Appendix Two; Developing Intelligent Targets for Stroke- responses
Responses to Stroke IT Paper
Content
Comment/Consideration
Possible Actions
Are these the most
appropriate three
aspects?
Not necessarily-community support and interventions are often more
meaningful and effective
Consider developing driver diagram for community
services
Will improving the
reliability (reducing
the variability) in care
by improving
compliance rates with
the drivers improve
the quality of stroke
care?
Possible mismatch between these targets and the audit criteria in the
Sentinel audit (such as 90% of the inpatient stay being on a stroke unit).
Perhaps it is worth flagging this up with Tony Rudd?
It is possible to calculate the % of people who
spend more than 90% of their time on a stroke unit
from the data collected. If it is felt this an
appropriate outcome for every stroke patient it
can be included.
Only if the interventions are delivered by stroke competent staff. The
document needs to be more detailed with greater reference to RCP
guidelines to demonstrate compliance and needs of services
If there are specific evidence based competencies
for each discipline these could be included in the
“How to Guide”
Are there any other
specific outcome
measures or targets
that might be more
appropriate?
What functional outcome measure? E.g. the barthel score would not pick up
higher executive problems
Is it appropriate
 to designate a functional outcome measure
that must be used across Wales and if so which
one
 should this be decided locally.
 Should this be discussed/agreed at the first
learning session
Is it appropriate to
concentrate on three
aspects of the whole
care pathway in the
first instance?
For transfer of care measures: Follow up services referred for and patient
has information on ongoing goals and services they have been referred to
Apart from the functional measure all other measures are organisational not
patient outcome measures looking at quality of life
Mood of patient and carer as an outcome measure
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Is there one appropriate Quality of Life or Mood
measure to be used across Wales. At what point
should this be administered- at week one/
four/six? This can go in the “How to Guide”
Appendix Two; Developing Intelligent Targets for Stroke- responses
There are challenges in using these to make comparisons between services,
and the difficulties caused by incomplete data. The targets (probably rightly
in the first instance) allow for significant variation in interpretation in
implementation, which again will limit the validity of any comparative
analysis. I am sure this situation will improve as the targets are developed
and refined over time.
Using the data to look at capability as well as
compliance rates would help this- needs further
discussion
How will the information derived from the targets be used in service
development / planning - can we build on the limited success of audit and
feedback of performance more generally. Must ensure that implementation
of the targets is accompanied by evaluation to inform target development.
As per AWSSIC. Local teams have control of the
data as they collect it and can use it to inform
service developments
When it comes to measuring the overall effect of the development of the
service is it worth mentioning that those patients who are subsequently
diagnosed with something else will have benefited from the new sense of
urgency which attends Stroke; they may have just as much or more to gain
from the stroke initiatives because they will be diagnosed as having their
migraine/subdural/abscess/tumour/MS/epilepsy, much quicker than in the
past. From the perspective of the hospitals and the trusts this is a win-win
situation, once the system is up and running. Put another way, in the slip
stream of developing services for stroke patients lots of other patients with
acute neurological deficits related to all sorts of disease will benefit. As
Prof Richards says the system will have to be able to cope with all those who
have had a transient event which could have been ischaemic, if it is going to
have a beneficial effect. Suddenly we will have to find a new confidence
about diagnosing something as not a TIA or Stroke, as well as finding the
confidence to make these diagnoses!
Would not be an intelligent target for stroke, but
very valuable information. How could we capture
this information?
Need to clarify outcome measures. Outcome measures differ in the progress
report the third measure states one of the outcomes is % of patients who
receive a specialist assessment within the time frame. Where as in the driver
diagram in states % of patients reviewed in secondary care. Also need
clarification of what is a specialist assessment.
Need to ensure that local outcomes cover the cognitive and emotional needs
of the patient and carers. Need to ensure there are quality of life indicators
used that will evaluate participation and employment based on RCP guidance
if patient able to tolerate and delivered by stroke competent personnel
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Should the outcome be:
Appendix Two; Developing Intelligent Targets for Stroke- responses
How will percentage of people who present with a mini or transient stroke
be determined? In other words, how will the denominator be defined?
 Are we concerned about people who have developed a stroke who did
have a previous funny turn? Some will not have recognised its
significance: a measure of public education. Some may have presented
that funny turn to A&E, the GP, NHS Direct or the Out of Hours Service
who did not recognise it: a measure of diagnostic suspicion or
management in that setting. Some may have presented and been
referred appropriately but the pathway did not work: a measure of the
system’s performance.
