National View on Stroke Care Tony Rudd

Stroke Issues  Variability of quality of care and slow progress achieving change  Hospital  Community  Issues around prevention including AF management  Increasing difficulty accessing social care and care homes  Workforce esp. medical  Trials of intra-arterial treatments

Team-centred performance table Source: SSNAP April – June 2015 Team-centred performance table for South East Coast SCN

Why are the standards important?

Time to dysphagia screen and risk of stroke- associated pneumonia Modelled association adjusted for age, sex, stroke type (ischaemic, primary intracerebral haemorrhage, undetermined), pre-stroke functional level (modified Rankin Score), place of stroke (out of hospital or inpatient) and comorbidity, and NIHSS

Time to SALT dysphagia assessment and risk of stroke-associated pneumonia Modelled association adjusted for age, sex, stroke type (ischaemic, primary intracerebral haemorrhage, undetermined), pre-stroke functional level (modified Rankin Score), place of stroke (out of hospital or inpatient) and comorbidity, and NIHSS

Care bundles associated with lower mortality risk after stroke aOR95% CI Seen by stroke consultant or associate specialist within 24 hours of admission Brain scan within 24 hours of admission Bundle 1: Seen by nurse and one therapist within 24 hours and all relevant therapists within 72 hours Bundle 2: Nutrition screening and formal swallow assessment within 72 hours where appropriate Bundle 3: First ward of admission was stroke unit and they arrived there within four hours of hospital admission Bundle 4: Given antiplatelet therapy where appropriate and had adequate fluid and nutrition for first 72 hours *Adjusted for age, sex, independent in ADL prior to stroke, O 2 requirement in first 24 hours, reduced consciousness in first 24 hours, arm weakness/sensory impairment, leg weakness/sensory impairment, dysphasia, hemianopia. Hospital level random intercepts Lower mortality

Association of care with good outcomes Scottish Stroke Care Audit “Stroke unit” item CT scan within 24 hours Early swallow assessment Early admission to stroke unit Early aspirin for ischaemic stroke (Adjusted for SSV, year of admission,and hospital-level random effects) P value NS < Odds of death at 30 days Turner et al JNNP (2015)

Figure 3 Source: The Lancet (DOI: /S (13) )The Lancet CLOTS 3 Trial results. Risk of death

Does the size of unit matter?  Door to needle times  Number of patients thrombolysed

Do staffing levels matter….?

Adjusted Hazard Ratio of 30-day Mortality of Patients Admitted on Weekends, by Ratio of Registered Nurses Per Ten Beds on the Weekend Bray BD, Ayis S, Campbell J, Cloud GC, et al. (2014) Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study. PLoS Med 11(8): e doi: /journal.pmed Higher mortality with fewer nurses 22

Figure 1. Scatter plot of weekday nurses per ten beds versus weekend nurses per ten beds. Bray BD, Ayis S, Campbell J, Cloud GC, et al. (2014) Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study. PLoS Med 11(8): e doi: /journal.pmed

Adjusted mortality odds ratios for normal hours and out of hours patients Campbell et al PLOS One 2014

Variation in care during the week

Assessment by a physiotherapist within 72 hours Sites with a 7 day PT service (57/182)Sites without a 7 day PT service (125/182) Source: 2014 SSNAP acute organisational audit; SSNAP clinical audit Report 6

Variation in care during the week

Admission to a Stroke Unit within 4 hours

Adjusted Hazard Ratio of 30-day Mortality of Patients Admitted on Weekends, by Ratio of Registered Nurses Per Ten Beds on the Weekend Bray BD, Ayis S, Campbell J, Cloud GC, et al. (2014) Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study. PLoS Med 11(8): e doi: /journal.pmed Higher mortality with fewer nurses 32

Medical Workforce  Probably the single biggest factor limiting service provision  Must not compromise on quality  Services must offer specialist care  Recognition of crisis of provision general acute medicine  Need to find ways to attract trainees  Need to make the case to expand number of training opportunities

Need to link to national strategy: 5 year forward view  Prevention.  Setting local ambition  National diabetes prevention programme  Returning to employment  New models of care  multispecialty community providers (MCPs), which may include a number of variants  integrated primary and acute care systems (PACS)  additional approaches to creating viable smaller hospitals  models of enhanced health in care homes  Integrated personalised commissioning  Priority for mental health and learning difficulties  Supporting carers

5 year forward view  ‘For specialised care where quality and patient volumes are strongly related, such as trauma, stroke and some surgery, the NHS will continue to move towards consolidated centres of excellence’.  Improving quality, outcomes and safety  Publishing patient data  7 day services All for 2-3% efficiency savings per year

Delivering a thrombectomy service  5 trials published in the last year all showing that clot retrieval produces better outcomes in selected patients compared to intravenous thrombolysis

Endovascular Treatment for Stroke: Unanswered questions  How many suitable in real life?  If try to calculate those that might benefit  Suitable for IV thrombolysis – 12.6% according to Royal College of Physicians criteria  Prior Rankin 2 or less – 81%  Arrive within 0-3 hours of onset symptoms - 80% of those thrombolysed  Don’t respond to IV thrombolysis - 86% and have proximal vessel occlusion – approx. 25% unresponsive to IV tPA Reduces the percentage of potentially eligible to about 2% of the total or 1600 in England/yr. Between patients would benefit if made available to everyone

What do we need to deliver IA treatment in England?  Population of 60 million  Minimum 50 centres running 24/7  This would be the only circumstance where need access to 24/7 interventional neuroradiology services  6 interventionists per centre  Neuro-radiologists. Only 100 consultants at present. Would need minimum of 300. What would they do during the day?  Interventional radiologists? But not many services 24/7  Cardiologists, but why would they want to take it on  Train stroke physicians???

What do we need to do?  Reconfigure acute care through collaborative commissioning.  Don’t compromise the needs of the majority to maintain equality of care  strokes a year  Staffed well with stroke expertise 24/7 with high levels of nursing and therapy staff  Travel times = depends on geography  Long term financial viability  High quality in patient rehab on a stroke unit  Community rehab  Find a way to provide seamless health and social care