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RBFT Stroke Services 2011
Dr André van Wyk
Stroke Consultant
Members event
Royal Berkshire Hospital
28 June 2011
Stroke seminar June 2011
Introduction
What is a Stroke?
How does one recognise a Stroke?
Impact of Stroke: patient, on the family, on society, economy
How does one diagnose, assess and manage: TIA, Stroke and Risk factors
What are the National Guidelines and way services are measured
Vital different components of TIA and Stroke service and benefits
The whole pathway Stroke service at RBFT and surrounding areas
The Future
Stroke 2010
Stroke seminar June 2011
What is a TIA and Stroke?
A TIA (sometimes called a mini stroke) is similar to a full stroke
but the symptoms may only last a few minutes and will have
completely gone within 24 hours
TIA -Acute focal cerebral or monocular symptoms less than 24 hours as a result of thromboembolic disease
A stroke is a brain attack. It happens when the blood supply to
the brain is disrupted. Most strokes occur when a blood clot
blocks the flow of blood to the brain. Some strokes are caused
by bleeding in or around the brain from a burst blood vessel.
Stroke syndrome, rapidly developing clinical symptoms, focal occasionally global loss of cerebral function, lasting more than 24 hours or leading to death
Brain Attack or Acute Stroke Syndrome for symptom present with in 24 hours of onset
Stroke seminar June 2011
Stroke types and mechanisms
Stroke seminar June 2011
Stroke Complex patients (need for specialists): -
• medically unstable at risk complications and early
• functional- motor leg & arm power: sitting, walking; speech: communication; brain processing: memory, planning, orientation
• body working swallowing: feeding, medication –affects survival
Change occurs in first 24 hours- need early access Stroke Unit
Stroke management requires coordinated multidisciplinary working
Integrated local health, social and voluntary sector working (quality): prevention, hyperacute, acute stroke unit, specialist community rehab, long-term care
Whole pathway required to treat stroke –interdependent
Spending by commission or omission: reablement/ less functional dependency vs or on care
Stroke seminar June 2011
How does one recognise a Stroke?
Early recognition and management of a stroke is important
Commonly patient may not recognise they’ve had a stroke
FAST common but also other types stroke and symptoms eg sudden loss balance; dizziness; vision: loss in one or both eyes or double; inability swallow
Stroke seminar June 2011
Impact of Stroke: patient
Sense of self
Loss confidence, self worth, depression
Changes way one thinks, all the functional daily activities and extended activities one takes for granted
Loss independence
Need to come to terms with dramatic change while engaging in very activity physical and cognitive rehabilitation to find a new ‘orbit’
Stroke seminar June 2011
Impact of Stroke: on the family
Stroke impact is often life long
‘family’ disease
affect family dynamics and relationships
role: bread winner / parent / husband or wife
career and hobbies
Stroke seminar June 2011
Impact of Stroke: on society
Facts about stroke
Every five minutes someone in the UK has a stroke.
Each year an estimated 150,000 people in the UK have a stroke.
Stroke is the third most common cause of death in the UK.
There are over a million people who have had a stroke living in
the UK, and around half of all stroke survivors are left dependent
on others for everyday activities
Single largest cause of adult disability
Stroke seminar June 2011
Stroke Data 110,000/ y England.
third highest cause death England : 11 per cent of deaths England.
20–30 % die within a month.
25 % occur under age of 65.
>900,000 people living in England have had a stroke.
single largest cause of adult disability
devastating and lasting impact on lives of people and their families.
Often live with the effect of stroke rest of their lives.
A third are left with long-term disability..
Costs NHS and economy about £7 billion/y: £2.8 billion direct costs NHS, £2.4 billion informal care costs (e.g. the costs of home nursing borne by patients’ families) and £1.8 billion income lost to productivity and disability.
Outcomes UK compare poorly internationally, despite expense, unnecessarily long lengths of stay and high levels avoidable disability and mortality.
Stroke seminar June 2011
Impact of Stroke: economy
– Costs NHS and economy about £7 billion/y: £2.8 billion direct costs NHS, £2.4 billion informal care costs (e.g. the costs of home nursing borne by patients’ families) and £1.8 billion income lost to productivity and disability.
– Situation till recently is that outcomes UK poor compared to internationally, despite expense, unnecessarily long lengths of stay with high levels avoidable disability and mortality.
