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Stroke Guidelines

WSO Global Stroke Services Guidelines and Action Plan

In line with the WSO mission to reduce the global burden of stroke, the WSO has launched a Global Stroke Services Guidelines and Action Plan during the World Stroke Congress in Istanbul in 2014. The Global Stroke Services Guidelines and Action Plan is intended to augment stroke advocacy efforts throughout the world, providing a strategic plan for optimizing stroke outcomes. Despite differences in resource availability, the message the WSO wishes to convey is that stroke awareness, education, prevention, and treatment should always be feasible.

Download the WSO Global Stroke Services Guidelines and Action Plan

 

Clinical Practice Guideline Development Handbook for Stroke Care

The clinical practice guideline development handbook for stroke care has been developed by the WSO Stroke Guideline Sub-Committee from January to June 2009.

This handbook has been developed to provide a basic guide for healthcare professionals who wish to develop or adapt clinical guidelines for stroke care across any point in the continuum of care.

This handbook is particularly intended for healthcare professionals who manage stroke patients in developing countries or where healthcare resources are scarce. It aims to promote the use of evidence-informed care through locally developed or adapted guidelines without compromising the quality of the resource.

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CONTENTS


Acknowledgements

The World Stroke Organization wishes to acknowledge the efforts and contributions of the members of the WSO Guideline Subcommittee in the preparation of the content of this handbook. These members include: Dr. A. Hakim (Chair, Canada), Dr. A. Culebras (United States), Dr. W. Hacke (Europe), Dr. J. Jowi (Kenya), Dr. E. Lalor (Australia), Dr. P. Lindsay (Canada), Dr. M. Mehndiratta (Asia_Indian Sub-Continent), Dr. B. Norrving (Europe), Dr. K.S.L. Wong (Hong Kong). In addition we are grateful for the work of Mr. Kelvin Hill (Australia) and Ms. Chelsea Hellings (Canada) in completing this Handbook.

We also gratefully acknowledge the efforts of Ms. Isabelle Bourzeix and Ms. Clea Estruch for their assistance in preparing and disseminating this document to the membership of the World Stroke Organization.

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Disclaimer

The information presented in this Handbook and the lists of guidelines included in the appendices were gathered through a WSO member survey, environmental scans, and research literature searches.

The guidelines listed in Appendix Two have not been systematically evaluated for accuracy, comprehensiveness, or the process applied by individual groups for guideline development. The inclusion of any guideline in this Handbook does not imply endorsement or approval by the World Stroke Organization.

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Purpose of this Handbook

This handbook has been developed to provide a basic guide for healthcare professionals who wish to develop or adapt clinical guidelines for stroke care across any point in the continuum of care. This handbook is particularly intended for healthcare professionals who manage stroke patients in developing countries or where healthcare resources are scarce. It aims to promote the use of evidence-informed care through locally developed or adapted guidelines without compromising the quality of the resource.

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Background

The mission of the World Stroke Organization (WSO) is to provide access to stroke care and to promote research and teaching in this area that will improve the care of stroke patients throughout the world by:

  1. Promoting prevention of and care of persons with stroke and vascular dementia;
  2. Fostering the best standards of practice
  3. Educating, in collaboration with other international, public, and private organizations
  4. Facilitating clinical research

To accomplish some of the objectives of the WSO, a guideline sub-committee was established in 2008 to create and implement a framework and action plan for collaboration in the development and dissemination of stroke guidelines across the continuum of care and across organizations and jurisdictions.

The WSO guideline sub-committee conducted a survey that produced an extensive list of existing stroke guidelines internationally, primarily in industrialized countries (Appendix Two). This sub-committee is committed to promoting evidence-informed stroke care in all jurisdictions where stroke patients are managed across the globe. They also recognize that not all jurisdictions have access to the same human and capital resources and medical services to meet the most comprehensive levels of stroke service delivery prescribed in many existing guidelines. This handbook has therefore been developed to assist all healthcare professionals, regardless of available resources, to understand the steps to adopt, adapt or develop evidence-informed stroke care guidelines for their clinical environment and available services and resources.

Clinical practice guidelines are systematically developed statements that assist clinicians, consumers and policy makers to make appropriate health care decisions and to improve the quality of care. Developing a new guideline requires a rigorous process to be followed and often takes 1-2 years to accomplish. This consumes considerable effort by developers and those experts who volunteer to be involved in relevant working groups. Limited resources for guideline development, and for delivery of evidence based care, can present challenges.

