The Changing Face of Stroke Care

Amanda JonesStroke Nurse ConsultantSheffield Teaching Hospitals NHS FT

Aim of sessionAim of session

Background about stroke National drivers NICE and RCP Guidelines Stroke awareness

Some stroke factsSome stroke facts

Stroke is the 3rd leading cause of death in the Stroke is the 3rd leading cause of death in the UK.UK.

Leading cause of disability.Leading cause of disability. Kills twice as many women as breast cancer.Kills twice as many women as breast cancer. 130,000 people suffer a stroke in the UK each 130,000 people suffer a stroke in the UK each

year (a stroke is happening every 5 minutes to year (a stroke is happening every 5 minutes to some-one)some-one)

Approx 20-30% of people who have a stroke will Approx 20-30% of people who have a stroke will die within the first month.die within the first month.

1000 children suffer strokes per year 1000 children suffer strokes per year

Some stroke factsSome stroke facts

Approx 12,000 under the age of 55- ¼ of all Approx 12,000 under the age of 55- ¼ of all strokes are in the under 65’s.strokes are in the under 65’s.

Approx 900,000 people are living with Approx 900,000 people are living with stroke in England and around 50% of stroke in England and around 50% of those are dependant on others for help those are dependant on others for help with everyday activities with everyday activities

Approx 1 in 4 people who live until the age Approx 1 in 4 people who live until the age of 85 can expect to have a strokeof 85 can expect to have a stroke

Some stroke factsSome stroke facts

People aged between 65 and over increased by 4 People aged between 65 and over increased by 4 million between 1952-2002, the projected % of older million between 1952-2002, the projected % of older people in England is expected to rise from 16% in people in England is expected to rise from 16% in 2003- 23% in 2031- this will increase the numbers of 2003- 23% in 2031- this will increase the numbers of people with strokepeople with stroke

£7 billion is spent on stroke by the NHS and wider £7 billion is spent on stroke by the NHS and wider economy each yeareconomy each year

A huge issue and likely to get bigger with the rise in the A huge issue and likely to get bigger with the rise in the ageing population- this is why stroke is currently in the ageing population- this is why stroke is currently in the

spot-lightspot-light

National guidance- what’s new?

National Drivers for strokeNational Drivers for stroke

1st evidence based document; National Clinical Guidelines for Stroke, 1st ed 2000, 2nd ed 2004, 3rd Edition- RCP, 2008, 4th Edition September 2012

NSF for Older People, Standard 5, DoH 2001 National Audit Report 2005 (a damming report

about stroke services) which led to:- Reducing Brain Damage- DoH 2006 Mending Hearts and Brains- DoH, 2006 National Stroke Strategy- DoH December 2007 Diagnosis and initial management of Acute

Stroke and TIA- NICE, July 2008 Draft NICE stroke rehabilitation guidelines- due

for publication 2013 following major review

National Drivers for strokeNational Drivers for stroke

SINAP- SSNAP- Sentinel Stroke National Audit Programme- mandatory from April 2012- continuous audit instead of National Sentinel Audit- quarterly reports in the public domain

Accreditation- Peer review

Overview of of key indicatorsOverview of of key indicators Time from admission to scanTime from admission to scan First contact with member of the stroke teamFirst contact with member of the stroke team Number of patients transferred to a stroke bed within Number of patients transferred to a stroke bed within

4 hours4 hours Number of patients thrombolysed/eligibleNumber of patients thrombolysed/eligible Known time of onsetKnown time of onset Discussion within 72 hrs with patient and familyDiscussion within 72 hrs with patient and family Continence plan drawn up within 72 hrsContinence plan drawn up within 72 hrs Seen by a nurse and therapist within 24 hrs and all Seen by a nurse and therapist within 24 hrs and all

relevant therapists within 72 hrsrelevant therapists within 72 hrs Nutrition screen and formal swallow assessment in Nutrition screen and formal swallow assessment in