 Are we concerned about those people who have been referred and for
whom the diagnosis of mini-stroke has been made? That will miss those
in whom the diagnosis was missed and those not referred for assessment.
 From the GP perspective the denominator of concern is ‘those suspected
of having had a transient event’. It is these people who all need to
proceed through the pathway, even if the final diagnosis is not TIA
whether or not they develop a Stroke. If the pathways are successful we
will see fewer people go on to develop a stroke, but that doesn’t mean
that the numbers presenting with symptoms and needing the systems in
place will go down. Indeed, if the public education campaigns are
successful, the NHS will see more referrals for assessment and, if the
systems are working, fewer strokes.


% of patients who receive specialist assessment
and/or
% of patients reviewed in secondary care
Should this be:
 % of people who are suspected of having
Mini/transient stroke
Ideas?
Will improving
compliance with any
one of these drivers
have a negative
impact on services
delivered in other
parts of the patient’s
pathway?
Improving on referral to action times by professions could increase caseloads
and lead to less interventions and poorer patient outcomes.
This may be the case, but at least the data would
be available to back this up.
Will improving the
reliability of the
interventions in the
bundles have a
positive impact on
outcome following
The first three hours is the accepted therapeutic window of opportunity for
thrombolysis and to be able to deliver it we need the patient to get to a
hospital with a CT scanner (which may or may not include a prior primary
care consultation), be subjected to some sort of further triage (in addition to
that which will have happened in the primary care consult and/or in the
ambulance), have a CT scan (which needs interpreting), and then be
Either:
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Move CT into 3 hour bundle, however this does not
reflect the current RCP guidelines, and most trusts
are not meeting the 24 hour bundle.
Appendix Two; Developing Intelligent Targets for Stroke- responses
stroke?
reviewed again by a clinician who is competent to make a decision about
whether or not on the basis of the story, the signs and the scan the diagnosis
of an ischaemic vascular event in the head can be made, and thrombolysis
given. This new treatment of thrombolysis (which causes bleeding in about
5% of patients) has produced this diagnostic urgency, and has changed stroke
from a Cinderella to a Rambo specialty, overnight
As an Emergency Medicine physician it is my view that the first hour bundles
should include an urgent CT scan (I would be advised of the timing 3-4 hours
by my specialist colleagues) - especially when we are considering
interventions such as thrombolysis. Access to a stroke bed inside the Four
hour target must be in the bundle too.
Therefore should the 3 hour bundle include the ambulance journey to a
hospital, the triage, the CT scan, and the final diagnosis? Clinicians will not
be able to make the diagnosis of an ischaemic stroke without a CT scan, and
if a CT is readily available most would probably hold off giving an aspirin
until a bleed (or other ischaemic stroke mimics) has been excluded.
I think the first day bundle is not ambitious enough and any concerns about
emergency treatment should be linked to the first three hours. Would it be
more relevant to have three bundles i.e. first 3 hours, first 3 days and first 7
days. After the first three hours the opportunity for intervention at a
biological level decrease dramatically. For every 100 stroke patients given
aspirin, one will be saved from death or a recurrent stroke (First
International Stroke Trial, Lancet 1997). The accepted figure for
Thrombolysis is that for every ten treated one will be saved from death or
disability; with better patient selection using more refined imaging
techniques (and possibly by excluding patients with extensive small vessel
disease) this figure will only get better. This intervention has an effect
which is an order of magnitude different and deserves being centre stage in
the Intelligent Targets. Put another way the term “Emergency Treatment”
belongs in the first three hours, more than in the first 24 hours.
Is there any chance of replacing the term “Swallow Screen” with
“Assessment of ability to eat and drink” or “Eating and Drinking
Assessment”? This is only to broaden the debate about the mechanisms and
management of people who are not able to feed by mouth; for many their
swallowing is relatively preserved but it is their cough, respiratory function,
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Monitor the time to CT data and move to 3hr
bundle once it is actually achievable with the
service configuration and resources in place.
Appendix Two; Developing Intelligent Targets for Stroke- responses
conscious level, and other neurological deficits (e.g. posture, limb function,
vertigo) that make oral feeding so difficult, or hazardous, or both.
Assessment of ability to eat and drink, or feed
could require full specialist SALT, physio and OT
assessments for some patients. Is this feasible
within the 24hr time frame in A&E?