In an effort to reduce the work associated with developing guidelines, processes for adapting existing guidelines have been suggested and published.The process of adaptation — defined as “the systematic approach for considering the use and/or modifying guideline(s) produced in one cultural and organizational setting for application in a different context” has been outlined by groups such as the ADAPTE group.1 The adapt process can be useful to healthcare groups, and requires a systematic process to be followed and significant effort to coordinate. This handbook provides a clear and concise summary of the steps involved in guideline adaptation.

Given the time and effort needed to develop a guideline, it is important to consider if a guideline is actually needed. Groups considering guidelines should determine whether it is more appropriate to develop evidence based protocol/s or pathway which are practical tools that apply the evidence in a local setting on a specific process of care, or whether a more in-depth guideline is required.

A guideline may be needed when:
there is uncertainty or a difference of opinion about what care should be provided, as evidenced by wide variation in practice or outcome;

  1. there is proven treatment for a condition and mortality or morbidity can be reduced;
  2. there is a need to bring together scientific knowledge and expertise on a subject.

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How to use this Handbook

Each of the steps to be undertaken in developing a guideline is presented in a flow diagram on the next page followed by more detailed descriptions and information on subsequent pages. Practical considerations are provided where possible for each step. This guide also provides links to useful resources should more detailed information be required.

In areas where resources are limited, some steps may be modified or skipped altogether. It is important to weigh the benefits and risks of doing this. For example, in establishing the working group, a decision may be made to keep it small; however, it should still ideally include representation from multiple disciplines. And modification of this step may not carry the same risk as choosing not to grade the evidence for each recommendation, for example.

1ADAPTE: manual for guideline adaptation. ADAPTE Group; 2007.www.adapte.org

2Graham I, etc Clinical Guideline evaluation and adaptation cycle

3Davis, Goldman and Palda. Handbook on Clinical Practice Guidelines. Canadian Medical association 2007.
http://www.cma.ca//multimedia/CMA/Content_Images/CMAInfobase/EN/handbook.pdf

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Steps to Stroke Guideline Development or Adaptation

1.0. Set up the working group

Guidelines should be developed by a group of people with a broad range of expertise relevant to the guideline topic being developed. Lists of people to be considered are found in the various guideline developer handbooks (refer to links at the end of this document). The way the group works together can have a significant effect on the outcome of the process.

For stroke care, healthcare professionals from the following disciplines should be considered for participation in guideline development: medicine (neurology, internal medicine, emergency, primary care, Physiatry), nursing, rehabilitation (physiotherapy, occupational therapy, speech-language pathologists, rehab assistants), social work, psychology, and pharmacy. Other disciplines and system leaders may be relevant as well, depending on the phase(s) of the continuum being included in the guideline. It is important to include stroke survivors and carers in the group as well.

Practical notes:

  • Keep a list of people involved in the process
  • Contact any professional organization and ask for recommendations for a representative from that profession with expertise in stroke
  • Make sure you think about all the stakeholders involved in stroke care e.g. Primary care doctor, hospital administrator etc.
  • Development groups should be kept to a manageable size (6 – 10 people) where possible.
  • Expertise in stroke guideline development is available in other jurisdictions. You may consider contacting the World Stroke Guidelines Committee Chair for referrals to stroke guideline experts in your country or region if additional expertise is required by your group.

2.0. Define topics

The group will normally have a good idea what topics they want included in the guideline. It is important for the group to agree on exactly which questions/topics to be addressed as this decision will direct the searching and appraisal steps.

Stroke care encompasses the full continuum of care from primary prevention to long term recovery and reintegration into the community. The scope of any guideline could cover a few distinct segments of the continuum or they can be more comprehensive and incorporate much more of the continuum. The WSO has identified critical content areas that should be considered for inclusion at each stage of the continuum. These content areas should be reviewed to ensure adequate coverage of a topic once the topics have been confirmed (Appendix One).

Practical note:

  • The more topics are included the more work it takes to develop a guideline.
  • Make sure the group understands the resources and timeframes and agrees only on the KEY topics to include.
  • Look to existing guidelines to see what topics are commonly included to be able to draw on the evidence summaries (Refer to Appendix One for a list of the critical topics to address at each segment of the continuum).
  • Decide on the breadth and depth of content to be included for each topic (level of granularity and amount of detail for each recommendation)
  • References, and links where available, are provided in Appendix Two for existing stroke guidelines.