72hrs72hrs Antiplatelet and adequate fluids and nutrition in 24 Antiplatelet and adequate fluids and nutrition in 24

hrshrs

Infoflex - our local database

Accreditation- levels of stroke care

Level

Terminology Elements of Service provision

1 Comprehensive Acute Stroke and thrombolysis centre

Tertiary neurosciences disciplinesTIA & minor stroke managementAcute stroke managementThrombolysis serviceStroke rehabilitation

2 Acute stroke and thrombolysis centre

TIA & minor stroke managementAcute stroke managementThrombolysis serviceStroke rehabilitation

3 Local acute stroke centre TIA & minor stroke managementAcute stroke managementStroke rehabilitation

4 Stroke recovery and rehabilitation centre

Stroke rehabilitation

10 year strategy- 2007-2017 10 year strategy- 2007-2017 (5 years to go!)(5 years to go!)

Stroke Strategy

Prevention and Public Awareness

Post-Hospital Care

Workforce

Hospital Care

TIA and Minor Stroke

Emergency Care

Key stroke strategy themesKey stroke strategy themes

Informedpublic

Strokecentre

Paramedictriage

999 call

Local hospital

Shorter intensive acute & rehabilitative hospital stay, followed by

specialist care closer to home

Better outcomes

Direct to CT scan, thrombolysis

CT scan < 24 hrsStroke unit care

Tim

e = b

rain

The stroke pathway: Prevention and early diagnosis: managing risk

factors, raising awareness of symptoms, and tackling TIAs

Taking people direct to

specialist services Improving rehabilitation and community based

care; longer term support to regain independence

A stroke skilled workforce Involving and informing individuals and carers Research and audit

Time is brain

Active symptoms

Person Experiences Stroke Like Symptoms

999 call; ambulanceconfirms likely stroke

and pre-notifies hospital

GP refers toTIA clinic (low risk), or direct toHospital (high risk), advises nodriving and prescribes aspirin

(unless strong suspicion ofhaemorrhage/contraindications)

GP refers to TIA service

Recent resolved symptoms

Older resolved symptoms

Direct to stroke service One-stop specialist service; investigated, treated in 24 hours

Time is brain- Stroke PathwayTime is brain- Stroke Pathway

Management of Stroke

Stroke Unit• Specialised assessment and care• Swallowing test• Brain scan within 24hrs

Acute Stroke Unit Specialised clinical assessment• Urgent brain imaging for those who need it (next CT slot or within 1hr out of hours)/ MRI• Thrombolysis if appropriate• Swallowing test • Intensive (hyper-acute) stroke unit care for 24/48 hours

Minority

Specialist rehabilitation/inpatient and ESD

Specialist review at 6 weeks and 6 monthsLong-term community stroke and support services

Carotid intervention

Majority

End-of-life care

High risk TIA

National Recommendations for a Stroke PathwayNational Recommendations for a Stroke Pathway

All stroke patients should spend at least 90% of their All stroke patients should spend at least 90% of their hospital stay in a specialist stroke unit. hospital stay in a specialist stroke unit.

Pathway should be made up of distinct phases of care;Pathway should be made up of distinct phases of care;

1. Initial urgent specialist assessment- direct transfer to dedicated stroke unit (within 4 hours)

2. Hyper-acute- up to 48 hours (monitored beds/intensive nursing)

3. Acute- up to 7 days4. Sub-acute- 7-12 days5. Intensive inpatient rehabilitation-up to 21 days6. Specialist Community rehabilitation- from 3-6 months 7. Medium/Long-term- 6 month review- life long review8. Access back to specialist rehab for targeted input when

needed

Specialist validated immediate Specialist validated immediate assessment- Recognition Of Stroke In the assessment- Recognition Of Stroke In the Emergency Room (Emergency Room (ROSIER)

Validated scoring Validated scoring system.system.

For use by health For use by health professionals.professionals.

ROSIERROSIER Symptom onset: Date & Time.Symptom onset: Date & Time.

Assessment: Date & Time.Assessment: Date & Time.

