Governance of a Stroke Thrombolysis Service Barry Moynihan

Framework Pathway Protocols Outcomes Monitoring Process Clinical Local M&M SITS/NICE

and of course…………………. Training & Education

Pathway Mapping Geography & People Where the drug is given

Protocols Pre-hospital Hospital assessment & administration Inclusion/exclusion checklist Thrombolysis proforma The 1st 24 hours Nursing care plan What to do about deterioration Repeat brain imaging Outcomes

Outcomes Process Clinical ‘door to needle time’ Death Haemorrhage NIHSS Modified Rankin Score

Haemorrhage after stroke rtPA Extracranial Intracranial Symptomatic Asymptomatic

NIHSS National Institutes of Health Stroke Scale 15 point clinical scale Predicts lesion size & outcome Validated Requires certification

Modified Rankin Score (mRS) 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention 6 Dead

Monitoring Local Clinical Networks National SITS NICE SINAP

What is SITS? 2000: SITS set up in Sweden for local purposes (Svenska Implementeringskommittén för Trombolys vid Stroke) 2001: EMEA licensed Alteplase until 2005 on 2 conditions: There was a trial of therapy at 3-4 hours All patients were entered onto the SITS register. 200

Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007 Jan 27;369(9558):275-82

SITS (Safe Implementation of Thrombolysis in Stroke) prospective internet-based audit of the International Stroke Thrombolysis Registry (ISTR)

Process 28 50 39 62 Time delay (minutes): NOW Center UK All centres Onset to A&E time Median 62 70 64 Door to imaging time 28 30 24 Imaging to report time 6 Door to needle time 50 58 65 Onset to needle time 130 135 145 Time delay (minutes): PREVIOUS Center UK All centres Onset to A&E time Median 66 69 65 Door to imaging time 39 36 25 Imaging to report time 5 Door to needle time 62 70 Onset to needle time 139 155 145

Clinical Outcome

NICE 2007 This appraisal covers the use of Alteplase in acute ischaemic stroke.

None of these criteria are available from SITS

SINAP April 2010

SINAP April 2010

SINAP Local Monthly Report Feb 2011 Admissions Total: 134 Stroke: 77 (57%) TIA: 22 (16%) Non Stroke: 35 (26%) Thrombolysis Total Thrombolysed: 7 (9% of patients with a diagnosis of stroke – one as part of IST3) 100% eligible cases Mean DTN time 49 mins (32 minutes Feb 2012) DTN > 60 mins exceptions IST3 70 mins 90 mins (45 mins to confirm time of onset in aphasic pt)

Second National SINAP report (Feb 2011)

Summary Pathway Protocols Outcomes Monitoring Training

Useful Links http://nihss-english.trainingcampus.net/uas/modules/trees/windex.aspx http://www.rankinscale.org/links.shtml http://www.acutestroke.org/ http://www.nice.org.uk/guidance/TA122 http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/SINAP.aspx