: Patients with a final diagnosis of ischaemic stroke.
Exclusions: Patients with unknown time of symptom onset.
Denominator: Total number of patients with a final diagnosis of ischaemic stroke.
Inclusions: Patients with a final diagnosis of ischaemic stroke.
Exclusions: Patients with Hemmorhagic stroke. Patients with unknown time of symptom
onset. Patients for whom thrombolysis is contraindicated, and for whom the
contraindication is documented.

Comments:
Thrombolysis within 4.5 hours of symptom onset is indicated for ischaemic stroke. However,
it is recognised that in many cases patients and their families or carers will not be able to
describe with precision the time from symptom onset.30
Contraindications for thrombolysis include:
 Presentation >4.5 hours from stroke onset or uncertain onset time
 Evidence of intracranial haemorrhage on the CT-scan

27
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4839134/
28
https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.109.577106?url_ver=Z39.88-
2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
29
https://www.sciencedirect.com/science/article/pii/S0140673607601494
30
Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. The Cochrane
database of systematic reviews 2014;7.

73
  Persistent high blood pressure on repeated measures (systolic blood pressure
≥185mmHg or diastolic blood pressure >110mmHg)
 INR >1.7 if patient is taking warfarin or other anticoagulation therapy
 Heparin given within the last 24 hrs , or direct thrombin inhibitors or direct factor Xa
inhibitors given in the last 48 hours or thrombocytopenia with platelets count
100,000/mm with aPTT >40 s, or PT >15 s elevated PTT or has a known hereditary or
acquired haemorrhagic diathesis (e.g. PT or APTT greater than normal) IV alteplase
should not be administered to patients who have received a treatment dose of
LMWH within the previous 24 h31
 Recent (within 2 weeks) major surgery is a contraindication
 Major co-morbidity or receiving palliative care
 Clinical suggestion of intracranial haemorrhage even if CT scan normal or recent or
past history of haemorrhage that, in the opinion of the clinician, the increased risk of
intracranial bleeding would outweigh the potential benefits of treatment
 Other absolute and relative contraindications as per the Product Information may
also apply.

Reference Benchmark:
Minimum Acceptable Good Excellent
5% 6-15% More than 15%

KPI 8: Proportion of eligible ischemic or hemorrhagic stroke patients who received Venous
Thromboembolism prophylaxis

Computation method: (Numerator ÷ Denominator) × 100

Numerator:
Total number of ischemic or hemorrhagic stroke patients who received any form of VTE
prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the
day after hospital admission.
Inclusions: All patients brought into ED with a final diagnosis of stroke
Exclusions: Nil

Denominator:
Total number of Ischemic or hemorrhagic stroke patients admitted to the hospital.
Inclusions: All patients brought into ED with a final diagnosis of stroke
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

31
PTT is partial thromboplastin time; PT is prothrombin time; APPT is activated partial thromboplastin time.

74
KPI 9: Proportion of ischemic stroke and TIA patients receiving antithrombotic therapy
administered by the end of day 2 of hospital stay

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ischemic stroke and TIA patients who had antithrombotic
therapy e.g. antiplatelet or anticoagulant, administered by end of day 2 of hospital stay.
Inclusions: All patients with a final diagnosis of ischemic stroke or TIA
Exclusions: Patients with haemorrhagic stroke or those patients in whom antithrombic
therapy is contraindicated.

Denominator: Total number of Ischemic stroke and TIAs admitted to the hospital.
Inclusions: All patients with a final diagnosis of ischemic stroke or TIA
Exclusions: Patients with haemorrhagic stroke or those patients in whom antithrombic
therapy is contraindicated.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

KPI 10: Proportion of all stroke and TIA patients and their family members who received
information about stroke education, stroke management, support services before hospital
discharge

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients and TIAs who received information at hospital
discharge.
Inclusions: Patients diagnosed with stroke or TIA
Exclusions: Nil

Denominator: All strokes and TIAs

Inclusions: Patients diagnosed with stroke or TIA
Exclusions: Patients and family members refusing to receive the information and education.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91 - 95% 96 - 100%

KPI 11: Proportion of TIA patients who received documented urgent ABCD2, ECG and
brain imaging within 2 hours of ED presentation

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of suspected TIA patients with documented ABCD2, ECG and
brain imaging within 2 hours of ED visit.
Inclusions: All patients with a confirmed diagnosis of TIA presenting in ED

75
Exclusions: Nil

Denominator: Total number of suspected TIA patients seen.

Inclusions: All patients presented to ED with symptom suggestive of TIA diagnosis
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable Good Excellent
70-79% 80-89% 90-100%

KPI 12: Proportion of acute ischemic stroke patients with atrial fibrillation who are treated
with anticoagulant therapy upon discharge from hospital

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute ischemic stroke patients who have atrial fibrillation
treated with anticoagulation therapy.
Inclusions: Patients diagnosed with acute ischemic stroke patients and non-valvular atrial
fibrillation for whom anticoagulation is not contraindicated.
Exclusions: Patients for whom anticoagulation is contraindicated.

Denominator: Total number of acute ischemic stroke patients diagnosed with atrial
fibrillation.
Inclusions: Patients diagnosed with ischemic stroke and Atrial Fibrillation.
Exclusions: Patients for whom anticoagulation therapy is contraindicated and for whom the
contraindication is documented.

Comments:
Contraindications for oral anticoagulants may include patient refusal or where there are
limitations of therapy (i.e. advance care directive is enacted or the patient is on a palliative
care pathway). Oral anticoagulants include warfarin, apixaban, rivaroxaban or dabigatran.

Reference Benchmark:
To be determined (this KPI will be measured during the initial phase and then benchmarks
agreed by the end of 2019.

KPI 13: Proportion of patients who received rehabilitation assessment at admission to the
acute stroke unit

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients admitted to a stroke unit for whom there is
documented evidence of an assessment from the rehab team within defined working days
of patient admission.

Numerator criteria:
Inclusions: Total number of patients with the diagnosis of stoke admitted to the hospital.

76
Exclusions: Nil

Denominator: Total number of patients admitted to the stroke unit.

Denominator criteria:
Inclusions: Patients with a diagnosis of stroke who were admitted to the hospital.
Exclusions: Patients who refused assessment.

Reference Benchmark:
Minimum Acceptable
100%

77
List of all the key performance indicators by chapter:

Chapter 1: Saudi Stroke Hospital Classification System

KPI – ASR1: Median time interval from door to physician.

Computation method: Median time interval from patient entry in emergency room to
physician evaluation.

