Stroke - Standard Operating Procedure

Publication: 23/12/2010  --
Last review: 29/01/2019  
Next review: 01/01/2022  
Standard Operating Procedure
ID: 2357 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2019  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Stroke: Standard Operating Procedure

  1. Purpose
  2. Centralisation of acute stroke beds to LGI
  3. Direct admission
  4. Bed Management
  5. Stroke medical team
  6. Nurse staffing
  7. Hours of operation

1. Purpose

1.1 The purpose of the Stroke SOP is to provide clear and unambiguous guidance for the management of acute stroke patients in order to ensure that patients are safely admitted to the right place, first time, more often and to maximise the number of acute stroke patients who are admitted directly to the Hyper Acute stroke Unit (HASU).

1.2 The audience for the policy is staff working on an acute stroke unit, stroke rehabilitation unit or interfacing wards and departments with responsibility for admitting, transferring, and lodging or discharging stroke patients.

1.3 This SOP should be read in conjunction with relevant LTHT policy and guidance including, but not exclusively, the LTHT ‘Transfer of Patients’ policy (2018) and LTHT ‘Discharge Policy’ (2016).

1.4 The transfer of a patient to another ward or department or within a department should be based on clinical need and ideally should not occur during the hours of 22.00 to 07.00. Where a patient is moved to another area to continue their treatment an appropriate risk assessment should be completed and documented.

1.5 The principles set out in the ‘Transfer of Patients’ policy should be used to support decision making when identifying the level of support the patient requires during internal or external transfer and to minimise the risks associated with HCAI.

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2. Centralisation of stroke beds to LGI

2.1 All FAST positive acute stroke patients are brought to the LGI in line with the protocol agreed with YAS.  The overall aim is for no admissions to SJUH for patients who are confirmed as having a new acute stroke.  However, some patients may need to be transferred to the medical / elderly bed base at SJUH.  Patients identified as having a new acute stroke in SJUH ED or AMU will be transferred to the appropriate LGI HASU/ASU as soon as possible if ROSIER positive (see section 3) but only after discussion and/or review with the SPOC.  Figure 1 details bed provision for Acute Stroke. Only in exceptional circumstances will a patient be admitted directly to the ASU (for example following a delayed presentation of stroke) 

2.2 The HASU beds will admit new acute stroke patients 24/7.  Ward L21 will receive stroke patients from HASU irrespective of age.

2.3 Ward L12 will receive stroke patients from ASU irrespective of age.

Figure 1

Ward number

Bed numbers


Receives patients from

Discharges patients to

Lodges patients to

Can receive lodging patients from


L21 (Hyperacute Stroke)

(min 2 ring fenced overnight)

Mixed sex





For stroke admissions only


For stroke admissions only

(Acute Stroke)


Mixed Sex

Other wards

Other wards




L12 (Rehabilitation Stroke)


Mixed Sex

Other wards,

Home, Care Home


Should maintain 100% stroke patient bed occupancy


C1 (Neuro and Stroke Rehabilitation) Chapel Allerton

8 for Stroke

Mixed Sex


Home, Care Home


Should maintain 100% stroke patient bed occupancy


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3. Direct admission

3.1 All patients with a confirmed acute new stroke (as defined in referral criteria section 3.5 ) will be admitted directly to a HASU bed (ward 21) from the ED. 

3.2 The HASU beds on ward 21 will accommodate patients of all ages (male and female).

3.3 Female patients with a confirmed new stroke (any age) will be admitted to ward L21 ASU after 48 hours maximum stay in the HASU

3.4 Male patients with a confirmed stroke (any age) will be admitted to ward L21  ASU after 48 hours maximum stay in the HASU

3.5 Clinical diagnosis of new acute stroke.

  • Clinical diagnosis of stroke can be assisted by ROSIER scoring system (sensitivity 93 %, specificity 83%)
  • Assessment by Stroke Physician on Call (SPOC) on daily HASU ward round to confirm diagnosis and clinical stability to facilitate transfer from HASU. We request that the Stroke Physician on call (SPOC) should be contacted via switchboard (during 0800-2000 Mon - Fri and 0800-1400 Sat-Sun) about all patients before they are admitted to an ASU if not already discussed.  Contact details should be available from switchboard.  This is an opportunity to discuss any doubts about diagnosis and to reduce the number of stroke mimics admitted as we may be able to offer advice regarding diagnosis and optimal management.
  • Specifically patients who are on a Care of the Dying Patient treatment plan should be discussed with SPOC prior to making a decision to admit the person to the HASU.
  • Out of hours contact the neurology-stroke junior doctor (FY2/CMT: “old SHO Grade equivalent”) on bleep 2921.   
  • Middle grade support is in the form of the Neurology Registrar on call 1700-0900

