1. The Changing Face of Stroke Care
Amanda Jones
Stroke Nurse Consultant
Sheffield Teaching Hospitals NHS FT

2. Aim of session Background about stroke National drivers
NICE and RCP Guidelines
Stroke awareness

3. Some stroke facts Stroke is the 3rd leading cause of death in the UK.
Leading cause of disability.
Kills twice as many women as breast cancer.
130,000 people suffer a stroke in the UK each year (a stroke is happening every 5 minutes to some-one)
Approx 20-30% of people who have a stroke will die within the first month.
1000 children suffer strokes per year

4. Some stroke facts
Approx 12,000 under the age of 55- ¼ of all strokes are in the under 65’s.
Approx 900,000 people are living with stroke in England and around 50% of those are dependant on others for help with everyday activities
Approx 1 in 4 people who live until the age of 85 can expect to have a stroke

5. Some stroke facts
People aged between 65 and over increased by 4 million between , the projected % of older people in England is expected to rise from 16% in % in this will increase the numbers of people with stroke
£7 billion is spent on stroke by the NHS and wider economy each year
A huge issue and likely to get bigger with the rise in the ageing population- this is why stroke is currently in the spot-light

6. National guidance- what’s new?

7. National Drivers for stroke
1st evidence based document; National Clinical Guidelines for Stroke, 1st ed 2000, 2nd ed 2004, 3rd Edition- RCP, 2008, 4th Edition September 2012
NSF for Older People, Standard 5, DoH 2001
National Audit Report 2005 (a damming report about stroke services) which led to:-
Reducing Brain Damage- DoH 2006
Mending Hearts and Brains- DoH, 2006
National Stroke Strategy- DoH December 2007
Diagnosis and initial management of Acute Stroke and TIA- NICE, July 2008
Draft NICE stroke rehabilitation guidelines- due for publication 2013 following major review

8. National Drivers for stroke
SINAP- SSNAP- Sentinel Stroke National Audit Programme- mandatory from April continuous audit instead of National Sentinel Audit- quarterly reports in the public domain
Accreditation- Peer review

9. Overview of of key indicators
Time from admission to scan
First contact with member of the stroke team
Number of patients transferred to a stroke bed within 4 hours
Number of patients thrombolysed/eligible
Known time of onset
Discussion within 72 hrs with patient and family
Continence plan drawn up within 72 hrs
Seen by a nurse and therapist within 24 hrs and all relevant therapists within 72 hrs
Nutrition screen and formal swallow assessment in 72hrs
Antiplatelet and adequate fluids and nutrition in 24 hrs

10. Infoflex - our local database

11. Accreditation- levels of stroke care
Terminology
Elements of Service provision 1
Comprehensive Acute Stroke and thrombolysis centre
Tertiary neurosciences disciplines
TIA & minor stroke management
Acute stroke management
Thrombolysis service
Stroke rehabilitation 2
Acute stroke and thrombolysis centre 3
Local acute stroke centre 4
Stroke recovery and rehabilitation centre

12. 10 year strategy- 2007-2017 (5 years to go!)

14. Key stroke strategy themes
Better
outcomes
The stroke pathway:
Prevention and early diagnosis: managing risk factors, raising awareness of symptoms, and tackling TIAs
Taking people direct to
specialist services
Improving rehabilitation and community based care; longer term support to regain independence
A stroke skilled workforce
Involving and informing individuals and carers
Research and audit
Shorter intensive acute &
rehabilitative hospital stay, followed by
specialist care closer to home
Direct to CT scan,
thrombolysis
CT scan < 24 hrs
Stroke unit care
Stroke
centre
Local
hospital
Time = brain
Paramedic
triage
999 call
Informed
public