BP GCS Eyes Motor Verbal BP GCS Eyes Motor Verbal

Has there been loss of consciousness or Syncope Y (-1) N (0)Has there been loss of consciousness or Syncope Y (-1) N (0)

Has there been any seizure activity Y (-1) N (0)Has there been any seizure activity Y (-1) N (0)

Is there New acute onset (or awakening from sleep) of:-Is there New acute onset (or awakening from sleep) of:-

1.1. Asymmetrical facial weakness Y (+1) N (0)Asymmetrical facial weakness Y (+1) N (0)

2.2. Asymmetrical arm weakness Y (+1) N (0)Asymmetrical arm weakness Y (+1) N (0)

3.3. Asymmetrical leg weakness Y (+1) N (0)Asymmetrical leg weakness Y (+1) N (0)

4.4. Speech disturbance Y (+1) N (0)Speech disturbance Y (+1) N (0)

5.5. Visual field defect Y (+1) N (0)Visual field defect Y (+1) N (0)

Total score: (Stroke is unlikely but not completely excluded if Total score: (Stroke is unlikely but not completely excluded if total score is < or = to 0)total score is < or = to 0)

The National Institute of Health Stroke Scale The National Institute of Health Stroke Scale (NIHSS)(NIHSS)

Not a diagnostic tool.Not a diagnostic tool. Quantifies stroke severity in a consistent way.Quantifies stroke severity in a consistent way. Useful in determining suitability for thrombolysis.Useful in determining suitability for thrombolysis.

(Patients within licence treated have a NIHSS >4 or (Patients within licence treated have a NIHSS >4 or <25.)<25.)

Useful for post thrombolysisUseful for post thrombolysis monitoringmonitoring

NIH Stroke scaleNIH Stroke scale

HASU- Hyper Acute Stroke UnitsHASU- Hyper Acute Stroke Units

Aim of hyper acute careAim of hyper acute care

Stroke is associated with significant Stroke is associated with significant physiological disturbance in vascular and physiological disturbance in vascular and

neuronal functionneuronal functionAim to;Aim to; Optimise physiological variablesOptimise physiological variables Maintain brain perfusionMaintain brain perfusion Maintain homeostasis- to try to restore normal state Maintain homeostasis- to try to restore normal state

once it has been disturbed.once it has been disturbed. Early detection and interventionEarly detection and intervention Prevent secondary events Prevent secondary events Safe administration of thrombolysisSafe administration of thrombolysis

Hyper acute nursing careHyper acute nursing care Hypoxia- O2 sats<92%Hypoxia- O2 sats<92% Hyper/ hypoglycaemiaHyper/ hypoglycaemia Hypertension- closely monitored- no clear consensus Hypertension- closely monitored- no clear consensus

on optimal management- should be treated post on optimal management- should be treated post stroke (usually after 7 days)stroke (usually after 7 days)

Intracranial pressure- drowsiness/gaze Intracranial pressure- drowsiness/gaze palsy/breathing problemspalsy/breathing problems

Pyrexia- worsens infarct- needs to be lowered if over Pyrexia- worsens infarct- needs to be lowered if over 37.5 37.5

Dehydration- maintain hydration Dehydration- maintain hydration AspirationAspiration DVT / PEDVT / PE SeizuresSeizures

Saver, Stroke 2006

0 2 4 6

30

20

10

0

Number making full recovery per 100 treated

Impact of thrombolysis

Time (hours)

Benefit

Harm

Time is BrainTime is Brain

How many stroke patients per year in UK* might How many stroke patients per year in UK* might avoid being ‘dead or dependent’ with each avoid being ‘dead or dependent’ with each

treatment?treatment?   % treated with

this intervention

Number treated per

year

Benefit per 1000

treated

Number who avoid death or dependency

Aspirin 80% 104000 13 1350

Stroke Unit 60% 78000 56 4370

Thrombolysis 2% 2080 63 130

Thrombolysis 30% 31200 47 1470

Based on 130,000 strokes per year in the UKIST 3 Collaborators

National targets- must be National targets- must be dones- Best Practice Tariffdones- Best Practice Tariff= Best evidence based care = Best evidence based care

for patientsfor patients

NICE STROKE QUALITY STANDARDS 2012NICE STROKE QUALITY STANDARDS 20121 Ambulance staff use a validated tool to diagnose stroke/TIA, and transfer

them to a specialist stroke unit within an hour

2 Brain imaging within an hour of arrival in hospital if indicated

3 Admitted directly to a stroke unit, assessed for thrombolysis

4 Swallow screen within 4 hours with a written nutrition plan

5 Assessed and managed by specialist nursing staff and at least 1 member of the specialist MDT by 24 hrs, and all relevant members within 72 hours with written MDT goals within 5 days of admission

