Managing acute stroke:
What should cardiologists know?
Prof. Charlie Davie
UCL Partners Stroke Lead
University College London
Why the need for change?
•The National Service Framework for long term conditions
‘Better care demands changing
organisation of services’
Professor R Boyle. Mending Hearts and brains
on
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Odds ratio (v. Monday = 1)
7 day in-hospital mortality for all stroke patients in England
April 2009-March 2010
93,621 admissions. Dr Foster data
350 avoidable deaths/year if weekend performance
matched the normal working week
Thrombolysis rates in UK-
April 2009-March 2010
Rates comparable with USA.
2.5%
Best centres in each country
15% or more
Graph of model estimating odds ratio for favourable outcome at 3 months
in i.v. thrombolysis treated patients compared to placebo treated
patients by time from stroke onset to treatment with 95% confidence
intervals
Model of acute stroke care in London before February 2010
999
Local A&E
then MAU*
Ambulance travels to
nearest hospital with A&E
Community
Rehabilitation
Services
ASU or
ward
After an unspecified time,
when bed available
Discharge from
acute phase
Initial treatment
Acute Stroke Units (ASUs)
• Patients triaged on arrival to A&E
• Generally patients then admitted to
a Medical Assessment Unit while
awaiting definitive bed
• Length of stay up to 72 hours
before bed available
• Inpatient treatment and rehabilitation in a local hospital
• Admission to a general medical ward, geriatric ward, or
ASU depending on local practice, bed availability
(occupancy and staffing levels)
• Not all hospitals treating stroke patients had ASUs
• Generally only stroke physicians had admitting rights to
ASUs, but various types of physician in charge of stroke
patients (including general physicians, geriatricians)
• In all settings, length of stay variable and level of
expertise and available treatments/therapies variable
• Wide variation in numbers of patient treated across
settings
Source: Healthcare for London Stroke Strategy, 2007
6
The development of the strategy was subject to wide
engagement with the model of care agreed by clinicians
and user groups
New acute model of care
999
30 min
LAS journey*
HASU
SU
After 72 hours
Community
Rehabilitation
Services
Discharge from
acute phase
HASUs
Stroke Units
• 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
• High quality inpatient rehabilitation
in local hospital
• Multi-therapy rehabilitation
• On-going medical supervision
• On-site TIA assessment services
• Length of stay variable
*This was the gold standard maximum journey time agreed for any Londoner travelling
by ambulance to a HASU.
7
‘FAST’ Public awareness campaign
Source: NHS London Public Information campaign, 2008-10
8
Implementation has taken place in stages from February
2010 and went ‘fully live’ July 2010
• Stroke networks across London led implementation with
oversight from the pan-London cardiac and stroke
network board
• A new stroke tariff was devised to reflect the changes in
the pathway and the cost of the improvements in service
• Major workforce and recruitment across all trusts was
necessary
9
• Opening of hyper-acute beds took place in phases from
Feb 2010
 116 beds now open across 8 units in London
• Stroke units commenced opening in October 2009
 484 beds now open across 22 units in London
• Robust LAS protocols developed to reflect
implementation phases
The 2010 National Sentinel Stroke Audit has shown huge
improvements in stroke care in London
• 5 of the 6 top stroke services were in London
• All HASUs in London were in the top quartile of national performance
HASUs achieving all 7 standards for quality
acute stroke care
Patients directly admitted to a stroke unit
for pre-72 hour care
London HASUs
No
London HASUs
No
25%
25%
Yes
75%
Yes
75%
Yes
National result
National result
7%
Yes
39%
No
93%
No
61%
11
Performance data shows that London is performing
better than all other SHAs in England
13.8%
Thrombolysis rates have increased
since implementation began to a rate
higher than that reported for any large
city elsewhere in the world
12%
10%
3.5%
90
90
85
85
80
80
75
75
70
London
65
England
60
Target
55
% achievement
% achievement
Feb – Jul 2009
Feb – Jul 2010 Jan-March 2011
AIM
70
London
65
England
60
Target
55
50
50
45
45
40
40
Q1
Q2
Q3
2009/10
Q4
Q1
2010/11
% of patients spending 90% of their time on a
dedicated stroke unit
Q1
Q2
Q3
2009/10
Q4
Q1
2010/11
% of TIA patients’ treatment initiated within 24
hours
12
Efficiency gains are also beginning to be seen
Average length of stay
HASU destination on discharge
20
60%
18
16
50%
14
40%
12
10
30%
8
6
20%
4
2
10%
0
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2009/10
Jul
2010/11
• The average length of stay has fallen from
approximately 15 days in 2009/10 to
approximately 11.5 days in 20010/11 YTD
Aug
0%
Stroke Unit
Home
Other
RIP
• Approximately 35% of patients are discharged
home from a HASU. The estimate at the
beginning of the project was 20%.