Reference Benchmark:
Maximum Acceptable Achievable Excellent
Up to 15 min 7-15 minutes Less than 7 minutes

KPI – ASR2: Median time interval from door to CAT scan

Computation method: Median time interval from patient entry in emergency room to non-
contrast CAT scan of the brain.
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for all the time
intervals for patients arriving into ED and receiving a CAT scan.
1) Rank the total values of time in minutes between acute stroke patient arriving in ED
and receiving CAT scan.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Inclusions: All patients with a final diagnosis of stroke or TIA.

Exclusions: Nil

Reference Benchmark:
Maximum Acceptable Achievable Excellent
20 min 15-20 minutes Less than 15 minutes

KPI – ASR3: Median time interval from door to IV r-tPA

Computation method: Median time interval from patient entry in emergency room to IV R-
tPA bolus.
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for all the time
intervals for patients arriving into ED and receiving IV r-tPA.
1) Rank the total values of time in minutes between acute stroke patient arriving in ED
and receiving IV r-tPA.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

78
Inclusions: Patients with a final diagnosis of acute ischemic stroke who received r-TPA
within 3-4.5 hours from symptoms onset.
Exclusions: Patients with unknown time of symptom onset.

Reference Benchmark:
Maximum Acceptable Achievable Excellent
45-60 minutes 30-45 minutes Less than 30 minutes

KPI – ASR4: Median time interval from door-in to door-out.

Computation method: Median time interval from patient entry in ASRH emergency room to
leaving ASRH.
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for door in door
out of ED for acute stroke patients:
1) Rank the total values of time in minutes between acute stroke patient arriving in ED
and leaving ED.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Reference Benchmark:
Maximum Achievable Excellent
Acceptable
With IV r-tPA 100-120 minutes 80-100 minutes Less than 80 minutes
capabilities
Without IV r-tPA 30-40 min 20-30 minutes Less than 20 minutes
capabilities

Chapter 2: QM Community Activation

KPI-CA 1: Time from presentation to emergency care unit to stroke/TIA identification

(code activation)

Computation method: Median time from presentation to stroke/TIA identification (code

activation).
The median will be the {(n + 1) ÷ 2}th value, where n is the number of values for all the time
intervals between patient arriving in emergency care unit and stroke/TIA code activation.
1) Rank the total values of time in minutes between acute stroke patient arriving in ED
and stroke/TIA identification.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.

79
 3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Inclusions: All patients with a final diagnosis of stroke or TIA.

Exclusions: Nil

Reference Benchmark:
Maximum Acceptable Good Excellent
15 min 15 min-10 min Less than 10 min

KPI-CA 2: Proportion of stroke/TIA cases identified (code activated) successfully

Computation method: Percentage of stroke/TIA cases identified successfully. Percentage of

facility pre-notification. (Numerator ÷ Denominator) × 100.
Numerator: Number of stroke/TIA cases identified at triage and upon EMS response (arrival
or telehealth engagement).

Denominator: Total number of stroke/TIA cases identified.

Reference Benchmark:
Minimum Acceptable Good Excellent
75% 76 - 90% 91 – 100%

KPI-CA 3: Mean time from symptoms onset to first professional contact

Computation method: Mean time interval between time of symptom onset and first
professional contact for suspected stroke patients.
Reference Benchmark:
Maximum Acceptable Good Excellent
40 min 20 min - 40 min Less than 20 min

Chapter 3: QM EMS Response

KPI - EMS 1: Proportion of stroke patients who received advance life support as a primary
response unit

Computation method: (Numerator ÷ Denominator) × 100.

Numerator: Total number of stroke patients who received advance life support as a primary
response via the EMS.
Denominator: Total number of stroke patients transported by EMS.

Reference Benchmark:
Minimum Acceptable Good Excellent
10% 11 - 30% 31 - 100%

80
KPI - EMS 2: Ninetieth percentile of ambulance response time to stroke

Computation method:
1. Order all the values in the data set of ambulance response times from smallest to
largest.
2. Multiply 90 percent by the total number of values, n.
This number is called the index.
3. If the index obtained in Step 2 is not a whole number, round it up to the nearest whole
number and go to Step 4a. If the index obtained in Step 2 is a whole number, go to Step
4b.
4. 4a. Count the values in your data set from left to right (from the smallest to the largest
value) until you reach the number indicated by Step 3.
The corresponding value in your data set is the 90th percentile.
4b. Count the values in your data set from left to right until you reach the number
indicated by Step 2.
The 90th percentile is the average of that corresponding value in your data set and
the value that directly follows it.

Reference Benchmark:
Maximum Acceptable Good Excellent
11 - 15 minutes 9 - 10 minutes 0 – 8 minutes

KPI - EMS 3: Ninetieth percentile of ambulance scene time to stroke patients

Computation method:
1. Order all the values in the data set of ambulance scene times from smallest to largest for
stroke patients.
2. Multiply 90 percent by the total number of values, n.
This number is called the index.
3. If the index obtained in Step 2 is not a whole number, round it up to the nearest whole
number and go to Step 4a. If the index obtained in Step 2 is a whole number, go to Step
4b.
4. 4a. Count the values in your data set from left to right (from the smallest to the largest
value) until you reach the number indicated by Step 3.
The corresponding value in your data set is the 90th percentile.
5. 4b. Count the values in your data set from left to right until you reach the number
indicated by Step 2.
The 90th percentile is the average of that corresponding value in your data set and
the value that directly follows it.

Reference Benchmark:
Maximum Acceptable Good Excellent
15 minutes 11 – 14 minutes 0 - 10 minutes

81
KPI - EMS 4: Proportion of patients with documented use of a validated stroke detection
tool

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients that have had a documented assessment using
a validated stroke detection tool by the EMS.

Denominator: Total number of stroke patients assessed by EMS.

Reference Benchmark:
Minimum Acceptable Good Excellent
80-89% 90-94% 95-100%

KPI - EMS 5: Proportion of stroke patients screened for mimics

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients assessed for stroke mimics by the EMS.

Denominator: Total number of stroke patients assessed by the EMS.

Reference Benchmark:
Minimum Acceptable Good Excellent
60-69% 70-79% 80-100%

KPI - EMS 6: Proportion of transfers where advance notification was performed by EMS

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of advance notifications performed by the EMS.

Denominator: Total number of stroke patients transferred by the EMS.

Reference Benchmark:
Minimum Acceptable Good Excellent
80-89% 90-95% 96-100%

KPI - EMS 7: Proportion of transfers with ‘false positive’ activation

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ‘false positive’ activation performed by EMS.

Denominator: Total number of stroke patients transferred by the EMS.