6 Treated in a specialist rehab unit for those who need it.

7 A minimum of 45 minutes relevant therapies offered over 5 days

8 Loss of bladder control is reassessed at 2 weeks i/c an ongoing plan

9 Cognition and mood is screened within 6 weeks

10 Following discharge, stroke related disability, followed up in 72 hrs by a specialist team

11 Carers should have a named contact for info and support

24 access to thrombolysis24 access to thrombolysis

TelemedicineTelemedicine

Direct deliveryDirect delivery of hyper acute care by specialists of hyper acute care by specialists cannot always be achieved in every hospital- cannot always be achieved in every hospital- telemedicine allows patient/carers to talk to a stroke telemedicine allows patient/carers to talk to a stroke specialist remotely, and for the specialist to observe specialist remotely, and for the specialist to observe a clinical examination and view imaging. a clinical examination and view imaging.

The system should include a stroke nurse specialist The system should include a stroke nurse specialist to be present at the admitting hospital with the to be present at the admitting hospital with the patient under assessment. patient under assessment.

This will enable 24/7 access to thrombolytic This will enable 24/7 access to thrombolytic treatmenttreatment

NICE Stroke Rehabilitation NICE Stroke Rehabilitation Guidelines Guidelines (1(1stst stroke rehab guideline) stroke rehab guideline)

Draft was circulated nationally for consultation last Draft was circulated nationally for consultation last yearyear

Negatively received and strongly criticised by MDTs Negatively received and strongly criticised by MDTs nationally mainly due to the limitations under NICE nationally mainly due to the limitations under NICE e.g. For some-one who has a stroke- consider e.g. For some-one who has a stroke- consider offering physiotherapy!- significant implications for offering physiotherapy!- significant implications for rehabilitation.rehabilitation.

Guideline to be reviewed and changedGuideline to be reviewed and changed Hope for new guideline in 2013- vital to get it right!Hope for new guideline in 2013- vital to get it right! As a result a delay in publication of the RCP national As a result a delay in publication of the RCP national

Clinical Guidelines for Stroke- September instead of Clinical Guidelines for Stroke- September instead of June 2012June 2012

2626thth March Therapy consensus day event with the March Therapy consensus day event with the RCPRCP

NICE Stroke Rehabilitation NICE Stroke Rehabilitation GuidelinesGuidelines Types of studies consideredTypes of studies considered; Systematic reviews, ; Systematic reviews,

double blinded and unblinded parallel RCTs, and double blinded and unblinded parallel RCTs, and cross over randomised studies. cross over randomised studies.

No qualitative studies were included- much No qualitative studies were included- much rehabilitative care is qualitative in nature and cannot rehabilitative care is qualitative in nature and cannot easily be captured in an RCT.easily be captured in an RCT.

Intensity of therapy after stroke Intensity of therapy after stroke consensus meeting- consensus meeting-

2626thth March RCP, London March RCP, London Expert speakers Voting panel 45 minutes of therapy Appropriateness of therapy How to capture therapy Therapy research Patients perspectives in relation to therapy Limited places- £10-

email:therapy.meeting@rcplondon.ac.uk

Possible new inclusions to the 4Possible new inclusions to the 4thth Edition of the Edition of the RCP National Clinical Guidelines for StrokeRCP National Clinical Guidelines for Stroke

Acupuncture should only be used if part of a clinical Acupuncture should only be used if part of a clinical trialtrial

Do not routinely offer Functional Electrical Do not routinely offer Functional Electrical Stimulation or TENSStimulation or TENS

