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Understanding and Managing Stroke: RBFT Stroke Services 2011 Conference

Join Dr. André van Wyk and other stroke consultants at the Royal Berkshire Hospital on June 28, 2011, for an informative event on stroke. Learn about recognizing and diagnosing stroke, the impact on patients, families, and society, and the future of stroke management. Explore the whole pathway of stroke services at RBFT and surrounding areas.

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Understanding and Managing Stroke: RBFT Stroke Services 2011 Conference

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  1. RBFT Stroke Services 2011Dr André van Wyk Stroke Consultant Members event Royal Berkshire Hospital 28 June 2011

  2. Introduction • What is a Stroke? • How does one recognise a Stroke? • Impact of Stroke: patient, on the family, on society, economy • How does one diagnose, assess and manage: TIA, Stroke and Risk factors • What are the National Guidelines and way services are measured • Vital different components of TIA and Stroke service and benefits • The whole pathway Stroke service at RBFT and surrounding areas • The Future Stroke 2010

  3. What is a TIA and Stroke? • A TIA (sometimes called a mini stroke) is similar to a full stroke but the symptoms may only last a few minutes and will have completely gone within 24 hours • TIA -Acute focal cerebral or monocular symptoms less than 24 hours as a result of thromboembolic disease • A stroke is a brain attack. It happens when the blood supply to the brain is disrupted. Most strokes occur when a blood clot blocks the flow of blood to the brain. Some strokes are caused by bleeding in or around the brain from a burst blood vessel. • Stroke syndrome, rapidly developing clinical symptoms, focal occasionally global loss of cerebral function, lasting more than 24 hours or leading to death • Brain Attack or Acute Stroke Syndrome for symptom present with in 24 hours of onset

  4. Stroke types and mechanisms

  5. Stroke • Complex patients (need for specialists): - • medically unstable at risk complications and early • functional- motor leg & arm power: sitting, walking; speech: communication; brain processing: memory, planning, orientation • body working swallowing: feeding, medication –affects survival • Change occurs in first 24 hours- need early access Stroke Unit • Stroke management requires coordinated multidisciplinary working • Integrated local health, social and voluntary sector working (quality): prevention, hyperacute, acute stroke unit, specialist community rehab, long-term care • Whole pathway required to treat stroke –interdependent • Spending by commission or omission: reablement/ less functional dependency vs or on care

  6. How does one recognise a Stroke? • Early recognition and management of a stroke is important • Commonly patient may not recognise they’ve had a stroke • FAST common but also other types stroke and symptoms eg sudden loss balance; dizziness; vision: loss in one or both eyes or double; inability swallow

  7. Impact of Stroke: patient • Sense of self • Loss confidence, self worth, depression • Changes way one thinks, all the functional daily activities and extended activities one takes for granted • Loss independence • Need to come to terms with dramatic change while engaging in very activity physical and cognitive rehabilitation to find a new ‘orbit’

  8. Impact of Stroke: on the family • Stroke impact is often life long • ‘family’ disease • affect family dynamics and relationships • role: bread winner / parent / husband or wife • career and hobbies

  9. Impact of Stroke: on society • Facts about stroke • Every five minutes someone in the UK has a stroke. • Each year an estimated 150,000 people in the UK have a stroke. • Stroke is the third most common cause of death in the UK. • There are over a million people who have had a stroke living in the UK, and around half of all stroke survivors are left dependent on others for everyday activities • Single largest cause of adult disability

  10. Stroke Data • 110,000/ y England. • third highest cause death England : 11 per cent of deaths England. • 20–30 % die within a month. • 25 % occur under age of 65. • >900,000 people living in England have had a stroke. • single largest cause of adult disability • devastating and lasting impact on lives of people and their families. • Often live with the effect of stroke rest of their lives. • A third are left with long-term disability.. • Costs NHS and economy about £7 billion/y: £2.8 billion direct costs NHS, £2.4 billion informal care costs (e.g. the costs of home nursing borne by patients’ families) and £1.8 billion income lost to productivity and disability. • Outcomes UK compare poorly internationally, despite expense, unnecessarily long lengths of stay and high levels avoidable disability and mortality.

  11. Impact of Stroke: economy • Costs NHS and economy about £7 billion/y: £2.8 billion direct costs NHS, £2.4 billion informal care costs (e.g. the costs of home nursing borne by patients’ families) and £1.8 billion income lost to productivity and disability. • Situation till recently is that outcomes UK poor compared to internationally, despite expense, unnecessarily long lengths of stay with high levels avoidable disability and mortality.