Reference Benchmark:

82
 Minimum Acceptable Good Excellent
80-89% 90-95% 96-100%

KPI - EMS 8: Proportion of patients where ambulance bypassed local non-stroke hospitals

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ambulances to bypass local non-stroke hospitals.

Denominator: Total number of stroke patients transferred by the EMS.

Reference Benchmark:
Minimum Acceptable Good Excellent
80-89% 90-95% 96-100%
Chapter 4: QM ED Assessment

KPI-ED 1: Proportion of hospitals within a network that have established ED protocol for
acute stroke management ( including IVr-tPA, swallow assess etc.)

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of hospitals with established ED protocol for acute stroke
management.
Inclusions: Hospitals admitting acute stroke patients in ED.
Exclusions: Nil

Denominator: Total number of hospitals accepting stroke patients in ED.

Inclusions: Hospitals admitting acute stroke patients in ED.
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable
100%

KPI-ED 2: Proportion of patients for whom stroke code response was triggered in ED

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of stroke code responses triggered in ED.

Denominator: Total number of acute stroke patients admitted in ED.

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI-ED 3: Proportion of hospitals with established door to imaging and door to needle
time.

83
Computation method: (Numerator ÷ Denominator) × 100
Numerator: Total number of hospitals with established door to imaging and door to needle
time.

Denominator: Total number of hospitals accepting stroke patients in ED.

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI-ED 4: Proportion of patients with acute stroke who have point of care glucose check
upon arrival to ED

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of suspected acute stroke patients receiving point of care glucose
check upon arrival in ED.

Denominator: Total number of acute stroke patients admitted in the ED.

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI-ED 5: Proportion of hospitals with designated acute stroke team to manage and assess
acute stroke

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of hospitals with a designated team to assess and manage acute
stroke in ED (per cluster)
Inclusions: All hospitals admitting acute stroke patients
Exclusions: Nil

Denominator: Total number of hospitals accepting acute stroke patients in ED (per cluster).
Inclusions: All hospitals admitting acute stroke patients
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91 - 99% 100%

KPI-ED 6: Proportion of documented NIHSS at ED neurological assessment for patients

with acute stroke (prior treatment and 24 hours after treatment).

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of documented NIHSS at ED neurological assessment for patients
with acute stroke (prior treatment and 24 hours after treatment).

84
Denominator: Total number of acute stroke patients seen in the ED.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81-90% 91-100%

KPI-ED 7: Proportion of competent ED staff in neurological stroke assessment e.g. STARS

competencies

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ED staff competent in neurological stroke assessment.

Denominator: Total number of ED staff involved in assessing acute stroke patients.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 90% 100%

Chapter 4a: QM Protocol for Acute Stroke Screening

No KPI as ED assessment covers the KPIs for this chapter.

Chapter 4b: QM Protocol for Acute Stroke Pathway

KPI- SCP 1: Proportion of acute stroke patients admitted to ED that have brain image
study obtained and interpreted

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute stroke patients who had their treatment decisions made
in ED based on brain imaging.

Denominator: Total number of acute stroke patients admitted to ED.

Reference Benchmark:
Minimum Acceptable Good Excellent
95% 96-100% 96-100%

KPI- SCP 2: Median time interval between ED arrival and CT Brain for suspected stroke
patients

Computation method: {(n + 1) ÷ 2}th value, where n is the number of values for time
interval between ED arrival and CT brain image being obtained for acute stroke patients.

85
 1) Rank the total values of time in minutes between acute stroke patient’s arrival in
emergency department and CT brain being documented as completed.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Reference Benchmark:
Maximum Acceptable Good Excellent
Up to 25 min 24 - 20 min 19 - 15 min

KPI- SCP 3: Median time interval for brain image interpretation

Computation method: {(n + 1) ÷ 2}th value, where n is the number of values for time
interval between brain image being obtained and interpreted for acute stroke patients.

1) Rank the total values of time in minutes between acute stroke patient’s brain
imaging being completed and interpreted.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Reference Benchmark:
Maximum Acceptable Good Excellent
Up to 45 min 44 – 30 min Less than 29 min

Chapter 4c: QM Swallow Screening

KPI SA 1: Swallowing screening on within 4 hours of presentation to ED

Computation method: Proportion of acute stroke patients who received swallow screening
within 4 hours on presentation to ED (Numerator ÷ Denominator) × 100.

Numerator: Total number of stroke patients who received swallowing screening within 4
hours of presentation to ED
Inclusions: All patients brought into ED with a final diagnosis of stroke.
Exclusions: Nil.

Denominator: Total number of stroke patients admitted to the hospital/ED.

Inclusions: All patients brought into ED with a final diagnosis of stroke.
Exclusions: Comatose patients.

Reference Benchmarks:
Minimum Acceptable Good Excellent
85% 86-95% 96-100%

86
KPI SA 2: Proportion of eligible acute stroke patients who received a comprehensive
assessment by a speech–language pathologist.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute stroke patients receiving a comprehensive assessment
by a Speech-Language Pathologist.

Denominator: Total number of acute stroke patients failing initial dysphagia screening.

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI SA 3: Proportion of stroke patients that have developed aspiration pneumonia in

hospital

Computation method: Proportion of stroke patients who developed aspiration pneumonia

within 7 days of admission. (Numerator ÷ Denominator) × 100
Numerator: Total number of stroke patients who developed stroke related aspiration during
hospital stay.

Denominator: Total number of stroke patients admitted to the hospital.

Reference Benchmark:
Minimum Acceptable Good Excellent
10% 5% 0%

KPI SA 4: Percentage of stroke patient diagnosed with dysphagia who received swallowing
exercises

Computation method: Proportion of stroke patients who are diagnosed with dysphagia and
swallowing exercises were given. (Numerator ÷ Denominator) × 100
Numerator: Total number of stroke patients who received swallowing exercises.

Denominator: Total number of stroke patients diagnosed with dysphagia.

Reference Benchmark:
Minimum Acceptable Good Excellent
40% 41 - 80% 81 - 100%

Chapter 4d: QM Hemorrhagic Stroke assessment and treatment

KPI- H1: Proportion of patients with Intra Cerebral Hemorrhage admitted to acute stroke
unit

87
Computation method: (Numerator ÷ Denominator) × 100
Numerator: Total number of hemorrhagic stroke patients admitted to acute stroke unit.

