Managing acute stroke: What should cardiologists know?

Prof. Charlie DavieUCL Partners Stroke Lead

University College London

Why the need for change?

‘Better care demands changing organisation of services’

Professor R Boyle. Mending Hearts and brains

•The National Service Framework for long term conditions

7 day in-hospital mortality for all stroke patients in EnglandApril 2009-March 2010

93,621 admissions. Dr Foster data

0.50.60.70.80.9

11.11.21.31.41.5

Odd

s ra

tio (v

. Mon

day

= 1)

350 avoidable deaths/year if weekend performancematched the normal working week

Thrombolysis rates in UK-

April 2009-March 2010 2.5%

Rates comparable with USA.

Best centres in each country 15% or more

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

Model of acute stroke care in London before February 2010

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

After an unspecified time, when bed available

Discharge from acute phase

Community Rehabilitation

ServicesLocal A&E then MAU*

ASU or ward

999

Source: Healthcare for London Stroke Strategy, 2007

Ambulance travels to nearest hospital with A&E

7

The development of the strategy was subject to wide engagement with the model of care agreed by clinicians

and user groups

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

30 min LAS journey* After 72 hours

Discharge from acute phase

Community Rehabilitation

ServicesHASU SU

*This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU.

999

New acute model of care

8

‘FAST’ Public awareness campaign

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

• 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

HASUs achieving all 7 standards for quality acute stroke care

• 5 of the 6 top stroke services were in London• All HASUs in London were in the top quartile of national performance

No

Yes

No

Yes

London HASUs

National resultYes

Yes

No

No

London HASUs

National result

93%

7%

39%

61%

75%

25%

75%

25%

Patients directly admitted to a stroke unit for pre-72 hour care

12

Performance data shows that London is performing better than all other SHAs in England

40

45

50

55

60

65

70

75

80

85

90

Q1 Q2 Q3 Q4 Q1

2009/10 2010/11

% a

chie

vem

ent

London

England

Target

Thrombolysis rates have increased since implementation began to a rate

higher than that reported for any large city elsewhere in the world

% of patients spending 90% of their time on a dedicated stroke unit

40

45

50

55

60

65

70

75

80

85

90

Q1 Q2 Q3 Q4 Q1

2009/10 2010/11

% a

ch

iev

em

en

tLondon

England

Target

% of TIA patients’ treatment initiated within 24 hours

12%

10%

3.5%

Feb – Jul 2009 Feb – Jul 2010AIM Jan-March 2011

13.8%

13

Efficiency gains are also beginning to be seen

0

2

4

6

8

10

12

14

16

18

20

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

2009/10 2010/11

Average length of stay HASU destination on discharge

• Approximately 35% of patients are discharged home from a HASU. The estimate at the beginning of the project was 20%.

0%

10%

20%

30%

40%

50%

60%

Stroke Unit Home Other RIP

• 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

UCLP Hyperacute Stroke Unit (HASU) opened in February 2010 and will disseminate good practice

in London and to other large global cities     

UCLP COLLABORATIVE STROKE INITIATIVE

Brings together the largest critical mass of stroke neurologists in the UK in a comprehensive stroke service

 The clinical program will drive a major academic development bringing translational stroke

researchers in an "Institute of Stroke Research”

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

Discharge destination:

26, 38%

8, 12%

24, 35%

10, 14%1, 1%

Home NHNN Other SU

Other teams RIP Breakdown of SU destinations

NHNN: 8 ptsNorth Midd: 5 ptsWhipps Cross: 1 ptRoyal Free: 5 ptsSt Mary’s: 5 ptsSt George’s 1 ptBarnet: 4 ptsC Cross 1 ptC & West 1 ptOthers: 1 pts

COLLABORATIVE STROKE INITIATIVE

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&D anatomy of specific deficits

Small Population impact

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

NCL SU and TIA

HfL HASU designation

Comprehensive NCL programme 1500 pts p.a.

Coordinated network of 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

BEFORE NOW COMING

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

1. Stroke education and public awareness

2. Primary prevention and population risk factors

3. Stroke and TIA hospital admissions (acute management and treatment)

4. Rehabilitation/access to services/ PROMS*/Mortality

5. Follow-up/secondary prevention and hospital readmissions

6. 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?

Element of pathway Whole-pathway outcome measure

* PROMS: Patient Reported Outcome Measures Source: NCL/UCLPartners stroke working group

“Whole pathway” approach to measuring quality in stroke