1. Governance of a Stroke Thrombolysis Service
Barry Moynihan

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

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

4. Pathway
Mapping
Geography & People
Where the drug is given

5. 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

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

7. Haemorrhage after stroke rtPA
Extracranial
Intracranial
Symptomatic
Asymptomatic

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

9. 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

10. Monitoring
Local
Clinical Networks
National
SITS
NICE
SINAP

11. 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

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

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

14. 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

15. Clinical Outcome

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

17. None of these criteria are available from SITS

18. SINAP April 2010

19. SINAP April 2010

20. 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)

21. Second National SINAP report (Feb 2011)

22. Summary
Pathway
Protocols
Outcomes
Monitoring
Training

23. Useful Links