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Governance of a Stroke Thrombolysis Service

Governance of a Stroke Thrombolysis Service. Barry Moynihan. Framework. Pathway Protocols Outcomes Process Clinical Monitoring Local M&M SITS/NICE. and of course…………………. Training & Education. Pathway. Mapping Geography & People Where the drug is given. Protocols. Pre-hospital

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Governance of a Stroke Thrombolysis Service

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  1. Governance of a Stroke Thrombolysis Service Barry Moynihan

  2. Framework • Pathway • Protocols • Outcomes • Process • Clinical • Monitoring • Local M&M • SITS/NICE

  3. and of course………………….Training & Education

  4. Pathway • Mapping • Geography & People • Where the drug is given

  5. Protocols • Pre-hospital • Hospital assessment & administration • Inclusion/exclusion checklist • Thrombolysis proforma • The 1st 24 hours • Nursing care plan • What to do about deterioration • Repeat brain imaging • Outcomes

  6. Outcomes • Process • ‘door to needle time’ • Clinical • Death • Haemorrhage • NIHSS • Modified Rankin Score

  7. Extracranial Intracranial Symptomatic Asymptomatic Haemorrhage after stroke rtPA

  8. NIHSS • National Institutes of Health Stroke Scale • 15 point clinical scale • Predicts lesion size & outcome • Validated • Requires certification

  9. Modified Rankin Score (mRS) 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention 6 Dead

  10. Monitoring • Local • Clinical Networks • National • SITS • NICE • SINAP

  11. What is SITS? • 2000: SITS set up in Sweden for local purposes (Svenska Implementeringskommittén för Trombolys vid Stroke) • 2001: EMEA licensed Alteplase until 2005 on 2 conditions: • There was a trial of therapy at 3-4 hours • All patients were entered onto the SITS register.

  12. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007 Jan 27;369(9558):275-82

  13. SITS (Safe Implementation of Thrombolysis in Stroke) prospective internet-based audit of the International Stroke Thrombolysis Registry (ISTR)

  14. Process

  15. Clinical Outcome

  16. NICE 2007 This appraisal covers the use of Alteplase in acute ischaemic stroke.

  17. None of these criteria are available from SITS

  18. SINAP April 2010

  19. SINAP April 2010

  20. SINAP Local Monthly Report Feb 2011 • Admissions • Total: 134 • Stroke: 77 (57%) • TIA: 22 (16%) • Non Stroke: 35 (26%) • Thrombolysis • Total Thrombolysed:7 (9% of patients with a diagnosis of stroke – one as part of IST3) • 100% eligible cases • Mean DTN time 49 mins (32 minutes Feb 2012) • DTN > 60 mins exceptions • IST3 70 mins • 90 mins (45 mins to confirm time of onset in aphasic pt)

  21. Second National SINAP report (Feb 2011)

  22. Summary • Pathway • Protocols • Outcomes • Monitoring • Training

  23. Useful Links • http://nihss-english.trainingcampus.net/uas/modules/trees/windex.aspx • http://www.rankinscale.org/links.shtml • http://www.acutestroke.org/ • http://www.nice.org.uk/guidance/TA122 • http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/SINAP.aspx

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