Stroke seminar June 2011
How does one diagnose, assess and manage: Risk factors for TIA and Stroke
Lifestyle, genetic and biological make up and impact of disease
Campaigns, education
History eg of family, smoking; Examination eg weight, checking BP and Investigations cholesterol, ECG check for AF then more specialised eg cardiac and scanning carotid arteries
Management: working out specific risk factors and education eg stopping smoking, diet and exercise
Medication aspirin statin blood pressure warfarin
Specialised eg. urgent referral carotid surgery
Stroke seminar June 2011
Concepts
Risk factors
– Hypertension Meta analysis Stroke 2004 : 35:776 >188000 with 6800 stroke events
10 mm Hg reduction systolic blood pressure reduces stroke by 1/3
– Cholesterol meta analysis Amarenco Stroke 2004:35:2902
Effect related to LDL reduction each 10% reduction decreased stroke by 15.6%
Stroke seminar June 2011
Effect of carotid endarterectomy stratified by time from last event to randomisationIpsilateral ischaemic stroke and operative stroke or death
32.7
16.0
11.2 9.413.8
3.4
0.0 -2.9
-20.0
-10.0
0.0
10.0
20.0
30.0
40.0
50.0
0-2 2-4 4-12 12+
Weeks between symptomatic event and randomisation
AR
R (
%),
95
% C
I
70-99% 50-69%
Lancet 2004; 363: 915-24
Stroke seminar June 2011
Non-urgentHigher risk < 1 day
Lower risk < 1 week
Management of TIA
Recent symptoms Old symptoms
TIA ONE-STOP-SHOP SERVICE• Specialised clinical assessment • Doppler (ultrasound) neck scan
• MRI brain scan is the ideal • Heart tests if needed• Assessment of risk factors • Advice on lifestyle and medication
Review and Secondary Prevention
Carotid (neck) surgery
Higher risk < 2 days
Lower risk < 2 weeks
Stroke seminar June 2011
TIA Mobile phone service (40595)
Clinics 5 days a week
Aim to see patients within 24 hours of referral – patients decline appointments!
578 patients seen in clinic in 2009
340 were TIAs
65% high risk seen within 24 hours
Stroke seminar June 2011
Stroke seminar June 2011
Stroke seminar June 2011
Stroke seminar June 2011
Principles in managing Stroke patients – Need to diagnosis: stroke, type and cause EARLY access to high tech
radiology and cardiac
– Time is brain
– emergency pathway to restore blood supply brain –thrombolysis
– Brain receptive to remodelling the dendrites sprouting- early rehab
– Early admission to Stroke Unit for Multidisciplinary assessment and closely coordinated management to deal with all complex issues in stroke with rehabilitating and caring for patient and their family
– Prevention and treatment risk factors that may result further stroke and complications of the stroke
– Specialist rehabilitation and person specific goal setting done with patient and family both in Stroke Unit and if needed with specialist stroke Early Supported Discharge team in the community to extend and reintegrate function to home
– Long Term Care
Stroke seminar June 2011
Management of Stroke
Acute Stroke Unit if >3h• Specialised Ax, Ix, Mx and care• Swallowing test• Brain scan within 24hrs• Rehab• Prevention Complications
Hyper Acute Stroke Unit if < 3 h• Specialised clinical assessment• Urgent brain scan (next CT slot or within 1hr out of hours)• Thrombolysis if appropriate• Swallowing test • Intensive stroke unit care for first days
Stroke Rehabilitation Unit
Early Supported Discharge and Community services
Lifestyle & 2˚Prevention
End-of-life care
Stroke seminar June 2011
What has changed in Stroke?
National Stroke Strategy 5 Dec 2007 : 20 quality markers /10-point plan of action
– Prevention treat TIA as emergency 2/3 seen and treated within 24h
– Hyperacute Stroke Pathway 1/3 admissions thrombolyse 1:3 (10 % 24/7 service)
– Stroke Specialist rehabilitation geared individual needs 7 days per week :Stroke Unit and ESD
– Long Term care/ follow up-emotional needs psychological
Radical change in Stroke management since 2007
– 2 Guidelines on being major acute Hospital
• DARZI & RCP acute medical care Oct. 2007
Delivery: NSS Organisational matrix / Performance Indicators / National Sentinel Stroke Audit / Ambulance Trust
Stroke seminar June 2011
Stroke seminar June 2011
Ten-point plan for action
Awareness
Preventing stroke
Involvement
Acting on the warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation
Workforce
Service improvement
Stroke seminar June 2011
Vital different components of TIA and Stroke service and benefits Avoid having a stroke –lifestyle and risk factors esp. hypertension
Act on warning TIA or Stroke- medical emergency
Rapid Access TIA service
Stroke Unit (coordinated MDT) benefits all patients specialist rehab
Hyperacute Stroke service able to provide 24/7 thrombolysis
Early Supported Discharge (specialist stroke rehab at home)
Long Term Care
Stroke seminar June 2011
Thrombolysis Cochrane library 2003
Thrombolysis
A&I 44.3 A&D 38.4 Dd 17.3
