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.

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

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200

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100

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0

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Time from Stroke to Scan

242220181614121086420

24-hour clock

1,200

1,000

800

600

400

200

0

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irs

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aft

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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

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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

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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%

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