Case History 1

78 year retired Professor of HistoryHaving lunch with friend February 06 at 13.40Sudden onset right hemiparesis and expressive

dysphasiaArrived A&E 14.30Hemianopia, Dense paresis arm and weak leg,

right hemisensory loss and neglectNIH score 16Thrombolysis at 15.10

Case 1 pre CT

Case History 1

At 2 hours NIH score 5Dysphasia dramatically better and full

visual fields, slight weakness right armAt 24 hours NIH score 2

Case 1 24 hours post-stroke

Case History 1

At one week full neurological recovery

Conclusion: Full recovery without infarction as a result of thrombolysis

Case History 2

28 year old visitor from HullDysphasic and right hemiparesis on an open

top busArrived A & E on a SaturdayInitial scan at 3 hours 15 minutes

Case 2 Initial CT

Case History 2

Consented to IST 3Thrombolysed at 3 hours 30 minutesWithin 1 hour complete recovery clinically

Case 2, 24 Hour MRI

Case History 2

Discharged after 4 days asymptomatic

Conclusion: Full recovery but with residual infarction

Key Recommendations:Emergency Response

Ambulance services: Category A and use FASTTake patients to a hospital capable of providing

high quality ‘hyper-acute’ care 24 hours a day. Minimum requirements are an acute stroke unit and 24 hour access to brain imaging

Immediate structured assessment e.g. ROSIERWhere brain scanning urgent – next scan slot or

maximum of 1 hour

Key Recommendations:Emergency Response

Thrombolysis where appropriateDirect admission to acute stroke unit Specialist neuro-intensivist care including

neuroradiology and neurosurgery rapidly available (malignant MCA infarction, Basilar artery occlusion and posterior fossa haemorrhage

Currently <0.2% of patients in England, Wales and Northern Ireland receive thrombolysis

How does thrombolysis look?

205 patients in total thrombolysedduring 2006

• 33 North East• 15 in Scarborough• 20 in Cambridge• 43 in London• 12 in Oxford• 16 in Dorset• 17 in Devon• 10 in Bristol• 4 in West Midlands• 7 in Stoke• 17 on Merseyside• 6 in Manchester• 5 in Sheffield

What about the other 100,000?

109876543210

10,000

8,000

6,000

4,000

2,000

0

Nu

mb

er

of

pa

tie

nts

Time from stroke to admission (Days)

48444036322824201612840

Time from stroke to admission (hours)

2,000

1,500

1,000

500

0

Nu

mb

er

of

pa

tie

nts

Time from Stroke to Admission (in hours for those admitted within 2 days)

Brain Imaging

Only 42% of patients had brain imaging to confirm the diagnosis within 24 hours of the onset of symptoms.

% Brain Scan Performed Within 24 hours by Region

0

10

20

30

40

50

60

70

Median for all hospitals

42

48444036322824201612840

Time from stroke to first brain scan (hours)

500

450

400

350

300

250

200

150

100

50

0

Nu

mb

er

of

pa

tie

nts

Time from Stroke to Scan

242220181614121086420

24-hour clock

1,200

1,000

800

600

400

200

0

Nu

mb

er

of

pa

tie

nts

rec

eiv

ing

fir

st

bra

in s

can

aft

er

str

ok

e

Time of Day Scanning Performed

7531504921809 334635378332N =

Age group

85+75-8465-74<65

Bra

in S

can

With

in 2

4 H

ours

of S

trok

e

100

90

80

70

60

50

40

30

20

10

0

Weekend

Weekday

Age and Brain Imaging

Hospital Care and Longer term Rehabilitation

20151050

Time (days) from stroke to admission to stroke unit

2500

2000

1500

1000

500

0

N o

f p

ati

en

ts

Time from Stroke to Stroke Unit Admission

Results: Stroke unit provision –comparison over time

2002 2004 2006

Stroke unit in hospital

73% 79% 91%

Median (IQR) stroke beds

20 (14-27) 20 (15-29) 24 (16-30)

Specialist Community Stroke team

31% 27% 32%

0

10

20

30

40

50

60

70

80

Median for all hospitals

62

% Patients treated in Stroke Unit by Region

Quality of Acute Stroke UnitsCharacteristics Compliance(%)

Cont. Physiological Monitoring

57

Scanning within 3 hours 48

24 hour brain imaging access

95

Direct admission A & E 48

Specialist rounds at least 5/week

74

Protocols 97

% Patients Screened for Swallowing Deficits by Region

0

10

20

30

40

50

60

70

80

EASTMIDLANDS

SHA

EAST OFENGLAND

SHA

LONDONSHA

NORTHEAST SHA

NORTHWEST SHA

SOUTHCENTRAL

SHA

SOUTHEAST

COASTSHA

SOUTHWEST SHA

WESTMIDLANDS

SHA

YORKSHIRE& THE

HUMBERSHA

ISLANDS NORTHERNIRELAND

WALES

Region

Per

cen

tag

e C

om

pli

an

ce

66

Median for all hospitals

Impact per SHA - outcomes

Numbers of Patients with better outcomes per annum through adopting 4 key stroke interventions

0

100

200

300

400

500

600

700

800

900

EastMidlands

Eastern London North East North West SouthCentral

South EastCoast

South West WestMidlands

Yorkshire &Humber

Nu

mb

er

of

Pati

en

ts p

er

an

nu

m w

ith

bett

er

ou

tco

me

s Specialist Stroke Unit 2006

Thrombolysis

Early Supported Discharge Team

TIA Clinics (strokes avoided)

Dr Stephen Green DH Vascular Programme December 2007

Numbers of Beddays Saved through adopting 4 key stroke interventions

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

EastMidlands

Eastern London North East North West SouthCentral

South EastCoast

South West WestMidlands

Yorkshire &Humber

Nu

mb

er o

f B

edd

ays

Sav

ed

Equivalent Beds Saved (Text)

Specialist Stroke Unit 2006

Thrombolysis

Early Supported Discharge Team

TIA Clinics (strokes avoided)

121 beds

169 beds

184 beds

56 beds

231 beds

83 beds

102 beds

156 beds

165 beds

137 beds

Impact per SHA – bed days

Dr Stephen Green DH Vascular Programme December 2007

Requirements to deliver change

Change acceptedCollaborationClinical engagementClinical leadershipCo-operationCollective commissioning

Lessons from the Audit

1. One audit is not enough. It needs to keep on coming back

2. It needs to keep evolving but with a sufficiently stable core to enable time comparisons

3. Performing badly on the audit is a very powerful tool for change. Performing well may incite complacency

Lessons from the Audit

4. Not everything can be changed at once. Pick one or two key items to push each time data becomes available. Use the arts of spinning

5. Need a comprehensive political strategy of which audit is just one cog

Optimism or Depression?

Best chance ever to improve stroke careGovernment unchanged for next 2-3 years

therefore no excuse for change in directionNAO report due to Public Accounts Committee

before the end of the parliamentStroke seems to be near top of agendaLikely that audit funding will be continued