3.0. Find the best evidence

Like most research, the quality and trustworthiness of a guideline is based on the methods used to reduce any bias. Finding and appraising the best and most current evidence is possibly the most important part of guideline development and requires a systematic approach.

When searching for evidence, it is strongly recommended that this process be done with the help of an expert in the area of literature searching. To complete this step the working group should carefully develop questions they want answered and articulate the topics they plan to address in the guideline. Questions generally focus on the effects of a specific intervention and are developed in three parts: the intervention, the population and the outcomes. An example is “What is the effect of anticonvulsant therapy on reducing seizures in people with post-stroke seizures?” In this example, anticonvulsant therapy is the intervention, reduction of post-stroke seizures is the outcome, and the population is people with post-stroke seizures.

The more specific the questions and phrases the easier it will be for the information specialist to identify relevant studies. Searching for studies should include:

  • Electronic databases (e.g. Cochrane, MEDLINE, CINAHL and EMBASE) –see links in Canadian Medical Association Handbook p14.
  • Contact with international experts in the field and specific topic areas of interest
  • Manual search in key journals and reference lists in articles and other stroke-related guidelines.

Search efforts could produce an extremely large number of research papers, especially for topics such as hypertension. Additional criteria should be identified to assist in narrowing down the articles that would undergo detailed appraisal.

Using Existing Searches as a Starting Point:
An alternate and simpler way of finding the best evidence, especially when resources are scarce, is to use the searches done by an existing guideline. Evidence summaries are normally produced by guideline development groups. Your guideline development group may choose to contact another guideline development group and ask for their search or evidence tables if not publically available. Alternatively, it may be decided to use such summaries but update the list by searching for subsequent studies since the last search date included in the previous effort. This approach considerably reduces time, effort and resource use without compromising quality.

When deciding to update and use searches done for previous guidelines, it is important that the searches you are drawing from have been carried out in a robust way. The AGREE tool is a measure that allows you to identify the quality of the process used to develop an existing guideline. If you have multiple existing guidelines to draw upon, you can use the AGREE tool to choose which guidelines have followed the most systematic development process on which to base your own guideline (See Appendix Two for a list of existing stroke guidelines). This process may also help you to identify other guidelines that more closely resemble your population or resource availability, making them more appropriate for adaptation or adoption.

Practical notes:

  • If undertaking searches, employ an information specialist experienced in this area.
  • Use existing good quality guidelines where possible to identify the key evidence for a particular topic. Contact previous developers for additional information and sharing of resources when possible.
  • If a recent guideline exists a decision can be made to search for studies published subsequently or just use existing information and save time searching for other information.
  • Regardless of approach, some effort should be made to ensure that emerging research which may significantly affect the content and direction of a recommendation is identified. This will reduce the risk of guidelines becoming outdated before they ever get finalized and implemented.
  • Always aim to find and use the highest level of evidence (systematic reviews). Where these exist there is normally no need to search for further evidence.
  • Have a preset list of inclusion criteria to keep the results of the search on target and manageable.

4.0. Appraise and collate evidence

Once the key literature has been identified, the working group must review the evidence from the primary literature search and summarize the findings for each topic. As with identifying the evidence, it is strongly recommended that a systematic approach be followed to appraise the evidence. The working group should agree at the start which approach to use to guide grading the evidence and forming recommendations. Members of the group should be familiar with and have some training in the grading system chosen. Most of the stroke guideline developers use a similar process as that outlined by the Scottish Intercollegiate Guidelines Network (SIGN) –see link to SIGN guideline handbook in the resource section.

Several databases also have evidence summaries available on selected topics. Some examples include:
www.effectivestrokecare.org
www.strokengine.org
www.ebrsr.com

Practical notes:

  • Evidence summaries from existing guideline/s can be used to allow for easy collation of the evidence for specific topics.
  • Use existing evidence appraisal and summary resources where possible.
  • Levels of evidence may be assigned differently by different guideline development groups. Choose your preferred method and be consistent in the approach to evidence grading for all research your group reviews or chooses to include.

4AGREE Tool reference to be added

5.0. Draft recommendations

Once the evidence has been found and summarised the working group must carefully draft the recommendations for each topic. It is important that recommendations are as clear as possible and that it is easy to see the link between the recommendation and the evidence. Grading the strength of the recommendations is also useful and various systems are used around the world (see various handbooks for more details).

Research suggests that a formal process of forming conclusions/recommendations is better than an informal consensus processes (i.e. it minimises potential bias for strong opinions from one or two members of the group). Two common formal consensus approaches are the nominal group technique and the Delphi approach. More information on these approaches can be found in the guideline development resources.