Denominator: Total number of hemorrhagic stroke patients discharged from hospital.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91-95% 96-100%

Chapter 4e: QM Door to Needle Time

KPI DN 1: Proportion of acute ischemic stroke patients who received IV-Alteplase

Computation method: (Numerator ÷ Denominator) X 100

Numerator: Total number of patients with a final diagnosis of ischaemic stroke who
presented to hospital within 4.5 hours (i.e. within 270 minutes) of symptom onset, with
documentation that intravenous thrombolysis was administered.
Inclusions: Patients with a final diagnosis of ischaemic stroke.
Exclusions: Patients with unknown time of symptom onset.
Denominator: Total number of patients with a final diagnosis of ischaemic stroke.
Inclusions: Patients with a final diagnosis of ischaemic stroke.
Exclusions: Patients with Hemmorhagic stroke. Patients with unknown time of symptom
onset. Patients for whom thrombolysis is contraindicated, and for whom the
contraindication is documented.

Reference Benchmark:
Minimum Acceptable Good Excellent
5% 6-15% More than 15%

KPI DN 2: Proportion of hospitals with evidence-based protocols for administration of

intravenous thrombolytic therapy

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of hospitals in the cluster with evidence-based protocols for
administration of intravenous thrombolytic therapy.

Denominator: Total number of hospitals in the cluster that accept and treat acute stroke
patients.

Reference Benchmark:
Minimum Acceptable Good Excellent
95% 95% 96 - 100%

Chapter 4f: QM Mechanical Thrombectomy

88
KPI MT1: Mean door to groin time for a "MT-capable center/hospital"

Computation method: {(n + 1) ÷ 2}th value, where n is the number of values for door to
groin time for acute stroke patients in MT capable center/hospital who received mechanical
thrombectomy.
1) Rank the total values of time in minutes between acute stroke patients arriving in ED
and receiving mechanical thrombectomy.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Reference Benchmark:
Maximum Acceptable Good Excellent
91 - 120 min 61 – 90 min Less than 60 min

KPI MT2: Mean IIb/III TICI scores

Computation method: {(n + 1) ÷ 2}th value, where n is the number of values for IIb/III TICI
scores for acute stroke patients.
1) Rank the total values of time in minutes between acute stroke patient arriving in ED
and leaving ED.
2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Reference Benchmark:
Minimum Acceptable Good Excellent
60% 70 – 80% More than 80%

KPI MT3: Number of mechanical thrombectomy procedures performed at each hospital

per year

Computation method: Calculate the total number of MT procedures performed at each

hospital per year.

Reference Benchmark:
Minimum Acceptable Good Excellent
25 26 - 35 More than 35

KPI MT4: Proportion of Ischemic stroke patients who receive mechanical thrombectomy

Computation method: (Numerator ÷ Denominator) × 100

89
Numerator: Total number of acute stroke patients receiving mechanical thrombectomy per
year.

Denominator: Total number of acute ischemic stroke patients admitted at the hospital.

Reference Benchmark:
Minimum Acceptable Good Excellent
At least 10% 11-15% More than 15%

KPI MT5: Number of mechanical thrombectomies per interventionalist per year

Computation method: Count the total number of mechanical thrombectomy interventions

being carried out by each interventionalist per year.

Reference Benchmark:
Minimum Acceptable Good Excellent
At least 10 11-20 More than 20

Chapter 4g: QM Acute Stroke Unit

KPI-ASU 1: Proportion of eligible ischemic or hemorrhagic stroke patients who received

Venous Thromboembolism prophylaxis

Computation method: (Numerator ÷ Denominator) × 100

Numerator:
Total number of ischemic or hemorrhagic stroke patients who received any form of VTE
prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the
day after hospital admission.
Inclusions: All patients brought into ED with a final diagnosis of stroke
Exclusions: Nil

Denominator:
Total number of Ischemic or hemorrhagic stroke patients admitted to the hospital.
Inclusions: All patients brought into ED with a final diagnosis of stroke
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

KPI-ASU 2: Proportion of ischemic stroke and TIA patients receiving antithrombotic

therapy administered by the end of day 2 of hospital stay

Computation method: (Numerator ÷ Denominator) × 100

90
Numerator: Total number of ischemic stroke and TIA patients who had antithrombotic
therapy e.g. antiplatelet or anticoagulant, administered by end of day 2 of hospital stay.
Inclusions: All patients with a final diagnosis of ischemic stroke or TIA
Exclusions: Patients with haemorrhagic stroke or those patients in whom antithrombic
therapy is contraindicated.

Denominator: Total number of Ischemic stroke and TIAs admitted to the hospital.
Inclusions: All patients with a final diagnosis of ischemic stroke or TIA
Exclusions: Patients with haemorrhagic stroke or those patients in whom antithrombic
therapy is contraindicated.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

KPI-ASU 3: Proportion of ischemic stroke patients prescribed anticoagulation therapy at

hospital discharge

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ischemic stroke patients prescribed anticoagulation therapy at
hospital discharge.

Denominator: Total number of Ischemic stroke patients and TIAs with documented atrial
fibrillation/flutter.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

KPI-ASU 4: Proportion of eligible ischemic stroke patients prescribed antithrombotic

therapy at hospital discharge.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ischemic stroke patients prescribed antithrombotic therapy at
hospital discharge.

Denominator: Total number of Ischemic stroke patients discharged from hospital.

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI-ASU 5: Proportion of eligible Ischemic stroke patients and TIAs prescribed statin
medication at hospital discharge

91
Computation method: (Numerator ÷ Denominator) × 100
Numerator: Total number of Ischemic stroke patients and TIAs prescribed statin medication
at hospital discharge.

Denominator: Ischemic stroke and TIA patients with a low-density lipoprotein cholesterol
(LDL-C) ≥100 mg/dL, or LDL-C not measured, or who were taking a lipid-lowering medication
before hospital arrival.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91 - 95% 96 - 100%

KPI-ASU 6: Proportion of all stroke and TIA patients and their family members who
received information about stroke education, stroke management, support services
before hospital discharge

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients and TIAs who received information at hospital
discharge.
Inclusions: Patients diagnosed with stroke or TIA
Exclusions: Nil

Denominator: All strokes and TIAs

Inclusions: Patients diagnosed with stroke or TIA
Exclusions: Patients and family members refusing to receive the information and education.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91 - 95% 96 - 100%

KPI-ASU 7: Proportion of all eligible acute ischemic stroke and TIA patients that have
carotid imagining reported

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of Patients with ischemic stroke or TIAs who have carotid imaging
reported (based on either ultrasound, CT angiography, magnetic resonance imaging
angiography, or conventional angiography) by the end of hospital day 2.

Denominator: All ischemic strokes and TIAs.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91 - 95% 96 - 100%

92
KPI-ASU 8: Proportion of ischemic stroke patients who received cardiac rhythm
monitoring within 2 hours of arrival at hospital

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients who receive continuous cardiac rhythm monitoring
within 2 hours of arrival on a hospital unit and for whom rhythm monitoring is continued
through the first 24 hours of hospital admission.

