The Changing Face
of Stroke Care
Amanda Jones
Stroke Nurse Consultant
Sheffield Teaching Hospitals NHS FT
Aim of session
Background about stroke
 National drivers
 NICE and RCP Guidelines
 Stroke awareness
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Some stroke facts
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Stroke is the 3rd leading cause of death in the
UK.
Leading cause of disability.
Kills twice as many women as breast cancer.
130,000 people suffer a stroke in the UK each
year (a stroke is happening every 5 minutes to
some-one)
Approx 20-30% of people who have a stroke will
die within the first month.
1000 children suffer strokes per year
Some stroke facts
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Approx 12,000 under the age of 55- ¼ of all
strokes are in the under 65’s.
Approx 900,000 people are living with
stroke in England and around 50% of
those are dependant on others for help
with everyday activities
Approx 1 in 4 people who live until the age
of 85 can expect to have a stroke
Some stroke facts
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People aged between 65 and over increased by 4
million between 1952-2002, the projected % of older
people in England is expected to rise from 16% in 200323% in 2031- this will increase the numbers of people
with stroke
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£7 billion is spent on stroke by the NHS and wider
economy each year
A huge issue and likely to get bigger with the rise in the
ageing population- this is why stroke is currently in the
spot-light
National guidance- what’s new?
National Drivers for stroke
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1st evidence based document; National Clinical
Guidelines for Stroke, 1st ed 2000, 2nd ed 2004, 3rd
Edition- RCP, 2008, 4th Edition September 2012
NSF for Older People, Standard 5, DoH 2001
National Audit Report 2005 (a damming report
about stroke services) which led to:Reducing Brain Damage- DoH 2006
Mending Hearts and Brains- DoH, 2006
National Stroke Strategy- DoH December 2007
Diagnosis and initial management of Acute
Stroke and TIA- NICE, July 2008
Draft NICE stroke rehabilitation guidelines- due
for publication 2013 following major review
National Drivers for stroke
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SINAP- SSNAP- Sentinel Stroke
National Audit Programme- mandatory
from April 2012- continuous audit
instead of National Sentinel Auditquarterly reports in the public domain
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Accreditation- Peer review
Overview of of key indicators
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Time from admission to scan
First contact with member of the stroke team
Number of patients transferred to a stroke bed within
4 hours
Number of patients thrombolysed/eligible
Known time of onset
Discussion within 72 hrs with patient and family
Continence plan drawn up within 72 hrs
Seen by a nurse and therapist within 24 hrs and all
relevant therapists within 72 hrs
Nutrition screen and formal swallow assessment in
72hrs
Antiplatelet and adequate fluids and nutrition in 24
hrs
Infoflex - our local database
Accreditation- levels of stroke care
Leve Terminology
l
Elements of Service provision
1
Comprehensive Acute
Stroke and thrombolysis
centre
Tertiary
neurosciences disciplines
TIA & minor stroke management
Acute stroke management
Thrombolysis service
Stroke rehabilitation
2
Acute stroke and
thrombolysis centre
TIA &
3
Local acute stroke centre
TIA &
4
Stroke recovery and
rehabilitation centre
Stroke
minor stroke management
Acute stroke management
Thrombolysis service
Stroke rehabilitation
minor stroke management
Acute stroke management
Stroke rehabilitation
rehabilitation
10 year strategy- 2007-2017 (5 years to go!)
Stroke Strategy
Prevention and Public Awareness
Emergency Care
TIA and Minor Stroke
Hospital Care
Post-Hospital Care
Workforce
Key stroke strategy themes
The stroke pathway:
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Prevention and early diagnosis:
Shorter intensive acute &
managing risk factors, raising
rehabilitative hospital stay, followed by
awareness of symptoms, and
specialist care closer to home
tackling TIAs
Taking people direct to
Direct to CT scan,
CT scan < 24 hrs
specialist services
thrombolysis
Stroke unit care
Improving rehabilitation and
community based care; longer term
Stroke
Local
support to regain independence
centre
hospital
A stroke skilled workforce
Paramedic
Involving and informing individuals
triage
and carers
Research and audit
999 call
Informed
public
Time = brain
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Better
outcomes
Time is brain
Person Experiences Stroke Like Symptoms
Active symptoms
Recent resolved
symptoms
Older resolved
symptoms
GP refers to
999 call; ambulance
GP refers to
confirms likely stroke TIA clinic (low risk), or direct to TIA service
and pre-notifies hospital Hospital (high risk), advises no
driving and prescribes aspirin
(unless strong suspicion of
haemorrhage/contraindications)
Direct to stroke service One-stop specialist service; investigated,
treated in 24 hours
Time is brain- Stroke Pathway
Management of Stroke
Minority
Stroke Unit
• Specialised
assessment and care
• Swallowing test
• Brain scan within
24hrs
End-of-life care
Majority
High risk TIA
Acute Stroke Unit
Specialised clinical assessment
• Urgent brain imaging
for those who need it (next CT slot or
within 1hr out of hours)/ MRI
• Thrombolysis if appropriate
• Swallowing test
• Intensive (hyper-acute) stroke unit care
for 24/48 hours
Specialist rehabilitation/inpatient and ESD
Carotid intervention
Specialist review at 6 weeks and 6 months
Long-term community stroke and
support services
National Recommendations for a Stroke Pathway
All stroke patients should spend at least 90% of their
hospital stay in a specialist stroke unit.