3.6 The following are criteria for not admitting to the HASU:

  • Clinical diagnosis of stroke unlikely
  • ROSIER score negative
  • Stroke mimic, e.g. seizure with Todd’s paresis, syncope, sepsis, migraine.  Consider whether the patient has a category ‘A’ diagnosis for admission to Neurology.
  • Additional clinical problem beside stroke requiring more immediate specialist intervention
  • Those patients with a non-stroke diagnosis and who require admission to medicine or geriatrics should be identified and transferred as a matter of priority by contacting SJUH bed coordinator. If no bed is created in 2 hours, escalate to site matron and then Directorate Manager to facilitate.

Please note, there are no Acute or Elderly Medicine beds at LGI

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4. Bed Management

4.1 A minimum of 2 ring-fenced / identified beds on the HASU to facilitate direct admissions from ED.  In effect this will mean that HASU will always have identified the next 2 patients to move out. The Band 6 in HASU will manage all admissions and discharges to and from the HASU.

The nurse co-ordinator on ASU is responsible for the daily communication to the HASU Band 6 of the actual and potential number of beds available.  Points of exit for ASU patients are inpatient rehabilitation (ward C1 or L12), Community Stroke team/home without ongoing rehabilitation, or other healthcare facility (other hospital, care homes or hospice).

Daily ward and board rounds on both HASU and ASU will discuss bed management in terms of ring fenced beds to ensure capacity for direct admissions to HASU and patient movement through the service.

If non-stroke patients are within the HASU bed base, and require further neurology,/ geriatric / general medicine assessment and treatment, they will be transferred to the appropriate speciality bed base and not transferred to ASU.  If a bed cannot be created in the relevant speciality bed base it must be then escalated to the Matron or Directorate Manager for  Stroke for further action with the relevant speciality.

To assist patient flow the neuroscience bed manager will be overseeing and assisting the above, there will be a 4 hour in-house timescale to transfer patients when deemed ready to step-down from HASU to ASU, if this is not achieved it will be escalated to the Matron /Directorate Manager for Stroke.

4.2 Liaison between ASU and SRU. 

Before 09.00 each morning the nurse in charge on L12 will provide information to the nurse in charge on ASU (L21) about their expected capacity to enable the ASU to transfer patients to stroke rehabilitation, as appropriate. 
L12 will contact ASU immediately should their capacity change.
Ward C1 CAH will follow the same procedure and criteria.

Wards L12 and C1 must discharge patients in line with the LTHT Discharge Policy (2009) ensuring all discharges are co-ordinated before 12 noon.
The nurse in charge on ward C1 will liaise with the Neuroscience bed manager (or equivalent) @ LGI (bleep 1290) of availability of beds that can be used for appropriate step down from stroke rehab beds if bed pressures occur.

4.3 Transfer and step down from ASU. 

Ward rounds on the ASU will identify patients to transfer to the Stroke Rehabilitation Unit (SRU)

In order to transfer to a SRU the following criteria must be met:

  • Stroke diagnosis i.e. cerebral infarction and intracerebral/intraventricular haemorrhage (this excludes subarachnoid haemorrhage, subdural haematoma, head injury and all other neurological problems)
  • Medically stable
  • Specialised medical/nursing and/or therapy needs with identified rehab goals
  • If transfer to Ward C1 – has PEG in-situ if artificial feeding required – not necessary for L12
  • Cannot be discharged directly from ASU within 1 or 2 weeks

4.4 Stroke Mimics.

If a stroke mimic is identified in LGI ED, the person should not be admitted to a stroke bed.  ED colleagues should liaise with Stroke Physicians and BAT nurses to identify stroke mimics, where suspected, in order to minimise the number of stroke mimics being admitted to the stroke bed base. The patient should be transferred from ED in LGI to SJUH Acute Medical Floor for assessment or to the Neurology bed base if another serious neurological condition is suspected (category A neurological diagnosis).

If a stroke mimic is identified after admission to the HASU the following transfer should occur:

  • the patient should be transferred to SJUH via the SJUH patient flow co-ordinator for transfer to the Acute Medical Floor for further assessment.
    Stroke physicians will play a key role in the identification of stroke mimics to ensure these patients are admitted to the correct ward from the emergency department and where necessary transferred from the HASU to the appropriate ward, 7 days of the week.