Control
A&I 30.2 A&D 51.4 Dd 18.4
Differences per 1000 – 141 extra AI
130 fewer D, 12 fewer Dd
Stroke seminar June 2011
Pooled Analysis tPA TrialsLancet 2004:363:768-774
OR for favourable tPA (95% CI) TIME
2.8 (1.8-4.5) 0-90 mins
1.6 (1.1-2.2) 91-180
1.4 (1.1-1.9) 180-270
Stroke seminar June 2011
DATA from SITS-MOST registry Lancet 27 January 2007
Figure 4. Proportion of patients with modified Rankin score of 0–6 at 3 months in SITS-MOST and in pooled randomised controlled trials for both placebo and alteplase patients2
Stroke seminar June 2011
Thrombolysis 08.00 – 18.00 Thrombolysis Service
Ambulance response upgraded to Cat A
27 patients thrombolysed so far
Only one haemorrhage
Stroke seminar June 2011
Stroke seminar June 2011
Stroke seminar June 2011
Stroke seminar June 2011
Stroke seminar June 2011
Press launch for ESD January 2010www.royalberkshire.nhs.uk/new/new_video/stroke.aspx
Stroke seminar June 2011
The whole pathway Stroke service at RBFT and surrounding areas
Acute Stroke Unit started 2001 6 beds to 13 Battle Hospital now 28 combined Stroke Unit RBFT since 2007
Neurorehabilitation service 8 stroke beds, vocation and spasticity service
Rapid Access TIA service 2005 extended pilot to the last 22 months week days seeing high risk patients within 24h
Thrombolysis 10h /d week days 18 months with Cat A ambulance
ESD Early Supported Discharge rehab service Berk West 13 months with CBNRT for further targeted input
Currently 3 Stroke patients family support workers (2 have funding only further 9 months)
Stroke seminar June 2011
Employed 2nd Stroke Consultant (Sept 08)
Stroke Registrar shred rotation Oxford (new post)
More junior doctors
Funding for band 6 & band 2 nurses
Business case for increase in therapy team
Stroke seminar June 2011
The Future
Plans currently for business case to extend Thrombolysis to 24/7 by April 2011. This will involve the RBFT first use of telemedicine
Rapid Access TIA would be 7/7 by April 2011
ESD service has been agreed for S Oxon currently setting up
Ensure extending funding for 2 Stroke Family and Support worker posts with key role in support and Longer Term Care stroke patients with co-ordinator Stroke support networks eg stroke clubs, information and sign posting
Setting up education programme staff and Information resources
Stroke seminar June 2011
Stroke Guidelines for Royal Berkshire Hospital and the Primary Health Care Team (Autumn 2008)
1. Prevention: Identification of those at high risk by PHCT e.g. hypertension, smokers, high cholesterol, atrial fibrillation, poorly controlled diabetics, high BMI, inactivity. Modify risk factors wherever possible. 2. Suspected T.I.A.: Home/ G.P. / A&E / CDU / IP RBH via Rapid Access TIA Phone:
ABCD2 score if 4 ≤ → Rapid Access TIA within 24h
ABCD2 score if ≤ 3 →triage next available Rapid Access TIA All seen as Day Case Rapid Access TIA ‘one stop shop’.
3. Suspected Stroke: 999 Admit all to Acute Stroke Unit via A&E *if unable to go directly home or home via ESD 4. Hyperacute Stroke Pathway- Cat A ambulance (1/3 of Stroke admissions weekday 08-18h00) 5. Early Supported Discharge stroke rehabilitation in community 6.Secondary prevention - Blood pressure - <140/85 for non-diabetics 6 monthly <130/80 for diabetics (or a minimum of annually) Simvastatin 40mg to all unless c-i The responsibility of the PHCT Atrial Fibrillation – give warfarin if no c-i
Lifestyle- exercise, diet, no smoking, etc. Aspirin – add dipyridamole if asp. resistant Tight diabetic control
Italics if pathway not currently in place SU includes ASU + SRU- important in Pathway of Care
≥3 hrs
Head scan Within 24 hours
STROKE UNIT Acute Stroke Unit
tPA protocol, intensivist Mx and monitoring 24h
Ix, Dx, Ax & Mx. MDT. Stroke Rehab Unit
Transfer Care Medical/ Palliative
IP Rehabilitation: Neuro-Rehab Unit
Comm Hospital Tanfield, WILC*
Early Supported Discharge
CBNRT HOME
Social Care - Rehab at home - OPD Review
CRT
Long term follow up
2˚ prevention
- Specialist Stroke Nurse - carer support voluntary - agencies
Hyperacute Pathway to CT
ONSET Stroke ≤ 3 hrs
Stroke seminar June 2011
Stroke Pathway
StrokeUnit
Community Based Neuro-Rehabilitation
Team
Intermediate Care
Teams(Reading,
Wokingham,West Berkshire)
(Early SupportedDischarge)
(CBNRT)
Home Care Package
(LA funded if Eligible or
Self funded)
Long Term Care
(NHS, LA, Voluntary Sector)
+
Renewed Need forIntensiveRehab?
Community Hospital
ResidentialRehabilitation
ICT in theCommunity
Home Care PackageAs above
+ Community Therapy-based
Reablement (Wokingham only)
+
Long Term Care
(NHS, LA, Voluntary Sector)
Home
OutpatientTherapy
If required
Stroke Pathway Incorporating ESD Service
Stroke seminar June 2011
HQIP GOLD award won by stroke service RBFT for improvements to service through Audit 2010
Stroke seminar June 2011
Thank you for your attention
Any questions