Pathway should be made up of distinct phases of care;
1.
2.
3.
4.
5.
6.
7.
8.
Initial urgent specialist assessment- direct transfer to
dedicated stroke unit (within 4 hours)
Hyper-acute- up to 48 hours (monitored beds/intensive
nursing)
Acute- up to 7 days
Sub-acute- 7-12 days
Intensive inpatient rehabilitation-up to 21 days
Specialist Community rehabilitation- from 3-6 months
Medium/Long-term- 6 month review- life long review
Access back to specialist rehab for targeted input when
needed
Specialist validated immediate
assessment- Recognition Of Stroke In the
Emergency Room (ROSIER)
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Validated scoring
system.
For use by health
professionals.
ROSIER
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Symptom onset: Date & Time.
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Assessment: Date & Time.
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BP GCS Eyes Motor Verbal
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Has there been loss of consciousness or Syncope Y (-1) N (0)
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Has there been any seizure activity Y (-1) N (0)
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Is there New acute onset (or awakening from sleep) of:-
1.
Asymmetrical facial weakness Y (+1) N (0)
2.
Asymmetrical arm weakness
Y (+1) N (0)
3.
Asymmetrical leg weakness
Y (+1) N (0)
4.
Speech disturbance
Y (+1) N (0)
5.
Visual field defect
Y (+1) N (0)
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Total score: (Stroke is unlikely but not completely excluded if
total score is < or = to 0)
The National Institute of Health Stroke Scale
(NIHSS)
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Not a diagnostic tool.
Quantifies stroke severity in a consistent way.
Useful in determining suitability for
thrombolysis.(Patients within licence treated have a
NIHSS >4 or <25.)
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Useful for post thrombolysis monitoring
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NIH Stroke scale
HASU- Hyper Acute Stroke Units
Aim of hyper acute care
Stroke is associated with significant
physiological disturbance in vascular and
neuronal function
Aim to;
 Optimise physiological variables
 Maintain brain perfusion
 Maintain homeostasis- to try to restore normal state
once it has been disturbed.
 Early detection and intervention
 Prevent secondary events
 Safe administration of thrombolysis
Hyper acute nursing care
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Hypoxia- O2 sats<92%
Hyper/ hypoglycaemia
Hypertension- closely monitored- no clear consensus
on optimal management- should be treated post
stroke (usually after 7 days)
Intracranial pressure- drowsiness/gaze
palsy/breathing problems
Pyrexia- worsens infarct- needs to be lowered if over
37.5
Dehydration- maintain hydration
Aspiration
DVT / PE
Seizures
Time is Brain
Impact of thrombolysis
Number making full recovery per 100 treated
30
Benefit
20
10
Harm
0
0
2
4
6
Time (hours)
Saver, Stroke 2006
How many stroke patients per year in UK* might
avoid being ‘dead or dependent’ with each
treatment?
% treated with
this
intervention
Number
treated per
year
Benefit per
1000
treated
Number who
avoid death or
dependency
Aspirin
80%
104000
13
1350
Stroke Unit
60%
78000
56
4370
Thrombolysis
2%
2080
63
130
Thrombolysis
30%
31200
47
1470
Based on 130,000 strokes per year in the UK
IST 3 Collaborators
National targets- must be
dones- Best Practice Tariff
= Best evidence based care
for patients
NICE STROKE QUALITY STANDARDS 2012
1
Ambulance staff use a validated tool to diagnose stroke/TIA, and transfer
them to a specialist stroke unit within an hour
2
Brain imaging within an hour of arrival in hospital if indicated
3
Admitted directly to a stroke unit, assessed for thrombolysis
4
Swallow screen within 4 hours with a written nutrition plan
5
Assessed and managed by specialist nursing staff and at least 1 member of
the specialist MDT by 24 hrs, and all relevant members within 72 hours with
written MDT goals within 5 days of admission
6
Treated in a specialist rehab unit for those who need it.