15. Time is brain
Active symptoms

16. Time is brain- Stroke Pathway
Majority
High risk TIA
End-of-life care

17. National Recommendations for a Stroke Pathway
All stroke patients should spend at least 90% of their hospital stay in a specialist stroke unit.
Pathway should be made up of distinct phases of care;
Initial urgent specialist assessment- direct transfer to dedicated stroke unit (within 4 hours)
Hyper-acute- up to 48 hours (monitored beds/intensive nursing)
Acute- up to 7 days
Sub-acute days
Intensive inpatient rehabilitation-up to 21 days
Specialist Community rehabilitation- from 3-6 months
Medium/Long-term- 6 month review- life long review
Access back to specialist rehab for targeted input when needed

18. Specialist validated immediate assessment- Recognition Of Stroke In the Emergency Room (ROSIER)
Validated scoring system.
For use by health professionals.

19. ROSIER Symptom onset: Date & Time. Assessment: Date & Time.
BP GCS Eyes Motor Verbal
Has there been loss of consciousness or Syncope Y (-1) N (0)
Has there been any seizure activity Y (-1) N (0)
Is there New acute onset (or awakening from sleep) of:-
Asymmetrical facial weakness Y (+1) N (0)
Asymmetrical arm weakness Y (+1) N (0)
Asymmetrical leg weakness Y (+1) N (0)
Speech disturbance Y (+1) N (0)
Visual field defect Y (+1) N (0)
Total score: (Stroke is unlikely but not completely excluded if total score is < or = to 0)

20. The National Institute of Health Stroke Scale (NIHSS)
Not a diagnostic tool.
Quantifies stroke severity in a consistent way.
Useful in determining suitability for thrombolysis.(Patients within licence treated have a NIHSS >4 or <25.)
Useful for post thrombolysis monitoring

21. NIH Stroke scale

22. HASU- Hyper Acute Stroke Units

23. Aim of hyper acute care
Stroke is associated with significant physiological disturbance in vascular and neuronal function
Aim to;
Optimise physiological variables
Maintain brain perfusion
Maintain homeostasis- to try to restore normal state once it has been disturbed.
Early detection and intervention
Prevent secondary events
Safe administration of thrombolysis

24. Hyper acute nursing care
Hypoxia- O2 sats<92%
Hyper/ hypoglycaemia
Hypertension- closely monitored- no clear consensus on optimal management- should be treated post stroke (usually after 7 days)
Intracranial pressure- drowsiness/gaze palsy/breathing problems
Pyrexia- worsens infarct- needs to be lowered if over 37.5
Dehydration- maintain hydration
Aspiration
DVT / PE
Seizures

25. Time is Brain Impact of thrombolysis 30 20 10 0 2 4 6 Time (hours)
Number making full recovery per 100 treated 30 20 10
Benefit
Harm
Time (hours)
Saver, Stroke 2006

26. How many stroke patients per year in UK
How many stroke patients per year in UK* might avoid being ‘dead or dependent’ with each treatment?
% treated with this intervention
Number treated per year
Benefit per 1000 treated
Number who avoid death or dependency
Aspirin
80%
104000 13
1350
Stroke Unit
60%
78000 56
4370
Thrombolysis 2%
2080 63
130
30%
31200 47
1470
Based on 130,000 strokes per year in the UK
IST 3 Collaborators

27. National targets- must be dones- Best Practice Tariff = Best evidence based care for patients

29. NICE STROKE QUALITY STANDARDS 2012
Ambulance staff use a validated tool to diagnose stroke/TIA, and transfer them to a specialist stroke unit within an hour 2
Brain imaging within an hour of arrival in hospital if indicated 3
Admitted directly to a stroke unit, assessed for thrombolysis 4
Swallow screen within 4 hours with a written nutrition plan 5
Assessed and managed by specialist nursing staff and at least 1 member of the specialist MDT by 24 hrs, and all relevant members within 72 hours with written MDT goals within 5 days of admission 6
Treated in a specialist rehab unit for those who need it. 7
A minimum of 45 minutes relevant therapies offered over 5 days 8
Loss of bladder control is reassessed at 2 weeks i/c an ongoing plan 9
Cognition and mood is screened within 6 weeks 10
Following discharge, stroke related disability, followed up in 72 hrs by a specialist team 11
Carers should have a named contact for info and support

