Evaluation of current evidence and practice to inform development of a Standardised Neurological Observation Schedule for Stroke (SNOBSS)

Abstract

Early neurological deterioration (END) is a poorly defined, but common complication significantly affecting outcome post-stroke. This thesis uses mixed methods in 3 phases to inform development of a consistent approach for neurological assessment and monitoring in acute stroke; allowing a range of staff to promptly identify changes, and take corrective action. Phase 1 A scoping review identified 26 scales for neurological assessment and monitoring in acute stroke. Several reviews allowed comparison of the clinimetric properties of 20 scales where data utility was available. There was limited evidence to support the use of specific scale(s), and none had been fully tested across a whole stroke population. Yet, the review clarified the importance of assessments allowing early detection of change in individual items, rather than the total score, for END detection. The review clarified the key clinimetric properties to be established by future research. Phase 2 A UK-wide survey of stroke units (n=125) demonstrated extensive variation in neurological assessment and monitoring practice. Most units use the Glasgow Coma Scale or AVPU (Alert, Voice, Pain, Unresponsive), for monitoring, which are not stroke-specific and only highlight late signs of deterioration (e.g. altered consciousness). Phase 3 Semi-structured interviews (n=23) utilising Normalisation Process Theory explored current practice and barriers and facilitators for implementation of a new standardised assessment. Staff recognised the need for better guidance and practice change for this important element of care. An expert group agreed on the Standardised Neurological OBservation Schedule for Stroke (SNOBSS). The SNOBSS and decision flowchart were presented to clinicians to consider acceptability and implementation concerns. Recommendations which reduce variations in clinical practice and inform future research will progress SNOBSS development and implementation. SNOBSS development is a first step towards consistent stroke-specific monitoring to identify neurological changes, specifically END in acute stroke.