Stroke Care in the UK

1
Stroke Care in the UK

• Tony Rudd

2
Organisation of Services

• 120,000 new strokes per year
• Approx 200 hospitals treating acute stroke
  patients
• Most services providing combined acute and
  rehabilitation services
• Specialist rehabilitation services in community
  e.g. Early supported discharge
• General practitioners doing most of secondary
  prevention

3
Stroke Aggregated Audit Score Country
Comparison
4
Results Stroke unit provision comparison over
time
2002 2004 2006 2008
Stroke unit in hospital 73 79 91 92
Median (IQR) stroke beds 20 (14-27) 20 (15-29) 24 (16-30) 25 (20-34)
Specialist community/ domiciliary rehabilitation team 31 27 32 70
5
Time from Stroke to Scan
6
Time of Day Scanning Performed
7
Thrombolysis Provision
Intercollegiate Stroke Working Party
8
Thrombolysis Service
Thrombolysis
National median 14 National total 3284
Intercollegiate Stroke Working Party
9
National Initiatives for Change
Stroke Improvement Programme
10
Transforming Stroke Care in London
11
Case for change
Patients treated in a Stroke Unit
90
Physiotherapist assessment within 72 hours of
admission
90
Emergency brain scan within 24 hours of stroke
90
In 2004 the Sentinel Stroke Audit showed that
stroke services in London were poor
11
12
More strokes occurred in outer London but most
providers were in inner London
GAPS
GAPS
OVERLAPS
GAPS
The more intense the red the greater number of
providers available to provide service to the
area.
13
Story so far
The development of the strategy was subject to
wide engagement with the model of care agreed by
clinicians and user groups
New acute model of care
Community Rehabilitation Services
Discharge from acute phase
30 min LAS journey
After 72 hours

• Stroke Units
• High quality inpatient rehabilitation
• in local hospital
• Multi-therapy rehabilitation
• On-going medical supervision
• On-site TIA assessment services
• Length of stay variable

• HASUs
• Provide immediate response
• Specialist assessment on arrival
• CT and thrombolysis (if appropriate)
• within 30 minutes
• High dependency care and
• stabilisation
• Length of stay less than 72 hours

This was the gold standard maximum journey time
agreed for any Londoner travelling by ambulance
to a HASU
14
Prophets of doom predictions

• It would not be possible to implement major
  system reorganisation in London for a condition
  as complex as stroke
• Staffing requirements would not be achievable
• Patients would not accept being taken to a
  hospital that is not local to them
• It would not be possible to transport people
  within 30 minutes to a HASU
• Repatriation would fail and HASUs would quickly
  become full
• Trusts would fight to retain services
• Even if acute services work it would fail because
  it would be impossible to change community
  services
• The new model would be unsustainable

15
Following bidding and evaluation a preferred
model was agreed and consulted on
16
London Stroke Care How is it working?

• 1st February 8 Hyperacute (HASU) stroke units
  opened taking all patients who might be suitable
  for thrombolysis
• 19th July all stroke patients taken to one of the
  HASUs
• Over 400 additional nurses and 87 additional
  therapists recruited to work in stroke care in
  London by July 2010

17
The number of stroke patients taken by London
Ambulance Service to a HASU has been increasing
as implementation progresses
18
Performance data shows that London is performing
better than all other SHAs in England
Thrombolysis rates have increased since
implementation began to a rate higher than that
reported for any large city elsewhere in the world
12
10
3.5
Feb Jul 2009
Feb Jul 2010
AIM
of patients spending 90 of their time on a
dedicated stroke unit
of TIA patients treatment initiated within 24
hours
19
Efficiency gains are also beginning to be seen
Average length of stay
HASU destination on discharge

• The average length of stay has fallen from
• approximately 15 days in 2009/10 to
• approximately 11.5 days in 20010/11 YTD
• This represents a potential saving of
• approximately DN - insert figure

• Approximately 35 of patients are discharged
• home from a HASU. The estimate at the
• beginning of the project was 20.

20
London Stroke Care How is it working?

• No significant problems with repatriation to SUs.
  Good exchange of patient information.
• Significantly improved quality of care in SUs
• Evidence of constructive collaboration between
  hospitals
• SU Consultants joining HASU rotas and
  participating in post-take rounds and educational
  meetings
• Very positive anecdotal patient feedback

21
Areas where issues remain

• Community services in many areas still
  insufficient
• Early supported discharge
• Longer term rehabilitation
• Vocational rehabilitation
• Collecting data to prove the model is worth it

22
The Future

• Reorganisation of health care in UK with less
  central control
• Abolition of strategic health authorities
• General practitioners commissioning care
• May mean that major changes to stroke care will
  be difficult
• Probably funding cuts