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Innovations in Stroke Services in the United Kingdom

Innovations in Stroke Services in the United Kingdom. Dr Ben Bray Quality Improvement Fellow, Royal College of Physicians Clinical Lead (Stroke), Cardiovascular Intelligence Network, Public Health England. Innovations in Stroke Services in the United Kingdom*. Dr Ben Bray

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Innovations in Stroke Services in the United Kingdom

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  1. Innovations in Stroke Services in the United Kingdom Dr Ben Bray Quality Improvement Fellow, Royal College of Physicians Clinical Lead (Stroke), Cardiovascular Intelligence Network, Public Health England

  2. Innovations in Stroke Services in the United Kingdom* Dr Ben Bray Quality Improvement Fellow, Royal College of Physicians Clinical Lead (Stroke), Cardiovascular Intelligence Network, Public Health England *Mainly England

  3. Outline • Where have we come from? • Audit and quality improvement • Changing services: 7 day working, reconfiguration • Current priorities and future directions

  4. Stroke Services

  5. Where have we come from?

  6. What has happened in the past 30 years? • Stroke unit based care • Thrombolysis services • Stroke specialist training for physicians • Development of multidisciplinary teams • Early supported discharge • Rapid TIA services • Much better imaging • Secondary prevention • Primary prevention, especially atrial fibrillation

  7. “The performance of the UK in terms of premature mortality….is below the mean of the EU15+…….further progress will require improved public health, prevention, early intervention and treatment activities……and deserves an integrated and strategic response”

  8. Changes in Stroke Mortality 1968-2006

  9. Mortality: Ischaemic stroke Source: SINAP

  10. Mortality: Primary intracerebral haemorrhage Source: SINAP

  11. Mortality: Older people Source: SINAP

  12. Thrombolysis Source: SINAP/SSnap

  13. Appropriate place of care Source: SINAP/SSNAP

  14. Access to physiotherapy Source: SINAP/SSNAP

  15. Proportion of patients (by age band) receiving a scan within 24 hours of admission after stroke

  16. Audit & Quality Improvement

  17. Admission to acute stroke service Transfer to in-patient rehabilitation Data Discharge to community rehabilitation team 6 month review Complete pathway record

  18. Reorganising services

  19. Strokes happen on weekends!

  20. Differences in the processes of care for patients admitted in normal working hours and out of hours Eligibility for and compliance with process measures for normal hours and out of hours patients (adjusted odds ratios) Campbell et al. PLOS One 2014

  21. 7 day working - thrombolysis

  22. 7 day working – occupational therapy

  23. 7 day working - physiotherapy

  24. Risk of death by 30 days and weekend ratio of trained nurses per 10 stroke beds, by day of admission Higher nurse:bed ratio Adjusted for patient level prognostic variables, stroke service characteristics, consultant and care assistant staffing levels and care quality Bray et al. Submitted to PLOS Medicine

  25. Median arrival-tPA time by annual thrombolysis volume Bray et al. Stroke 2013

  26. Arrival-tPA for each volume group Bray et al. Stroke 2013

  27. Thrombolysis rate by onset-arrival time Bray et al. Stroke 2013

  28. London Stroke Reconfiguration • 28 stroke units  8 hyperacute SU and 20 post acute SU • 11,500 strokes a year in London – 2,000 deaths

  29. Percentage of all stroke admissions thrombolysed in London

  30. Risk adjusted mortality by quarter at 30 days in London, Manchester and the Rest of England

  31. Current priorities • Intermittent pneumatic compression for VTE prevention (CLOTS 3 Trial) • Evidence based care: AF, acute stroke, TIA management, thrombolysis pathway • Integration across cardiovascular diseases • Psychological, mental health and cognitive impairment after stroke

  32. Vascular Disease – One Event Leads to Another • Having Chronic Kidney Disease increases your chance of: • Heart attack by 2 times • Stroke up 50% • Having a stroke • increases your chance of: • Heart attack by 2-3 times • Another stroke by 9 times • Having a heart attack • increases your chance of: • Having another heart attack by 5-7 times • Stroke by 3-4 times Diabetes (type 2) Because of the increased risk associated with diabetes the risk is equivalent to having a heart attack • Having PAD increases your chance of: • Heart attack by 4 times • Stroke by 2-3 times Data is increased risk vs general population (%) *Includes angina and sudden death. Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD) **Includes only fatal heart attack and other CHD death; does not include non-fatal heart attack, + Includes death ++Includes TIA 1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9. 3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63. 4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.

  33. Cardiovascular Integration • Prevention • Cardiopulmonary rehabilitation after stroke and TIA • Shifting care where appropriate to community and primary care • Joining cardiovascular datasets for clinical care, quality improvement and research

  34. Thank you benjamin.bray@kcl.ac.uk

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