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Title:
Management of Stroke Rehabilitation Care
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Citation
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Management
of Stroke Rehabilitation. Washington, DC: VA/DoD Clinical
Practice Guideline Working Group, Veterans Health Administration, Department
of Veterans Affairs and Health Affairs, Department of Defense, February
2003. Office of Quality and Performance publication 10Q CPG/STR-03.
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Completion Date:
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December 2002
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Release Date:
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February 2003
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Source(s):
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The Management
of Stroke Rehabilitation guideline was developed by and written for clinicians
by clinical experts from the DoD, VHA, academia, and a team of guideline
facilitators from the private sector. An experienced moderator facilitated
the multidisciplinary working group that included internists, physiatrists,
neurologists, geriatricians, nurse practitioners, occupational therapists,
physical therapists, recreational therapists, speech and language pathologists,
psychologists, social workers, kinesiotherapists, pharmacists, nurses and
rehabilitation/clinic coordinators.
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Adaptation:
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The development
process of the guideline incorporated information from several sources
into a format intended to maximally facilitate clinical decision-making.
The effort drew heavily from the following sources: 1996 VA Stroke/Lower
Extremity Amputee Algorithms Guide, Agency for Health Care Policy and Research
(AHCPR) Post –Stroke Rehabilitation (1995), Royal College of Physicians
(RCP) National Clinical Guidelines for Stroke (2000), and Scottish Intercollegiate
Guidelines Network (SIGN) Management of Patients with Stroke, 20 (1997).
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Guideline Status:
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This is the current version of the guideline. An update
is targeted for 2005.
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Developer(s):
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Veterans
Health Administration (VHA), Department of Veterans Affairs (VA) - Federal
Government Agency [U.S.]
Department of Defense (DoD) – Federal Government
Agency [US]
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Funding Source:
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U.S. Government
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Committee:
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The VA/DoD Stroke
Rehabilitation Working Group
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Group Composition:
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The list
of contributors (APPENDIX G) to this guideline includes internists,
physiatrists, neurologists, geriatricians, nurse practitioners, occupational
therapists, physical therapists, recreational therapists, speech and
language pathologists, psychologists, social workers, kinesiotherapists,
pharmacists, nurses, rehabilitation/clinic coordinators and experts in
the field of guideline and algorithm development.
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Disease/Condition:
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Stroke Rehabilitation
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Category:
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Diagnosis, Assessment, Evaluation, Secondary Prevention,
and Follow-Up.
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Intended Users:
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Designed for
use by primary and specialty care providers. The guideline can also be
used to coordinate and standardize care and as a teaching tool for students
and house staff.
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Target Population:
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Persons eligible for care in the VA or DoD health care delivery system.
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Contact Person(s):
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VHA
Barbara Bates, M.D.
Acting Director, PM&RS
Physical Medicine Rehabilitation (117)
Albany VAMC
113 Holland Avenue
Albany, NY 12208
Phone: 518 626-5817
Fax: 518 626-5467
E-mail: barbara.bates@med.va.gov DoD
MAJ Charles Walters, M.Ed.,OTR/L
Occupational
Therapy
Evans Army Community Hospital
7500 Cochrane CircleFort Carson,
CO 80913
Phone: (719) 526-7110
E-mail: Charles.Walters@cen.amedd.army.mil
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GOALS/OBJECTIVES
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To provide a scientific evidence-base for practice
interventions and evaluations.
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To guide clinicians in determining the best interventions
and timing of care for their patients, to better stratify stroke patients,
and reduce re-admission and optimize healthcare utilization.
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To assist facilities to
implement processes of care that are evidence-based and designed
to achieve maximum patient functionality and independence and improve
patient/family quality of life.
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INTERVENTIONS AND
PRACTICES
The guideline consists of three phases that are designed
to assist clinicians in determining best interventions and timing of
care for their patients. The guideline also contains four appendices
that provide pharmacotherapy and assessment instruments.
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OUTCOMES CONSIDERED
Goals for management stroke rehabilitation in primary
care include the following:
Preventing complications, minimizing impairments and maximizing function.
Determining best interventions and timing of care, reducing re-admission and
optimizing healthcare utilization.
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MAJOR RECOMMENDATIONS
The Stroke Rehabilitation guideline is presented in algorithmic format
and is intended to provide a systematic approach to the assessment and management
of patients with strokes.
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CLINICAL ALGORITHM(S) ARE
PROVIDED FOR:
Phase One: Assessment
Phase Two: Inpatient Rehabilitation
Phase Three: Community Based
Rehabilitation
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TYPE OF EVIDENCE
The development process for the guideline was evidence-based whenever
possible. Evidence-based practice integrates clinical expertise with the
best available clinical evidence derived from systematic research. Where
evidence was ambiguous or conflicting, or scientific data were lacking, the
clinical experience within the multidisciplinary group guided the development
of consensus-based recommendations.
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DESCRIPTION OF METHODS TO COLLECT EVIDENCE
A systematic search of the literature was conducted. It
focused on the best available evidence to address each key question, and
ensured maximum coverage of studies at the top of the hierarchy of study
types: evidence-based guidelines, meta analyses, and systematic reviews
(Cochrane, EBM, and EPC reports). The seed guidelines evidence was carefully
reviewed. The search continued using well-known and widely
available databases that were appropriate for the clinical subject. Limits
on language (English) and type of research (randomized controlled trials
[RCTs]) were applied. The search included MEDLINE and additional specialty
databases (DARE), depending on the topic. |
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METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE
See
appendix E
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REVIEW METHODS
The
final draft of the guideline is distributed for review by an at large audience
across VA and DoD. Patient Care Services and the Network-appointed Guideline
Champions solicit feedback from a broader group of end users. Members of
related QUERI groups are also asked to comment. Network designated staff
will be asked to use the guideline in the direct care setting and provide
feedback to the Network Guideline Champions. This portion of the field
test is intended to provide feedback regarding the format and usability.
At this time, the peer review of the guideline will also be completed by
at least three VA /DoD staff, including primary care clinicians, who have
been trained and previously assigned to perform the independent review.
Within 3 weeks, the rating tool containing the reviewer’s comments and
recommendation will be forwarded to the Office of Quality and Performance
and the Vice Chairperson of the NCPG Council. The Vice Chairperson of the
NCPG Council will forward a summary of the recommendations from the peer
reviewers to the National Champions. Final editing incorporates feedback
as appropriate. The National Senior Champions along with the Evidence Chaperone
and the NCGPC Representative will integrate comments and suggestions into
the final document as appropriate. Discussion of serious controversies
regarding interpretation of the evidence will be included in the introduction
to the guideline and may be the subject of discussion at the time of review
with the Council. Provider tools will also be finalized and submitted to
Employee Education System for final formatting. Prior to delivery to the
NCPG Council, the champions group will re-convene by conference call to
approve the final draft and tools.
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QUALIFYING STATEMENTS
Clinical
practice guidelines, which are increasingly being used in health care,
are seen by many as a potential solution to inefficiency and inappropriate
variations in care. Guidelines should be evidenced-based as well as
based upon explicit criteria to ensure consensus regarding their internal
validity. However, it must be remembered that the use of guidelines
must always be in the context of a health care provider's clinical
judgment in the care of a particular patient. For that reason, the
guidelines may be viewed as an educational tool analogous to textbooks
and journals, but in a more user-friendly format.
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GUIDELINE AVAILABILITY
Electronic
copies are available at: www.oqp.med.va.gov/cpg/ Print copies: Available from the Office of Quality and
Performance (10Q), Veterans Health Administration, Department of Veterans
Affairs, 810 Vermont, NW, Washington, DC 20420.
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