30. 24 access to thrombolysis
Telemedicine
Direct delivery of hyper acute care by specialists cannot always be achieved in every hospital- telemedicine allows patient/carers to talk to a stroke specialist remotely, and for the specialist to observe a clinical examination and view imaging.
The system should include a stroke nurse specialist to be present at the admitting hospital with the patient under assessment.
This will enable 24/7 access to thrombolytic treatment

32. NICE Stroke Rehabilitation Guidelines (1st stroke rehab guideline)
Draft was circulated nationally for consultation last year
Negatively received and strongly criticised by MDTs nationally mainly due to the limitations under NICE e.g. For some-one who has a stroke- consider offering physiotherapy!- significant implications for rehabilitation.
Guideline to be reviewed and changed
Hope for new guideline in vital to get it right!
As a result a delay in publication of the RCP national Clinical Guidelines for Stroke- September instead of June 2012
26th March Therapy consensus day event with the RCP

33. NICE Stroke Rehabilitation Guidelines
Types of studies considered; Systematic reviews, double blinded and unblinded parallel RCTs, and cross over randomised studies.
No qualitative studies were included- much rehabilitative care is qualitative in nature and cannot easily be captured in an RCT.

34. Intensity of therapy after stroke consensus meeting- 26th March RCP, London
Expert speakers
Voting panel
45 minutes of therapy
Appropriateness of therapy
How to capture therapy
Therapy research
Patients perspectives in relation to therapy
Limited places- £10-

35. Possible new inclusions to the 4th Edition of the RCP National Clinical Guidelines for Stroke
Acupuncture should only be used if part of a clinical trial
Do not routinely offer Functional Electrical Stimulation or TENS
Pain control- offer amitryptyline, gabapentin or pregabalin for neuropathic pain
SALT should be provided for more than 2 hours per week if patient is able to tolerate this
Return to work enhanced section
More emphasis on the timing and giving of information to carers
Changes within the psychology section- stepped care and use of validated tools to screen and assess for mood and cognition
More about post stroke fatigue

36. Possible new inclusions to the 4th Edition of the RCP National Clinical Guidelines for Stroke
Secondary prevention- emphasis on Life style changes being of equal importance as secondary prevention medications
Emphasis on exercise programmes in secondary prevention
More detail about diet and weight loss (use of weight loss medications)
Hypertension levels
Calcium Channel blockers are recommended as first line treatments (e.g. Amlodopine)- enhanced section on hypertension management
Carotid endarterectomy surgery should be undertaken ASAP and within 7 days (was 14) of symptoms- working towards 48 hours by 2017

37. Possible new inclusions to the 4th Edition of the RCP National Clinical Guidelines for Stroke
A new section on telemedicine which states that this should be regularly audited.
More emphasis on younger stroke patients
ESD and the need for the same intensity and specialist staff as inpatient stroke rehab units
Community interaction section
A section with recommendations regarding therapy/nursing and medical levels included for the first time- emphasising the need for 24/7 nursing and stroke consultant cover

38. New Campaign to increase public awareness
Act FAST launch 27th February from original campaign
TV advertising Feb 27th-March 25th
March 5th-March 18th- radio advertising particularly for BME (Black Minority Ethnic) communities

39. The changing face of stroke- not just an inevitability of old age

40. But can happen to anyone at any age

41. What used to happen

42. What happens now

49. Act FAST
Time lost is brain lost- for every minute when a stroke first happens approximately 1.9 million neurones are lost!
Vital to get to the hospital for specialist assessment, and treated as soon as possible to help preserve as much brain as possible!

50. In conclusion Significant developments in stroke care
The new RCP guidelines will provide enhanced national guidance
The new NICE stroke rehabilitation guideline should help with developments in rehabilitation
Need to continually raise awareness of stroke symptoms as people are still not accessing services early enough!
More emphasis and research is still needed in medium and long term stroke care