Denominator: Total number of patients admitted with ischemic stroke.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 91-95% 96-100%

KPI-ASU 9: Proportion of stroke patients assessed for rehabilitation within the acute
stroke unit

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of Patients who were screened, assessed for, or who received,
rehabilitation services during the first 72 hours of admission.

Denominator: Total number of stroke patients admitted

Reference Benchmark:
Minimum Acceptable Good Excellent
70% 71-80% More than 80%

KPI-ASU 10: Proportion of acute stroke patients admitted directly to an acute stroke unit
from ED or home

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute stroke patients admitted directly to an acute stroke unit
from ED or home.

Denominator: Total number of patients admitted to acute stroke unit.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81-90% 91-100%

KPI-ASU 11: Proportion of stroke patients discharged home from acute stroke unit

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients discharged home from an acute stroke unit.

93
Denominator: Total number of stroke patients discharged from an acute stroke unit.

Inclusion criteria: All stroke patients discharged from an acute stroke unit.

Exclusion criteria: Total number of deaths in an acute stroke unit or discharge to hospice.

Reference Benchmark:
Minimum Acceptable Good Excellent
40% 41 - 50% More than 50%

KPI-ASU 12: Proportion of stroke patients receiving bedside swallowing assessment by SLP
within 72 hours of the referral from Primary team

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients who have a documented bedside swallowing
assessment completed by a SLP within 72 hours of referral.

Denominator: Total number of acute stroke patients referred to SLP for an assessment.

Inclusion criteria: All patients with Glasgow Coma Scale of 12 or higher. In case of
Tracheostomy, patients with Glasgow Coma Scale of at least 11.

Exclusion criteria: All patients with Glasgow Coma Scale of 11 or lower, with exception to
Tracheostomy patients (less than 10).

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI-ASU 13: Proportion of stroke patients requiring NGT upon discharge from acute stroke
Unit

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients who required NGT on the acute stroke unit.

Denominator: Total number of acute stroke patients admitted to the acute stroke unit.

Inclusion criteria: All patients with Glasgow Coma Scale of 12 or higher. In case of
Tracheostomy patients those with Glasgow Coma Scale of at least 11.

Exclusion criteria: All patients with Glasgow Coma Scale of 11 or lower, with exception to
Tracheostomy patients (less than 10).

Reference Benchmark:
Minimum Acceptable Good Excellent
6 - 10% 1 - 5% 0%

94
Chapter 4h: QM Acute in-patient Stroke Rehabilitation

KPI-Rehab 1: Proportion of patients who received rehabilitation assessment at admission

to the acute stroke unit

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients admitted to a stroke unit for whom there is
documented evidence of an assessment from the rehab team within defined working days
of patient admission.

Denominator: Total number of patients admitted to the stroke unit.

Inclusion criteria:
All patients with Glasgow Coma Scale of 12 or higher. In case of Tracheostomy patients
those with Glasgow Coma Scale of at least 11.

Exclusion criteria: All patients with Glasgow Coma Scale of 11 or lower, with exception to
Tracheostomy patients (less than 11).

Reference Benchmark:
Minimum Acceptable
100%

KPI-Rehab 2: Proportion of acute stroke patients with a discharge plan before discharge
from acute hospital

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients who were discharged from stroke unit with
discharge plan.

Denominator: Total number of stroke patients discharged from the stroke unit.

Inclusion criteria: All patients with Glasgow Coma Scale of 12 or higher. In case of
Tracheostomy, patients with Glasgow Coma Scale of at least 11.

Exclusion criteria:
All patients with Glasgow Coma Scale of 11 or lower, with exception to Tracheostomy
patients (less than 10).

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

95
KPI-Rehab 3: Patient and family satisfaction rates from acute stroke rehabilitation

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Sum of stroke patients/their family satisfaction who receive rehabilitation care
in stroke unit.

Denominator: Total number of stroke patients who receive rehabilitation care in stroke
unit.

Inclusion criteria: All stroke patient who receive rehabilitation care in stroke unit.

Reference Benchmark:
Minimum Acceptable Good Excellent
50 51 - 65 More than 65%

KPI-Rehab 4: Proportion of acute stroke patients developing secondary complications such

as pressure ulcer, DVT, or contractures in the rehabilitation unit.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute stroke patients who developed any secondary
complications such as pressure ulcer, DVT, or contractures. Each patient with any secondary
complication that developed during the stay in rehabilitation unit will be counted as one
patient with secondary complication.

Denominator: Total number of stroke patients who receive rehabilitation care in stroke
unit.

Exclusion criteria: Patients arriving in the rehabilitation unit with pre-existing secondary
complication.

Reference Benchmark:
Minimum Acceptable Good Excellent
Up to 6-10% Up to 1-5% 0%

KPI-Rehab 5: Mean time interval between acute stroke patients being referred for a
comprehensive swallowing assessment and receiving an instrumental swallowing
assessment

Computation method: {(n + 1) ÷ 2}th value, where n is the number of values for time
intervals between acute stroke patients being referred for a comprehensive swallowing
assessment after failing a swallow screen and actually receiving an instrumental swallowing
assessment.
1) Rank the total values of time in hours between acute stroke patients being referred
for a comprehensive swallowing assessment and actually receiving an instrumental
swallowing assessment.

96
 2) If the number of values of time in minutes is odd, the middle value in ranked order
of values is the median time in minutes.
3) If the number of values of time in minutes is even, then the median is found by
taking the mean (average) of the two middlemost numbers.

Inclusion criteria: All patients with Glasgow Coma Scale of 12 or higher. In case of
Tracheostomy, patients with Glasgow Coma Scale of at least 11.

Exclusion criteria: All patients with Glasgow Coma Scale of 11 or lower, with exception to
Tracheostomy patients (less than 11).

Reference Benchmark:
Maximum Acceptable Good Excellent
Up to 72 hours 72 - 48 hours 48 - 24 hours

KPI-Rehab 6: Proportion of stroke patients discharged from acute stroke Unit on long-
term alternative form of nutrition.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients who discharged on long-term alternative form
of nutrition from the acute stroke unit.

Denominator: Total number of patients discharged with any alternative form of nutrition
from the acute stroke unit.

Inclusion criteria: All stroke patients discharged from acute stroke unit.