The reasoning behind swallow screen is that it
would ensure patient safety immediately and
trigger more specialist assessment.
For quick wins on improving RCP audit scores could we align the content of
one or some of these bundles with the RCP boxes (weekly weight and mood
assessment come to mind as easy wins)?
As discussed in the core group meetings, it would
be difficult to add additional interventions to the
acute bundles at this point. Local teams could
agree that weight and mood assessments were
required for proper MDT goal planning to be
complied with.
Under intervention in the first 24 hours, I wonder if it should be made
explicit in that section that a referral should be made to SLT if the swallow
screen identifies that swallow safety is compromised. SLT assessment of
speech, language and communication needs to be in this diagram.
need to add in
 cognitive screening
 psychological support for patient and family
 advice on driving and employment
See point above. This should be done before
compliance with MDT goal planning is done.
If some professions are included eg physio and OT, all professions should be
mentioned or there is the potential for this document to be interpreted that
other professions are not required
The MDT assessments required to fulfil MDT goal
planning are decided locally and these should
certainly be included.
Professions involved should be stroke specialist with relevant competencies,
as per RCP guidelines, this needs to be highlighted in the bundles of care.
It is difficult to change the acute bundles at this
point as data is already being collected across
Wales. The reason for including OT and physio
originally was because these were specific
questions in the last RCP audit. It was decided not
to put any specific professions in the TIA and
Rehab bundles for this reason.
From RCP Guidelines Edition 3
A specialist is defined as a healthcare professional
with the necessary knowledge and skills
in managing people with the problem concerned,
usually evidenced by having a relevant
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Appendix Two; Developing Intelligent Targets for Stroke- responses
further qualification and keeping up-to-date through
continuing professional development.It will usually
also require good knowledge of stroke, especially in
acute care settings. It does not require the person
exclusively to see people with stroke, but does require
them to have specific knowledge and experience of
stroke.
i A specialist team or service is defined as a group of
specialists who work together regularly managing
people with a particular group of problems (for these
guidelines stroke) and who between them have the
knowledge and skills to assess and resolve the majority
of problems.
At a minimum any specialist unit (team, service) must
be able to fulfil all the relevant recommendations
made in this guideline. As above, the team does not
have to manage stroke exclusively, but the team should
have specific experience of and knowledge about
people with stroke.
If these competencies and methods of assessing
them are evidenced based and available they
would be included in the How to Guide. If they are
under development, they could be included as they
become available.
Need to state on diagram physio within 48 hours(could be interpreted as
3days) and OT within 4 days (could be interpreted as 7 days) if this is not on
there, it is a high risk that the longer time frame will be used and slippage
will occur
Do the guidelines state within 4 days of admission
or onset and is this working days?
From RCP Guidelines:
All patients with any impairment at 24 hours should
receive a full multidisciplinary assessment using an
agreed procedure or protocol within five working
days, and this should be documented in the notes.
We are saying 7 days form stroke, not 5 working
days from admission.
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Appendix Two; Developing Intelligent Targets for Stroke- responses
Appropriate cognitive assessment is also relevant to the ‘patient-centred
and goal-orientated specialist care’ – from my experience staff fail to
understand what a score on a screening assessment indicates for the patient
in terms of behaviour/functioning. Thus the goals are set unrealistically (due
to poor understanding of executive impairments) and frequently fail leading
to patient low mood! (I am often explaining this to even the highly skilled
and experienced staff on our rehab unit).
As with other interventions there will be
competency and training issues around this. Are
there any evidence based competencies or
standards already in place?
Relying on OTs to do an adequate cognitive screening and provide
appropriate advice/information at the Acute is going to be very variable and
without access to advice/support/ further assessment from
psychology/neuropsychology this will remain a major concern for some
patients (particularly the younger patients and/or those wishing to return to
work).
See above
Occasionally medical staff will do the Mini-Mental State Examination. But
this screening tool misses the nature of ‘executive’ cognitive impairment
(i.e. the walkers and talkers who go home and develop the significant
psychosocial problems!). I recently saw a patient medical colleagues said had
depression not a CVA (as CT was normal). Neuropsychological assessment
indicated that the patient appeared to have had an organic event, physician
agreed to do an MRI – this highlighted rare type of CVA. Without the
neuropsychological assessment patient would have been discharged home
with major cognitive problems and a young family!
