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Acute Stroke Service Development


Learning objectives

  • Core aspects of acute service
  • Key points in improving care

Introduction

  • Any stroke service depends on efficient organisation of the patient pathway
  • Avoidance of any delays to time critical therapies
  • Adequate staffing with appropriate training and competencies
  • Effective self audit and governance
  • Involvement of patients and carers to ensure patient always at centre
  • Stroke medicine never remains static so a willingness to accept continual change

History of Services

It is useful to know where we have come from to know where we are and where we are going. A little bit of history is useful. Stroke medicine in the UK has transformed greatly over the past 15 years. As recent as the early 2000s in many UK hospitals patients with stroke could be found in any bed, on a gastrointestinal ward, in a side room in orthopaedics and the care was very poor. There were a few centres of excellence but outside of teaching hospitals where there was an academic interest care was very piecemeal. It seems bizarre now but the concept of even having designated geographical areas dedicated to stroke patients was a new concept. In some organisations back then one had to earn ones place on the stroke unit which was very rehabilitation focused. It was a bit like a spartan test of survival. Few units took stroke patients acutely. Access to imaging was difficult. It was not guaranteed that a CT scan would even be done and the best one could hope for was a scan in the first few days. Stroke was not a high priority for radiology. When I first started to set up thrombolysis this was only possible by myself in a room with the Chief executive telling the director of radiology to support immediate scanning which he reluctantly agreed to by labelling it as a "trials". All improvements in stroke care where hard won. It was only with the dedication and hard work of many of us in convincing our colleagues and often leading single consultant services that got us to where we are now.

Pre Hospital Care

ItemComments
Rapid IdentificationStrokes are painless and the symptoms may incapacitate or prevent immediate seeking of help. Rapid self identification or identification of stroke by laypeople, family and public. The FAST test has been adopted in the UK, Huge investment in National advertising helps for only a short period of time. Need to rapidly educate a population.
Public knowledge of what to doImportant that public understand that patient must be brought to a stroke centre. Difficulties when patients self present to the wrong hospital puts delays in system and care. Public should call emergency services. The exception is when local responders have a mobile stroke unit.
First respondersNeed to be trained on recognition of stroke. FAST also useful
First Responders Communications and supportIt can be useful for first responders to have access to nurse specialist by phone to discuss grey cases and also enables pre warning so can meet and greet and hand over in the ED
First Responders supportIt can be useful for first responders to have direct phone access to stroke specialist (nurse/doctor) to discuss grey cases and also enables pre warning so can meet and greet and hand over in the ED. This can also be used for stroke clinician to quickly determine time of onset, history, contraindications and previous level of function (mRS) and this can minimise need to retake the history on arrival and is used in the Helsinki model. It would be useful if the patient can be entered on Hospital IT systems to enable early scanning.

Mobile Stroke Units

Mobile stroke units (MSUs) have been developed and their role in the stroke pathway is not fully clear. The MSUs include a CT scanner to provide a non contrast CT head though some can also do CTA, point of care laboratory testing and a stroke physician, a nurse and paramedic and radiographer and so thrombolysis decisions can be made quickly. They were first developed in Germany. Now there are units across the US and UK (Southend). They may well deliver early delivery of thrombolysis but the cost in terms of manpower in a service in the UK which is short of same will be challenging.

Hospital

ItemComments
Meeting and GreetingThe stroke team should meet and greet paramedics in the ED and the patient taken straight to CT and NIHSS assessed on way and history clarified. CT is done in all and CTA if there is access to mechanical thrombectomy.
Rapid AssessmentImmediate assessment by stroke physician or neurologist 24/7 which may involve telemedicine and a decision made on acute reperfusion therapies
Neuro Intensive careA small number of stroke patients will require expert neurointensive care for neurology or cardiorespiratory support.
Endovascular therapiesImmediate access to Interventional Neuroradiologist 24/7 consideration for thrombectomy for those with large vessel obstruction. This may require transfer to another centre providing thrombectomy
Early Swallowing AssessmentSwallowing screening should be done early to reduce the risk of inappropriate feeding and to reduce the risk of aspiration pneumonia
Neurosurgical reviewImmediate Neurosurgical review 24/7 when appropriate - haemorrhage, hemicraniectomy, hydrocephalus
Multidisciplinary Stroke UnitImmediate admission to a stroke unit with access to the full complement of the multidisciplinary members of the stroke team. This is often difficult as there is a constant be shortage and there may not be a stroke bed. The SSNAP audit looks at admission to a stroke unit within 4 hours as a quality marker.