Reference Benchmark:
Minimum Acceptable Good Excellent
Up to 20% 21 - 50% 51 - 80%

Chapter 4i: QM Transfer of Care

KPI-ToC 1: Proportion of hospitals caring for stroke patients that have established transfer
mechanisms and protocols in the cluster

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of hospitals caring for stroke patients that have established
transfer mechanism and protocols across the cluster.

Denominator: Total number of hospitals across the cluster accepting stroke patients.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 90% 91 - 100%

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KPI-ToC 2: Proportion of eligible patients transferred for reperfusion therapy from
hospitals that can’t administer reperfusion therapy

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of candidate patients for reperfusion therapies who are
transferred for reperfusion therapies.

Denominator:
Total number of acute stroke patients eligible for reperfusion therapies arrived at the
hospital (candidate and transferred+ candidate but not transferred).

Reference Benchmark:
Minimum Acceptable Good Excellent
100% 100% 100%

KPI-ToC 3: Mean length of stay in Acute Stroke Unit for Ischemic and ICH

Computation method: Mean length of stay in acute stroke unit for all types of stroke
patients.

Reference Benchmark:
Maximum Acceptable Good Excellent
Up to 6 days 4-5 days 0-3 days

Chapter 4j: QM Transient Ischemic Attack

KPI-TIA 1: Proportion of TIA patients who received documented urgent ABCD2, ECG and
brain imaging within - 2 hours of ED presentation

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of suspected TIA patients with documented ABCD2, ECG and
brain imaging within 2 hours of ED visit.
Inclusions: All patients with a confirmed diagnosis of TIA presenting in ED
Exclusions: Nil

Denominator: Total number of suspected TIA patients seen.

Inclusions: All patients presented to ED with symptom suggestive of TIA diagnosis
Exclusions: Nil

Reference Benchmark:
Minimum Acceptable Good Excellent
70-79% 80-89% 90-100%

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KPI-TIA 2: Proportion of high-risk TIA inpatients referred to TIA clinic within 24 hours from
symptom onset and for low risk TIA patients, within 48 hours of symptom onset

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of high-risk TIA patients (ABCD2 scores of 5 or above) referred to
TIA clinic or equivalent within 24 hours or within 48 hours if deemed low risk (ABCD2 scores
3 or below).

Denominator: Total number of high risk and low risk TIA patients identified.

Reference Benchmark:
Minimum Acceptable Good Excellent
60-69% 70-79% 80-100%

KPI-TIA 3: Proportion of patients with anterior circulation symptoms who have

documented carotid imaging within 48 hours

Computation method: (Numerator ÷ Denominator) × 100.

Numerator: Total number of patients with acute anterior circulation symptoms with
documented carotid imaging within 48 hours.

Denominator: Total number of documented patients with acute anterior circulation issues
eligible for carotid surgery.

Reference Benchmark:
Minimum Acceptable Good Excellent
80-89% 90-99% 100%

KPI-TIA 4: Proportion of patients who have suffered from a TIA with high risk of stroke
receiving specialist assessment within 24 hours of onset of symptoms

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of high-risk TIA patients with ABCD2 scores of 5 or above with
documented specialist assessment and investigations within 24 hours of onset of symptoms.

Denominator: Total number of high-risk TIA patients seen.

Reference Benchmark:
Minimum Acceptable Good Excellent
60-69% 70-79% 80-100%

KPI-TIA 5: Proportion of TIA patients who have had an out-patient clinic appointment
completed within 1 week of onset of a TIA with low risk of stroke

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Computation method: (Numerator ÷ Denominator) × 100
Numerator: Total number of suspected TIA patients at low risk (ABCD2 score of 3 or below),
with a documented outpatient clinic appointment within 1 week of symptoms onset.

Denominator: Total number of suspected TIA patients at low risk seen.

Reference Benchmark:
Minimum Acceptable Good Excellent
60-69% 70-79% 80-100%

KPI TIA 6: Proportion of TIA patients who have received specialist assessment and brain
scan within 24 to 48 hours of symptom onset.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute stroke patients who received specialist assessment including a
brain scan within 24 to 48 hours.

Denominator: Total number of acute stroke patients admitted to hospitals

Reference Benchmark:
Minimum Acceptable Good Excellent
70-79% 80-89% 90-100%

KPI TIA 7: Mean time taken for Carotid Imaging for high risk TIA patients

Computation method: Mean time interval between patient arriving in ED and Carotid
imaging being completed.

Reference Benchmark:
Maximum Acceptable Good Excellent
90-100 minutes 80-89 minutes 60-79 minutes

Chapter 5: QM Psycho-social, cognitive and support

KPI-SS 1: Percentage of patients screened for post stroke mood and cognitive issues

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Patient screened for post stroke mood & cognitive issues.

Denominator: Total number of stroke patients in a health care setting along the care
pathway.

Reference Benchmark:
Minimum Acceptable Good Excellent
70% 71 - 80% 81 - 90%

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KPI-SS 2: Percentage of patients given education and information related to post stroke
mood and cognitive issues before discharge from hospital

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number patients/care givers who received education and were given
information about post stroke mood and cognitive issues, prior to discharge.

Denominator: Total number of stroke patients in stroke units in a given timeframe.

Reference Benchmark:
Minimum Acceptable Good Excellent
85% 86 - 95% 96 - 100%

Chapter 5: QM Secondary Prevention

KPI SP1: Proportion of stroke patients receiving counselling for lifestyle modification
including counselling for smoking cessation and assessment from a primary care physician

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of patients referred to specialty clinic for lifestyle modification.

Denominator:
Total number of stroke survivors with identified stroke risk factors.

Inclusion criteria:
Stroke survivors with risk factors identified.

Exclusion criteria:
No clear identification for the reason of the initial stroke.

Reference Benchmark:
KPI Title Minimum Good Excellent
acceptable
Received stroke 80% 81 - 90% 91 - 100%
education
Number of visits for 80% 81 - 90% 91 - 100%
nutritional specialist
clinic
Referral to primary 80% 81 - 90% 91 - 100%
care physician

Counselling for 100% 100% 100%

smoking cessation
Yes
No

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KPI: SP2 Proportion of stroke patients discharged on antihypertensive medications
 Target Blood Pressure documented and communicated to the patient.
 Referral made to primary care physician.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of stroke patients with history of hypertension

Denominator: Total number of stroke patients

Reference Benchmark:
KPI title Minimum Good Excellent
acceptable
Discharge on 60% 61 - 80% 81 - 100%
antihypertensive
medication
Target Blood
Pressure achieved
Yes
No

KPI-SP3: Proportion of acute ischemic strokes classified using TOAST sub-type

classification 32

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute ischemic strokes classified using TOAST classification
method.

