Title: Standardised Neurological OBservation Schedule for Stroke (SNOBSS)
Funder: Department of Health and Social Care

Abstract: Background/ Research question Early neurological deterioration (END) after stroke is common and experienced by up to 40% of patients within 24 hrs (Seners et al 2015). This can reflect progression of tissue injury or physiological factors affecting cerebral blood flow. It is vital to identify and if possible promptly intervene to minimise END and the resulting secondary brain injury.Neurological assessment and monitoring is considered a fundamental component of acute stroke care in national guidelines (National Clinical Guidelines for Stroke 2016). However there is no specific guidance in terms of how to perform neurological observation and monitoring at the bedside with a matching clinical response, including the assessment process to use, workforce training etc . Despite significant improvements in the standardisation of stroke care across the NHS, there is still wide variation in terms of the content and timing of neurological observations to identify END. A standardised schedule and response protocol will improve effectiveness in tracking clinical condition, responding appropriately to medical deterioration to minimise harmful long term effects. Aim To develop a standardised neurological observation schedule and response protocol for patients in the acute phase of stroke.Objectives/ Methods Use a survey to ascertain current practice in neurological observation and response protocols across UK stroke units (Months 1-8). Undertake a systematic review to develop an evidence overview of the reliability, responsiveness, utility and acceptability of the scales/tools used or available for neurological observation in the acute phase of stroke (Months 1-14). Complete semi-structured interviews with a range of staff from different stroke units to determine knowledge, understanding and acceptability of neurological observation tools for acute stroke and the barriers and facilitators to implementation in clinical practice (Months 12-24).Develop a stakeholder consensus group to evaluate the findings/ results from the objectives above to agree the acute stroke neurological observation schedule, response protocol and planned implementation strategy (Months 1-36). Test the implementation of the agreed acute stroke neurological observation and response schedule for acceptability and utility at one site (Months 24-30). Anticipated impact and dissemination Deployment of standardised neurological observation of stroke patients with associated matching responses would further improve the care provided by NHS stroke services to 83,000 people admitted as emergencies each year. Quantifying neurological changes to identify END will allow prompt intervention to prevent worsening of status and ultimately improve outcomes. It will also facilitate communication and understanding of status amongst teams and allow better prognostication, communication, prioritisation and planning for patients and families. Future steps would be to implement the schedule and protocol with a view to evaluate effectiveness and drive future refinement. Research findings would be shared with all UK stroke centres as well as published and presented through appropriate channels including: stroke and nursing conferences, journals, submission to the national clinical guidelines group, workshop at the UK Stroke Forum training day with training materials created as part of the implementation strategy. Future post-doc work would be created to fully test the observation schedule and response protocol.

Lay abstract: Background Stroke can be described as a Brain Attack' where the blood supply is reduced to part of the brain. It is a neurological condition and can cause a range of problems depending upon which parts of the brain are affected. There are approximately 83,000 emergency admissions with stroke per year. Stroke is the fourth single leading cause of death in the UK and the leading cause of disability almost two thirds of stroke survivors leave hospital with a disability. Despite improvements in preventing stroke total numbers continue to rise. It is therefore crucial good quality organised acute stroke care is provided as it is associated with better outcomes in terms of death and dependency.Stroke symptoms continue to get worse for up to four in ten people in the 24-48 hours after arriving in hospital, often from events that if detected and treated early could reduce long term effects. Careful monitoring by stroke unit nurses could promptly detect change and allow intervention. However there are no specific guidelines about what, how, when and over what period patients should be monitored to identify important changes in neurological status after stroke except for a very small number of patients. Currently, a range of tools are used by different staff at different time points with potentially different interventions resulting in differences in care and possibly poorer outcomes for some patients.Aim To develop a consistent plan of how the neurological effects of stroke are recorded and monitored over time (neurological observation schedule) to promptly identify any changes and decide what should be done if the patient's condition gets worse (response protocol) with the aim of improving outcomes for patients.Methods In this research all UK stroke units will be surveyed to find out what they currently do to monitor patients soon after having a stroke.All the tools available for monitoring will be identified, reviewed and compared using the evidence found across a range of factors (e.g. whether they are consistent, suitable to detect change, acceptable to staff and patients).Staff will be interviewed about their understanding of neurological observation, why they do or do not monitor patients and what helps or prevents them from carrying this out. This information obtained will help plan the best way to make sure staff and hospitals adopt the neurological observation and response protocol.An expert group will use all this information to agree on what should be done, when and by whom if a patient is seen to be getting worse and the best way to get staff to carry this out.This plan will be tested in one hospital to check that it can and will be completed and identify if changes need to be made before it is introduced into other hospitals.Patient and Public Involvement (PPI) There will be a minimum of two PPI members on the expert group overseeing the findings and outputs of the research. Their views on what is important will be crucial in making changes happen.Dissemination The research would create standard recommendations and training materials to ensure patients are regularly and consistently observed. This would ensure staff are aware of changes in the patient's condition sooner and if treatment is available it is given without delay, resulting in better outcomes for patients. It will allow better communication and understanding of status between professionals and potentially to patients and families.Research findings would be shared with all UK stroke centres as well as published and presented via stroke and nursing conferences and journals. Future steps would be to implement the schedule and protocol to test its effectiveness.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: STROKE