My aim has been to train the clinical nurse specialists/OTs (or anyone else
appropriate!) to use and understand the Addenbrooks Cognitive Examination
Screen (ACE-R) …BUT I have been surprised to find how difficult this had
been. They need considerable supervision to do this correctly and need to
have ongoing support. Otherwise – from my experience they do not have the
skills, knowledge or confidence to understand the information that they are
collecting – and to explain to the person and their family how the specific
cognitive difficulties could impact on functioning once they are at home.
‘information sharing with patients and carers’ – research shows early on most
questions asked by the family are medical but over time it is the
cognitive/personality/emotional changes that families want to ask about.
Research shows problems in these areas have a greater impact on long-term
outcome than coping with significant physical disability. From my experience
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Appendix Two; Developing Intelligent Targets for Stroke- responses
‘general information’ about stroke is not enough for many individuals and
their family experiencing these cognitive/personality problems …… in these
cases they need specialist, specific information about the nature of their
stroke and cognitive impairments. The advice on coping strategies needs to
be tailored to their individual cognitive strengths and weaknesses, and put in
the context of their own environment.
“give patient information in relevant format”- what information?
need to state recommended levels and competencies as per RCP guidance
What are these?
Is it possible to
improve reliability of
the interventions and
compliance with the
care bundles within
allocated resources in
the next 18 months?
limited improvement in acute care in some settings- resources allocated are
far below what is necessary to meet the need in acute- many areas have no
dedicated stroke professions at all at present. Monies allocated were to
upgrade services- this is only feasible if you have a service to upgrade and
are not starting from a blank sheet.
The target would be to improve compliance year
on year, not achieve 100%
Will improving the
reliability of the
interventions in the
bundles have a
positive impact on
outcome following
stroke?
The pathways for TIA, mini-stroke and late presentation do not focus enough
on general practice. I cannot think of a symptom complex that could be
better dealt with in primary care. Most of the work is low tech and only
requires support with what would be considered to be simple investigations
these days. There are issues of access (to imaging and also rapid community
rehabilitation) and education particularly focusing on best choice of and
most appropriate imaging. The other issue highlighted, quite rightly, is
seamlessness.
From a DGH point of view, the imaging cannot be delivered within current
resources (equipment or staff). As regards complex imaging for
thrombolysis (which I believe is essential for a safe, effective practice) it cannot
be delivered within current skills, either.
However desirable the stated outcome may be, we cannot keep accepting
'targets' without the necessary resources. Continual pressure to get a quart out
of a pint pot is dangerous to the health of staff as well as patients.
What the Primary Care team needs is a timely assessment and in my view
that includes the specialist’s skill as well as the CT and Carotid Doppler
assessment. General Practice can certainly deliver everything else, provided
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Is it appropriate to
 specify the model of care in which TIA patients
are first seen ie must see GP before going on
to more specialist assessment
 maintain what should happen at first contact
and allow the models to develop in each
locality based on local issues/needs and data
collected through IT
Appendix Two; Developing Intelligent Targets for Stroke- responses
we can access timely rehabilitation if needed.
Should the document also specify opticians and ophthalmologists in the first
point of contact section? I have seen delays in diagnosis because amaurosis
fugax was not acted upon speedily.
there is a role for specialist care in the specific areas you describe but the
reality is that a lot of this care is already undertaken (and well) in general
practice.
Recognising a TIA in primary care should not be difficult any more than it is
secondary care. Important, however, to:
1. Start treatment ASAP
2. Refer for a specialist assessment which should be within 24 hours for high
risk and 7 days for low risk patients.
A lot of work can be done in primary care, but only after appropriate
training. Arriving at correct diagnosis is the key issue. We need to look at all
possible models of care and be pragmatic.
Primary Care has a key role to play in the management of both acute strokes
and TIAs. It is, however, important to recognize that the diagnosis of strokes
and TIAs is difficult without specialist training and appropriate
investigations. I do not feel that investigation of TIAs should be primary care
based. The role of primary care should be to identify suspected strokes/TIAs
and refer them for urgent specialist assessment in appropriate situations
(i.e high risk TIAs, strokes suitable for thrombolysis etc).
The diagnosis of TIA in any setting is not easy. My own experience is that
many of TIA patients referred to my stroke prevention clinic from both
primary and secondary care do not actually have had a TIA. The other
important thing is the ability to recognize the underlying pathophysiology of
TIA. Without specialist training, doctors in primary and secondary care are
unlikely to be able to confidently achieve both these goals. This is the point I
am trying to
make: specialist assessment is absolutely essential because it determines
course of further management, which is crucial from prognostic point of
view.
