Governance of a Stroke
Thrombolysis Service
Barry Moynihan
Framework
• Pathway
• Protocols
• Outcomes
– Process
– Clinical
• Monitoring
– Local M&M
– SITS/NICE
and of course………………….
Training & Education
Pathway
• Mapping
• Geography & People
• Where the drug is given
Protocols
• Pre-hospital
• Hospital assessment & administration
– Inclusion/exclusion checklist
– Thrombolysis proforma
• The 1st 24 hours
– Nursing care plan
– What to do about deterioration
– Repeat brain imaging
• Outcomes
Outcomes
• Process
– ‘door to needle time’
• Clinical
– Death
– Haemorrhage
– NIHSS
– Modified Rankin Score
Haemorrhage after stroke rtPA
• Extracranial
• Intracranial
– Symptomatic
– Asymptomatic
NIHSS
• National Institutes of
Health Stroke Scale
• 15 point clinical scale
• Predicts lesion size &
outcome
• Validated
• Requires certification
Modified Rankin Score
(mRS)
0 No symptoms at all
1 No significant disability despite symptoms; able to carry
out all usual duties and activities
2 Slight disability; unable to carry out all previous activities,
but able to look after own affairs without assistance
3 Moderate disability; requiring some help, but able to walk
without assistance
4 Moderately severe disability; unable to walk without
assistance and unable to attend to own bodily needs
without assistance
5 Severe disability; bedridden, incontinent and requiring
constant nursing care and attention
6 Dead
Monitoring
• Local
– Clinical Networks
• National
– SITS
– NICE
– SINAP
What is SITS?
•
2000: SITS set up in Sweden for local
purposes
(Svenska Implementeringskommittén för
Trombolys vid Stroke)
•
2001: EMEA licensed Alteplase until 2005
on 2 conditions:
1. There was a trial of therapy at 3-4 hours
2. All patients were entered onto the SITS register.
Thrombolysis with alteplase for acute
ischaemic stroke in the Safe Implementation
of Thrombolysis in Stroke-Monitoring Study
(SITS-MOST): an observational study. Lancet.
2007 Jan 27;369(9558):275-82
SITS (Safe Implementation of
Thrombolysis in Stroke)
prospective internet-based audit of the
International Stroke Thrombolysis Registry (ISTR)
Process
Time delay (minutes): NOW
Center
All
centres
UK
Onset to A&E time
Median
62
70
64
Door to imaging time
Median
28
30
24
Imaging to report time
Median
0
6
6
Door to needle time
Median
50
58
65
Onset to needle time
Median
130
135
145
Time delay (minutes): PREVIOUS
Center
All
centres
UK
Onset to A&E time
Median
66
69
65
Door to imaging time
Median
39
36
25
Imaging to report time
Median
0
5
5
Door to needle time
Median
62
70
66
Onset to needle time
Median
139
155
145
Clinical Outcome
NICE 2007
This appraisal covers the use of Alteplase in acute
ischaemic stroke.
None of these criteria are available from SITS
SINAP April 2010
SINAP April 2010
SINAP Local Monthly Report Feb 2011
• Admissions
–
–
–
–
Total: 134
Stroke: 77 (57%)
TIA: 22 (16%)
Non Stroke: 35 (26%)
• Thrombolysis
– Total Thrombolysed: 7 (9% of patients with a
diagnosis of stroke – one as part of IST3)
– 100% eligible cases
– Mean DTN time 49 mins (32 minutes Feb 2012)
– DTN > 60 mins exceptions
• IST3 70 mins
• 90 mins (45 mins to confirm time of onset in aphasic pt)
Second National SINAP report (Feb 2011)
Summary
•
•
•
•
•
Pathway
Protocols
Outcomes
Monitoring
Training
Useful Links
• http://nihssenglish.trainingcampus.net/uas/modules/trees/
windex.aspx
• http://www.rankinscale.org/links.shtml
• http://www.acutestroke.org/
• http://www.nice.org.uk/guidance/TA122
• http://www.rcplondon.ac.uk/clinicalstandards/ceeu/Currentwork/stroke/Pages/SINAP.aspx