1. Effectiveness of an acute stroke team in a primary health care hospital
Jones B 1, Patel R 1,2, Siracusa E 1, Sahathevan R 1, Gawarikar Y 1,2
1. Stroke Service, Calvary Health Care Bruce, ACT
2. Australian National University, ACT
I would like to thank the scientific committee for the opportunity to speak here today.
I will be presenting on behalf of my co-authors on our audit on the ‘Effectiveness of an acute stroke team in a regional primary health care hospital’

2. Background Calvary Health Care Bruce 250 bed hospital
Provides public hospital services to North side of Canberra
Referral hospital for NSW hospitals north of Canberra
Goulburn
Yass
Harden
Boorowa
Young
Calvary is about 1/3 the capacity of Canberra Hospital at 250 beds
It provides public hospital services to the North side of Canberra
Also acts as a referral hospital for smaller towns to the North of Canberra.

3. Calvary
Canberra
Calvary Health Care Bruce is located in the Northern part of Canberra.
This red line is important as it used to be one of deciding factors in if you received stroke unit care or not.
With the ACT Ambulance Service North of the line patients are taken to Calvary where there was no stroke unit, South of the line to the Canberra Hospital where there was a stroke unit.

4. Background Prior to May 2014 no acute stroke unit
Approx. 240 stroke presentations to ED each year (Ischaemic/Haemorrhagic/TIA) –based on retro analysis of 5 yr local data
<11% transferred to Canberra Hospital stroke unit for organised stroke care – prospective audit
Most admitted to medical ward under general physicians with neurology consulting –often day 2 of admission
No co-ordinated team of allied health dedicated to stroke
No acute stroke swallow screening tool
Previously no stroke unit
Received around 240 stroke presentations each year through the emergency department based on an audit of 5 years of local data
Very few patients (less than 11%) did get into the stroke unit at Canberra Hospital, but for those that remained was not unusual for patients to spend long periods of time in the emergency department
Patients were then transferred to the medical ward under the care of a general physician, there was a neurologist consulting but often not involved until day 2.
No co-ordinated team of allied health focused on stroke
No swallow screening tool so all patient’s ideally had to be seen by speech pathology, which had very limited resources

5. Background
The National Stroke Foundation recommends that any health facility who receives over 100 stroke presentations per year are classified as category B facilities or a primary stroke centres and should have dedicated beds and clinical staff with expertise in treating and managing strokes. (National Stroke Foundation, 2011)
Studies have shown that acute stroke teams are effective at:
Improving thrombolysis rates
Reducing time to diagnostics (door to CT times)
Reducing delays in treatment (door to needle times)
Reducing in hospital mortality
(Nazir et al. 2009, Hamidon et al. 2007)
The National Stroke Foundation recommendations meant that Calvary should ideally have a stroke unit qualifying as a primary stroke centre
Studies have also shown that having an acute stroke team would help all round with improving thrombolysis rates, improving time to diagnositcs and treatment and improving mortality

6. A new service ACT government funded 4 bed acute stroke unit
Neurology
Nursing
Allied health
Model of care, care pathways (including ED), policies
Including swallow screening tool and systems of referral to speech pathology on failure
Acute Stroke Team (business hours only)
Neurologist (on-standby)
Neurology Advanced Trainee
Stroke Liaison Nurse (primary point of contact/triage)
After persistent lobbying and the success of a business case ACT Health agreed to fund the Stroke Service which opened in May 2014.
The new service included funds for a 4 bed acute unit and additional neurology, nursing and allied health FTE.
It included policies an ED pathway and a swallow screening tool that could be performed by trained nursing staff.

7. We knew that for the stroke team to be effective we needed a really good relationship with our ED.
We did a lot of work prior to the roll out of the service, signs like this pasted up around the ED.
For weeks prior we went to every handover and explained our role and what they could expect from us, and what expectations we had.
We had regular ED/Stroke forums to highlight particular issues and to feed back key metrics on tpa numbers, door to needle and stroke call rates.
There was no formalised pre-notification from the ambulance service so we encouraged referral as early as possible from Triage or at any point they suspected stroke.

8. The Question
Is a stroke team in a primary health care hospital effective at improving:
thrombolysis rates
door to CT times
door to needle times
length of stay
Mortality
Swallow screening rates
We knew that the stroke unit would improve outcomes for patients, but was the stroke team itself effective at improving access to treatment.
We were particularly interested if the impact of our business hours service was able to be expanded to after hours.