• This represents a potential saving of
approximately £3.5m over a 6 month period
13
UCLP COLLABORATIVE STROKE INITIATIVE
Brings together the largest critical mass of stroke
neurologists in the UK in a comprehensive stroke service
UCLP Hyperacute Stroke Unit (HASU) opened in
February 2010 and will disseminate good practice
in London and to other large global cities
The clinical program will drive a major academic
development bringing translational stroke
researchers in an "Institute of Stroke Research”
North Central London Stroke Service
Outcomes from February 2010-June 2010
• 12 neurologists/stroke physicians from ALL NCL
acute trusts running UCLH HASU
• June 2010 -30 day in-hospital Mortality of 6% for
stroke patients admitted via UCH HASU v UK
national stroke mortality rate 20.7%*
• Thrombolysis rates in North Central London
increased by 204% compared to previous year
•
* Dr Foster data
Discharge destination:
Home
NHNN
Other teams
RIP
10, 14%
Other SU
Breakdown of
SU destinations
1, 1%
26, 38%
24, 35%
8, 12%
NHNN:
North Midd:
Whipps Cross:
Royal Free:
St Mary’s:
St George’s
Barnet:
C Cross
C & West
Others:
8 pts
5 pts
1 pt
5 pts
5 pts
1 pt
4 pts
1 pt
1 pt
1 pts
COLLABORATIVE STROKE INITIATIVE
NCL SU and TIA
HfL HASU designation
BEFORE
NOW
Fragmented NCL
provision (e.g. RFHUCH -2 small competing
units, 300 cases each)
Comprehensive NCL programme
1500 pts p.a.
Thrombolysis rate
18% vs average 9%
Endovascular stroke service
Low inpt mortality
10% vs 20.7%
R&D anatomy of
specific deficits
Small Population
impact
Coordinated network of 12 NCL
stroke physicians and neurologists
HASU accreditation and
commendation from HfL
>50% decrease in door to needle time
Successful repatriation from HASU
systematic approach to quality
COMING
Link across HIEC > 8000 pts p.a.
R&D network, : prevention, novel
treatment, rehabilitation,
Endovascular stroke service 24/7
aim for a pan-London network
Demonstrable quality improvement
across whole stroke pathway-working
with Kings Fund
Reduced stroke mortality and
morbidity for the population
Global benchmarking-Yale,
Cleveland clinic
A few ways to improve patient
care at scale
• Use of Networks to support integrated
care
• Reliable and regular collection of
comparable data preferably across whole
pathway
• Monitoring of Quality standards
“Whole pathway” approach to measuring quality in stroke
Element of pathway
Whole-pathway outcome measure
1.
Stroke education and public awareness •
•
Population awareness of risk factors
Population awareness of FAST
2.
Primary prevention and population risk
factors
•
Population incidence of stroke
•
•
•
Acute mortality
%discharges direct to home from HASU
Readmissions
•
Functional status
• Return to pre-stroke life role
• SF36
•
•
Secondary incidence
Population mortality
3.
4.
5.
6.
Stroke and TIA hospital admissions
(acute management and treatment)
Rehabilitation/access to services/
PROMS*/Mortality
Follow-up/secondary prevention and
hospital readmissions
Measurement of patient experience
•
•
Was care well-connected?
Did you get understand care plan & have
* PROMS: Patient Reported Outcome Measures chance to make choices?
Source: NCL/UCLPartners stroke working group