The nature of the symptoms that cerebrovascular disease produces (negative
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Appendix Two; Developing Intelligent Targets for Stroke- responses
i.e. loss of function rather than a seizure or an abnormal movement, no
pain, preservation of conscious level (at least initially), difficult to interpret,
easily passed off as something else) militates against people seeking help
urgently and I think most will be seen in primary care first, particularly the
TIA and the stroke that has improved or was passed off as a sprain or “I must
have slept on it”. Therefore I think it is important for thinking and planning
to start with the primary care perspective.
the National Clinical Guidelines and NICE guidance are clear about the need
and timeframes for specialist assessment of TIAs. The challenges are: the
speed with which patients with TIA can be seen promptly within primary care
(and public awareness is a key factor here), and the lack of clarity about
what constitutes 'specialist' within the guidance (other than the ability to
exclude stroke mimics). The impression I have from the centres I link with is
that the trend is for high risk TIAs to be admitted to acute stroke units (or at
least seen within them) to ensure compliance with NICE.
Agree urgent specialist assessment especially for high risk TIA is important
but there is no harm, I think, in starting treatment by any body who the
patients presents to as long as definition of TIA is strictly adhered to. Most
non TIAs are collapses of some sort which need assessment in their own right
and who better than a geriatrician to provide theta assessment! Perhaps we
should collect info on patients referred as TIAs.
It would be too easy to have a debate over territory when the real challenge
is seamless and evidence-based care focussed on the patient. I look forward
to getting it right.
The nature of the symptoms that cerebrovascular disease produces (negative
i.e. loss of function rather than a seizure or an abnormal movement, no
pain, preservation of conscious level (at least initially), difficult to interpret,
easily passed off as something else) militates against people seeking help
urgently and I think most will be seen in primary care first, particularly the
TIA and the stroke that has improved or was passed off as a sprain or “I must
have slept on it”. Therefore I think it is important for thinking and planning
to start with the primary care perspective.
There may need to be some clarity as to what is deemed an appropriate
format that for giving information
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Appendix Two; Developing Intelligent Targets for Stroke- responses
Strategy reinforced by AHP. Who & How?
Is it possible to
improve reliability of
the interventions and
compliance with the
care bundles within
allocated resources in
the next 18 months?
Regarding the question about whether or not it can all be done from within
existing resources I think the bottom line for acute stroke is whether job
plans can be changed to allow diagnosticians with experience in acute
medicine to drop what they are doing and see someone immediately,
whether job plans for radiographers can be modified to allow immediate
scanning, and whether Radiology opinions can be obtained from within
existing radiology services.
Do the data points
capture all the
information needed to
assess compliance
with the bundles?
Will improving the
reliability of the
interventions in the
bundles have a
positive impact on
outcome following
stroke?
Only if the interventions are delivered by stroke competent staff and
sufficient treatment sessions are available The document needs to be more
detailed with greater reference to RCP guidelines to demonstrate
compliance and needs of services
Appropriate intensity of rehab. - deemed by who?
“Intensity of rehab”- RCP guidelines suggest up to 45 mins daily per therapy
profession if patient is able to tolerate (this needs to be highlighted on the
diagram as a guide)
The rehab part of the diagram is vague in terms of how it is decided what is
the most appropriate setting for rehab and how appropriate intensity of
therapy is calculated.
The appropriate intensity of therapy would be
decided by the team treating the patient, based on
their assessments. The MDT team would need to
agree what sessions a patient needed and what
level of specialism would be needed to deliver
them. This would be marked as achieved or not
achieved the following week. As in the AWSSIC at
the moment, if there was a valid clinical reason
that this intensity not delivered, ie patient not
able to tolerate or was unwell, this would still
count as achieved. If not achieved because of acts
of commission- not enough staff/ equipment or
omission- someone forgot/ wasn’t told then this
would not be achieved.
Which ones should be used- is there agreement
across Wales? This can be put in the How to Guide
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Appendix Two; Developing Intelligent Targets for Stroke- responses
Assessment tools and outcome measures should include patient centred
tools/outcomes to measure the patients’ functional recovery both in the
hospital and in the community, mood, cognition and family/carer needs.
