Reading Stroke Service 2016 Dr André van Wyk Stroke Consultant

1. Reading Stroke Service 2016Dr André van Wyk Stroke Consultant

2. Stroke types and mechanisms

3. Stroke • Complex (need for specialists): - • medically unstable at risk complications and early progression • functional- motor leg & arm power: sitting,walking; speech: communication; brain processing: memory, planning, orientation, mood • body working swallowing: feeding, medication –affects survival • Unstable first 24 hours- need early access Stroke Unit • Stroke management requires coordinated multidisciplinary working

4. Integrated local health, social and voluntary sector working (quality): prevention, hyperacute, acute stroke unit, specialist stroke community rehab, long-term care • Whole pathway required to treat stroke –interdependant • Spending by commission or omission: reablement/ less functional dependency vs or on care • clearly costed Stroke Strategy its cheaper and more cost effective to provide quality stroke service

5. 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 detects common but not other types stroke and symptoms eg sudden loss balance; dizziness; vision: loss in one or both eyes or double; inability swallow

6. 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’

7. 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

8. Impact of Stroke: on society • Every five minutes someone in the UK has a stroke. • Each year estimated 150,000 people in UK have a stroke. • Stroke third most common cause of death in the UK. • Over a million people have had a stroke living in the UK, around half of all stroke survivors dependent on others for everyday activities • Single largest cause of adult disability

9. How does one diagnose, assess and manage: Risk factors for TIA and Stroke • Campaigns, education • Lifestyle, genetic and biological make up and impact of other disease • History in family, smoking, activity; Examination weight, checking pulse BP and Investigations blood sugar cholestrol, ECG check for AF then more specialised eg very young patient screen cardiac and scanning carotid arteries • Management: individualise recog specific risk factors and education eg stopping smoking, diet and exercise • Medication aspirin statin blood pressure warfarin NOAC • Specialised eg. urgent referral carotid surgery or closure of Left Atrium if unable anticoag or closing hole in heart PFO

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

11. TIA Mobile phone service (40595) Clinics 7/7 days a week Aim to see patients within 24 hours of referral – patients decline appointments! Already in 2009 578 patients seen in clinic in 340 were TIAs 65% high risk seen within 24 hours

15. 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 • Direct admission HASU/ Acute Stroke Unit for initial hyperacute treatment, monitoring restoration of physiological milieu • Prevention and treatment risk factors that may result further stroke and complications of the stroke

16. Multidisciplinary assessment and closely coordinated management to deal with all complex issues in stroke with rehabilitating and caring for patient and their family • Specialist rehabilitation and person specific goal setting done with patient and family both in Stroke Unit • Specialist Stroke Early Supported Discharge team (a third patients) in the community needed to extend and reintegrate function to home • Long Term life after stroke, Voluntary agencies Stroke patient and family Stroke Recovery Service Coordinator Return to Work strategies. Need for equipment and Care

17. End-of-life care

18. 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: National Sentinel Stroke Audit now evolved to SSNAP data on every stroke patient admission/ Ambulance Trust

20. Stroke Strategy 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 especially hypertension • Act on warning TIA or Stroke- medical emergency • Rapid Access TIA service • Hyperacute Stroke serviceable to provide 24/7 thrombolysis • Stroke Unit (coordinated MDT) benefits all patients specialist rehab • Early Supported Discharge (specialist stroke rehabat home) • Long Term Care

22. Thrombolysis • 24/7 Thrombolysis Service • Ambulance response upgraded to Cat A • 51 patients thrombolysed so far with 3 in last 5 days

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

24. The whole pathway Stroke service at RBFT and surrounding areas • Acute Stroke Unit started 2001 6 beds Battle Hospital now 30 bed combined Acute Stroke Unit RBFT with 6 bed HASU • RBFT Stroke Service awarded HASU 24/7 April 2011 extended Thrombolysis started 2009 after hours off site stroke consultant • Rapid Access TIA would be 7/7 by April 2011 (started 5/7 initially 2005 extended pilot last 22 months) • ESD Stroke Early Supported Discharge rehab service Berk West plus extended with CBNRT, also ESD S Oxon and East Berkshire ESD • Patient and family Stroke Recovery Service Coordinators posts with key role in support and Longer Term Care stroke patients with coord Stroke support networks eg stroke clubs, information and sign posting

25. The Future • Continue to provide the best service accordence with SSNAP • Move to London Model Jan 2017 where all patients with stroke would only be able to be admitted to a HASU stroke service (redesign stroke pathways increase stroke capacity need at RBFT • Time is brain • Continue to provide clot busting thrombolysis service safely to as many as are eligible in the shortest door to needle time • Need to start to provide clot extraction thrombectomy and maybe develop locally • Incorporate new developments in service as evidence emerges

27. Stroke Pathway Incorporating ESD Service

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

29. National NHIR SRN Team of the Year Research Runner Up Award 2013

30. RBFT stroke service "fastest thrombolysis centre quartile April to June 2015 average 25 minutes DTNT, thrombolysing 4th highest proportion 24.4% UK.”

31. RBFT stroke research team winning “Best Green Shoots Research “NIHR TVH Health research 12/10/2016 award St Hildas College Oxford

32. Thank you for your attention Any questions?