1. RBFT Stroke Services 2011 Dr André van Wyk Stroke Consultant
Members event
Royal Berkshire Hospital
28 June 2011

2. Introduction What is a Stroke? How does one recognise a Stroke?
Impact of Stroke: patient, on the family, on society, economy
How does one diagnose, assess and manage: TIA, Stroke and Risk factors
What are the National Guidelines and way services are measured
Vital different components of TIA and Stroke service and benefits
The whole pathway Stroke service at RBFT and surrounding areas
The Future
Stroke 2010

3. What is a TIA and Stroke?
A TIA (sometimes called a mini stroke) is similar to a full stroke
but the symptoms may only last a few minutes and will have
completely gone within 24 hours
TIA -Acute focal cerebral or monocular symptoms less than 24 hours as a result of thromboembolic disease
A stroke is a brain attack. It happens when the blood supply to
the brain is disrupted. Most strokes occur when a blood clot
blocks the flow of blood to the brain. Some strokes are caused
by bleeding in or around the brain from a burst blood vessel.
Stroke syndrome, rapidly developing clinical symptoms, focal occasionally global loss of cerebral function, lasting more than 24 hours or leading to death
Brain Attack or Acute Stroke Syndrome for symptom present with in 24 hours of onset

4. Stroke types and mechanisms

5. Stroke Complex patients (need for specialists): -
medically unstable at risk complications and early
functional- motor leg & arm power: sitting, walking; speech: communication; brain processing: memory, planning, orientation
body working swallowing: feeding, medication –affects survival
Change occurs in first 24 hours- need early access Stroke Unit
Stroke management requires coordinated multidisciplinary working
Integrated local health, social and voluntary sector working (quality): prevention, hyperacute, acute stroke unit, specialist community rehab, long-term care
Whole pathway required to treat stroke –interdependent
Spending by commission or omission: reablement/ less functional dependency vs or on care

6. How does one recognise a Stroke?
Early recognition and management of a stroke is important
Commonly patient may not recognise they’ve had a stroke
FAST common but also other types stroke and symptoms eg sudden loss balance; dizziness; vision: loss in one or both eyes or double; inability swallow

7. Impact of Stroke: patient
Sense of self
Loss confidence, self worth, depression
Changes way one thinks, all the functional daily activities and extended activities one takes for granted
Loss independence
Need to come to terms with dramatic change while engaging in very activity physical and cognitive rehabilitation to find a new ‘orbit’

8. Impact of Stroke: on the family
Stroke impact is often life long
‘family’ disease
affect family dynamics and relationships
role: bread winner / parent / husband or wife
career and hobbies

9. Impact of Stroke: on society
Facts about stroke
Every five minutes someone in the UK has a stroke.
Each year an estimated 150,000 people in the UK have a stroke.
Stroke is the third most common cause of death in the UK.
There are over a million people who have had a stroke living in
the UK, and around half of all stroke survivors are left dependent
on others for everyday activities
Single largest cause of adult disability

10. Stroke Data
110,000/ y England.
third highest cause death England : 11 per cent of deaths England.
20–30 % die within a month.
25 % occur under age of 65.
>900,000 people living in England have had a stroke.
single largest cause of adult disability
devastating and lasting impact on lives of people and their families.
Often live with the effect of stroke rest of their lives.
A third are left with long-term disability..
Costs NHS and economy about £7 billion/y: £2.8 billion direct costs NHS, £2.4 billion informal care costs (e.g. the costs of home nursing borne by patients’ families) and £1.8 billion income lost to productivity and disability.
Outcomes UK compare poorly internationally, despite expense, unnecessarily long lengths of stay and high levels avoidable disability and mortality.

11. Impact of Stroke: economy
Costs NHS and economy about £7 billion/y: £2.8 billion direct costs NHS, £2.4 billion informal care costs (e.g. the costs of home nursing borne by patients’ families) and £1.8 billion income lost to productivity and disability.
Situation till recently is that outcomes UK poor compared to internationally, despite expense, unnecessarily long lengths of stay with high levels avoidable disability and mortality.

