Managing acute stroke: What should cardiologists know?

1. Managing acute stroke: What should cardiologists know? Prof. Charlie Davie UCL Partners Stroke Lead University College London

2. Why the need for change? • The National Service Framework for long term conditions ‘Better care demands changing organisation of services’ Professor R Boyle. Mending Hearts and brains

3. 7 day in-hospital mortality for all stroke patients in EnglandApril 2009-March 201093,621 admissions. Dr Foster data 350 avoidable deaths/year if weekend performance matched the normal working week

4. Thrombolysis rates in UK- April 2009-March 2010 2.5% Rates comparable with USA. Best centres in each country 15% or more

5. Graph of model estimating odds ratio for favourable outcome at 3 months in i.v. thrombolysis treated patients compared to placebo treated patients by time from stroke onset to treatment with 95% confidence intervals

6. 999 Local A&E then MAU* ASU or ward Model of acute stroke care in London before February 2010 Community Rehabilitation Services Ambulance travels to nearest hospital with A&E After an unspecified time, when bed available Discharge from acute phase • Initial treatment • Patients triaged on arrival to A&E • Generally patients then admitted to • a Medical Assessment Unit while • awaiting definitive bed • Length of stay up to 72 hours • before bed available • Acute Stroke Units (ASUs) • Inpatient treatment and rehabilitation in a local hospital • Admission to a general medical ward, geriatric ward, or • ASU depending on local practice, bed availability • (occupancy and staffing levels) • Not all hospitals treating stroke patients had ASUs • Generally only stroke physicians had admitting rights to • ASUs, but various types of physician in charge of stroke • patients (including general physicians, geriatricians) • In all settings, length of stay variable and level of • expertise and available treatments/therapies variable • Wide variation in numbers of patient treated across • settings 6 Source: Healthcare for London Stroke Strategy, 2007

7. The development of the strategy was subject to wide engagement with the model of care agreed by clinicians and user groups 999 HASU SU New acute model of care Community Rehabilitation Services Discharge from acute phase 30 min LAS journey* 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 • 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 *This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU. 7

8. ‘FAST’ Public awareness campaign 8 Source: NHS London Public Information campaign, 2008-10

9. Implementation has taken place in stages from February 2010 and went ‘fully live’ July 2010 Stroke networks across London led implementation with oversight from the pan-London cardiac and stroke network board A new stroke tariff was devised to reflect the changes in the pathway and the cost of the improvements in service Major workforce and recruitment across all trusts was necessary 9

10. Opening of hyper-acute beds took place in phases from Feb 2010 • 116 beds now open across 8 units in London • Stroke units commenced opening in October 2009 • 484 beds now open across 22 units in London • Robust LAS protocols developed to reflect implementation phases

11. The 2010 National Sentinel Stroke Audit has shown huge improvements in stroke care in London • 5 of the 6 top stroke services were in London • All HASUs in London were in the top quartile of national performance Patients directly admitted to a stroke unit for pre-72 hour care HASUs achieving all 7 standards for quality acute stroke care London HASUs London HASUs No No 25% 25% Yes 75% Yes 75% National result National result Yes 7% Yes 39% No No 61% 93% 11

12. Performance data shows that London is performing better than all other SHAs in England 13.8% Thrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world 12% 10% 3.5% Feb – Jul 2009 AIM Feb – Jul 2010 Jan-March 2011 % of patients spending 90% of their time on a dedicated stroke unit % of TIA patients’ treatment initiated within 24 hours 12

13. Efficiency gains are also beginning to be seen Average length of stay HASU destination on discharge • The average length of stay has fallen from • approximately 15 days in 2009/10 to • approximately 11.5 days in 20010/11 YTD • This represents a potential saving of • approximately £3.5m over a 6 month period • Approximately 35% of patients are discharged • home from a HASU. The estimate at the • beginning of the project was 20%. 13

14. UCLP COLLABORATIVE STROKE INITIATIVE Brings together the largest critical mass of stroke neurologists in the UKin a comprehensive stroke service UCLP Hyperacute Stroke Unit (HASU) opened in February 2010 and will disseminate good practice in London and to other large global cities  The clinical program will drive a major academic development bringing translational stroke researchers in an "Institute of Stroke Research”

15. North Central London Stroke ServiceOutcomes from February 2010-June 2010 • 12 neurologists/stroke physicians from ALL NCL acute trusts running UCLH HASU • June 2010 -30 day in-hospital Mortality of 6% for stroke patients admitted via UCH HASU v UK national stroke mortality rate 20.7%* • Thrombolysis rates in North Central London increased by 204% compared to previous year • * Dr Foster data

16. Discharge destination: Breakdown of SU destinations NHNN: 8 pts North Midd: 5 pts Whipps Cross: 1 pt Royal Free: 5 pts St Mary’s: 5 pts St George’s 1 pt Barnet: 4 pts C Cross 1 pt C & West 1 pt Others: 1 pts

17. COLLABORATIVE STROKE INITIATIVE NCL SU and TIA HfL HASU designation NOW COMING BEFORE Fragmented NCL provision (e.g. RFH-UCH -2 small competing units, 300 cases each) Thrombolysis rate 18% vs average 9% Low inpt mortality 10% vs 20.7% R&Danatomy of specific deficits Small Population impact Comprehensive NCL programme 1500 pts p.a. Coordinated networkof 12 NCL stroke physicians and neurologists Endovascular stroke service HASU accreditation and commendation from HfL >50% decrease in door to needle time Successful repatriation from HASU systematic approach to quality Link across HIEC > 8000 pts p.a. R&D network, :prevention, novel treatment, rehabilitation, Endovascular stroke service 24/7 aim for a pan-London network Demonstrable quality improvement across whole stroke pathway-working with Kings Fund Reduced stroke mortality and morbidity for the population Global benchmarking-Yale, Cleveland clinic

18. A few ways to improve patient care at scale • Use of Networks to support integrated care • Reliable and regular collection of comparable data preferably across whole pathway • Monitoring of Quality standards

19. “Whole pathway” approach to measuring quality in stroke • Element of pathway • Whole-pathway outcome measure Stroke education and public awareness Primary prevention and population risk factors Stroke and TIA hospital admissions (acute management and treatment) Rehabilitation/access to services/ PROMS*/Mortality Follow-up/secondary prevention and hospital readmissions Measurement of patient experience • Population awareness of risk factors • Population awareness of FAST • Population incidence of stroke • Acute mortality • %discharges direct to home from HASU • Readmissions • Functional status • Return to pre-stroke life role • SF36 • Secondary incidence • Population mortality • Was care well-connected? • Did you get understand care plan & have chance to make choices? * PROMS: Patient Reported Outcome Measures Source: NCL/UCLPartners stroke working group