Managing acute stroke: What should cardiologists know? Prof. Charlie Davie UCL Partners Stroke Lead University College London

Why the need for change? ‘Better care demands changing organisation of services’ Professor R Boyle. Mending Hearts and brains The National Service Framework for long term conditions

7 day in-hospital mortality for all stroke patients in England April 2009-March ,621 admissions. Dr Foster data 350 avoidable deaths/year if weekend performance matched the normal working week

Thrombolysis rates in UK- April 2009-March % Rates comparable with USA. Best centres in each country 15% or more

Graph of model estimating odds ratio for favourable outcome at 3 months in i.v. thrombolysis treated patients compared to placebo treated patients by time from stroke onset to treatment with 95% confidence intervals

6 Model of acute stroke care in London before February 2010 Initial treatment Patients triaged on arrival to A&E Generally patients then admitted to a Medical Assessment Unit while awaiting definitive bed Length of stay up to 72 hours before bed available Acute Stroke Units (ASUs) Inpatient treatment and rehabilitation in a local hospital Admission to a general medical ward, geriatric ward, or ASU depending on local practice, bed availability (occupancy and staffing levels) Not all hospitals treating stroke patients had ASUs Generally only stroke physicians had admitting rights to ASUs, but various types of physician in charge of stroke patients (including general physicians, geriatricians) In all settings, length of stay variable and level of expertise and available treatments/therapies variable Wide variation in numbers of patient treated across settings After an unspecified time, when bed available Discharge from acute phase Community Rehabilitation Services Local A&E then MAU* ASU or ward 999 Source: Healthcare for London Stroke Strategy, 2007 Ambulance travels to nearest hospital with A&E

7 The development of the strategy was subject to wide engagement with the model of care agreed by clinicians and user groups HASUs Provide immediate response Specialist assessment on arrival CT and thrombolysis (if appropriate) within 30 minutes High dependency care and stabilisation Length of stay less than 72 hours Stroke Units High quality inpatient rehabilitation in local hospital Multi-therapy rehabilitation On-going medical supervision On-site TIA assessment services Length of stay variable 30 min LAS journey* After 72 hours Discharge from acute phase Community Rehabilitation Services HASUSU *This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU. 999 New acute model of care

8 ‘FAST’ Public awareness campaign Source: NHS London Public Information campaign,

9 Implementation has taken place in stages from February 2010 and went ‘fully live’ July 2010 Stroke networks across London led implementation with oversight from the pan-London cardiac and stroke network board A new stroke tariff was devised to reflect the changes in the pathway and the cost of the improvements in service Major workforce and recruitment across all trusts was necessary

Opening of hyper-acute beds took place in phases from Feb 2010  116 beds now open across 8 units in London Stroke units commenced opening in October 2009  484 beds now open across 22 units in London Robust LAS protocols developed to reflect implementation phases

11 The 2010 National Sentinel Stroke Audit has shown huge improvements in stroke care in London HASUs achieving all 7 standards for quality acute stroke care 5 of the 6 top stroke services were in London All HASUs in London were in the top quartile of national performance No Yes No Yes London HASUs National result Yes No London HASUs National result 93% 7% 39% 61% 75% 25% 75% 25% Patients directly admitted to a stroke unit for pre-72 hour care

12 Performance data shows that London is performing better than all other SHAs in England Thrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world % of patients spending 90% of their time on a dedicated stroke unit % of TIA patients’ treatment initiated within 24 hours 12% 10% 3.5% Feb – Jul 2009Feb – Jul 2010 AIMJan-March %

13 Efficiency gains are also beginning to be seen Average length of stayHASU destination on discharge Approximately 35% of patients are discharged home from a HASU. The estimate at the beginning of the project was 20%. The average length of stay has fallen from approximately 15 days in 2009/10 to approximately 11.5 days in 20010/11 YTD This represents a potential saving of approximately £3.5m over a 6 month period

UCLP Hyperacute Stroke Unit (HASU) opened in February 2010 and will disseminate good practice in London and to other large global cities UCLP COLLABORATIVE STROKE INITIATIVE Brings together the largest critical mass of stroke neurologists in the UK in a comprehensive stroke service The clinical program will drive a major academic development bringing translational stroke researchers in an "Institute of Stroke Research”

North Central London Stroke Service Outcomes from February 2010-June neurologists/stroke physicians from ALL NCL acute trusts running UCLH HASU June day in-hospital Mortality of 6% for stroke patients admitted via UCH HASU v UK national stroke mortality rate 20.7%* Thrombolysis rates in North Central London increased by 204% compared to previous year * Dr Foster data

Discharge destination: Breakdown of SU destinations NHNN: 8 pts North Midd: 5 pts Whipps Cross: 1 pt Royal Free: 5 pts St Mary’s: 5 pts St George’s 1 pt Barnet: 4 pts C Cross 1 pt C & West 1 pt Others: 1 pts

COLLABORATIVE STROKE INITIATIVE Fragmented NCL provision (e.g. RFH- UCH -2 small competing units, 300 cases each) Thrombolysis rate 18% vs average 9% Low inpt mortality 10% vs 20.7% R&D anatomy of specific deficits Small Population impact Link across HIEC > 8000 pts p.a. R&D network, : prevention, novel treatment, rehabilitation, Endovascular stroke service 24/7 aim for a pan-London network Demonstrable quality improvement across whole stroke pathway-working with Kings Fund Reduced stroke mortality and morbidity for the population Global benchmarking-Yale, Cleveland clinic NCL SU and TIA HfL HASU designation Comprehensive NCL programme 1500 pts p.a. Coordinated network of 12 NCL stroke physicians and neurologists Endovascular stroke service HASU accreditation and commendation from HfL >50% decrease in door to needle time Successful repatriation from HASU systematic approach to quality BEFORE NOWCOMING

A few ways to improve patient care at scale Use of Networks to support integrated care Reliable and regular collection of comparable data preferably across whole pathway Monitoring of Quality standards

1.Stroke education and public awareness 2.Primary prevention and population risk factors 3.Stroke and TIA hospital admissions (acute management and treatment) 4.Rehabilitation/access to services/ PROMS*/Mortality 5.Follow-up/secondary prevention and hospital readmissions 6.Measurement of patient experience Population awareness of risk factors Population awareness of FAST Population incidence of stroke Acute mortality %discharges direct to home from HASU Readmissions Functional status Return to pre-stroke life role SF36 Secondary incidence Population mortality Was care well-connected? Did you get understand care plan & have chance to make choices? Element of pathwayWhole-pathway outcome measure * PROMS: Patient Reported Outcome Measures Source: NCL/UCLPartners stroke working group “Whole pathway” approach to measuring quality in stroke