stroke care in the uk
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Stroke Care in the UK
Tony Rudd
Organisation of Services• 120,000 new strokes per year• Approx 200 hospitals treating acute stroke
patients• Most services providing combined acute and
rehabilitation services• Specialist rehabilitation services in community
e.g. Early supported discharge• General practitioners doing most of secondary
prevention
Stroke: Aggregated Audit Score: Country Comparison
100908070605040302010
Total organisational score 2006
England
Northern Ireland
Wales
The Islands
Results: Stroke unit provision –comparison over time
2002 2004 2006 2008
Stroke unit in hospital 73% 79% 91% 92%
Median (IQR) stroke beds
20 (14-27) 20 (15-29) 24 (16-30) 25 (20-34)
Specialist community/ domiciliary
rehabilitation team31% 27% 32% 70%
48444036322824201612840
Time from stroke to first brain scan (hours)
500
450
400
350
300
250
200
150
100
50
0
Nu
mb
er
of
pa
tie
nts
Time from Stroke to Scan
242220181614121086420
24-hour clock
1,200
1,000
800
600
400
200
0
Nu
mb
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of
pa
tie
nts
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ivin
g f
irs
t b
rain
sc
an
aft
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str
ok
eTime of Day Scanning Performed
Thrombolysis Provision
Less than 24/7 on-site,
36.3%
No provision, 11.9%
Less than 24/7 off-site only, 1.5%
24/7 service provided on-site, 28.4%
24/7 service on-site and off-
site, 9.0%
24/7 service off-site only,
12.9%
Intercollegiate Stroke Working Party
Thrombolysis Service
National median: 14
National total: 3284
Thrombolysis
Intercollegiate Stroke Working Party
National Initiatives for Change
NAO 2005
National SentinelAudit 2008
NICE and ICWPStroke Guidelines
2008
Stroke Improvement Programme
National Stroke Strategy 2007
Transforming Stroke Care in London
11 11
In 2004 the Sentinel Stroke Audit showed that stroke services in London were poor…
Physiotherapistassessment within72 hours of admission%
64656163
96
73
53
877568
32
64
2943
7057
4943
87
68
94
75
91
26
9082
75
100100
84
697057
7776
59
28
8683
38
7790
52
7481
64
45
9191
75
100
70
34
65
89100
93
70
95
79Emergency brain scan within 24 hours of stroke%
90%
90%
Patients treated in a Stroke Unit%
00358151820
3035384545455055585960646672
828485859395
100100
90%
Case for change
12
More strokes occurred in outer London but most providers were in inner London
GAPS
GAPS
GAPSOVERLAPS
The more intense the red the greater number of providers available to provide service to the area.
Story so far
13
The development of the strategy was subject to wide engagement with the model of care agreed by clinicians and user groups
HASUs • Provide immediate response • Specialist assessment on arrival • CT and thrombolysis (if appropriate) within 30 minutes • High dependency care and stabilisation• Length of stay less than 72 hours
Stroke Units • High quality inpatient rehabilitation in local hospital • Multi-therapy rehabilitation• On-going medical supervision • On-site TIA assessment services• Length of stay variable
30 min LAS journey* After 72 hours
Discharge from acute phase
Community Rehabilitation
Services
*This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU
New acute model of care
Prophets of doom predictions• It would not be possible to implement major system
reorganisation in London for a condition as complex as stroke• Staffing requirements would not be achievable• Patients would not accept being taken to a hospital that is not
local to them• It would not be possible to transport people within 30 minutes
to a HASU• Repatriation would fail and HASUs would quickly become full• Trusts would fight to retain services• Even if acute services work it would fail because it would be
impossible to change community services• The new model would be unsustainable
15
Following bidding and evaluation a preferred model was agreed and consulted on
London Stroke Care: How is it working?
• 1st February 8 Hyperacute (HASU) stroke units opened taking all patients who might be suitable for thrombolysis
• 19th July all stroke patients taken to one of the HASUs
• Over 400 additional nurses and 87 additional therapists recruited to work in stroke care in London by July 2010
17
The number of stroke patients taken by London Ambulance Service to a HASU has been increasing
as implementation progresses
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Non-HASU
HASU
18
Performance data shows that London is performing better than all other SHAs in England
40
45
50
55
60
65
70
75
80
85
90
Q1 Q2 Q3 Q4 Q1
2009/10 2010/11
% a
chie
vem
ent
London
England
Target
Thrombolysis rates have increased since implementation began to a
rate higher than that reported for any large city elsewhere in the
world
% of patients spending 90% of their time on a dedicated stroke unit
40
45
50
55
60
65
70
75
80
85
90
Q1 Q2 Q3 Q4 Q1
2009/10 2010/11
% a
ch
iev
em
en
tLondon
England
Target
% of TIA patients’ treatment initiated within 24 hours
0%
2%
4%
6%
8%
10%
12%
14%
16%
12%10%
3.5%
Feb – Jul 2009 Feb – Jul 2010AIM
19
Efficiency gains are also beginning to be seen
0
2
4
6
8
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12
14
16
18
20
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
2009/10 2010/11
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%.
0%
10%
20%
30%
40%
50%
60%
Home Other Stroke Unit RIP (blank)
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
Areas where issues remain
• Community services in many areas still insufficient– Early supported discharge– Longer term rehabilitation– Vocational rehabilitation
• Collecting data to prove the model is worth it
The Future
• Reorganisation of health care in UK with less central control– Abolition of strategic health authorities– General practitioners commissioning care
• May mean that major changes to stroke care will be difficult
• Probably funding cuts
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