Where existing guidelines have been used to identify and summarise the evidence, the ADAPTE approach suggests you can:

  • accept an entire guideline and recommendations;
  • accept the evidence summaries only and write your own recommendations;
  • accept specific recommendations but not others;
  • modify specific recommendations.

It is important to make sure you reference the sources and process used. When adapting an existing guideline it is important and helpful to contact the original guideline development group in order to obtain permission to use the guideline, to discuss any modifications to the actual recommendations (to make sure it still accurately reflects the evidence as applied to the local setting), and to gain helpful suggestions and lessons learned form professionals who have experience with the guideline development process.

The guideline document should include a report outlining the steps followed in developing the guideline including working group members, systematic reviews or adaption process, drafting processes and consensus approach. In addition, the strength of the evidence that supports each recommendation statement included in a stroke guideline should be clearly stated as a part of the documentation and presentation of the recommendations.

Practical notes:

  • Each recommendation statement should be clear, concise and only address one topic, action or intervention. Avoid ambiguity and negative recommendations.
  • It is good to include a brief summary of the evidence for each topic as well as the recommendation/s.
  • Specifically link the recommendations to the evidence (where possible note the type or level of evidence and the recommendations strength).
  • Where possible and appropriate, align wording of recommendations with those included in stroke-related recommendations produced by other disease groups in your jurisdiction (such as diabetes group, hypertension group, and local guidelines related to primary prevention)
  • Including suggested performance indicators can also encourage sites to monitor their adherence to the guidelines.
  • Clearly reporting what was done increases transparency and trust in the guideline.
  • Present each recommendation with supporting documentation including: rationale, system implications, performance measures and summary of the evidence.

5ADAPTE: manual for guideline adaptation. ADAPTE Group; 2007. www.adapte.org

7.0. Finalize recommendations and submit for approval / endorsement

Once all consultation and updates are completed the final document can be submitted to relevant health authorities and professional bodies for endorsement. Endorsement has been shown to improve acceptance and uptake of guidelines.

Practical note:

  • It is useful to contact the relevant authorities and professional bodies as early as possible in the whole process. The authorities may have requirements that must be considered during the development process.
  • Publicly acknowledging such endorsements and including them within the guideline documentation may increase acceptance and uptake of guidelines.

8.0. Implement guideline

Once complete, the guideline must be made as widely available as possible. A dissemination strategy should be developed and launched as soon as the guideline is available for public release. A master list of all relevant stakeholders should be created as well as a mechanism for dissemination of the guideline to these stakeholders

Often organizations will produce a dissemination package that may include a summary document along with summary slides to supplement the full document but provide an overview of the guideline. Electronic copies of any resource should be circulated to all relevant organizations and health professional networks. You may choose to publish a summary of the guidelines in a relevant journal.

Development of a quality guideline does not automatically equate to greater use and most strategies to implement guidelines produce only modest effects at best. An implementation plan should be developed simultaneously to developing the content of the guideline, and executed as soon as possible. Guidelines should be implemented along with other strategies to encourage their uptake, such as professional education, audit and feedback, and where possible, accreditation. The challenge is to use a systems approach that links guidelines to quality data collection, effective multi-pronged implementation, and a mechanism for evaluation. There are many opportunities to learn from other countries that routinely develop and use guidelines.

Strategies to promote uptake of guidelines are discussed in many existing guideline handbooks, including examples provided in the reference section of this handbook.

Practical note:

  • Use the links and networks of your working group to disseminate and promote the guidelines.
  • Considering implementation early in the process as this will help you focus on how you write the recommendations and improve their uptake.
  • Work in tandem with data analysts and evaluation specialists to develop appropriate audit and feedback processes. These can be very basic or more complex. See reference list for existing stroke evaluation models and performance measures (such as the Canadian Stroke Strategy Performance Measurement Manual)

9.0. Update guideline

Due to constant publication of new research and the rapidly changing nature of health care delivery it is important that the guideline remain up to date. It is recommended that any guideline be reviewed at least every 3 years if possible.

Where resources prohibit a complete update with this frequency, special interim bulletins can be produced that address specific topics where significant new research has emerged that changes the nature or direction of the current recommendations. These bulletins can be released at anytime between major updates and should be disseminated as widely and inclusively as the initial guideline release to ensure all users are aware of new recommended changes to stroke practice.