“It is the nature of a stroke to
partly take away the use of a
man’s limbs and to throw him
onto the parish if he had no
children to look to”
George Eliot
The Cripples (1949)
All cerebrovascular events in OXVAS
(Rothwell et al. Lancet 2005; 366: 1773-83)
Rates / 1000 / yr
STROKE
•
•
•
•
Sudden onset
Focal neurological deficit
Of presumed vascular origin
Symptoms lasting more than 24 hours or
leading to death
TRANSIENT ISCHAEMIC ATTACK
•
•
•
•
Sudden onset
Focal neurological deficit
Of presumed vascular origin
Symptoms lasting less than 24 hours
Strategies to reduce the
burden of stroke
• Primary prevention
• Secondary prevention
• Acute treatment
• Rehabilitation
• Reintegration
Cumulative risk of stroke following a TIA or
minor stroke in OXVASC
Risk of stroke (%)
25
20
15
10
TIA
5
Minor stroke
Log rank p = 0.8
0
0
BMJ 2004; 328: 326-8
30
60
Days
90
Atrial Fibrillation
Annual risk of recurrent stroke in patients
who are in atrial fibrillation
15%
[VALUE]
10%
5%
[VALUE]
0%
Warfarin
Control
Compared with aspirin about 90serious vascular events
are avoided each year for every 1000 treated (NNT = 11)
Carotid Ultrasound
CT Angiography
ABCD2
Age
> 60 years
1
BP
> 140 / 90 mmHg
1
Clinical
Unilateral weakness
Speech disturbance
2
1
Duration
> 60 mins
10 – 59 mins
< 10 mins
2
1
0
Diabetes
Yes
1
Risk of stroke after a TIA
ABCD2
2 days
7 days
90 days
Low risk
<4
1%
1.2%
3.1%
Mod risk
4–5
4.1%
5.9%
9.8%
High risk
>5
8.1%
11.7%
17.8%
The LTHT TIA Pathway
• High risk (ABCD2 > 3)
– Direct to LGI A&E -> CDU
– Assessed by Brain Attack Team nurse (7 day)
– Investigations
– Reviewed by Consultant Stroke Physician (7 day)
– Treatment initiated
– Aim is all < 24 hours
The LTHT TIA Pathway
• Low risk (ABCD2 < 4)
– Fast track TIA clinics (5 day)
– LGI, SJUH, CAH, SFT
– Seen by Consultant Stroke Physician
– Investigations ordered
– Treatment initiated
– Aim is all < 7 days
John Hughlings Jackson
He who treats apoplexy with
potions or medicaments is
wasting his time – he is treating
a hole in the brain !
Sir Godfrey Hounsfield
Infarction (85%)
Haemorrhage (15%)
Lancet 2014
Public Education
The LTHT Acute Stroke Pathway
•
•
•
•
All FAST +ve patients direct to LGI A&E
Pre-alert to Brain Attack Team nurses (24/7)
If potential thrombolysis – direct to CT scan
Review by Consultant Stroke Physician
including the use of telemedicine (24/7)
• Between 10% and 15% patients thrombolysed
• Median door to needle time 44 minutes
SSNAP October–December 2015
Individual Team Slideshow
www.strokeaudit.org/results
[email protected]
Median time from clock start to stroke nurse (hh:mm)
2
1:06
1
0:47
0:45
0:37
0:46
0:42
0:37
0:34
0:33
0:34
0:25
0:23
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 4.4B
Oct 2015
Team 189
Scan within 12 hours
100
97
95
93
91
87
85
Jan 2015
Apr 2015
91
86
90
89
87
89
%
75
50
25
0
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 1.2B
Oct 2015
Team 189
Stroke consultant within 24 hours
100
88
84
%
75
83
83
81
84
82
77
81
80
80
72
50
25
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 4.1B
Oct 2015
Team 189
The LTHT Acute Stroke Pathway
• On site availability
– Neuroradiology
– Neurosurgery
– Neuro critical care
– Vascular surgery
Large Vessel Occlusion
Proximal anterior
circulation large vessel
occlusion (ICA / M1)
accounts for 18% - 25%
of all ischaemic stroke
but 60% - 70% of deaths
or severe disability.
Benefits of stroke unit care
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Death
Death or Institutional Care
Stroke Unit
General Ward
The LTHT Stroke Wards
• Hyper-acute stroke unit (L 21) – 8 beds
• Acute stroke unit (L 21) – 25 beds
• Rehabilitation stroke unit (L 12) – 27 beds
• Rehabilitation unit (CAH 1) – 8 beds
Stroke unit within 4 hours
100
75
65
%
61
55
50
49
57
52
59
59
56
50
44
41
25
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 2.1B
Oct 2015
Team 189
At least 90% of stay on a stroke unit
100
86
83
%
75
78
76
79
83
79
79
81
83
79
78
50
25
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Patient-centred results at team level for Key Indicator 2.3A
Oct 2015
Team 189
OT assessment within 72 hours
100
80
75
66
65
57
56
%
82
72
63
50
78
81
49
49
25
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 8.1B
Oct 2015
Team 189
PT assessment within 72 hours
100
85
%
75
79
87
88
85
76
90
84
80
77
82
75
50
25
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 8.3B
Oct 2015
Team 189
SALT communication assessment within 72 hours
100
94
81
82
80
82
%
75
82
79
90
79
82
79
72
50
25
0
Jan 2015
Apr 2015
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 8.5B
Oct 2015
Team 189
Standards by Discharge
60
Your score
50
40
30
20
10
0
0
10
20
Source: SSNAP Oct-Dec 2015
Team-centred results for Domain 9
30
40
50
60
70
Team-centred Domain 9 score
80
90
100
Team 189
Discharge Process
60
Your score
50
40
30
20
10
0
0
10
20
Source: SSNAP Oct-Dec 2015
Team-centred results for Domain 10
30
40
50
60
70
Team-centred Domain 10 score
80
90
100
Team 189
Discharged with stroke skilled ESD team
100
%
75
50
25
19
7
0
Jan 2015
7
0
Apr 2015
0
0
0
Jul 2015
Source: SSNAP Oct-Dec 2015
Team-centred results at team level for Key Indicator 10.2B
0
0
0
0
0
Oct 2015
Team 189
“Success is a journey not a destination”