9. Methods Retrospective audit of stroke data
6 months prior to the commencement of the acute stroke team
6 months post the commencement of the acute stroke team
Focused on following parameters:
thrombolysis rates
door to CT times
door to needle times
length of stay
Mortality
Swallow screening rates
So we undertook a retrospective audit of patients admitted 6 months pre and post the acute stroke team to see what effect it had on:
thrombolysis rates,
door to CT,
door to needle time,
length of stay and mortality.
At the same time a as a quality measure we thought we would look at swallow screening rates as well.

10. The Challenges Only a part time service New system Switch board
Change in ED culture
These are but a few of the many challenges that we faced
Being only a part time service there was lack of consistency after hours and everything slowed down
Being new and despite the introductory campaign the ED had a lot of staff and staff turn over so we had to keep the momentum going so the shine didn’t wear off
Switch became quite a delay, so we bypassed the paging system and had a direct line to the Stroke Liaison Nurse as the point of contact.
But by far the biggest factor was changing the ED culture, changing the workflow, and getting across the time sensitive nature of acute stroke. There was a real persistent attitude that we had 4.5hrs to get people treated.

11. Results 120* 160 75 (31-98) 68 (18-95) 57% 51% 40.8% (49) 31.3% (50)
Pre Acute Stroke Team
Post Acute Stroke Team
Patients
120*
160
Mean Age (range)
75 (31-98)
68 (18-95)
% Male
57%
51%
% TIA
40.8% (49)
31.3% (50)
% Ischaemic Stroke
51.7% (62)
42.5% (68)
% Haemorrhagic Stroke
5.8% (7)
3.1% (5)
% Stroke Mimic
1.7% (2)
23.1% (37)
We had complete data for 120 patients with a discharge coding of stroke vs 160 post patients which were able to be captured from the stroke unit database.
*Data missing /incomplete for 32 pre stroke team patients

12. Results 118 123 41.5% (49) 40.6% (50) 52.5% (62) 55.3% (68) 6.0% (7)
While numbers of mimics were significantly higher in the Post group, this was due to the retrospective nature of the pre audit capturing patients based on discharge diagnosis. With mimics excluded:
Pre Acute Stroke Team
Post Acute Stroke Team
Patients
118
123
% TIA
41.5% (49)
40.6% (50)
% Ischaemic Stroke
52.5% (62)
55.3% (68)
% Haemorrhagic Stroke
6.0% (7)
4.1% (5)
When mimics are excluded we see a very similar breakdown on TIA, Ischaemic and haemorrhagic strokes

13. Results 9 70 7.6% 12.9% 132.4 minutes 88.2 minutes 88.3 minutes
Pre Acute Stroke Team
Post Acute Stroke Team
Stroke Calls 9 70
Thrombolysis (Rate)
7.6%
12.9%
Door to CT Times
132.4 minutes
88.2 minutes
Door to Needle Times
88.3 minutes
68.5 minutes
Mean Length of Stay
8 days
4 days
In-Hospital Mortality
12.5%
6.2%
Stroke calls in the pre group were early dressed rehersal calls prior to the official opening of the stroke unit.
The thrombolysis rate improved by 5.3%
There was a significant reduction in time to diagnositcs by 44 minutes on the door to CT time
The average door to needle time also improved for stroke call group by 20 minutes.
The average length of stay for patients post stroke unit halved along with in hospital mortality.

14. Results 51.1% 5.0% Pre Acute Stroke Team Post Acute Stroke Team
Missed Swallow Screens
51.1%
5.0%
Failure to obtain swallow screens prior to oral intake rates fell after the introduction of the swallow screening tool.
While the stroke team is not solely responsible for this improvement, stroke screens were conducted on patients during stroke calls prior to transfer to unit.
Determining rates of aspiration or complications secondary to failure to screen were out of scope for this audit.

15. Conclusions
Results highlight that an acute stroke team running even only during business hours was effective at:
Improving the thrombolysis rate
Improving door to needle times
Improving door to CT times

16. Conclusions
Improved LOS and mortality while not solely due to the Acute Stroke team were influenced by increased rates of treatment, shorter times to diagnostics, and shorter ED times.
Swallow screening improved, this was in part facilitated by the acute stroke team completing screens prior to admission to stroke unit.

17. References
National Stroke Foundation. Acute Stroke Services Framework Melbourne Australia.
Nazir et al Introduction of an Acute Stroke Team: An effective approach to hasten assessment and management of stroke in the emergency department; Journal of Clinical Neuroscience 16 (2009)
Hamidon et al Impact of acute stroke team emergency calls on in hospital delays in acute stroke care; Journal of Clinical Neuroscience 14 (2007)