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

doing?Tony Rudd

St Thomas’ Hospital

“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

Evidence that stroke units save lives and reduce likelihood of disability•Reduced mortality (14%)•Reduced death or institutionalisation (18%)•Reduced death or dependency (18%)

What has changed since Oslers time?

Stroke Unit Trialists’ Collaboration (2006)

Stroke unitStroke unit

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:

• 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

Brain scanningBrain scanning

What has changed since Oslers time?

48444036322824201612840

Time from stroke to first brain scan (hours)

500

450

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200

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50

0

Nu

mb

er

of

pa

tie

nts

Time from stroke to scan (Audit data 2008)

7531504921809 334635378332N =

Age group

85+75-8465-74<65

Bra

in S

can

With

in 2

4 H

ours

of S

trok

e

100

90

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Weekend

Weekday

Age and brain imaging

Brain scanNationally

Brain scan after stroke 98%

within 3 hours of stroke 27%

within 24 hours of stroke 70%

within 3 hours of admission 39%

within 24 hours of admission 84%

National Sentinel Stroke Audit 2010

• Treating people early after a stroke improves outcome– Direct admission to an acute stroke unit– Treatment with thrombolysis can dramatically

improve outcome

Immediate treatmentImmediate treatment

What has changed since Oslers time?

Recognising the signs of stroke FAST

Risk of death, dependency and good functional outcome in randomized trials of rt-PA given

within 3 hours of acute ischaemic stroke

17.3

38.4

44.3

18.4

51.4

30.2

0

20

40

60

80

100

Thrombolysis Control

Alive andindependent

Alive butdependent

Dead

Differences/1000: 141 extra alive and independent (P<0.01)130 fewer dependent survivors (P<0.01)

12 fewer deaths (NS)Cochrane Library 2003

(3 trials, n=869)

Glenn D. Graham 2002

Observational studies: haemorrhage rates

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

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

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total therapy physio-therapy occupational therapy speech therapy other therapies

time

(min

.)

Belgium

England

Switzerland

Germany

Appropriateness of 45 minutes of therapy

NUMBER OF WEEKDAYS 45 MIN WAS APPROPRIATE (i.e. patients with impairment and known days)

National

Median (IQR) in days

Physiotherapy 2 (0-7)

Occupational Therapy 2 (0-6)

Speech & Language Therapy 1 (0-3)

National Sentinel Stroke Audit 2010

Amount of therapy received

Key MessageTherapy time should be spent delivering direct patient care and administrative work should be kept to a minimum

PHYSIOTHERAPY – provided on applicable days National45 min and above 32% Less than 20 min 33%

OCCUPATIONAL THERAPY – provided on applicable days National45 min and above 31%Less than 20 min 42%

SPEECH & LANGUAGE THERAPY – provided on applicable days National

45 min and above 18%Less than 20 min 64%

National Sentinel Stroke Audit 2010

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

Delays stroke to admission

94% of patients were admitted within 24 hours of stroke

56% of patients were admitted within 3 hours of stroke

For 6354 patients for whom both times is known in hours

Inpatient Strokes5% of patients were already in hospital at time of strokePerformance on several of the 9 key indicators is worse for patients who have a stroke while an inpatient

Key Indicators Already an Inpatient

Admitted after stroke

90% of stay in SU 51% 72%

Screened for swallowing disorders within 24 hrs of admission 72% 83%

Brain scan within 24 hrs of stroke 79% 70%

Aspirin within 48 hrs of stroke 92% 93%

PT assessment within 72 hours of admission 85% 92%

OT assessment within 4 working days of admission 69% 84%

Weighed during admission 91% 85%

Mood assessed by discharge 81% 80%

Rehab goals agreed by MDT 66% 79%

Location to which patient was initially admitted

NationalAdmissions / Medical Assessment Unit / Clinical Decisions Unit 57%

Coronary care unit 1%

Intensive Care Unit / High Dependency Unit 1%

Acute / Combined Stroke Unit 36%Other Ward 4%

Key MessageAll patients should be directly admitted to a stroke unit equipped to manage acute stroke patients

•Outcomes

•Care Planning

Rehabilitation goals

STANDARDNational

Written evidence that rehabilitation goals agreed by multidisciplinary team within 5 days of admission 78

Written evidence that rehabilitation goals agreed by multidisciplinary team by discharge 94

Patient was receiving nutrition within 72 hours of admission (Domain 4) 95

Nutrition

Continence

20% of patients had a urinary catheter in the first week of admission

In 10% of these cases no clear rationale for the insertion is documented

Only 63% of incontinent patients have a plan to promote urinary continence (Domain 4)

Key MessageAll patients with continence should have a documented plan with evidence that it has been implemented in their case notes

Planning for discharge

STANDARDNational My site

Of applicable patients

Follow up appointment with a member of stroke team at approximately 6 weeks post discharge (Domain 5)

74% %

Discharge organised involving use of an early supported discharge scheme 36% %

Rehabilitation planned before discharge 83% %

Key MessageStroke specialist early supported discharge teams should be made available in all districts

•Medication and secondary prevention

Pre-admission

81% of patients admitted with stroke have a history of known vascular risk factors

Only 27% of patients who had atrial fibrillation prior to stroke were taking warfarin on admission

Key MessageAll patients with ischaemic stroke in AF should be considered for anticoagulation and a clear reason documented where a decision is made not to treat

Anti-thrombotic Medication

89% of patients were prescribed any antithrombotic / antiplatelet at discharge

93% of patients were prescribed aspirin within 48 hours of stroke (Key Indicator/Domain 6)

39% of patients in whom AF has been identified as a co-mordidity were on warfarin by discharge or planned to start it

(Target of 60% set by DH in England as part of Accelerated Stroke Improvement metrics to be achieved by April 2011)

At discharge

Lipid regulating agents

81% of patients prescribed any lipid lowering agent

80% of these patients were prescribed statins

Anti-hypertensive Medication

68% of all stroke patients were prescribed blood pressure lowering medication

84% of patients in whom hypertension was a co-morbidity were discharged with antihypertensive medication

These rates have reduced since 2008

•The London Model

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.

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

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

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Total Organisational Score 2010

Num

ber

of S

ites

London ScoresNational Scores

40

Performance data shows that London is performing better than all other SHAs in England

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45

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55

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75

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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

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90

Q1 Q2 Q3 Q4 Q1

2009/10 2010/11

% a

ch

iev

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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

41

Efficiency gains are also beginning to be seen

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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%

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20%

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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

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

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

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

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

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

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?