Denominator: Total number of acute ischemic strokes seen at the hospital.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

KPI-SP 4: Proportion of patients with ischemic stroke or transient ischemic attack

prescribed antiplatelet therapy on discharge from secondary prevention clinic care

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of ischemic stroke or TIA patients prescribed antiplatelet therapy
on discharge from secondary prevention clinic.

Denominator: Total number of ischemic stroke or TIA patients seen in secondary prevention
clinic.

32
https://www.ahajournals.org/doi/pdf/10.1161/01.STR.24.1.35

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Reference Benchmark:
Minimum Acceptable Good Excellent
90% 90% 91 - 100%

KPI-SP 5: Proportion of acute ischemic stroke patients with atrial fibrillation who are
treated with anticoagulant therapy

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of acute ischemic stroke patients who have atrial fibrillation
treated with anticoagulation therapy.

Denominator: Total number of acute ischemic stroke patients diagnosed with atrial
fibrillation.

Reference Benchmark:
To be determined (this KPI will be measured during the initial phase and benchmarks will be
agreed by the end of 2019).

KPI-SP 6: Proportion of stroke or TIA patients with moderate to severe (50 – 99%)
symptomatic carotid artery stenosis who had a carotid revascularization procedure
following an index stroke/TIA event.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients with carotid artery stenosis who had revascularization
surgery.

Denominator: Total number of acute strokes diagnosed in patients with carotid artery
stenosis.

Reference Benchmark:
Minimum Acceptable Good Excellent
80% 81 - 90% 91 - 100%

KPI-SP 7: Proportion of patients who underwent revascularization, who experience

perioperative in-hospital stroke, acute myocardial infarction or death

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients with moderate to severe stenosis who underwent
surgery.

Denominator: All patients who underwent revascularization surgery.

Reference Benchmark:
Minimum Acceptable Good Excellent

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 Up to 6% 3-6% Less than 3%

Chapter 5b: QM Community Assessment and Review

KPI-CA 1: Proportion of stroke patients who received a multidisciplinary assessment of

health and care needs within six weeks, six months and one-year post discharge from
hospital

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients who received multidisciplinary assessment for
their changing needs after discharge home/care home after six weeks, six months and one
year.

Denominator: Total number of stroke patients discharged from hospital.

Reference Benchmark:
Minimum Acceptable Good Excellent
50% 51 – 65% More than 65%

Chapter 5c: QM Participation in the community

No KPIs

Chapter 5d: QM Vocational Therapy

KPI-VT 1: Percentage of stroke patients below 60 years old who returned to employment

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of stroke patients below 60 years old who returned to any form of
employment.

Denominator: Total number of stroke patients below 60 years.

Reference Benchmark:
Minimum Acceptable Good Excellent
40% 41 - 60% More than 60%

Chapter 5e: QM Long Term Care

KPI-LTC 1: Proportion of stroke patients monitored for any changes in their physical and
psychological condition

Computation method: (Numerator ÷ Denominator) × 100

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Numerator: Number of stroke patients in Network receiving regular reviews by specialized
services per year.

Denominator: Total number of stroke patients living at home or long-term care facilities in
Network.

Reference Benchmark:
Minimum Acceptable Good Excellent
50% 51 - 60% More than 60%

Chapter 5f: QM End of Life Care

KPI-EoL 1: Proportion of patients screened for palliative care if comatose for more than
three consecutive days

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients screened for palliative care if comatose for more than
three consecutive days.

Denominator: Total number of patients recorded to be comatose for more than three
consecutive days.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 90% 91 - 100%

KPI-EoL 2: Proportion of patients whose care is transferred to palliative care team within
24 hours of decision to transfer care to palliative care team being made

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of patients who are transferred to the palliative care team within
24 hours of the decision to transfer care to palliative care is made.

Denominator: Total number of patients transferred to palliative care team.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 90% 91 - 100%

KPI-EoL 3: Proportion of stroke patients who are supported to die in a place of their choice

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients who died supported in a place of their choice.

Denominator: Total number of patients identified as died from stroke in a period of time.

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Reference Benchmark:
Minimum Acceptable Good Excellent
50% 51 - 65% More than 65%

KPI-EoL 4: Evidence that the end of life service was supportive to meet the need of the
dying person and the family

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of the positive replies to the questionnaire from bereaved
families/care givers.

Denominator: Total number of completed responses to the questionnaire from bereaved

families/care givers.

Reference Benchmark:
Minimum Acceptable Good Excellent
65% 66 - 80% More than 80%

Chapter 5g: QM Leadership and Skills

KPI-LS 1: Proportion of acute stroke patients assessed by physiotherapist, occupational

therapist, speech–language pathologist and social workers during inpatient rehabilitation.

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke patients assessed by physiotherapist, occupational
therapist, speech and language therapist and social workers during inpatient rehabilitation.

Denominator: Total number of stroke patients admitted into inpatient rehabilitation.

Reference Benchmark:
Minimum Acceptable Good Excellent
90% 95% 100%

KPI-LS 2: Proportion of Doctors and other Healthcare professionals working in acute

stroke unit who receive appraisal of their skills and knowledge at least once per year

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of Doctors and other Healthcare professionals working on acute
stroke unit who have received an annual appraisal (performance review).

Denominator: Total number of Doctors and other Healthcare professionals working on

acute stroke unit.

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Reference Benchmark:
Minimum Acceptable Good Excellent
95% 100% 100%

Chapter 5h: QM Workforce

KPI-W 1: Distribution of stroke workforce professionals by sector of activity (public vs

private)

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of stroke workforce employed in the public (versus private or non-
governmental) sector.

Denominator: Total number of stroke workforce professionals.

Inclusion criteria:
Definitions of labor force participation and employment status.

Reference Benchmark:
Minimum Acceptable Good Excellent
>50 % are employed within > 75% are employed within > 90% are employed within
the cluster the cluster the cluster

KPI-W 2: Distribution of workforce by geographical location

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Number of health workers in a given geography (rural areas or large cities or
clusters/networks).

Denominator: Total number of health workers.

Inclusion criteria: Definition of rural (or other geographical delimitation).

Reference Benchmark:
Minimum Acceptable Good Excellent
Not more than 50% of the Not more than 60% of the Not more than 75% of the
available stroke-care available stroke-care available stroke-care
professionals are in the professionals are in the professionals are in the
large cities. large cities. large cities.

KPI-W 3: Stock (and density) of stroke workforce: Total number of stroke care
professionals (relative to the population)

Computation method: (Numerator ÷ Denominator) × 100

Numerator: Total number of stroke workforce professionals in a given cluster/network.

