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Governance of a Stroke Thrombolysis Service Barry Moynihan.

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Presentation on theme: "Governance of a Stroke Thrombolysis Service Barry Moynihan."— Presentation transcript:

1 Governance of a Stroke Thrombolysis Service Barry Moynihan

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

3 Training & Education 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 1 st 24 hours –Nursing care plan –What to do about deterioration –Repeat brain imaging Outcomes

6 Process –‘door to needle time’ Clinical –Death –Haemorrhage –NIHSS –Modified Rankin Score

7 Haemorrhage after stroke rtPA Extracranial Intracranial –Symptomatic –Asymptomatic

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: 1.There was a trial of therapy at 3-4 hours 2.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 Time delay (minutes): PREVIOUSCenterUK All centres Onset to A&E timeMedian 666965 Door to imaging timeMedian 39 3625 Imaging to report timeMedian 055 Door to needle timeMedian 62 7066 Onset to needle timeMedian 139155145 Time delay (minutes): NOWCenterUK All centres Onset to A&E timeMedian 627064 Door to imaging timeMedian 28 3024 Imaging to report timeMedian 066 Door to needle timeMedian 50 5865 Onset to needle timeMedian 130135145 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


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- windex.aspxhttp://nihss- windex.aspx standards/ceeu/Current- work/stroke/Pages/SINAP.aspx standards/ceeu/Current- work/stroke/Pages/SINAP.aspx

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