Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update on organizational stroke management



# Abstract
Aim Stroke is characterised by high morbidity, mortality and disability, which seriously affects the health and safety of the people. Stroke has become a serious public health problem in China. Organisational stroke management can significantly reduce the mortality and disability rates of patients with stroke. We provide this evidence-based guideline to present current and comprehensive recommendations for organisational stroke management. Methods A formal literature search of MEDLINE (1 January 1997 through 30 September 2019) was performed. Data were synthesised with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The Chinese Stroke Association's Levels of Evidence grading algorithm was used to grade each recommendation. results Evidence-based guidelines are presented for the organisational management of patients presenting with stroke. The focus of the guideline was subdivided into prehospital first aid system of stroke, rapid diagnosis and treatment of emergency in stroke centre, organisational management of stroke unit and stroke clinic, construction of regional collaborative network among stroke centres and evaluation and continuous improvement of stroke medical quality. Conclusions The guidelines offer an organisational stroke management model for patients with stroke which might help dramatically.
Stroke has become a serious global public health problem. To further reduce incidence rate, disability rate, mortality rate and recurrence rate of stroke and improve China's standardised prevention and treatment of cerebrovascular diseases, the Chinese Stroke Association organised a domestic expert to write the Chinese Stroke Association Guidelines for Clinical Management of Cerebrovascular Disorders. The guideline fully combines the research of Chinese scholars and the widely used clinical interventions in China to elaborate the clinical comprehensive management of the diagnosis, treatment, prevention and rehabilitation of a series of stroke-related diseases, so as to help medical service providers make better clinical decisions, improve the quality of medical services and maximise the benefits of patients. Evidence-based medical evidence confirms that the organisational stroke management model can benefit all patients with stroke, and significantly improve the survival rate and independent living ability of patients with stroke.Stroke organisational management covers prehospital first aid system of stroke, rapid diagnosis and treatment of emergency in stroke centre, organisational management of stroke unit and stroke clinic, construction of regional collaborative network among stroke centres at all levels and evaluation and continuous improvement of stroke medical quality related to the above-mentioned links. This chapter will elaborate on the above-mentioned content.
reCoMMended ClAssifiCATion And evidenCe level of The guideline This guideline adopts the recommended classification and evidence level specified in the guidelines for the development of Stroke Society of China. This recommended classification and evidence level are consistent with the system adopted in the latest American Heart Association and American Stroke Association (AHA/ ASA) guidelines. 1. Recommended classification -Class I: there is evidence to prove or unanimously agree that the operation or treatment given is effective.
Open access -Class II: there are controversial evidences or opinions on the effectiveness of operation or treatment. How to provide the best diagnosis and treatment services for patients with stroke, especially in rural and township areas, is still a serious challenge. High-quality planning and evaluation of patients with stroke is an essential part of acute stroke treatment, which can improve the quality of medical services and clinical outcomes. Professional treatment with evidence-based medical evidence is one of the most effective ways to reduce the mortality and disability rate after stroke. Therefore, it is necessary to build a reasonable stroke diagnosis and treatment system in qualified stroke centres according to clinical guidelines, to provide the best medical services, and actively explore the construction pattern of stroke centres that can adapt to various hospital scales.
reCoMMendATions organisational management of stroke emergency Main contents of stroke emergency management Rapid collection of clinical data  Emergency teams should rapidly identify patients with AIS and initiate thrombolytic procedures whenever possible for thrombolysis or endovascular therapy. (Class I, level of evidence A)  Emergency teams need to start the stroke diagnosis and treatment procedures for patients who have been notified in advance; emergency nurses should notify emergency doctors to receive and start the diagnosis and treatment procedures for patients who have arrived at the hospital after triage. (Class I, level of evidence B)  After initiating the thrombolytic or intravascular treatment process, emergency nurses need to quickly send the patient's laboratory samples, including blood routine, blood biochemistry and coagulation spectrum, which should not exceed 30 min after the Patients should first receive non-contrast CT to exclude bleeding, and/or choose CT angiography (CTA) to assess whether blood vessels are occluded, or CT perfusion (CTP) to assess the cerebral core Continuous quality improvement of emergency green channel  Apply Toyota Production System (TPS) to improve the quality of green channel, set up TPS improvement team, and analyse the delays in the current intravenous thrombolysis process. According to its importance and difficulty, list the problems that can be improved quickly and in a short time, and formulate specific solutions accordingly. (Class IIa, level of evidence B)  Apply PDCA (Plan, Do, Check, Action) cycle method to continuously improve the quality of green channel through four steps of cycle: Plan (making process time-consuming plan and problem); Do (implementing improvement plan); Check (checking and evaluating legacy problems) and Action (continuing implementation and execution). (Class IIa, level of evidence B)  Apply 6-SIGMA management method to improve the quality of green channel, implementing 'Define (setting process improvement objectives); Measure (decomposing process to measure the time needed in current process); Analysis (using various statistical strategies to analyse the reasons for failure to achieve standards); Improve (problem-based adjustment to improve process); Control (continuously monitoring process, ensuring continuous improvement of green channel quality)'. Five-step cycle. (Class IIa, level of evidence B)  Apply quality control circle, establish quality control circle within stroke team, promote circle cooperation ChApTer 3: regionAl CooperATive neTwork ConsTruCTion of sTroke CenTre The purpose of establishing stroke centre is to improve stroke medical staff and facilities, so as to adapt them to the methods of stroke treatment and improve the level of stroke diagnosis and treatment.The US health facility accreditation programme classifies stroke centres into three levels: CSC, PSC and stroke ready