Innovations in Stroke Services in
the United Kingdom
Dr Ben Bray
Quality Improvement Fellow, Royal College of
Physicians
Clinical Lead (Stroke), Cardiovascular Intelligence
Network, Public Health England
Innovations in Stroke Services in
the United Kingdom*
Dr Ben Bray
Quality Improvement Fellow, Royal College of
Physicians
Clinical Lead (Stroke), Cardiovascular Intelligence
Network, Public Health England
*Mainly England
Outline
• Where have we come from?
• Audit and quality improvement
• Changing services: 7 day working,
reconfiguration
• Current priorities and future directions
Stroke Services
Where have we come from?
What has happened in the past 30
years?
•
•
•
•
•
•
•
•
•
Stroke unit based care
Thrombolysis services
Stroke specialist training for physicians
Development of multidisciplinary teams
Early supported discharge
Rapid TIA services
Much better imaging
Secondary prevention
Primary prevention, especially atrial fibrillation
“The performance of the UK in terms of premature
mortality….is below the mean of the EU15+…….further
progress will require improved public health, prevention,
early intervention and treatment activities……and
deserves an integrated and strategic response”
Changes in Stroke Mortality 19682006
Mortality: Ischaemic stroke
30 day mortality: Ischaemic
30
25
15
10
5
0
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
%
20
Year
95%CI
Audit
95%CI
SLSR
Source: SINAP
Mortality: Primary intracerebral
haemorrhage
60
55
50
45
40
35
30
25
20
15
10
5
0
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
%
30 day mortality: ICH
Year
95%CI
Audit
95%CI
SLSR
Source: SINAP
Mortality: Older people
30 day mortality: Age 80+
40
35
30
20
15
10
5
0
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
%
25
Year
95%CI
Audit
95%CI
SLSR
Source: SINAP
Thrombolysis
15
0.7
.
2.2
7.3
9.6
11.8 11.2
10
5
Sentinel
SINAP
20
13
20
12
20
11
20
10
20
08
.
20 ..
04
0
SSNAP
Source: SINAP/SSnap
Appropriate place of care
Source: SINAP/SSNAP
Access to physiotherapy
Source: SINAP/SSNAP
Proportion of patients (by age band) receiving a
scan within 24 hours of admission after stroke
Audit &
Quality
Improvement
Data
Admission to
acute stroke
service
Transfer to inpatient
rehabilitation
Discharge to
community
rehabilitation
team
6 month review
Complete
pathway record
Reorganising services
Strokes happen on weekends!
Hospital arrival - Day of the week
Number of patients
3000
2000
1000
0
Mon
Source: SSNAP Jul-Sep 2013
National level results
Tues
Wed
Thur
Day of the week
Fri
Sat
Sun
Differences in the processes of care for patients
admitted in normal working hours and out of hours
Eligibility for and compliance with process measures for normal hours and out of hours
patients (adjusted odds ratios)
Campbell et al. PLOS One 2014
7 day working - thrombolysis
Thrombolysis - Day of the week
Number of patients
300
200
100
0
Mon
Source: SSNAP Jul-Sep 2013
National level results
Tues
Wed
Thur
Day of the week
Fri
Sat
Sun
7 day working – occupational therapy
Overall OT assessment - Day of the week
Number of patients
3000
2000
1000
0
Mon
Source: SSNAP Jul-Sep 2013
National level results
Tues
Wed
Thur
Day of the week
Fri
Sat
Sun
7 day working - physiotherapy
Overall PT assessment - Day of the week
Number of patients
3000
2000
1000
0
Mon
Source: SSNAP Jul-Sep 2013
National level results
Tues
Wed
Thur
Day of the week
Fri
Sat
Sun
Risk of death by 30 days and weekend ratio of trained nurses
per 10 stroke beds, by day of admission
Higher
nurse:bed
ratio
Adjusted for patient level prognostic variables, stroke service characteristics, consultant and care assistant staffing levels and care quality
Bray et al. Submitted to PLOS Medicine
Median arrival-tPA time by annual
thrombolysis volume
Bray et al. Stroke 2013
Arrival-tPA for each volume group
Bray et al. Stroke 2013
Thrombolysis rate by onset-arrival
time
Bray et al. Stroke 2013
London Stroke Reconfiguration
• 28 stroke units  8 hyperacute SU and 20 post acute SU
• 11,500 strokes a year in London – 2,000 deaths
38
Percentage of all stroke admissions
thrombolysed in London
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Feb-July 2009 Feb-July 2010
Jan-March
2011
Jan-July 2012
Jan-March
2013
Risk adjusted mortality by quarter at 30 days in
London, Manchester and the Rest of England
Current priorities
• Intermittent pneumatic compression for VTE
prevention (CLOTS 3 Trial)
• Evidence based care: AF, acute stroke, TIA
management, thrombolysis pathway
• Integration across cardiovascular diseases
• Psychological, mental health and cognitive
impairment after stroke
Vascular Disease – One Event Leads to Another
Having a stroke
increases your chance of:
• Heart attack by 2-3 times
• Another stroke by 9
times
Having a heart attack
increases your chance of:
• Having another heart
attack by 5-7 times
• Stroke by 3-4 times
Having PAD increases your
chance of:
• Heart attack by 4 times
• Stroke by 2-3 times
Having Chronic
Kidney Disease
increases your
chance of:
• Heart attack by 2
times
• Stroke up 50%
Diabetes
(type 2)
Because of the
increased risk
associated with
diabetes the risk
is equivalent to
having a heart
attack
Data is increased risk vs general population (%)
*Includes angina and sudden death. Sudden death defined as death documented within 1 hour and attributed to coronary heart
disease (CHD)
**Includes only fatal heart attack and other CHD death; does not include non-fatal heart attack,
+ Includes death
++Includes TIA
1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9.
3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63.
4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.
Cardiovascular Integration
• Prevention
• Cardiopulmonary rehabilitation after stroke
and TIA
• Shifting care where appropriate to community
and primary care
• Joining cardiovascular datasets for clinical
care, quality improvement and research
Thank you
benjamin.bray@kcl.ac.uk