From: When is referral from primary care to specialist services appropriate for survivors of stroke? A modified RAND-appropriateness consensus study
Consensus: primary care
Consensus: referral neededa
Consensus: referral to stroke specialist
Consensus was reached that difficulties with phlebotomy and issues relating to the side effects of anticoagulation drugs can generally be managed in primary care.
If a patient has multiple falls while anticoagulated, referral to a falls clinic would be appropriate.
If there is suspicion of new pathology increasing the risk of falls or bleeding, then referral for investigation to a geriatrician or stroke unit is appropriate.
Blood Pressure Control
There was a lack of consensus about where side effects from anti-hypertensives should be managed; this divide was not split along professional lines with disagreement between consultants as well as between GPs.
Practically speaking, whether a stroke survivor with difficult-to-manage hypertension is managed in primary care is likely to depend on the expertise of the individual GP.
End-of-life discussions about the risks and benefits of antihypertensive medications falls within the remit of primary care, where strong consensus was reached.
Cardiovascular Risk Factors
The panel reached consensus, although with two panelists disagreeing, that in general, cardiovascular risk management does not warrant specialist referral.
The panel agreed that it would be appropriate to refer for complex lipid management (for instance, patients with very high cholesterol or triglycerides in line with NICE guidance).
Activities of daily living
Non-engagement with allied health professionals was felt to not be a sufficient indication for referral on its own.
Loss of confidence due to physical disability post-stroke is likely to require a referral to a physiotherapist or occupational therapist, especially if it is limiting the patient’s activities or ability to self care.
The panel judged it reasonable to refer problems such as spatial inattention following stroke back to the specialist stroke team, even if a significant amount of time has elapsed since the stroke.
If the patient is falling then it is appropriate to consider falls clinic referral.
Deterioration in limb strength would be an indication for referral; if there is suspicion of new neurological pathology then referral to the stroke team or neurologist would be appropriate.
The panel agreed that spasticity is a specialised problem post-stroke and so consideration should be given to referral to a specialist service if the patient is affected by the symptoms – this might be to a specialist stroke service or to a spasticity clinic.
The panel reached consensus that neuropathic pain post-stroke should be managed in primary care providing it is not too severe, e.g. with amitriptyline or gabapentin.
Non-neuropathic pain, e.g. musculoskeletal pain relating to the stroke would generally be managed in primary care with referral for physiotherapy or occupational therapy as options.
Depending on the impact on the patient’s day-to-day life, psychological referral may also be considered although psychological interventions may also be available through the pain team.
Failure to respond to standard neuropathic pain medications would be an indication for onward referral to the pain team; in this case the panel decided that the stroke team may also be appropriate.
Consensus was strongly reached that it would be appropriate to refer a patient who is struggling with incontinence issues (urinary or faecal incontinence) to a continence team; there is unlikely to be anything that a stroke specialist team could offer.
Speech and language issues after stroke are specialist issues and the panel decided that these issues should be referred back to the stroke specialist speech and language therapists if the problem is affecting the stroke survivor’s daily life.
Adjustment after stroke
The lack of consensus in some clinical aspects here reflects the fact that there are many different facets to psychological adjustment after stroke, encompassing family, work and social factors and the panel expressed a wide range of views.
Third sector organisations such as the Stroke Association in the UK may be useful and would be able to advise on a range of issues.
Non-engagement in social activities or local stroke groups was not felt to warrant referral on its own; the panel felt that signposting to local community groups would be a more appropriate action.
Where psychological adjustment is impacting on return to work, it would be relevant to consider a referral to vocational rehabilitation services, but this would not be available in the UK National Health Service.
While the primary care physician may be best placed to manage these issues, the need for and destination of referral will depend on the specific factors involved.
It would be appropriate to refer for specific identifiable issues which were contributing to psychological recovery such as post-stroke speech issues to a stroke-specialist speech and language therapist. It would also be reasonable to consider referral for psychological therapy and ideally this would be to a specialist stroke psychologist.
The panel reached consensus that memory problems in patients who have had a stroke should be assessed as for any other patient with possible memory issues and referred to memory clinic if the patient meets relevant criteria.
The panel did not reach consensus about referral when presented with a case of mild fatigue 3 months post-stroke.
Referral may be required for a stroke survivor or carer for support (such as to social services or psychological services) if the carer is unable to cope as a result of the patient’s fatigue.
Post-stroke fatigue affecting day-to-day life would be an appropriate indication for referral to a stroke specialist team after an initial assessment by the GP has excluded other causes of tiredness.
The needs of the patient/carer dyad are complex and very dependent on the specific situation and may include difficulties relating to any of the previous scenarios. No consensus was reached on when carers should be formally referred for problems with mood relating to their caregiving responsibilities.
Occupational Therapy and/or Social Services referrals may be appropriate to consider if the carer is struggling with physical tasks of caring.
The panel recognised that the impact of post-stroke pain on carers should be considered. Decisions to refer carers for psychological therapy will depend on the individual; third sector and peer support services may also be appropriate to consider.
Consensus was reached that in general, issues with intimate relationships including erectile dysfunction and relationship issues should be dealt with in primary care.
Services such as psychosexual counselling are likely to be only available via the third sector or on a private basis in the UK rather than on the UK National Health Service*
*though advice on specialist physical treatments such as vacuum pumps or alprostadil injections may be available in NHS urology clinics (author’s note)
Difficulties with swallowing
There was disagreement over whether Speech and Language therapy referral would be helpful in the event that a patient has recently had a Speech and Language assessment.
Initial telephone advice may be helpful if previous assessments of swallowing function have been done and there is improvement that may indicate a potential need for change in swallow status such as removal of a percutaneous endoscopic gastrostomy.
Consensus was reached that swallowing issues post-stroke are likely to be best managed by a Stroke Specialist SALT, and referral is necessary if there has been a deterioration in swallowing function.
There was disagreement about whether referral would be necessary if the patient is struggling but their job does not seem to be imminently at risk and personal judgement is likely to be relevant here.
The panel agreed that work-related issues post-stroke should be referred to vocational services/vocational rehabilitation or for a neuropsychological referral if the stroke survivor is unable to perform the tasks required at work or is at risk of losing their job.