Acute Stroke Clinical Care Standard

Using screening tools at first clinical contact in the community, pre-hospital or emergency triage settings can quickly identify suspected stroke and enable rapid access to time-critical treatment in the hyperacute phase. A validated screening tool (see Box 1) can identify stroke with high specificity, and can be used by generalist clinicians and first responders. Other validated tools can be used by trained clinicians to assess and record the severity of stroke on admission (for example, National Institutes of Health Stroke Scale [NIHSS]). In community settings, including general practice, patients with a positive screening test or a strong suspicion of stroke should be transported rapidly to hospital – by ambulance, in most instances.

Ensure that protocols support the use of a validated screening tool in pre-hospital and hospital settings to enable the appropriate triage, transfer and diagnosis of people with stroke. Ambulance services can use screening tools to identify suspected stroke patients and ensure that they are treated as a time-critical emergency. This includes priority dispatch of ambulances and transfer directly to hospitals capable of reperfusion therapies, when the patient may be eligible. Emergency departments can use screening tools to trigger urgent assessment of patients who arrive at hospital independently. More detailed stroke severity scales (for example, NIHSS) may be used on admission but are not recommended in the pre-hospital setting.

If you or another person has any of the signs below, call 000 for an ambulance immediately. These are signs that someone may be having a stroke:

• Face – check their face. Has their mouth drooped?
• Arms – can they lift both arms?
• Speech – is their speech slurred? Do they understand you?
• Time – is critical. If you see any of these signs, call 000 straightaway

Consider reperfusion treatment for all patients with suspected ischaemic stroke. Urgently assess the patient and arrange imaging. Take into consideration the patient’s comorbidities, circumstances and preferences, and discuss the potential benefits and risks of treatment options with the patient and their family or carer. If clinically indicated, offer reperfusion treatment (thrombolysis and/or endovascular thrombectomy) within the time frames recommended in the current Australian Clinical Guidelines for Stroke Management. 

If a patient has a haemorrhagic stroke, consider time-critical therapies, such as blood pressure control.

Reperfusion therapy (thrombolysis and/or endovascular thrombectomy) is a time-critical therapy. These therapies require careful coordination between multiple systems, including pre-hospital services, emergency, radiology, and stroke and neurointervention teams. They also require suitable infrastructure, facilities and workflows, as described in Australian clinical guidelines. Ensure that systems and processes are in place, and that services are adequately resourced to offer reperfusion treatment to patients for whom it is clinically indicated, within the time frames recommended in the Clinical Guidelines for Stroke Management and in line with the National Acute Stroke Services Framework. These should include workflows to allow pre-notification, routing to a hospital able to provide reperfusion treatment, urgent access to computed tomography (CT), and protocols to support rapid assessment and treatment by suitably trained clinicians. Remote and telemedicine options should be in place in rural and regional centres to support decision-making.

There are two types of stroke: those caused by bleeding in the brain, and those that occur when a blood clot blocks a blood vessel. If a stroke is caused by a blood clot, treatment to restore blood flow in the brain (reperfusion) should be urgently considered. If your clinicians think this treatment could help, it should be offered as soon as possible, within hours. The treatment may involve medicines to dissolve the blood clot (thrombolysis) blocking the blood vessel or surgery to remove the blood clot, to prevent death of tissue in the brain (‘time is brain’). These treatments are not suitable for everyone with a stroke caused by a blood clot and cannot be used if the stroke is caused by bleeding in the brain. A decision on treatment is normally made after brain imaging, which should be done urgently. Your clinicians will discuss the options with you and your family, and seek consent whenever possible, bearing in mind that reperfusion is an emergency therapy and may be required without delay.

Ensure that patients with stroke are offered multidisciplinary care in a stroke unit, as defined in the National Acute Stroke Services Framework. Different models of stroke unit care are described in the framework, but important elements include care being provided in a geographically discrete unit, comprehensive assessment and a specialised interdisciplinary team. Very early admission to a stroke unit (within three hours of stroke onset) for ischaemic stroke patients results in significantly better recovery at three months.

Ensure that systems, infrastructure and resources are in place for patients with stroke to be treated in a stroke unit, and that these comply with the recommendations in the National Acute Stroke Services Framework. For rural and remote services, this includes arranging for transfer to a stroke unit, where safe to do so, or care at a locally agreed alternative facility with telemedicine support, bearing in mind the wishes of the patient and/or carer or family.

Being treated in a stroke unit by a team of health professionals who specialise in stroke care will increase your chance of a good recovery. A specialised team may include doctors, nurses, physiotherapists, speech pathologists, occupational therapists, dietitians, social workers and pharmacists. You should be offered treatment in a specialised stroke unit whenever possible, which might mean being transferred to a different hospital. If there is no stroke unit, this care should take place in the nearest similar unit meeting the recommended requirements for acute stroke care. You (and/or your carer or family) should be given the opportunity to discuss your wishes regarding transfer to a place where this care can be provided.

