330 likes | 612 Views
Case History 1. 78 year retired Professor of History Having lunch with friend February 06 at 13.40 Sudden onset right hemiparesis and expressive dysphasia Arrived A&E 14.30 Hemianopia, Dense paresis arm and weak leg, right hemisensory loss and neglect NIH score 16 Thrombolysis at 15.10.
E N D
Case History 1 • 78 year retired Professor of History • Having lunch with friend February 06 at 13.40 • Sudden onset right hemiparesis and expressive dysphasia • Arrived A&E 14.30 • Hemianopia, Dense paresis arm and weak leg, right hemisensory loss and neglect • NIH score 16 • Thrombolysis at 15.10
Case History 1 • At 2 hours NIH score 5 • Dysphasia dramatically better and full visual fields, slight weakness right arm • At 24 hours NIH score 2
Case History 1 • At one week full neurological recovery Conclusion: Full recovery without infarction as a result of thrombolysis
Case History 2 • 28 year old visitor from Hull • Dysphasic and right hemiparesis on an open top bus • Arrived A & E on a Saturday • Initial scan at 3 hours 15 minutes
Case History 2 • Consented to IST 3 • Thrombolysed at 3 hours 30 minutes • Within 1 hour complete recovery clinically
Case History 2 • Discharged after 4 days asymptomatic Conclusion: Full recovery but with residual infarction
Key Recommendations:Emergency Response • Ambulance services: Category A and use FAST • Take patients to a hospital capable of providing high quality ‘hyper-acute’ care 24 hours a day. Minimum requirements are an acute stroke unit and 24 hour access to brain imaging • Immediate structured assessment e.g. ROSIER • Where brain scanning urgent – next scan slot or maximum of 1 hour
Key Recommendations:Emergency Response • Thrombolysis where appropriate • Direct admission to acute stroke unit • Specialist neuro-intensivist care including neuroradiology and neurosurgery rapidly available (malignant MCA infarction, Basilar artery occlusion and posterior fossa haemorrhage
Currently <0.2% of patients in England, Wales and Northern Ireland receive thrombolysis
How does thrombolysis look? • 205 patients in total thrombolysed • during 2006 • 33 North East • 15 in Scarborough • 20 in Cambridge • 43 in London • 12 in Oxford • 16 in Dorset • 17 in Devon • 10 in Bristol • 4 in West Midlands • 7 in Stoke • 17 on Merseyside • 6 in Manchester • 5 in Sheffield What about the other 100,000?
Time from Stroke to Admission (in hours for those admitted within 2 days)
Brain Imaging • Only 42% of patients had brain imaging to confirm the diagnosis within 24 hours of the onset of symptoms.
% Brain Scan Performed Within 24 hours by Region 42 Median for all hospitals
% Patients treated in Stroke Unit by Region 62 Median for all hospitals
% Patients Screened for Swallowing Deficits by Region 66 Median for all hospitals
Impact per SHA - outcomes Dr Stephen Green DH Vascular Programme December 2007
Impact per SHA – bed days Dr Stephen Green DH Vascular Programme December 2007
Requirements to deliver change • Change accepted • Collaboration • Clinical engagement • Clinical leadership • Co-operation • Collective commissioning
Lessons from the Audit • One audit is not enough. It needs to keep on coming back • It needs to keep evolving but with a sufficiently stable core to enable time comparisons • Performing badly on the audit is a very powerful tool for change. Performing well may incite complacency
Lessons from the Audit • Not everything can be changed at once. Pick one or two key items to push each time data becomes available. Use the arts of spinning • Need a comprehensive political strategy of which audit is just one cog
Optimism or Depression? • Best chance ever to improve stroke care • Government unchanged for next 2-3 years therefore no excuse for change in direction • NAO report due to Public Accounts Committee before the end of the parliament • Stroke seems to be near top of agenda • Likely that audit funding will be continued