12. How does one diagnose, assess and manage: Risk factors for TIA and Stroke
Lifestyle, genetic and biological make up and impact of disease
Campaigns, education
History eg of family, smoking; Examination eg weight, checking BP and Investigations cholesterol, ECG check for AF then more specialised eg cardiac and scanning carotid arteries
Management: working out specific risk factors and education eg stopping smoking, diet and exercise
Medication aspirin statin blood pressure warfarin
Specialised eg. urgent referral carotid surgery

13. Concepts
Risk factors
Hypertension Meta analysis Stroke 2004 : 35: > with 6800 stroke events
10 mm Hg reduction systolic blood pressure reduces stroke by 1/3
Cholesterol meta analysis Amarenco Stroke 2004:35:2902
Effect related to LDL reduction each 10% reduction decreased stroke by 15.6%

14. Weeks between symptomatic event and randomisation ARR (%), 95% CI
Effect of carotid endarterectomy stratified by time from last event to randomisation Ipsilateral ischaemic stroke and operative stroke or death
32.7
16.0
11.2
9.4
13.8
3.4
0.0
-2.9
-20.0
-10.0
10.0
20.0
30.0
40.0
50.0
0-2
2-4
4-12
12+
Weeks between symptomatic event and randomisation
ARR (%), 95% CI
70-99%
50-69%
Lancet 2004; 363:

15. Higher risk < 1 day
Lower risk < 1 week
Non-urgent

16. TIA Mobile phone service (40595) Clinics 5 days a week
Aim to see patients within 24 hours of referral – patients decline appointments!
578 patients seen in clinic in 2009
340 were TIAs
65% high risk seen within 24 hours

18. Admitted on Monday imaging completed reviewed by Vasc surgeons CEA set up for Thusay
Had CEA Friday uneventful anphyl to gelofuse
Came back to SU
D?C
Monday

20. Principles in managing Stroke patients
Need to diagnosis: stroke, type and cause EARLY access to high tech radiology and cardiac
Time is brain
emergency pathway to restore blood supply brain –thrombolysis
Brain receptive to remodelling the dendrites sprouting- early rehab
Early admission to Stroke Unit for Multidisciplinary assessment and closely coordinated management to deal with all complex issues in stroke with rehabilitating and caring for patient and their family
Prevention and treatment risk factors that may result further stroke and complications of the stroke
Specialist rehabilitation and person specific goal setting done with patient and family both in Stroke Unit and if needed with specialist stroke Early Supported Discharge team in the community to extend and reintegrate function to home
Long Term Care

21. End-of-life care

22. What has changed in Stroke?
National Stroke Strategy 5 Dec 2007 : 20 quality markers /10-point plan of action
Prevention treat TIA as emergency 2/3 seen and treated within 24h
Hyperacute Stroke Pathway 1/3 admissions thrombolyse 1:3 (10 % 24/7 service)
Stroke Specialist rehabilitation geared individual needs 7 days per week : Stroke Unit and ESD
Long Term care/ follow up-emotional needs psychological
Radical change in Stroke management since 2007
2 Guidelines on being major acute Hospital
DARZI & RCP acute medical care Oct. 2007
Delivery: NSS Organisational matrix / Performance Indicators / National Sentinel Stroke Audit / Ambulance Trust

23. 23

24. Ten-point plan for action
Awareness
Preventing stroke
Involvement
Acting on the warnings
Stroke as a medical emergency
Stroke unit quality
Rehabilitation and community support
Participation
Workforce
Service improvement

25. Vital different components of TIA and Stroke service and benefits
Avoid having a stroke –lifestyle and risk factors esp. hypertension
Act on warning TIA or Stroke- medical emergency
Rapid Access TIA service
Stroke Unit (coordinated MDT) benefits all patients specialist rehab
Hyperacute Stroke service able to provide 24/7 thrombolysis
Early Supported Discharge (specialist stroke rehab at home)
Long Term Care

