Case History 1  78 year retired Professor of History  Having lunch with friend February 06 at  Sudden onset right hemiparesis and expressive dysphasia  Arrived A&E  Hemianopia, Dense paresis arm and weak leg, right hemisensory loss and neglect  NIH score 16  Thrombolysis at 15.10

Case 1 pre CT

Case History 1  At 2 hours NIH score 5  Dysphasia dramatically better and full visual fields, slight weakness right arm  At 24 hours NIH score 2

Case 1 24 hours post-stroke

Case History 1  At one week full neurological recovery Conclusion: Full recovery without infarction as a result of thrombolysis

Case History 2  28 year old visitor from Hull  Dysphasic and right hemiparesis on an open top bus  Arrived A & E on a Saturday  Initial scan at 3 hours 15 minutes

Case 2 Initial CT

Case History 2  Consented to IST 3  Thrombolysed at 3 hours 30 minutes  Within 1 hour complete recovery clinically

Case 2, 24 Hour MRI

Case History 2  Discharged after 4 days asymptomatic Conclusion: Full recovery but with residual infarction

Key Recommendations: Emergency Response  Ambulance services: Category A and use FAST  Take patients to a hospital capable of providing high quality ‘hyper-acute’ care 24 hours a day. Minimum requirements are an acute stroke unit and 24 hour access to brain imaging  Immediate structured assessment e.g. ROSIER  Where brain scanning urgent – next scan slot or maximum of 1 hour

Key Recommendations: Emergency Response  Thrombolysis where appropriate  Direct admission to acute stroke unit  Specialist neuro-intensivist care including neuroradiology and neurosurgery rapidly available (malignant MCA infarction, Basilar artery occlusion and posterior fossa haemorrhage

Currently <0.2% of patients in England, Wales and Northern Ireland receive thrombolysis

How does thrombolysis look? 205 patients in total thrombolysed during North East 15 in Scarborough 20 in Cambridge 43 in London 12 in Oxford 16 in Dorset 17 in Devon 10 in Bristol 4 in West Midlands 7 in Stoke 17 on Merseyside 6 in Manchester 5 in Sheffield What about the other 100,000?

Time from stroke to admission (Days)

Time from Stroke to Admission (in hours for those admitted within 2 days)

Brain Imaging  Only 42% of patients had brain imaging to confirm the diagnosis within 24 hours of the onset of symptoms.

% Brain Scan Performed Within 24 hours by Region Median for all hospitals 42

Time from Stroke to Scan

Time of Day Scanning Performed

Age and Brain Imaging

Hospital Care and Longer term Rehabilitation

Time from Stroke to Stroke Unit Admission

Results: Stroke unit provision – comparison over time Stroke unit in hospital 73%79%91% Median (IQR) stroke beds 20 (14-27)20 (15-29)24 (16-30) Specialist Community Stroke team 31%27%32%

Median for all hospitals 62 % Patients treated in Stroke Unit by Region

Quality of Acute Stroke Units CharacteristicsCompliance(%) Cont. Physiological Monitoring 57 Scanning within 3 hours48 24 hour brain imaging access 95 Direct admission A & E48 Specialist rounds at least 5/week 74 Protocols97

% Patients Screened for Swallowing Deficits by Region 66 Median for all hospitals

Impact per SHA - outcomes Dr Stephen Green DH Vascular Programme December 2007

Impact per SHA – bed days Dr Stephen Green DH Vascular Programme December 2007

Requirements to deliver change  Change accepted  Collaboration  Clinical engagement  Clinical leadership  Co-operation  Collective commissioning

Lessons from the Audit 1.One audit is not enough. It needs to keep on coming back 2.It needs to keep evolving but with a sufficiently stable core to enable time comparisons 3.Performing badly on the audit is a very powerful tool for change. Performing well may incite complacency

Lessons from the Audit 4.Not everything can be changed at once. Pick one or two key items to push each time data becomes available. Use the arts of spinning 5.Need a comprehensive political strategy of which audit is just one cog

Optimism or Depression?  Best chance ever to improve stroke care  Government unchanged for next 2-3 years therefore no excuse for change in direction  NAO report due to Public Accounts Committee before the end of the parliament  Stroke seems to be near top of agenda  Likely that audit funding will be continued