Transcript Stroke Audit in the UK

Stroke Care in the UK
Tony Rudd
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
Stroke: Aggregated Audit Score:
Country Comparison
England
Northern Ireland
Wales
The Islands
10
20
30
40
50
60
70
Total organisational score 2006
80
90
100
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)
31%
27%
32%
70%
Specialist community/
domiciliary
rehabilitation team
Time from Stroke to Scan
500
450
Number of patients
400
350
300
250
200
150
100
50
0
0
4
8
12
16
20
24
28
32
36
40
Time from stroke to first brain scan (hours)
44
48
Number of patients receiving first brain scan after stroke
Time of Day Scanning Performed
1,200
1,000
800
600
400
200
0
0
2
4
6
8
10
12
14
24-hour clock
16
18
20
22
24
Thrombolysis Provision
No provision,
11.9%
24/7 service
provided onsite, 28.4%
Less than
24/7 off-site
only, 1.5%
24/7 service
on-site and offsite, 9.0%
Less than
24/7 on-site,
36.3%
24/7 service
off-site only,
12.9%
Intercollegiate Stroke Working Party
Thrombolysis
Thrombolysis Service
National median: 14
National total: 3284
Intercollegiate Stroke Working Party
National Initiatives for Change
NAO 2005
National Stroke
Strategy 2007
Stroke Improvement Programme
National Sentinel
Audit 2008
NICE and ICWP
Stroke Guidelines
2008
Transforming Stroke Care in London
Case for change
100 100
Patients treated in a
Stroke Unit
%
95
93
90%
85
85
84
82
72
100 100
Physiotherapist
assessment within
72 hours of admission
%
90%
84
75
82
90
66
64
75
59
58
55
50
45
45
45
38
35
30
20
18
15
8
5
3
0
0
61
65
64
70
69
96
94
91
60
87
87
70
68
43
49
68
64
75
73
57
63
53
43
29
32
26
95
90%
Emergency brain scan
within 24 hours of stroke
%
93
100
100
91
89
79
70
70
65
90
91
75
64
45
34
83
77
81 74
86
76
59
52
38
28
In 2004 the Sentinel Stroke Audit showed that
stroke services in London were poor…
11
11
77
57
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.
12
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
999
30 min
LAS journey*
HASU
SU
After 72 hours
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
13was
*This
Community
Rehabilitation
Services
Discharge from
acute phase
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
the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU
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
Following bidding and evaluation a preferred model
was agreed and consulted on
15
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
The number of stroke patients taken by London
Ambulance Service to a HASU has been increasing as
implementation progresses
100%
90%
80%
70%
60%
Non-HASU
50%
HASU
40%
30%
20%
10%
e
-i
nd
ic
at
iv
Ju
l-1
0
ug
-1
0
A
Ju
n10
ay
-1
0
M
pr
-1
0
A
Fe
b10
M
ar
-1
0
O
ct
-0
9
N
ov
-0
9
D
ec
-0
9
Ja
n10
0%
17
Performance data shows that London is performing better
than all other SHAs in England
16%
Thrombolysis rates have increased
since implementation began to a
rate higher than that reported for
any large city elsewhere in the
world
12%
12%
10%
10%
8%
6%
4%
3.5%
2%
0%
Feb – Jul 2009
90
90
85
85
80
80
75
75
70
London
65
England
60
Target
55
AIM
Feb – Jul 2010
% of TIA patients’ treatment initiated within 24
hours
% achievement
% achievement
% of patients spending 90% of their time on a
dedicated stroke unit
14%
70
London
65
England
60
Target
55
50
50
45
45
40
40
Q1
Q2
Q3
2009/10
Q4
Q1
2010/11
Q1
Q2
Q3
2009/10
Q4
Q1
2010/11
18
Efficiency gains are also beginning to be
seen
Average length of stay
HASU destination on discharge
20
60%
18
50%
16
14
40%
12
10
30%
8
6
20%
4
10%
2
0
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2009/10
• The average length of stay has fallen from
approximately 15 days in 2009/10 to
approximately 11.5 days in 20010/11 YTD
2010/11
Jul
Aug
0%
Home
Other
Stroke Unit
RIP
(blank)
• Approximately 35% of patients are discharged
home from a HASU. The estimate at the
beginning of the project was 20%.
• This represents a potential saving of
approximately [DN - insert figure]
19
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
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
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