hospital. As early as 2000, BAC published a proposal to develop PSC, so as to improve the level of stroke diagnosis and treatment in the USA and improve stroke outcomes.Based on a large number of literature searches and the consultation of alliance members, the proposal requires PSC to have stroke team, stroke centre, fixed operating procedures, integrated emergency system, 24 hours CT examination and image interpretation, rapid laboratory examination and strong administrative support. Studies have shown that PSC using procedural procedures significantly improves the outcome of patients with stroke, compared with hospitals that do not use procedural procedures or have no stroke centres.In 2005, BAC launched a second proposal to define the standard of main medical types of CSC.Through evidence-based medicine, BAC has identified the following key steps: medical staff equipped with neurosurgery and neurovascular expertise; advanced nervous system imaging capabilities, such as cerebral angiography; surgery and intravascular operation technology, including aneurysm clipping, carotid endarterectomy, intra-arterial treatment and other infrastructure, such as neurointensive care unit. These measures may improve the prognosis of patients with complex cerebrovascular disease. Based on the basis of evidence-based medicine and the current situation of domestic medical environment, the expert committee of stroke field of the Center for Medical Quality Control of Neurological Medicine of the National Health and Family Planning Commission has initially formed a guideline for the construction of stroke centres in China in 2015 to standardise the access standards of stroke medical institutions,improve the quality of medical services and rationally distribute medical resources, which provided the basis for the allocation of medical resources and quality supervision of health administrative departments and reasonable and optimised treatment for patients with stroke, and improved the overall construction of stroke medical service system in China.
pattern of development and construction for stroke centre  We should actively promote the establishment of stroke centres at all levels, and all types of acute patients with stroke should enter the stroke centres for diagnosis and treatment. (Class I, level of evidence A)  For large-scale ischaemic or haemorrhagic stroke, stroke with unknown aetiology, stroke requiring special examination and treatment, stroke that PSC cannot complete and stroke requiring multidisciplinary treatment, direct entry or transfer to CSC is recommended for treatment. (Class I, level of evidence A)  Third-party stroke centre certification is strongly recommended. (Class I, level of evidence B) Construction of regional emergency network for stroke  Stroke centres with different treatment capabilities should establish a regional emergency network system with clear responsibilities, resource sharing and winwin cooperation. (Class II, level of evidence B)  It is suggested that stroke education programme be implemented for EMS personnel. (Class I, level of evidence B)  It is suggested that EMS personnel use the stroke assessment system to initiate the preliminary treatment of stroke on the spot and notify the receiving hospital of the suspected patients with stroke before arriving, so that the hospital can mobilise the corresponding resources before the arrival of the patients.
(Class I, level of evidence B)  The stroke emergency map should be jointly carried out with the 120 emergency centres, regional comprehensive stroke centres and other qualified medical institutions (stroke prevention and control centre, Operation and management of telemedicine  Comprehensive stroke centres should actively promote telemedicine, strengthen the integration of medical resources and form a stroke medical network covering the surrounding primary stroke centres or primary hospitals. (Class IIb, level of evidence B)
ChApTer 4: evAluATion And ConTinuous iMproveMenT of MediCAl quAliTy of sTroke Medical quality is the work quality of medical preventive institutions and the standard to measure the level of medical staff. It covers the content of medical quality, and emphasises patient satisfaction, medical work efficiency, medical technology and economic effect (input-output relationship), continuity and systematic effect of medical treatment. Therefore, medical quality is a comprehensive reflection of medical technology, management methods and economic benefits.
improvement of medical service quality in patients with stroke  Establish a stroke registration system for quality improvement, monitor medical quality and provide reliable data for quality improvement. Ideal stroke registration should have appropriate management structure and supervision methods to ensure the normal operation of the registration work. At the same time, the follow-up system should be improved to verify whether the quality improvement is related to the prognosis of patients. In order to ensure the authenticity and standardisation of data, the Quality Improvement Commissioner should check and upload data regularly. (Class I, level of evidence B)  Establishment of clinical pathway for stroke and written standardised operating procedures with continuous quality improvement. Organise multidisciplinary collaborative team to discuss continuous quality improvement. Analyse the current situation, find out the problems, put forward the possible solutions, put them into practice and test the feasibility of the scheme. Based on this, the standard operation process is updated to ensure its effectiveness and operability. (Class I, level of evidence B)  Establish standardised assessment and measurement criteria for stroke medical services, namely key performance indicators. Supervisory departments should strengthen link quality control, implement the existing evidence-based medicine guidelines to the greatest extent possible and supervise whether the centres implement the standard operating procedures. Setting up standard quality management standards, eliminating regional differences in medical quality and realising standardisation of medical services. (Class IIa, level of evidence B)
Open access quality indicators of medical services in primary stroke centres Mandatory quality indicators of PSC stroke diagnosis and treatment To be strengthened and regularly controlled. Indicators of medical services at discharge  The proportion of non-cardiogenic patients with ischaemic stroke treated with antiplatelet drugs.  The proportion of patients with atrial fibrillation receiving anticoagulation therapy.  The proportion of patients with low-density lipoprotein cholesterol >2.6 mmol/L receiving statins.  The proportion of hypertension patients treated with antihypertensive therapy.  The proportion of patients with diabetes mellitus treated with antidiabetic medication.  The proportions of previous or current smokers receiving smoking cessation education.  Average hospitalisation days and mortality.  Average hospitalisation expenses and average hospitalisation drug expenses.  Health education on risk factors and control of cerebrovascular disease, symptoms of stroke attack, medication compliance, rehabilitation treatment, etc.