107
Denominator: Total population of the same cluster/network catchment area.

Inclusion criteria:
Definition and boundaries of stroke workforce, such as by occupation (e.g. physicians,
nurses, etc.), industry or training – with distinction between headcounts versus job
positions.

Reference Benchmark:
Minimum Acceptable Good Excellent
50% - 74% of the needed 75% - 89% of the needed 90% - 100% of the needed
staff as shown in the staff as shown in the staff as shown in the
standards standards standards

108
Appendix 2 - Patient Selection Criteria for Rehabilitation Team
Inclusion criteria
1. Stroke inpatients at acute setting.
2. Have an impairment likely to be responsive to enhanced therapy with identifiable and
realistic rehabilitation goals
3. Be sufficiently clinically stable to tolerate 60 mins of therapy daily.
4. Have the desire and ability to actively participate in the rehabilitation program.
5. Patients over 65 will have MMSE conducted at the discretion of the Rehabilitation
Consultant.
6. Possess a level of independence prior to the onset of the impairment that allowed them
the ability to actively participate in the community and / or at home
7. Require at least two of the following therapies:
a. Physiotherapy
b. Occupational Therapy
c. Speech Therapy
d. Clinical Psychology
e. Social Work
g. Orthotics

Exclusion Criteria
1. Currently a patient in the Intensive Care unit
2. Febrile > 38.5oC in last 24 hours.
3. Glasgow Coma Scale < 13 or 12 if patient is non-verbal.

Process:
Initial Assessment Identification by Rehabilitation Resident or Registrar in accordance with
the Rehabilitation Selection criteria.
 Upon identification of/or referral of the patient to Rehabilitation Team, the
Rehabilitation CNC and Registrar will assess the patient , discuss suitability with
Rehabilitation consultant and document in the patients notes.
 The Rehabilitation Registrar will review patients daily, liaise with the acute treating
team and Rehabilitation Team members, and conduct ward rounds with the
rehabilitation consultant
 Education will be provided to the patient, carers and significant others by members
of the Rehabilitation Team.
 Patients who are assessed to require inpatient rehabilitation should be referred to
the inpatient rehabilitation ward or outpatient clinic.

Initial Assessment by Rehabilitation Team members

On advice of admission of the patient to the Rehabilitation Team program, allied health
team members will;
 Liaise with the acute treating team therapist to ascertain therapy needs and goals.
 Perform initial assessment and plan goals with the patient.
 Conduct a FIM and Goal Attainment Scale (GAS) and document in patient’s notes.

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Ongoing Patient therapy
 Goals should be attainable in the first week of assessment.
 Goals should be set in conjunction with the patient and monitored for achievement.
 Each patient progress and ongoing therapy / management plan will be discussed in
the multidisciplinary team meeting on a weekly basis.
 Patients who require inpatient rehabilitation will be discussed at the weekly
rehabilitation case conference.

Responsibility of a Physiotherapist includes:

 Get the patient to mobilize as early as possible
 Help the patient to regain muscle power and joint mobility
 Prevent failing and dislocation
 Educate the caregiver, patient and staff about the prober body position and transfer.

Responsibility of a Speech and Language Therapist includes:

 Initiate the safest way of nutrition (oral or tube)
 Recommend oral feeding diet modification if needed
 Initiate methods of communicating with non-verbal patient
 Educate the caregiver, patient, and health care provider regarding patient diet and
communication method
 Initiate swallowing therapy when needed
 Monitor swallowing function
 Monitor and initiate speech, language, and cognitive therapy

Action Needed:
 Every stroke program must have written SLP stroke manual including protocols,
policies, procedures, and referral guidelines.
 Every Stroke program should be located in a facility that has at least One operating
fluoroscopy Unit or portable Fibrotic Endoscopic Evaluation of Swallow station.
 Availability of ENT services for primary team (for tracheostomy patients)
 A minimum of One SLP required for any 12 active beds.

References:
ACHS Equip/Aged Care Standards:
1.1.1 Assessment ensures current and ongoing needs of the consumer/patient are identified
1.1.2 Care is planned in collaboration with the consumer/patient and when relevant, the
Carer, to achieve the best possible outcomes
1.1.5 Processes for clinical handover, transfer of care and discharge address the needs of
the consumer/patient for ongoing care
1.1.6 Systems for ongoing care of the consumer/patient are coordinated and effective

110
Version control

Version Date Author(s) Comments/ updates

V0.1 11/22/18 Amar Sharma Drafted initial skeleton document and
table of contents for review by the
Clinical Advisory Group (CAG).
V0.2 11/30/18 Amar Sharma Added Community Activation and
Integrated stroke care chapters.
V0.3 12/14/18 Amar Sharma Added Network and Stroke Hospital
Classification chapters.
V0.4 01/02/19 Amar Sharma Added chapters on Post stroke care,
Human Resource Development and
Glossary
V0.5 01/18/19 Amar Sharma Addressed comments from the CAG,
added Foreword, Executive Summary,
Purpose and Scope
V0.6 01/25/19 Amar Sharma Completed KPIs and benchmarks,
updated the high priority KPIs based on
CAG members survey
V0.7 01/28/19 Victoria Hughes Revised grammar, formatting and
commented on various sections
V0.8 01/28/19 Amar Sharma Revised and re-formatted based on
comments from Victoria Hughes
V0.9 01/29/19 Dr Fahmi M Al-Senani Edited Purpose and scope, chapters 1,2
and 3
V1.0 01/29/19 Amar Sharma Addressed comments from Dr Fahmi M.
Al-Senani and re-formatted the
document.
V1.1 02/05/19 Amar Sharma Added Hemicraniectomy and CVT
V1.2 02/11/19 Amar Sharma Added placeholders for post-acute
rehabilitation and sub-arachnoid
hemmorhage
V1.3 02/17/19 Dr Salwa Ali Ahmad Updated rehabilitation standards
V1.4 02/19/19 Amar Sharma Updated KPIs with time intervals from
minimum acceptable to maximum
acceptable
V1.5 02/23/19 Dr Omar Ayoub Updated TIA assessment and
management standards
V1.6 03/03/19 Amar Sharma Added Sub arachnoid hemorrhage
section and edited several sections,
deleted all indicators.
V1.7 03/11/19 Amar Sharma Added inclusion and exclusion criteria to
the 13-high priority KPIs.
V1.8 04/02/19 Amar Sharma Added QM2.1 and standards for
Networked stroke care
V1.9 28/10/19 Shatha Alsaidan Add the CAG member , External reviewr
and support team, Change the name of
the Document, remove Riyadh word in
the KPI and replace with Network.

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