1. Reading Stroke Service 2016 Dr André van Wyk Stroke Consultant

2. Stroke types and mechanisms

3. Stroke Complex (need for specialists): -
medically unstable at risk complications and early progression
functional- motor leg & arm power: sitting,walking; speech: communication; brain processing: memory, planning, orientation, mood
body working swallowing: feeding, medication –affects survival
Unstable first 24 hours- need early access Stroke Unit
Stroke management requires coordinated multidisciplinary working

4. Integrated local health, social and voluntary sector working (quality): prevention, hyperacute, acute stroke unit, specialist stroke community rehab, long-term care
Whole pathway required to treat stroke –interdependant
Spending by commission or omission: reablement/ less functional dependency vs or on care
clearly costed Stroke Strategy its cheaper and more cost effective to provide quality stroke service

5. How does one recognise a Stroke?
Early recognition and management of a stroke is important
Commonly patient may not recognise they’ve had a stroke
FAST detects common but not other types stroke and symptoms eg sudden loss balance; dizziness; vision: loss in one or both eyes or double; inability swallow

6. Impact of Stroke: patient
Sense of self
Loss confidence, self worth, depression
Changes way one thinks, all the functional daily activities and extended activities one takes for granted
Loss independence
Need to come to terms with dramatic change while engaging in very activity physical and cognitive rehabilitation to find a new ‘orbit’

7. Impact of Stroke: on the family
Stroke impact is often life long
‘family’ disease
affect family dynamics and relationships
role: bread winner / parent / husband or wife
career and hobbies

8. Impact of Stroke: on society
Every five minutes someone in the UK has a stroke.
Each year estimated 150,000 people in UK have a stroke.
Stroke third most common cause of death in the UK.
Over a million people have had a stroke living in
the UK, around half of all stroke survivors dependent
on others for everyday activities
Single largest cause of adult disability

9. How does one diagnose, assess and manage: Risk factors for TIA and Stroke
Campaigns, education
Lifestyle, genetic and biological make up and impact of other disease
History in family, smoking, activity; Examination weight, checking pulse BP and Investigations blood sugar cholestrol, ECG check for AF then more specialised eg very young patient screen cardiac and scanning carotid arteries
Management: individualise recog specific risk factors and education eg stopping smoking, diet and exercise
Medication aspirin statin blood pressure warfarin NOAC
Specialised eg. urgent referral carotid surgery or closure of Left Atrium if unable anticoag or closing hole in heart PFO

10. Higher risk < 1 day
Lower risk < 1 week
Non-urgent

11. TIA Mobile phone service (40595) Clinics 7/7 days a week
Aim to see patients within 24 hours of referral – patients decline appointments!
Already in 2009
578 patients seen in clinic in 340 were TIAs
65% high risk seen within 24 hours

13. Admitted on Monday imaging completed reviewed by Vasc surgeons CEA set up for Thusay
Had CEA Friday uneventful anphyl to gelofuse
Came back to SU
D?C
Monday

15. Principles in managing Stroke patients
Need to diagnosis: stroke, type and cause EARLY access to high tech radiology and cardiac
Time is brain
emergency pathway to restore blood supply brain –thrombolysis
Brain receptive to remodelling the dendrites sprouting- early rehab
Direct admission HASU/ Acute Stroke Unit for initial hyperacute treatment, monitoring restoration of physiological milieu
Prevention and treatment risk factors that may result further stroke and complications of the stroke

16. Multidisciplinary assessment and closely coordinated management to deal with all complex issues in stroke with rehabilitating and caring for patient and their family
Specialist rehabilitation and person specific goal setting done with patient and family both in Stroke Unit
Specialist Stroke Early Supported Discharge team (a third patients) in the community needed to extend and reintegrate function to home
Long Term life after stroke, Voluntary agencies Stroke patient and family Stroke Recovery Service Coordinator Return to Work strategies. Need for equipment and Care

17. End-of-life care

18. What has changed in Stroke?
National Stroke Strategy 5 Dec 2007 : 20 quality markers /10-point plan of action
Prevention treat TIA as emergency 2/3 seen and treated within 24h
Hyperacute Stroke Pathway 1/3 admissions thrombolyse 1:3 (10 % 24/7 service)
Stroke Specialist rehabilitation geared individual needs 7 days per week : Stroke Unit and ESD
Long Term care/ follow up-emotional needs psychological
Radical change in Stroke management since 2007
2 Guidelines on being major acute Hospital
DARZI & RCP acute medical care Oct. 2007
Delivery: National Sentinel Stroke Audit now evolved to SSNAP data on every stroke patient admission/ Ambulance Trust

19. 19

20. Stroke Strategy Ten-point plan for action
Awareness
Preventing stroke
Involvement
Acting on the warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation
Workforce
Service improvement

21. Vital different components of TIA and Stroke service and benefits
Avoid having a stroke –lifestyle and risk factors especially hypertension
Act on warning TIA or Stroke- medical emergency
Rapid Access TIA service
Hyperacute Stroke service able to provide 24/7 thrombolysis
Stroke Unit (coordinated MDT) benefits all patients specialist rehab
Early Supported Discharge (specialist stroke rehab at home)
Long Term Care

22. Thrombolysis 24/7 Thrombolysis Service
Ambulance response upgraded to Cat A
51 patients thrombolysed so far with 3 in last 5 days

23. Press launch for ESD January 2010 http://www. royalberkshire. nhs

24. The whole pathway Stroke service at RBFT and surrounding areas
Acute Stroke Unit started beds Battle Hospital now 30 bed combined Acute Stroke Unit RBFT with 6 bed HASU
RBFT Stroke Service awarded HASU 24/7 April 2011 extended Thrombolysis started after hours off site stroke consultant
Rapid Access TIA would be 7/7 by April 2011 (started 5/7 initially 2005 extended pilot last 22 months)
ESD Stroke Early Supported Discharge rehab service Berk West plus extended with CBNRT, also ESD S Oxon and East Berkshire ESD
Patient and family Stroke Recovery Service Coordinators posts with key role in support and Longer Term Care stroke patients with coord Stroke support networks eg stroke clubs, information and sign posting

25. The Future Continue to provide the best service accordence with SSNAP
Move to London Model Jan 2017 where all patients with stroke would only be able to be admitted to a HASU stroke service (redesign stroke pathways increase stroke capacity need at RBFT
Time is brain
Continue to provide clot busting thrombolysis service safely to as many as are eligible in the shortest door to needle time
Need to start to provide clot extraction thrombectomy and maybe develop locally
Incorporate new developments in service as evidence emerges

27. Stroke Pathway Incorporating ESD Service
Pathway is simple – one page of A4

28. HQIP GOLD award won by stroke service RBFT for improvements to service through Audit 2010

29. National NHIR SRN Team of the Year Research Runner Up Award 2013

30. RBFT stroke service "fastest thrombolysis centre quartile April to June 2015 average 25 minutes DTNT, thrombolysing 4th highest proportion 24.4% UK.”

31. RBFT stroke research team winning “Best Green Shoots Research “NIHR TVH Health research 12/10/2016 award St Hildas College Oxford

32. Thank you for your attention
Any questions?