Pain control- offer amitryptyline, gabapentin or Pain control- offer amitryptyline, gabapentin or pregabalin for neuropathic painpregabalin for neuropathic pain

SALT should be provided for more than 2 hours per SALT should be provided for more than 2 hours per week if patient is able to tolerate thisweek if patient is able to tolerate this

Return to work enhanced sectionReturn to work enhanced section More emphasis on the timing and giving of More emphasis on the timing and giving of

information to carersinformation to carers Changes within the psychology section- stepped care Changes within the psychology section- stepped care

and use of validated tools to screen and assess for and use of validated tools to screen and assess for mood and cognitionmood and cognition

More about post stroke fatigueMore about post stroke fatigue

Possible new inclusions to the 4Possible new inclusions to the 4thth Edition of the Edition of the RCP National Clinical Guidelines for StrokeRCP National Clinical Guidelines for Stroke

Secondary prevention- emphasis on Life style changes Secondary prevention- emphasis on Life style changes being of equal importance as secondary prevention being of equal importance as secondary prevention medicationsmedications

Emphasis on exercise programmes in secondary Emphasis on exercise programmes in secondary preventionprevention

More detail about diet and weight loss (use of weight More detail about diet and weight loss (use of weight loss medications)loss medications)

Hypertension levelsHypertension levels Calcium Channel blockers are recommended as first line Calcium Channel blockers are recommended as first line

treatments (e.g. Amlodopine)- enhanced section on treatments (e.g. Amlodopine)- enhanced section on hypertension managementhypertension management

Carotid endarterectomy surgery should be undertaken Carotid endarterectomy surgery should be undertaken ASAP and within 7 days (was 14) of symptoms- working ASAP and within 7 days (was 14) of symptoms- working towards 48 hours by 2017towards 48 hours by 2017

Possible new inclusions to the 4Possible new inclusions to the 4thth Edition Edition of the RCP National Clinical Guidelines of the RCP National Clinical Guidelines for Strokefor Stroke A new section on telemedicine which states that this A new section on telemedicine which states that this

should be regularly audited.should be regularly audited. More emphasis on younger stroke patientsMore emphasis on younger stroke patients ESD and the need for the same intensity and ESD and the need for the same intensity and

specialist staff as inpatient stroke rehab unitsspecialist staff as inpatient stroke rehab units Community interaction sectionCommunity interaction section A section with recommendations regarding A section with recommendations regarding

therapy/nursing and medical levels included for the therapy/nursing and medical levels included for the first time- emphasising the need for 24/7 nursing and first time- emphasising the need for 24/7 nursing and stroke consultant coverstroke consultant cover

New Campaign to increase public New Campaign to increase public awarenessawareness

Act FAST launch 27Act FAST launch 27thth February from original February from original campaigncampaign

TV advertising Feb 27TV advertising Feb 27thth-March 25-March 25thth

March 5March 5thth-March 18-March 18thth- radio advertising - radio advertising particularly for BME (Black Minority Ethnic) particularly for BME (Black Minority Ethnic) communitiescommunities

The changing face of stroke- not just The changing face of stroke- not just an inevitability of old agean inevitability of old age

But can happen to anyone at any ageBut can happen to anyone at any age

What used to happenWhat used to happen

What happens now What happens now

Act FAST

Time lost is brain lost- for every minute when a stroke first happens approximately 1.9 million neurones are lost!

Vital to get to the hospital for specialist assessment, and treated as soon as possible to help preserve as much brain as possible!

In conclusionIn conclusion

Significant developments in stroke careSignificant developments in stroke care The new RCP guidelines will provide The new RCP guidelines will provide

enhanced national guidanceenhanced national guidance The new NICE stroke rehabilitation guideline The new NICE stroke rehabilitation guideline

should help with developments in should help with developments in rehabilitationrehabilitation

Need to continually raise awareness of Need to continually raise awareness of stroke symptoms as people are still not stroke symptoms as people are still not accessing services early enough!accessing services early enough!

More emphasis and research is still needed More emphasis and research is still needed in medium and long term stroke carein medium and long term stroke care