Indicator 3a

Proportion of patients with a final diagnosis of acute stroke who have documented treatment in a stroke unit

Indicator 3b

Proportion of patients with a final diagnosis of acute stroke who spent at least 90% of their acute hospital admission in a stroke unit

Assess the rehabilitation needs and goals of patients with stroke within 24–48 hours of admission to the hospital, using a standardised comprehensive assessment tool such as the Australian Stroke Coalition’s Assessment for Rehabilitation: Pathway and Decision-Making Tool. Complete the sections of the assessment relevant to your practice (for example, medical, nursing, physiotherapy, speech therapy) or complete the assessment with others in a multidisciplinary team meeting or ward round. Identifying the patient’s rehabilitation needs while they are in hospital can help determine where they should be discharged or referred to for more rehabilitation. Start rehabilitation during the acute phase of care whenever clinically appropriate. Intensive early mobilisation within 24 hours of stroke onset is not recommended

Ensure that processes and resources are in place to assess the rehabilitation needs of patients with stroke within 24–48 hours using a standardised comprehensive assessment tool such as the Australian Stroke Coalition’s Assessment for Rehabilitation: Pathway and Decision-Making Tool. Identify and provide services to enable the patient’s rehabilitation as soon as possible while they are in hospital. Procedures should be in place for liaison with, and referral to, other rehabilitation providers responsible for continuing care, based on the patient’s assessed needs, as guided by the Rehabilitation Stroke Services Framework.

If you have had a stroke, it is very likely that you will need treatment, advice or assistance to help you deal with the impact of the stroke on your everyday life. These needs will be different for every stroke survivor. Rehabilitation covers many different things. For example, you may need help eating and drinking, walking, carrying out your other usual daily activities, or managing the emotional and psychological impact of any disability caused by the stroke. Your individual rehabilitation needs and goals will be assessed as early as possible after your stroke, so that planning and treatment for your recovery can start as soon as possible. Your rehabilitation assessment should occur within 24–48 hours of your arrival at the hospital.

Assess the patient’s risk of recurrent stroke and modifiable risk factors. Educate patients with stroke about their risk of another stroke by discussing risk factors, providing written information and prescribing medicines for secondary prevention, including antihypertensives, antithrombotics and lipid-modifying therapy. Other measures may include time-limited surgical interventions (for example, carotid endarterectomy). Refer to the Clinical Guidelines for Stroke Management for current recommendations.

Ensure that processes are in place and resources are available to educate patients about reducing their risk of another stroke and where they can go to find more information. Ensure that processes require preventive therapies to be prescribed, recommended or arranged, and documented before stroke patients are discharged, in line with current clinical practice guidelines.

People who have had a stroke are at high risk of having another one. While you are in hospital, your clinicians may recommend changes to your medicines and lifestyle to reduce your risk of another stroke. You will be provided with written information and advice to help you understand what you can do to improve your health, such as stopping smoking, having a balanced diet and increasing physical activity, where appropriate, and following recommended medical treatment.

Support carers 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 the patient with stroke leaves hospital.

Ensure that processes and resources are in place to provide carers with education about stroke, practical training on how to provide care, access to support services (for example, respite care), and other information to support them before patients with stroke leave hospital.

If you are involved in caring for someone who has had a stroke, you will be offered information and practical training on how to provide care for the person when they are discharged home. This may include information and training on personal care techniques, communication, safe physical handling, and managing specific issues such as swallowing, dietary modifications and emotional wellbeing. You will also be given contact details of support services before the patient with stroke leaves hospital.

The Stroke Foundation has developed many resources to assist stroke survivors, their carers and healthcare professionals in the process of discharge planning and transfer of care:

• My Stroke Journey – an information pack to give to stroke survivors and their carers before hospital discharge
• StrokeLine – a free telephone support service providing information and advice on stroke prevention, treatment and recovery, staffed by healthcare professionals : 1800 787 653 or email strokeline@strokefoundation.org.au
• EnableMe – a free web-based resource providing information, a community forum and a tool to track personal goals for recovery.

For more information, see: https://strokefoundation.org.au/what-we-do/for-survivors-and-carers

Develop an individualised care plan with each patient and their carer and/or family and provide it to them in writing before they leave hospital. Provide a copy to their general practitioner or ongoing clinical provider within 48 hours of the patient leaving hospital. The individualised care plan is separate from a clinical discharge summary. It includes information about the patient’s rehabilitation goals, risk factors, lifestyle modifications and medicines; any equipment they need; follow-up appointments; and contact details for ongoing support services available in the community. The Stroke Foundation’s My Stroke Journey is a useful planning resource that can be provided to patients before they leave hospital after an acute stroke.

Ensure that pre-discharge processes and resources are in place for clinicians to develop an individualised care plan for patients with stroke before they are discharged, in discussion with the patient and their carer and/or family. The individualised care plan should be provided to the patient before they leave hospital, and to their general practitioner or ongoing clinical provider within 48 hours of discharge. An individualised care plan is different to a discharge summary (for example, see the Stroke Foundation’s My Stroke Journey).

