1. Organising stroke services
Martin Dennis

2. Organising services This session is about stroke
Principles might be applied to other problems
Parkinsons
Fractures
Dementia
Organisation of comprehensive service or just one aspect?

3. Questions to be addressed
Which population is to be served?
What is the size of the problems?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

4. Questions to be addressed
Which population is to be served?
What is the size of the problems?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

5. What population? Your hospitals catchment population
Region e.g. Lothian
Country e.g Scotland
Will all aspects of service be delivered locally?

6. Questions to be addressed
Which population is to be served?
What is the size of the problem?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

7. Size of the problem Incidence Prognosis Prevalence
Who does it affect? Age, sex, subtypes etc
Prognosis
Prevalence
Where do you get this information?
Pros and cons of each source?

8. Sources of information
Local population based incidence study
Published data from similar populations
Locally available routine data
SMR01
GP registers
Locally collected hospital data
Hospital based register
Audit

9. Questions to be addressed
Which population is to be served?
What is the size of the problems?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

10. Pathway Early recognition Call for help Initial assessment
Hyper-acute care
Stroke unit care or ambulatory care
Rehabilitation
Secondary prevention
Longterm care/ monitoring

11. Questions to be addressed
Which population is to be served?
What is the size of the problems?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

12. Evidence based treatments
Thrombolysis
Hemicraniectomy
Aspirin
Stroke unit care
Secondary prevention
Antiplatelets
Statins
Blood pressure reduction
Warfarin for those in AF
Carotid Surgery
Early supported discharge
Effect size?
What % of patients benefit?
Impact?

13. Other essential elements
Nursing care for disabled people
Information for patients, carers etc
Longterm support
Palliative care

14. Questions to be addressed
Which population is to be served?
What is the size of the problems?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

15. Some choices?
Ambulatory or inpatients care for TIAs and minor strokes?
Centralised or distributed thrombolysis?
Stroke units – acute, rehab, comprehensive?
Stroke services for “young patients”?
Inpatient or community rehabiltation?
Who does the secondary prevention?

16. Questions to be addressed
Which population is to be served?
What is the size of the problems?
What are the needs of the individuals with the problem?
Which needs are most important to meet?
How should services be delivered?
What resources are available? What is the gap?

17. Resources People Skills / Knowledge Training
Consultant Pas – Job plans
Doctors in training / SAS
Nurses
AHPs
Radiology/radiography
A & C staff
Social work/ social care
Skills / Knowledge
Training

18. Other resources Stroke unit beds Outpatient rooms Scanners
IT – PACS, Electronic patient records
Day hospitals
Day centres
Access to other specialties – vascular, neuro etc
Geography is crucial

19. Services to not organise themselves!
Somebody has to coordinate them
To ensure performance is measured
Gaps in services and poor services identified
Make best use of resources
Coordination of staff
Communication IT
To identify additional resources

20. Local examples Collect info on consultant PAs for stroke
Compare with other areas
Get agreement of PAs needed to deliver service
Identify any GAP
Make case to management for additional PAs

21. Neurovascular clinics
Standards – 80% seen within 7 days
Frequency – Mon, Tues, Wed, Frid
Capacity – new patients per week
Imaging on day of appointment
Delays in communication with GPs

22. High early risk of stroke after TIA14
OXVASC
OCSP 12 10 8
Risk of stroke (%) 6
10% risk of stroke by 7 days 4 2 7 14 21 28
Days
Lancet 2005; 366: 29-36

24. GP TIA/stroke Hotline
GP TIA hotline/ thrombolysis service single phone number
Answered by Stroke Consultant/ Stroke Neurologist 24/7

25. Taking a call on the hotline at home

26. Process Listen to details of event
Sometimes take history from patients over phone
If TIA likely give GP an appointment time
Ask them to take bloods
Initiate immediate aspirin & statin
Ask for SCI Gateway referral
Deflect a significant number of referrals

27. GP, OOH and SAS guidelines
Distinguishing those with transient and ongoing symptoms
Ensuring patients enter the most appropriate pathway
Hyperacute admission
Routine admission
Same day assessment
Neurovascular clinic
Other service
No further action required

29. Neurovascular clinic booking (often next day)

30. TIA hotline introduced

31. TIA Hotline Has dramatically reduced delays to:
Optimum medical treatment
Specialist assessment & investigation
Referral for carotid surgery
Plan to extend service to:
A&E staff
Out of hours medical services
Eye Pavilion

32. Rapid pick-up and routing
Rota Router GP
A&E
Rapid pick-up and routing
The regional
On call
Specialist
Paramedic

34. Improvements
Advance planning of clinic staffing to maintain constant capacity
Links with GPs via SCI Gateway
Web based access to
clinic availability
on call physician
patient letters
results

35. Challenges “Chaotic” front doors of hospitals
Recent examples of bad practice
Rapidly rotating staff – difficult to train
Delivering “specialist” input as early as possible.
24/7 telephone/telemedicine access
EPR with decision support

37. Thrombolysis
Stroke centres
Hub and spoke
Telemedicine

38. The technology
Gateway
Broadband
VC recorder