Head Position in Stroke Trial

The lying flat (0 degree) head position - the intervention is for all patients to be nursed lying flat (0 degree) immediately after diagnosis of acute stroke is made and to remain in this position for 24 hours. These patients are to have strict bed rest for the first 24 hours after admission to hospital and should be toileted in bed. Patients may be nursed and/or allowed to turn on their side for comfort, feeding and toileting. However, if a patient is very uncomfortable and unable to tolerate this position, they may have their head slightly elevated with a pillow (i.e. no more than 5 degrees). If toileting is impossible in bed, they may sit up or use a commode near the side of the bed for a brief period. Feeding may commence after they have passed an appropriate swallowing screen or assessment; it is possible for patients to eat on their side in the flat position as swallow is an active process that is not dependent on gravity. However, if it is not practical for feeding to be undertaken in the lying flat (0 degree) head position, then a patient may be sat up to 30 degrees for a short time (<30 minutes) for meals. Patients should have no more than 3 breaks in the 30 degrees position in the first 24 hours, and none of the breaks are to be grouped together (i.e. no back-to back breaks are permitted). For patients with dysphagia, the options are: (i) to maintain ‘nil-by-mouth’ for the first 24 hours with hydration maintained by intravenous fluids; and/or (ii) insertion of a nasogastric tube with bolus interval rather than continuous enteral feeding to avoid aspiration. After 24 hours, those patients with minor strokes may have gradual elevation of their head and are allowed to commence gentle graded mobilisation with toilet privileges. Those patients with moderate-to-severe deficits may have the head position maintained for longer and mobilised according to local stroke care guidelines. An appropriately trained person (‘local champion’) will undertake assessments and quality checks on adherence to the randomised intervention protocol on a regular basis and train staff as required to ensure compliance.