Before you leave hospital, your doctors, nurses and therapists will discuss your recovery with you and your carer and/or family. They will develop a plan with you (and your carer and/or family) to guide your care after discharge. Your plan may change as your condition changes. You and your regular general practitioner will get a copy of this plan, which sets out:

• your goals
• the changes you may need to make to your lifestyle
• the medicines you may need to take
• the equipment you may need
• follow-up appointments
• the rehabilitation services, prevention services and other community support services you are referred to.

My Stroke Journey – a tool for clinician and patient care planning The Stroke Foundation resource My Stroke Journey covers all the essential elements of a care plan itself, and includes pages for clinicians and patients to complete together. My Stroke Journey is intended to be provided by hospital clinicians and discussed with patients in the first few days after their stroke, and it stays with patients in their transition from hospital to home. This resource is used by clinicians to deliver stroke education, explain treatment and care, secondary prevention education, and plan for discharge home. 

For more information, see: https://strokefoundation.org.au/what-we-do/for-survivors-and-carers/stroke-journey-resources

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

In Australia, stroke is one of the top five underlying causes of death and is a major cause of disability.¹ How much damage is caused by a stroke depends on how long the brain tissue is denied blood supply. This ‘time is brain’ concept underpins why it is essential to eliminate delays in stroke diagnosis and treatment. Care of acute stroke is time critical. Receiving the right care at the right time in the right place can significantly improve a person’s chance of surviving a stroke, and recovery to a full and independent life.^{2, 3}

Australia is fortunate to have excellent resources available to support quality improvement, including current, relevant and high-quality evidence-based guidelines for the management of stroke; clearly articulated system requirements for service organisation; and mechanisms for monitoring through stroke audits, quality indicators and data collection tools⁴.

Continued quality improvement and implementation of recommended care is needed to ensure that patients receive the best possible treatment during the acute phase of stroke management, no matter where they are in Australia.

Read more about the scope and goal of this Standard or see further background in the Acute Stroke Clinical Care Standard. 

This Standard applies to care provided in acute hospital settings, including public and private hospitals. Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement. 

When implementing this Standard, healthcare services should consider:

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service. 

In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:

• hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations.

A coordinated multidisciplinary team approach is essential for improving the care delivered to patients with stroke. Multidisciplinary care of patients can improve health outcomes, and offers more efficient use of health resources. Planning, coordination and regular communication between clinicians are essential components of multidisciplinary care.

This Standard relates to the care that patients should receive when they are having, or are suspected of having, a stroke. It covers recognition of stroke, rapid assessment, early management, and early initiation of an individualised rehabilitation plan.

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting. 

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Acute Stroke Clinical Care Standard has been endorsed by three key organisations:

• The Society of Hospital Pharmacists of Australia
• National Stroke Foundation
• Australian and New Zealand Society for Geriatric Medicine.

Supporting organisations

The Standard is supported by the following organisation:

• Therapeutic Guidelines Ltd

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Acute Stroke Clinical Care Standard Topic Working Group provided expert advice on the development and review of the Standard. In addition, a public consultation process was conducted with key stakeholders.

Acute Stroke Clinical Care Standard - Topic Working Group

The main roles of the Topic Working Group are to:

• advise on the continued scope and key components of care within the Standard
• advise on the key sources of evidence to inform the review
• advise on revisions to quality statements and supporting indicators
• recommend strategies to support the implementation of the updated Standard
• actively support raising awareness of the updated Standard.

All members of the Acute Stroke Clinical Care Standard Topic Working Group were required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. 

Disclosures were updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.

The key Australian evidence source for the Acute Stroke Clinical Care Standard was the Stroke Foundation’s Clinical Guidelines for Stroke Management 2017. 

• Acute Stroke Clinical Care Standard - Evidence Sources

The Standard is also consistent with international clinical practice guidelines, including those from:

• the United Kingdom’s National Institute for Health and Care Excellence, and the Intercollegiate Stroke Working Party
• the American Heart Association and American Stroke Association
• the Heart and Stroke Foundation of Canada.

Note: Since this Standard was released, the Clinical Guidelines for Stroke Management have evolved into living guidelines. See the Living Clinical Guidelines for Stroke Management. The Standard is currently being reviewed against the Living Guidelines.

The references below are not a complete list of references for the Standard. A full reference list is published in the Acute Stroke Clinical Care Standard which can be downloaded here.

1. Australian Institute of Health and Welfare. Australia’s health 2018. Canberra: AIHW; 2018.
2. Stroke Foundation. National Stroke Audit: Acute Services Report 2023.
3. Langhorne P. Organized inpatient (stroke unit) care for stroke. Stroke. 2014 February 1, 2014;45(2):e14–e5.
4. Australian Institute of Health and Welfare. Stroke and its management in Australia: an update. Canberra: AIHW; 2013.