Admissions Avoidance and Reducing Emergency Bed Days Focus on Stroke and Neurology

1. Admissions Avoidance and Reducing Emergency Bed DaysFocus on Stroke and Neurology Steve Pollock. SHA Clinical Advisor on Acute Care Lead Neurologist, EKHUFT

2. Acute stroke and neurology;what’s the problem? • Very common cause of admissions • 20% of medical admissions, 1987, (Morrow and Patterson) • 26% of medical admissions 2009 Bromley, Brex and Cai • 29% presentations to Leeds AMU April June 2008 Dunn • Occupied 248/1189 acute beds Audit Oct, 2009 EKHUFT • About half are stroke

3. Methods • The details of all medical patients admitted to PRUH over a 2-week period (Sept 2008) were recorded from daily handover sheets kept on EAU computer • Patients were considered neurological patients if • Main differential at most senior review was a neurological diagnosis (e.g. CVA, seizure etc.) • Unclear differential, but presenting complaint was neurological (e.g. confusion with no identified cause) • Social admissions due to problems arising principally from a neurological condition (Alzheimer’s and failure to cope)

4. Number of patients by specialty (n= 358)

5. 10th October 01:00 Bed Occupancy, with patients with neurological problem as the main cause of admission, major, or as secondary illness, minor. Figures in brackets are estimate of patients who could benefit from transfer to EKNU

6. Stroke, yes TIA clinics Thrombolysis Dedicated units Neurology, no Clinicsswamped by routine C&B, acute service reduced Admitted general beds Usually not seen by neurologist Care pathways

7. In-patient management by neurologists • “very few neurological in-patients are even seen by a neurologist”, Warlow et al , 2002 • “for epilepsy at least, diagnostic errors by non-neurologists were common”, Chadwick and Smith, 2002 • Encephalitis Society, in a survey of 1188 members, who had survived acute encephalitis, (28.5% response), demonstrated that of those who saw a neurologist less than half did so within the first day, while a third had to wait more than three days. Less than half were managed by nurses or therapists with specialist training in neurological diseases and only a quarter of those were transferred to a specialist ward on the first day. Easton, 2005

8. TIA Clinics- the theory • Incidence 0.25/1000 • High risk of stroke,15% in 2/52 after • Risk can be stratified by ABCD2 score • Urgent investigation and operation reduces risk of stroke

9. Risk of stroke • Score 1-3 (low) • 2 day risk = 1.0% • 7 day risk = 1.2% • Score 4-5 (moderate) • 2 day risk = 4.1% • 7 day risk = 5.9% • Score 6–7 (high) • 2 day risk = 8.1% • 7 day risk = 11.7%

10. TIA clinics, the theory • Only work properly if there is; • Same day MRI U/S • RACE within 2 days • Seven day service • Patients seen within 24 hours • Correctly triaged

11. TIA clinics- the practice • Surrey “This exists in all four hospitals but is office hours only and relies on a high level of admissions for ABCD2 of 4.” Agreed move to 7 day working but infrastructure uncertain • Sussex “All hospitals but only 5/7. No out of hour/weekend service for U/S or MRI, therefore patients are admitted.” • West Kent “Maidstone 5/7 urgent cases seen next day and non urgent within a week but triaging difficult, not yet using MRI and have some waits for U/S. Surgery improving but not upto National Strategy standards. Darenth Valley 5/7 U/S same day + 2 MRI slots per week.” • East Kent “365 clinics with same day access to MRA and 2 day access to neurovascular surgery”, but 50% patients referred not vascular but other neurological

12. Thrombolysis- the theory • Suitable patients can have strokes reversed by use of Alteplase • “ Time is brain” must be done within 3 hours • Requires good care pathway; • SECAMB • Reception area • Rapid scanning and consultant opinion

13. Thrombolysis in 3 hours Alive and 100 independent 30.2 80 Alive but 44.3 dependent 60 Dead 51.4 40 38.4 20 18.4 17.3 0 Thrombolysis Control Differences/1000: 141 extra alive and independent (P<0.01) 130 fewer dependent survivors (P<0.01) NINDS Trial Data: N Eng J Med 1995; 333:1581

14. Thrombolysis- the practice • Surrey “24/7 in each hospital except SASH. who are delayed because of staff problems, (hopefully resolved) and are diverting to Guildford with no local service.” • Sussex Currently 24/7 in Brighton, alternating OOH diverts in east sussex,24/7 Worthing and Chichester • West Kent Alternating OOH diverts between 4 hospitals, “not sustainable” • East Kent OOH telemedicine with 3 hospital and 1 in nine rota

15. Telemedicine advantages • Keeps service local • faster • reinforces local stroke unit • No difference in outcome • Only practical way to ensure rotas 24/7

16. VIMED.TELEDOC

17. Disadvantages • Clinician Suspicion • IT connectivity • Requires clinical governance and networking

18. Acute Neurology- some suggestions • TIA clinics make the them urgent neurovascular and neurology services • Change clinic emphasis to include urgent capacity • Increase emphasis on in-patient work by establishing liaison service and local beds • Why should neurology patients be treated differently to gastro-enterology?

19. Liaison neurology- the Leeds experience • What he does • Daily consultation to acute medical service • 3 liaison rounds to AMU • 2 acute clinics with direct access for acute physicians • How things have improved • Better/faster diagnoses • Noticeable improvement in management even when absent on leave of; • Spinal cord problems, alcohol/other fits, NEAD, stroke mimics • Better use of existing pathways and clinics • Reduced admissions and shorter stay.