Transfer of care should ensure that all patients are immediately provided
with the prescribed care package by the receiving team to prevent a
“stop/start” patient care pathway
Options appraisal – few options are available in many areas so this is good to
have in but unsure how this relates to the outcome measures chosen?
Unclear what 'Options appraisal of rehab or discharge settings completed and
agreed with patient/carers done' means…
Is it possible to
improve reliability of
the interventions and
compliance with the
care bundles within
allocated resources in
the next 18 months?
Not within existing resources
Do the data points
capture all the
information needed to
assess compliance
with the bundles?
Do goals have to be SMART? What the aspirational goals of patients that
keeps them motivated.(We all have these in life). These time scales are
often organisational led not patient led.
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Can one competent clinician prescribe what
another one can do? E.g. can a specialist therapist
working in acute stroke unit say what treatment/
how often should be carried out by a specialist
therapist in a rehab stroke unit or ESD service.
Patients/carers should have an opportunity to
decide where they want their rehab, based on
availability of services/ therapy. They should be
able to choose not to go to a rehab unit, but go
home, as long as they understand they will not
have the intensity or specialism of therapy and the
impact that might have
From RCP Guidelines;
Every patient involved in the rehabilitation process
should have goals that:
 are meaningful and relevant to the patient
 are challenging but achievable
 include both short-term (days/weeks) and longterm (weeks/months) targets
 include both single clinicians and also the whole
team
 are documented, with specified, time-bound
measurable outcomes
 have achievement evaluated using goal attainment
Appendix Two; Developing Intelligent Targets for Stroke- responses


Wow factor
I(WAG) am extremely keen for one of the key principles to be addressed in
this work i.e. that we are looking for key interventions / 'wow factors' across
the whole pathway (from primary care to rehabilitation).
include family members where appropriate
are used to guide and inform therapy and
treatment.
Do the driver diagrams have the wow factor?
If we do not address this issue we are in danger of missing a great
opportunity as one of the success criteria of the intelligent targets work will
be the ability / or not to show how we have changed the system. Thus, if
the current system of stroke care is felt to be too secondary focussed, what
has changed with the introduction of the intelligent targets (e.g. what are
the key interventions / measures that could have been taken in primary care
to prevent the stroke occurring?). This is particularly relevant in the context
of the NHS reform programme, where one of the key objectives is better
integration between primary and secondary care.
Stroke and TIA or
transient stroke
Stroke patients being seen and scanned within three hours, and TIA patients
being seen and investigated within 24 hours or 7 days.
I am not sure that our concerns about the terms Stroke and TIA lead to
greater clarity. Are we saying that Mini Stroke and Transient Stroke are two
terms describing the same phenomenon (previously referred to as Transient
Ischaemic Attack) or are we saying that a Mini Stroke is when someone is left
with a minor or trivial deficit, and a Transient Stroke is when someone is left
without any deficit? Mild stroke also is mentioned. Is that the same as Mini?
I am left thinking that although the terms TIA and Stroke are now well past
there sell by date (and immediately impoverish any discussion about vascular
diseases of the brain) it may be counter-productive to introduce new terms
at this stage; most people know what is meant when the terms TIA and
Stroke are used whilst at the same time appreciating their (significant)
limitations.
If we were going to really go for it would have to be something like
Ischaemic Cerebrovascular Event with Complete Recovery (ICECR?) and
Ischaemic Cerebrovascular Event with Incomplete Recovery (ICEIR) or we
could use the RCP approach of neurovascular event with or without residual
problem. We would then have to have Haemorrhagic Cerebrovascular Event
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What should we call TIAs?
Appendix Two; Developing Intelligent Targets for Stroke- responses
with Complete Recovery (HCECR?) and Haemorrhagic Cerebrovascular Event
with Incomplete Recovery (HCEIR); we may then have to accommodate into
the terms whether the bleed is primary or secondary!!
Prioritising/
weighting particular
interventions
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In view of the time constraints on the effectiveness of the interventions for
Stroke and TIA is there a case for prioritising the time to specialist
assessment component of the 3 hour bundle for Stroke and the 24 hours and
7 day bundles for TIA? When these are in place other things should follow.
They apply to every patient (carotid surgery is required for 1-2% of stroke
patients) and once established would provide the sense of urgency and
immediacy that this area of practice lacks when compared to anything
involving pain, visible bleeding, or monitors that make a beeping noise.
Specific interventions could be weighted if
presenting the data/bundles as process capacity
measures using the compliance data