RBFT Stroke Services 2011 Dr André van Wyk Stroke Consultant Members event Ro yal Berkshire...

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


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 types and mechanisms


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


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


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’


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


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 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.


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.


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


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%


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


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


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


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


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


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


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


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


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


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


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


Thrombolysis 08.00 – 18.00 Thrombolysis Service

Ambulance response upgraded to Cat A

27 patients thrombolysed so far

Only one haemorrhage


Press launch for ESD January 2010www.royalberkshire.nhs.uk/new/new_video/stroke.aspx


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)


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


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 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 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


HQIP GOLD award won by stroke service RBFT for improvements to service through Audit 2010


Thank you for your attention

Any questions

RBFT Stroke Services 2011 Dr André van Wyk Stroke Consultant Members event Ro yal Berkshire...

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