7
A minimum of 45 minutes relevant therapies offered over 5 days
8
Loss of bladder control is reassessed at 2 weeks i/c an ongoing plan
9
Cognition and mood is screened within 6 weeks
10
Following discharge, stroke related disability, followed up in 72 hrs by a
specialist team
11
Carers should have a named contact for info and support
24 access to thrombolysis
Telemedicine
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Direct delivery of hyper acute care by specialists
cannot always be achieved in every hospitaltelemedicine allows patient/carers to talk to a stroke
specialist remotely, and for the specialist to observe
a clinical examination and view imaging.
The system should include a stroke nurse specialist
to be present at the admitting hospital with the
patient under assessment.
This will enable 24/7 access to thrombolytic
treatment
NICE Stroke Rehabilitation
Guidelines (1st stroke rehab guideline)
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Draft was circulated nationally for consultation last
year
Negatively received and strongly criticised by MDTs
nationally mainly due to the limitations under NICE
e.g. For some-one who has a stroke- consider
offering physiotherapy!- significant implications for
rehabilitation.
Guideline to be reviewed and changed
Hope for new guideline in 2013- vital to get it right!
As a result a delay in publication of the RCP national
Clinical Guidelines for Stroke- September instead of
June 2012
26th March Therapy consensus day event with the
RCP
NICE Stroke Rehabilitation
Guidelines
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Types of studies considered; Systematic reviews,
double blinded and unblinded parallel RCTs, and
cross over randomised studies.
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No qualitative studies were included- much
rehabilitative care is qualitative in nature and cannot
easily be captured in an RCT.
Intensity of therapy after stroke
consensus meeting26th March RCP, London
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Expert speakers
Voting panel
45 minutes of therapy
Appropriateness of therapy
How to capture therapy
Therapy research
Patients perspectives in relation to therapy
Limited places- £10email:therapy.meeting@rcplondon.ac.uk
Possible new inclusions to the 4th Edition of
the RCP National Clinical Guidelines for Stroke
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Acupuncture should only be used if part of a clinical
trial
Do not routinely offer Functional Electrical
Stimulation or TENS
Pain control- offer amitryptyline, gabapentin or
pregabalin for neuropathic pain
SALT should be provided for more than 2 hours per
week if patient is able to tolerate this
Return to work enhanced section
More emphasis on the timing and giving of
information to carers
Changes within the psychology section- stepped care
and use of validated tools to screen and assess for
mood and cognition
More about post stroke fatigue
Possible new inclusions to the 4th Edition of
the RCP National Clinical Guidelines for Stroke
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Secondary prevention- emphasis on Life style changes
being of equal importance as secondary prevention
medications
Emphasis on exercise programmes in secondary
prevention
More detail about diet and weight loss (use of weight
loss medications)
Hypertension levels
Calcium Channel blockers are recommended as first line
treatments (e.g. Amlodopine)- enhanced section on
hypertension management
Carotid endarterectomy surgery should be undertaken
ASAP and within 7 days (was 14) of symptoms- working
towards 48 hours by 2017
Possible new inclusions to the 4th Edition
of the RCP National Clinical Guidelines
for Stroke
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A new section on telemedicine which states that this
should be regularly audited.
More emphasis on younger stroke patients
ESD and the need for the same intensity and
specialist staff as inpatient stroke rehab units
Community interaction section
A section with recommendations regarding
therapy/nursing and medical levels included for the
first time- emphasising the need for 24/7 nursing and
stroke consultant cover
New Campaign to increase public
awareness
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Act FAST launch 27th February from original
campaign
TV advertising Feb 27th-March 25th
March 5th-March 18th- radio advertising
particularly for BME (Black Minority Ethnic)
communities
The changing face of stroke- not just
an inevitability of old age
But can happen to anyone at any age
What used to happen
What happens now
Act FAST
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Time lost is brain lost- for every minute when
a stroke first happens approximately 1.9
million neurones are lost!
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Vital to get to the hospital for specialist
assessment, and treated as soon as possible
to help preserve as much brain as possible!
In conclusion
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Significant developments in stroke care
The new RCP guidelines will provide
enhanced national guidance
The new NICE stroke rehabilitation guideline
should help with developments in
rehabilitation
Need to continually raise awareness of
stroke symptoms as people are still not
accessing services early enough!
More emphasis and research is still needed
in medium and long term stroke care