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Stroke Care. What has been achieved so far and what still needs doing?

Stroke Care. What has been achieved so far and what still needs doing?. Tony Rudd. St Thomas’ Hospital.

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Stroke Care. What has been achieved so far and what still needs doing?

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  1. Stroke Care. What has been achieved so far and what still needs doing? Tony Rudd

  2. St Thomas’ Hospital

  3. “it is the duty of the physician to explain to the patient, or to his friends, that the condition is past relief, that medicines and electricity will do no good, and that there is no possible hope of cure” William Osler

  4. What has changed since Oslers time? Stroke unit Evidence that stroke units save lives and reduce likelihood of disability • Reduced mortality (14%) • Reduced death or institutionalisation (18%) • Reduced death or dependency (18%) Stroke Unit Trialists’ Collaboration (2006)

  5. The important components of a stroke unit A skilled team including • Doctors • Nurses • Physiotherapists • Occupational Therapists • Speech and Language Therapists • Psychologists • Social Workers • Direct admission from emergency department • Monitoring facilities for • Heart Rate • Blood Pressure • Oxygen • Breathing Rate • Multidisciplinary Working • Active involvement of patients and carers in care A dedicated ward with:

  6. What has changed since Oslers time? Brain scanning • Ease of access to imaging. Every hospital treating stroke now has a CT scanner. 95% of patients scanned, 65% within 24 hours • Quality of imaging • Differentiating between haemorrhage and infarction • Identifying where the damage is and how big it is • Identifying when acute treatments to rescue brain might work • Finding out why the stroke happened

  7. Time from stroke to scan (Audit data 2008)

  8. Age and brain imaging

  9. Brain scan National Sentinel Stroke Audit 2010

  10. What has changed since Oslers time? Immediate treatment • Treating people early after a stroke improves outcome • Direct admission to an acute stroke unit • Treatment with thrombolysis can dramatically improve outcome

  11. Recognising the signs of stroke FAST

  12. Risk of death, dependency and good functional outcome in randomized trials of rt-PA given within 3 hours of acute ischaemic stroke (3 trials, n=869) Differences/1000: 141 extra alive and independent (P<0.01) 130 fewer dependent survivors (P<0.01) 12 fewer deaths (NS) Cochrane Library 2003

  13. Observational studies: haemorrhage rates Glenn D. Graham 2002

  14. Thrombolysis • 5% of patients received altepase in 2010 Sentinel Audit (increased from 1.8% in 2008) • 14% of patients satisfied the 3 criteria for appropriateness of thrombolysis (presented within 3 hours, 80 yrs or under, infarction) • Still many areas of the country where hyperacute stroke care not adequately provided

  15. Duration of rehabilitation • Research evidence to show a link between intensity of therapy after stroke and outcome • In UK majority of rehabilitation resources concentrated in hospitals • Length of hospital stay falling after stroke (reduced from mean of 35 days to 20 days over last 10 years) • Patients frequently complain that they sit in hospital doing nothing for long periods of time

  16. CERISE European Stroke Rehabilitation Study How much rehabilitation? Between 7.00 am and 5.00 pm

  17. Appropriateness of 45 minutes of therapy National Sentinel Stroke Audit 2010

  18. Amount of therapy received Key Message Therapy time should be spent delivering direct patient care and administrative work should be kept to a minimum National Sentinel Stroke Audit 2010

  19. How deliver increased intensity? • Different patterns of working e.g. Cutting down on bureaucracy • Less one to one therapy and more group treatment • Using non specialist therapists to provide cover • Focussing treatment just on patients likely to benefit e.g. Stopping treatment earlier • More therapists

  20. Delays stroke to admission

  21. Inpatient Strokes 5% of patients were already in hospital at time of stroke Performance on several of the 9 key indicators is worse for patients who have a stroke while an inpatient

  22. Location to which patient was initially admitted Key Message All patients should be directly admitted to a stroke unit equipped to manage acute stroke patients

  23. Outcomes

  24. Care Planning

  25. Rehabilitation goals Nutrition

  26. Continence Key Message All patients with continence should have a documented plan with evidence that it has been implemented in their case notes

  27. Planning for discharge Key Message Stroke specialist early supported discharge teams should be made available in all districts

  28. Medication and secondary prevention

  29. Pre-admission Key Message All patients with ischaemic stroke in AF should be considered for anticoagulation and a clear reason documented where a decision is made not to treat

  30. At discharge

  31. The London Model

  32. Prophets of doom predictions • Not possible to implement major system reorganisation in London for a condition as complex as stroke • Staffing requirements unachievable • Recruitment – where will staff come from? • Training – how will staff develop the necessary skills? • Leadership – who can provide the necessary leadership? • There is a risk that the available workforce will be consumed by early implementers, leaving later implementers unable to recruit to posts.

  33. Prophets of doom predictions • Patients will not accept being taken to a hospital that is not local to them • Not possible to transport people within 30 minutes to a HASU • Repatriation will fail and HASUs will quickly become full • Trusts will fight to the bitter end to retain services e.g. Judicial review • Even if get acute services working it will fail because impossible to change community services • Unsustainable

  34. London stroke care: How is it working? • In the latest round of the National Sentinel Audit of stroke care in England, Wales and Northern Ireland 5 of the 6 top performing hospitals were in London. All of the HASUs were in the top quartile of performance London Scores National Scores

  35. Performance data shows that London is performing better than all other SHAs in England Thrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world 12% 10% 3.5% Feb – Jul 2009 AIM Feb – Jul 2010 % of patients spending 90% of their time on a dedicated stroke unit % of TIA patients’ treatment initiated within 24 hours

  36. Efficiency gains are also beginning to be seen Average length of stay HASU destination on discharge • The average length of stay has fallen from • approximately 15 days in 2009/10 to • approximately 11.5 days in 20010/11 YTD • This represents a potential saving of • approximately [DN - insert figure] • Approximately 35% of patients are discharged • home from a HASU. The estimate at the • beginning of the project was 20%.

  37. London Stroke Care: How is it working? • No significant problems with repatriation to SUs. Good exchange of patient information. • Significantly improved quality of care in SUs • Evidence of constructive collaboration between hospitals • SU Consultants joining HASU rotas and participating in post-take rounds and educational meetings • Very positive anecdotal patient feedback

  38. Workforce initiatives • 1 month intensive training for consultants on HASU rota • 6 month fast track training post CCST • E learning programme in development • Simulation centre courses funded and being developed • Senior doctors and nurses • Band 5 nurses and junior doctors

  39. Evaluation • Collecting data to prove the model is worth it • SINAP • Additional London data items • Patient and carer perception • Health economics: funded through SHA • SDO funding to evaluate process of change (PI Naomi Fulop) • SHA funding health economic evaluation

  40. Areas where issues remain • Acute stroke patients presenting at non HASU A&E departments • Too many • Some difficulties transferring to HASU • Concerns by some SUs that inappropriate to transfer to HASU and not in patients interest to move • Out of London patients being brought by ambulance to non HASU A&E departments

  41. Areas where issues remain • Community services in many areas still insufficient • Early supported discharge • Longer term rehabilitation • Vocational rehabilitation • Commissioning guidance for rehabilitation and longer term care

  42. Areas where issues remain • Outcomes framework • Need to collect real outcome data that is robust and interpretable by the public • Public data to be displayed by London Health Observatory

  43. What does the future hold? • Can the enhanced tariff be sustained? • How will Clinical Commissioning affect the London stroke model? • How will Clinical Commissioning affect similar projects elsewhere in England – concerns expressed by Kings Fund? • Will the Secretary of State seek to open up the market for stroke care in London?

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