Ongoing care

Seamless transfer of care from hospital to community
Long term care and support
Local services to support people with stroke

Marker of a quality service

Overview of the 20 Quality Markers from the National Stroke Strategy
Awareness raising Members of the public and health and care staff are able to recognise and identify the main symptoms of stroke and know it needs to be treated as an emergency.
Managing risk Those at risk of stroke and those who have had a stroke are assessed for and given information about risk factors and lifestyle management issues (exercise, smoking, diet, weight and alcohol), and are advised and supported in possible strategies to modify their lifestyle and risk factors. Risk factors, including hypertension, obesity, high cholesterol, a trial fibrillation (irregular heartbeats) and diabetes, are managed according to clinical guidelines, and appropriate action is taken to reduce overall vascular risk.
Information, advice and support People who have had a stroke, and their relatives and carers, have access to practical advice, emotional support, advocacy and information throughout the care pathway and lifelong.
Involving individuals in developing servicesPeople who have had a stroke and their carers are meaningfully involved the planning, development, delivery and monitoring of services. People are regularly informed about how their views have influenced services.
Assessment - referral to specialist
  • Immediate referral for appropriately urgent specialist assessment and investigation is considered in all patients presenting with a recent TIA or minor stroke
  • A system which identifies as urgent those with early risk of potentially preventable full stroke - to be assessed within 24 hours in high-risk cases; all other cases are assessed within seven days
  • Provision to enable brain imaging within 24 hours and carotid intervention, echocardiography and ECG within 48 hours where clinically indicated.
  • TreatmentAll patients with TIA or minor stroke are followed up one month after the event, either in primary or secondary care.
    Urgent responseAll patients with suspected acute stroke are immediately transferred by ambulance to a receiving hospital providing hyper-acute stroke services (where a stroke triage system, expert clinical assessment, timely imaging and the ability to deliver intravenous thrombolysis are available throughout the 24-hour period).
    Assessment Patients with suspected acute stroke receive an immediate structured clinical assessment from the right people. Patients requiring urgent brain imaging are scanned in the next scan slot within usual working hours, and within 60 minutes of request out-of-hours with skilled radiological and clinical interpretation being available 24 hours a day. Patients diagnosed with stroke receive early multidisciplinary assessment - to include swallow screening (within 24 hours) and identification of cognitive and perceptive problems.
    Treatment
    • All stroke patients have prompt access to an acute stroke unit and spend the majority of their time at hospital in a stroke unit with high-quality stroke specialist care.
    • Hyper-acute stroke services provide, as a minimum, 24-hour access to brain imaging, expert interpretation and the opinion of a consultant stroke specialist, and thrombolysis is given to those who can benefit.
    • Specialist neuro-intensivist care including interventional neuroradiology /neurosurgery expertise is rapidly available.
    • Specialist nursing is available for monitoring of patients.
    • Appropriately qualified clinicians are available to address respiratory, swallowing, dietary and communication issues.
    High-quality specialist rehabilitationPeople who have had strokes access high-quality rehabilitation and, with their carer, receive support from stroke-skilled services as soon as possible after they have a stroke, available in hospital, immediately after transfer from hospital and for as long as they need it.
    End-of-life carePeople who are not likely to recover from their stroke receive care at the end of their lives which takes account of their needs and choices, and is delivered by a workforce with appropriate skills and experience in all care settings.
    Seamless transfer of careA workable, clear discharge plan that has fully involved the individual (and their family where appropriate) and responded to the individual's particular circumstances and aspirations is developed by health and social care services, together with other services such as transport and housing.
    Long-term care and supportA range of services are in place and easily accessible to support the individual long-term needs of individuals and their carers.
    Assessment and review
  • People who have had strokes and their carers, either living at home or in care homes, are offered a review from primary care services of their health and social care status and secondary prevention needs, typically within six weeks of discharge home or to care home and again before six months after leaving hospital.
  • This is followed by an annual health and social care check, which facilitates a clear pathway back to further specialist review, advice, information, support and rehabilitation where required.
  • Participation in community lifePeople who have had a stroke, and their carers, are enabled to live a full life in the community.
    Return to workPeople who have had a stroke and their carers are enabled to participate in paid, supported and voluntary employment.
    NetworksNetworks are established covering populations of 0.5 to 2 million to review and organise delivery of stroke services across the care pathway.
    Leadership and skills All people with stroke, and at risk of stroke, receive care from staff with the skills, competence and experience appropriate to meet their needs.
    Workforce review and developmentCommissioners and employers undertake a review of the current workforce and develop a plan supporting development and training to create a stroke-skilled workforce.
    Research and audit All trusts participate in quality research and audit, and make evidence for practice available.

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