Once identified, non stroke patients should be moved off the HASU within 4 hours from confirmation.

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5. Stroke medical team

5.1 Stroke Consultant physician input will be provided by 7 stroke physicians: one elderly medicine, one neurologist, one acute medicine and one general medicine stroke physicians will support the beds on wards L21 and L12 for patients with complex medical needs. Three neurology stroke physicians will support the beds on wards L21 and L12 for the remaining patients. There is flexibility in this arrangement on a case by case basis. Rehabilitation Consultants support Ward C1 CAH beds. One additional Elderly Stroke Physician will not have in patient work but will contribute to seeing stroke referrals at SJUH and word cross cover. One Elderly Stroke Physician will do inpatient work but remain on his parent specialty rota. 

SPOC will remain responsible for the individual’s care on HASU for the first 48 hours or until the allocated consultant sees the patient themselves and takes over or there are other medical / neurological problems that another allocated team can manage.

SPOC will be available on site 0800-2000 Monday to Friday and 0800-1400 Sat-Sun.

5.2 Out of hours (OOH), on 1:7 rota, stroke physicians will provide a weekend review on HASU, Saturday and Sunday (and Bank Holidays), 0800 to 1400.  The SPOC on call will provide review if required to all stroke patients at the LGI wherever they are placed during this time.

5.3 Medical responsibility.  Outside 0900-1700 hours M-F, the SPOC will be responsible for all Stroke Patients.

5.4 Middle grade comes from the stroke team during office hours.

The Neurology/Stroke registrar should be called 1700-0900. They are non-resident all week.  There is an additional Registrar on site at LGI 0900-1700 Sat-Sun.

5.5 Each Stroke ward has its own ward team during office hours. 17.00-09.00 there is a 1:10 on call rota covering neurology and stroke admissions and inpatients including outliers (Bleep 2921). The bleep holder also covers the Crash Bleep to LGI Main Site and G Floor Jubilee Wing.  Any issues regarding their availability e.g. sickness should be escalated to the on-call consultant in Neurology/Stroke or the team to which they are attached. They are responsible for assessing all new stroke admissions and initiating treatment.  They should decide if a patient needs more senior review before the acute ward round the next morning.  They should not be responsible for phlebotomy, cannulation, urinary catheter or nasogastric tube insertion as the nurses on each HASU and ASU should undertake these tasks.

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6. Nurse staffing

6.1 In order to facilitate direct admissions from ED, staffing levels have been agreed as follows:

Ward L12 - SRU (27 Stroke Rehabilitation Beds)

Early-  5 registered nurses + 3 Clinical Support Workers
Late - 4 registered nurses + 3 Clinical Support Workers
Night - 2 registered nurses + 3 Clinical Support Workers

Ward 21 - ASU (25 Acute Stroke beds)

Early – 4 registered nurses + 2 Clinical Support Workers
Late - 4 registered nurses + 2 Clinical Support Workers
Night - 2 registered nurses +3 Clinical Support Workers

Ward 21 - HASU (8 Hyperacute Stroke beds)  

Early - 3 registered nurses + 1 Clinical Support Worker
Late - 3 registered nurses + 1 Clinical Support Worker
Night - 2 registered nurses + 1 Clinical Support Worker

Successful bed management will be dependent on staffing both in relation to number and experience. It is essential that the co-ordinator is not included in the ‘numbers’ for actually providing care on the wards.

6.2 If staffing levels and skill mix fall short of agreed numbers and the nurse in charge has not been able to resolve the issues locally this should be escalated to the Matron who will review staffing across the directorate (with Matron colleagues.  If following this review the shortfall remains then Matron will escalate to the appropriate Directorate Manager and Divisional Nurse.  Staff must not be moved to work in other areas if this will affect their ability to admit stroke patients direct from ED. Out of hours the nurse in charge must escalate to the clinical site manager.  If for any reason the CSMs cannot be contacted then contact the on call manager via switchboard.

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7. Hours of operation

7.1 Admissions to the acute stroke beds on Wards 21 will take place 24/7.

7.2 In and out of hours bed management for stroke across HASU & ASU is the responsibility of the HASU

7.3 HASU will manage admissions and discharges to the 8 beds on their ward.

7.4 Ward L12 will manage admissions and discharges to their beds.

7.5 All admissions, transfers and discharges will be overseen by the neurosciences bed manager in hours- Mon- Fri 8-4pm (bleep 1290)

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Record: 2357
Clinical condition:


Target patient group: Adult stroke patients
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Document history

LHP version 1.0

Related information

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