Governance of a Stroke Thrombolysis Service

Barry Moynihan

Framework

• Pathway

• Protocols

• Outcomes– Process– Clinical

• Monitoring– Local M&M– SITS/NICE

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

Pathway

• Mapping

• Geography & People

• Where the drug is given

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

Outcomes

• Process– ‘door to needle time’

• Clinical– Death– Haemorrhage– NIHSS– Modified Rankin Score

Haemorrhage after stroke rtPA

• Extracranial

• Intracranial– Symptomatic– Asymptomatic

NIHSS

• National Institutes of Health Stroke Scale

• 15 point clinical scale

• Predicts lesion size & outcome

• Validated

• Requires certification

Modified Rankin Score (mRS)

0 No symptoms at all1 No significant disability despite symptoms; able to carry

out all usual duties and activities2 Slight disability; unable to carry out all previous activities,

but able to look after own affairs without assistance3 Moderate disability; requiring some help, but able to walk

without assistance4 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

Monitoring

• Local– Clinical Networks

• National– SITS– NICE– SINAP

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:

1. There was a trial of therapy at 3-4 hours

2. All patients were entered onto the SITS register.

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

SITS (Safe Implementation of Thrombolysis in Stroke)

prospective internet-based audit of the International Stroke Thrombolysis Registry (ISTR)

Time delay (minutes): PREVIOUS Center UKAll

centres

Onset to A&E time Median 66 69 65

Door to imaging time Median 39 36 25

Imaging to report time Median 0 5 5

Door to needle time Median 62 70 66

Onset to needle time Median 139 155 145

Time delay (minutes): NOW Center UKAll

centres

Onset to A&E time Median 62 70 64

Door to imaging time Median 28 30 24

Imaging to report time Median 0 6 6

Door to needle time Median 50 58 65

Onset to needle time Median 130 135 145

Process

Clinical Outcome

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

None of these criteria are available from SITS

SINAP April 2010

SINAP April 2010

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)

Second National SINAP report (Feb 2011)

Summary

• Pathway

• Protocols

• Outcomes

• Monitoring

• Training

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/c

eeu/Current-work/stroke/Pages/SINAP.aspx