26. Thrombolysis Cochrane library 2003
A&I 44.3 A&D Dd 17.3
Control
A&I 30.2 A&D Dd 18.4
Differences per 1000 – 141 extra AI
130 fewer D, 12 fewer Dd

27. Pooled Analysis tPA Trials Lancet 2004:363:768-774
OR for favourable tPA (95% CI) TIME
2.8 ( ) mins
1.6 ( )
1.4 ( )

28. DATA from SITS-MOST registry Lancet 27 January 2007
                                                                                                                        
Figure 4. Proportion of patients with modified Rankin score of 0–6 at 3 months in SITS-MOST and in pooled randomised controlled trials for both placebo and alteplase patients2 
Modified Rankin Scale
SCOREDESCRIPTION
0No symptoms at all
1No significant disability despite symptoms; able to carry out all usual duties and activities
2Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
3Moderate disability; requiring some help, but able to walk without assistance
4Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6Dead
TOTAL (0–6): ____

29. Thrombolysis 08.00 – 18.00 Thrombolysis Service
Ambulance response upgraded to Cat A
27 patients thrombolysed so far
Only one haemorrhage

30. D,  D    MR PRE tPa FOR R TACI STROKE
:  Birth  Date                          :  12/31/1925 Sex                                    :  M   Date  of  Exam                    :  05/28/2009  04:55  PM   Report  Approval  Date          :  05/28/2009  04:55  PM Report  Approver                  :  Meanock,  Colin    CT  brain.    Indication:  Left  hemiplegia  1  hour  ago.    Findings:  The  low  density  change  on  the  right  both  above  and  below  the  tentorium  was  present  in  November  2007.  No  new  infarct  is  identified

32.   D,  D    MR 24 POST tPa FOR R TACI STROKE
Hospital  Number                  :  Birth  Date                          :  12/31/1925 Sex                                    :  M Date  of  Exam                    :  05/29/2009  10:09  AM   Report  Approval  Date          :  05/29/2009  10:09  AM   CT  brain.  Clinical  indication:  dense  left  hemiplegia  with  tPA  yesterday.      Findings:  There  is  no  evidence  of  recent  intracranial  haemorrhage  and  no  extra-axial  collection  is  identified.  However  today's  study  shows  an  area  of  low  attenuation  posteriorly  in  the  right  frontal  lobe  (images  15-23)  which  was  not  present  yesterday;  appearances  in  keeping  with  an  evolving  non-haemorrhagic  infarct.  This  measures  a  maximum  of  approximately  40  x  30  mm  in  the  axial  plane.

34. Press launch for ESD January 2010 www. royalberkshire. nhs
Press launch for ESD January

35. The whole pathway Stroke service at RBFT and surrounding areas
Acute Stroke Unit started beds to 13 Battle Hospital now 28 combined Stroke Unit RBFT since 2007
Neurorehabilitation service 8 stroke beds, vocation and spasticity service
Rapid Access TIA service 2005 extended pilot to the last 22 months week days seeing high risk patients within 24h
Thrombolysis 10h /d week days 18 months with Cat A ambulance
ESD Early Supported Discharge rehab service Berk West 13 months with CBNRT for further targeted input
Currently 3 Stroke patients family support workers (2 have funding only further 9 months)

36. Employed 2nd Stroke Consultant (Sept 08)
Stroke Registrar shred rotation Oxford (new post)
More junior doctors
Funding for band 6 & band 2 nurses
Business case for increase in therapy team

37. The Future
Plans currently for business case to extend Thrombolysis to 24/7 by April This will involve the RBFT first use of telemedicine
Rapid Access TIA would be 7/7 by April 2011
ESD service has been agreed for S Oxon currently setting up
Ensure extending funding for 2 Stroke Family and Support worker posts with key role in support and Longer Term Care stroke patients with co-ordinator Stroke support networks eg stroke clubs, information and sign posting
Setting up education programme staff and Information resources

39. Stroke Pathway Incorporating ESD Service
Pathway is simple – one page of A4

40. HQIP GOLD award won by stroke service RBFT for improvements to service through Audit 2010

41. Thank you for your attention
Any questions