## Quality indicators of medical services during acute hospitalisation

## Additional quality indicators for psc stroke diagnosis and treatment
At least three of them should be met:  The proportion of patients with atherosclerotic ischaemic stroke treated with statin during hospitalisation.  The proportion of hypertensive patients treated with antihypertensive therapy during hospitalisation.  The proportion of patients with stroke whose hospitalisation days are <14 days.  It is suggested that patients should be followed up in stroke prevention clinic 3 months and 6 months after discharge to evaluate the efficacy of stroke unit and ensure that patients receive standard secondary prevention.  Courses on stroke warning and prehospital training for hospital staff are designed to identify stroke symptoms quickly and to be admitted to stroke centres immediately.
quality indicators of medical services in comprehensive stroke centres Mandatory quality indicators of CSC stroke diagnosis and treatment Establishment of clinical pathway management  Central venous thrombolysis intervention plan compiled according to current clinical guidelines.  Establishment of emergency-related clinical standard process.  Standard clinical pathway and start-up process of intravascular therapy based on current guidelines.  Standard process of preoperative and postoperative management of multidisciplinary endovascular treatment of stroke.  Standard process of preoperative and postoperative management of multidisciplinary surgical intervention of stroke.  Standard procedure of dealing with two or more patients with complex cerebrovascular diseases at the same time.
Quality indicators of medical services for patients with acute ischaemic stroke receiving endovascular therapy  The average time from admission to multimode CT or multimode MRI (only one of them) in patients within 6 hours after onset of stroke.  The proportion of patients with AIS treated with endovascular therapy.  Average time from admission to intravascular therapy (door-to-groin) in patients with ischaemic stroke.  The proportion of intracranial haemorrhage with clinical symptoms within 36 hours after treatment in patients undergoing endovascular therapy.
Quality indicators of medical services for diagnosis and treatment of intracranial and extracranial vessels  The proportion of stroke or death after diagnostic cerebral angiography.
 The proportion of stroke or death within 30 days after carotid artery dissection or stenting.  The proportion of stroke or death within 30 days after intracranial angioplasty and/or stenting for atherosclerosis.

## Quality indicators of medical services for sah and ich
 The proportion of patients with SAH and ICH who had written records of the initial severity assessment.  The proportion of aneurysm clipping and interventional treatment in the past year.  The average time from admission to clipping or interventional treatment of ruptured aneurysms for patients with SAH with ruptured aneurysms within 48 hours from onset.  The proportion of patients with SAH confirmed ruptured aneurysm treated with nimodipine within 24 hours of diagnosis and continued to discharge or 21 days after bleeding.  Mortality rate of patients with ICH undergoing haematoma clearance.
Quality indicators of medical services for neurosurgery  Mortality rate of patients with massive cerebral infarction undergoing decompressive craniectomy.  The proportion of patients with ischaemic or haemorrhagic stroke undergoing ventricular drainage.  The proportion of patients with ischaemic or haemorrhagic stroke who underwent ventricular drainage and complicated with ventriculitis.
Quality indicators of medical services for warfarin-related intracranial haemorrhage  The average time from admission to the reversal measures of international normalised ratio in patients with warfarin-related intracranial haemorrhage.

## Additional quality indicators for csc stroke diagnosis and treatment
At least three of them should be met:  Frequency of non-invasive vasospasm monitoring in patients with aneurysmal SAH during 3-14 days.  The proportion of complications in patients undergoing aneurysm clipping or embolisation.  The proportion of patients with stroke with arteriovenous malformations treated surgically or with intravascular therapy within 30 days.  The average interval from telephone notification to CSC arrival in patients with ischaemic stroke or haemorrhagic stroke or transient ischaemic attack (TIA) who has written records of referrals from another hospital to CSC.  The proportion of patients with ischaemic stroke, SAH, intracranial haemorrhage, TIA, intracranial and extracranial vascular stenosis enrolled in clinical trials.
Construction of information platform for stroke medical quality monitoring and continuous quality improvement  Establish an information platform for medical quality monitoring and continuous quality improvement, strengthen the management of medical quality control, promote feedback of medical service safety and provide decision-making basis for the improvement of medical service quality in medical institutions at all levels. (Class I, level of evidence B)