  12. How does one diagnose, assess and manage: Risk factors for TIA and Stroke • Lifestyle, genetic and biological make up and impact of disease • Campaigns, education • History eg of family, smoking; Examination eg weight, checking BP and Investigations cholesterol, ECG check for AF then more specialised eg cardiac and scanning carotid arteries • Management: working out specific risk factors and education eg stopping smoking, diet and exercise • Medication aspirin statin blood pressure warfarin • Specialised eg. urgent referral carotid surgery

  13. Concepts • Risk factors • Hypertension Meta analysis Stroke 2004 : 35:776 >188000 with 6800 stroke events 10 mm Hg reduction systolic blood pressure reduces stroke by 1/3 • Cholesterol meta analysis Amarenco Stroke 2004:35:2902 Effect related to LDL reduction each 10% reduction decreased stroke by 15.6%

  14. 50.0 32.7 70-99% 50-69% 40.0 16.0 30.0 13.8 9.4 11.2 20.0 3.4 ARR (%), 95% CI -2.9 0.0 10.0 0.0 -10.0 -20.0 0-2 2-4 4-12 12+ Weeks between symptomatic event and randomisation Effect of carotid endarterectomy stratified by time from last event to randomisationIpsilateral ischaemic stroke and operative stroke or death Lancet 2004; 363: 915-24

  15. Higher risk < 1 day Lower risk < 1 week Non-urgent

  16. TIA Mobile phone service (40595) Clinics 5 days a week Aim to see patients within 24 hours of referral – patients decline appointments! 578 patients seen in clinic in 2009 340 were TIAs 65% high risk seen within 24 hours

  17. Principles in managing Stroke patients • Need to diagnosis: stroke, type and cause EARLY access to high tech radiology and cardiac • Time is brain • emergency pathway to restore blood supply brain –thrombolysis • Brain receptive to remodelling the dendrites sprouting- early rehab • Early admission to Stroke Unit for Multidisciplinary assessment and closely coordinated management to deal with all complex issues in stroke with rehabilitating and caring for patient and their family • Prevention and treatment risk factors that may result further stroke and complications of the stroke • Specialist rehabilitation and person specific goal setting done with patient and family both in Stroke Unit and if needed with specialist stroke Early Supported Discharge team in the community to extend and reintegrate function to home • Long Term Care

  18. End-of-life care

  19. What has changed in Stroke? • National Stroke Strategy 5 Dec 2007 : 20 quality markers /10-point plan of action • Prevention treat TIA as emergency 2/3 seen and treated within 24h • Hyperacute Stroke Pathway 1/3 admissions thrombolyse 1:3 (10 % 24/7 service) • Stroke Specialist rehabilitation geared individual needs 7 days per week : Stroke Unit and ESD • Long Term care/ follow up-emotional needs psychological • Radical change in Stroke management since 2007 • 2 Guidelines on being major acute Hospital • DARZI & RCP acute medical care Oct. 2007 • Delivery: NSS Organisational matrix / Performance Indicators / National Sentinel Stroke Audit / Ambulance Trust

  20. Ten-point plan for action • Awareness • Preventing stroke • Involvement • Acting on the warnings • Stroke as a medical emergency • Stroke unit quality • Rehabilitation and community support • Participation • Workforce • Service improvement

  21. Vital different components of TIA and Stroke service and benefits • Avoidhaving a stroke –lifestyle and risk factors esp. hypertension • Act on warning TIA or Stroke- medical emergency • Rapid Access TIA service • Stroke Unit (coordinated MDT) benefits all patients specialist rehab • Hyperacute Stroke service able to provide 24/7 thrombolysis • Early Supported Discharge (specialist stroke rehab at home) • Long Term Care

  22. Thrombolysis Cochrane library 2003 • Thrombolysis A&I 44.3 A&D 38.4 Dd 17.3 • Control A&I 30.2 A&D 51.4 Dd 18.4 • Differences per 1000 – 141 extra AI 130 fewer D, 12 fewer Dd

  23. Pooled Analysis tPA TrialsLancet 2004:363:768-774 • OR for favourable tPA (95% CI) TIME • 2.8 (1.8-4.5) 0-90 mins • 1.6 (1.1-2.2) 91-180 • 1.4 (1.1-1.9) 180-270

  24. DATA from SITS-MOST registryLancet 27 January 2007

  25. Thrombolysis • 08.00 – 18.00 Thrombolysis Service • Ambulance response upgraded to Cat A • 27 patients thrombolysed so far • Only one haemorrhage

  26. Press launch for ESD January 2010www.royalberkshire.nhs.uk/new/new_video/stroke.aspx

  27. The whole pathway Stroke service at RBFT and surrounding areas • Acute Stroke Unit started 2001 6 beds to 13 Battle Hospital now 28 combined Stroke Unit RBFT since 2007 • Neurorehabilitation service 8 stroke beds, vocation and spasticity service • Rapid Access TIA service 2005 extended pilot to the last 22 months week days seeing high risk patients within 24h • Thrombolysis 10h /d week days 18 months with Cat A ambulance • ESD Early Supported Discharge rehab service Berk West 13 months with CBNRT for further targeted input • Currently 3 Stroke patients family support workers (2 have funding only further 9 months)

  28. Employed 2nd Stroke Consultant (Sept 08) Stroke Registrar shred rotation Oxford (new post) More junior doctors Funding for band 6 & band 2 nurses Business case for increase in therapy team

  29. The Future • Plans currently for business case to extend Thrombolysis to 24/7 by April 2011. This will involve the RBFT first use of telemedicine • Rapid Access TIA would be 7/7 by April 2011 • ESD service has been agreed for S Oxon currently setting up • Ensure extending funding for 2 Stroke Family and Support worker posts with key role in support and Longer Term Care stroke patients with co-ordinator Stroke support networks eg stroke clubs, information and sign posting • Setting up education programme staff and Information resources

  30. Stroke Pathway Incorporating ESD Service

  31. HQIP GOLD award won by stroke service RBFT for improvements to service through Audit 2010

  32. Thank you for your attention Any questions

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