GP workshop

Maria FitzpatrickNurse Consultant

Kings CollegeStroke Centre

Stroke: the Facts– Every 5 minutes someone in the UK has a stroke

– 1 in 4 men and 1 in 5 women will have a stroke after the age of 45

– Mortality is 50% after one year (worse than cancer)

– Of the survivors• 50% remain dependant on others• 25% will have difficulties walking• 25% will have problems speaking• 33% will suffer depression

– Costs UK 4.8 billion a year in cost of care

“Little that medicine and nothing that surgery can do in the management of stroke”

For every £50 spent on cancer research and £20 on heart disease research, only £1 is spent on stroke research

Stroke: the Facts

Not so long ago……• Stroke is a non-acute condition

• Hospitalisation for nursing, therapy or social needs (1988)

• CT scan for more than 10% patients needs justification (1994)

• Little acute care can do, emphasis on rehabilitation (1997)

• Move away from hospitals and towards community care for stroke (2000)

But things have changed……..• Developments in neuroimaging (1980-)

• Recognition - stroke is complex (1990-)

• Pharmaceutical Interest (1990-

• Proven effectiveness of appropriate early management (1993)

• Introduction of thrombolysis (1995)

The impact of stroke

• Every year approximately 150,000 people in England have a stroke. • Stroke is the third largest cause of death in England: 11 per cent of

deaths in England are as a result of stroke. • 20–30 per cent of people who have a stroke die within a month. • 25 per cent of strokes occur in people who are under the age of 65. • There are over 900,000 people living in England who have had a

stroke. • Stroke is the single largest cause of adult disability. 300,000 people

in England live with moderate to severe disability as a result of stroke.

• People from certain ethnic minorities are at a higher risk of stroke. • National Audit Office, 2005, Reducing Brain Damage: Faster access

to better stroke care, London, NAO

Stroke recurrence

• The risk of recurrent stroke is greatest early after the first stroke; about 2–3% of survivors of a first stroke have another stroke within the first 30 days, about 9% in the first 6 months and 10–16% within a year.

National Audit Office – Acute Care

An emergency response to stroke with efficient and effective acute care is generally lacking

16% hospitals have protocols with ambulance services for the rapid referral of stroke patients

Rates of thrombolysis in England <1%

Only 41% patients receive specialist care for half their stay

Potential savings per year of more efficient practice in London:

• £20 million in care costs• 550 deaths avoided • 1,700 people fully recovering from their

strokes

What we know• Variable quality of acute stroke care• Very small proportion of patients admitted

directly to specialist acute stroke unit• Difficulty accessing imaging• Quality of ‘acute stroke units’ not consistent

(RCP)• Very few patients receiving thrombolysis• All patients should be managed on a stroke unit

(National Clinical Guidelines 2004)

Stroke Strategy

FAST

FAST who does it?

Impact of February FAST campaign

• 9 in 10 have seen/heard at least 1 part of the campaign. • Stroke is now regarded as the top illness for causing

long standing illness, disability or infirmity among general population (before campaign regarded as third behind cancer and heart disease)

• Prompted awareness of F.A.S.T. has also increased significantly (75% compared to 15% of people pre campaign)

• An increase in respondents claiming they would call 999 if they saw a ‘slumped face’ (64% pre to 87% post); ‘somebody unable to lift both arms’ (46% pre to 72% post) and ‘slurred speech’ (46% pre to 74% post).

KCH stroke managementDelivered on a 24 hours basis

Consists of diagnostic, supportive, preventive & therapeutic interventions

Ready availability of neuroimaging, staff trained in thrombolysis and specialist stroke care

Partnerships with Ambulance, ED, Neurosciences Vascular surgery

Integrated acute and rehabilitation services

Seamless hospital and community care

Outcome of Acute Unit Care

87

67

73

15

12

67

11

22

0%

20%

40%

60%

80%

100%

UNIT DOM TEAM

DeadAlive butdependentAlive andindependent

Difference per 100 treated:SU v DOM: 14 more alive & independent NNT=7SU v ST: 20 more alive & independent NNT=5

Healthcare for London

• Hyper-acute stroke centres (8 centres)– 24/7 immediate response, thrombolysis within 30 minutes– At least 6 consultants, on-site middle-grade doctors,

sophisticated imaging and interpretation– Specialist interventions e.g. intra-arterial thrombolysis and

stents.

• Local stroke units (20 centres)– Ongoing care after stabilisation, multi-therapy rehabilitation

• Transient ischaemic attack services (20 centres)– Rapid assessment and access to a specialist within 24 hours for

high-risk patients

Hyper-acute Stroke Centres

KCH centred networkKey Features• Network between KHP, South London Trust, Lewisham and Kent Hospitals• Delivers excellence in clinical care, training and research across South London and Kent• Enables PCTs to achieve good care for all and not a postcode lottery

King’s Stroke Centre

• Covers South East London (1.5 million) • Joint protocols with LAS and ED for rapid

assessment, management and transfer• 24/7 service for thrombolysis and

advanced management of hyperacute patients

• Interventional neuroradiology, neurosurgery, neuro-intensive care

• Rapid response TIA services• Joint specialist training programmes with

District Centres• Leadership in research, education and

training

Local Centres• iv thrombolysis at PRUH• Acute and Rehabilitation care • Local TIA services• Multidisciplinary specialist rehabilitation

Research and Academic at KCL• Epidemiology, Prevention, Ethnicity• Complex Interventions, HSR Research• Imaging, cortical plasticity, rehabilitation

Tertiary Services for Kent • 24/7 neurosciences service• Diagnostic, interventional and neuro-

intensive care facilities• Management of complex patients

Pathogenesis of ischaemic stroke

Penumbra

Infarction

What needs to be in place• Red phone / bleep system / team in ED • Protocols with paramedics (FAST)• Protocols with A&E (ROSIER)• National Institutes of Health Stroke Scale (NIHSS) (all

stroke team trained)• Protocol with radiology• Acute stroke bleep / rota• Agreement with bed management• Identified monitored bed• Trained nurses (rt-PA & acute skills)• Protocols of care, guidelines

Thrombolysis in 3 hours

17.3

38.4

44.3

18.4

51.4

30.2

0

20

40

60

80

100

Thrombolysis Control

Alive andindependent

Alive butdependent

Dead

Differences/1000: 141 extra alive and independent (P<0.01)130 fewer dependent survivors (P<0.01)

ECASS III• The European Cooperative Acute Stroke

Study• Randomized, placebo-controlled, phase 3

trial • Test efficacy of alteplase administered in

patients with acute ischemic stroke in an extended time window of 3 to 4.5 hours

• Primary efficacy outcome: 90 day disabilityECASS investigators, NEJM 2008

Thrombolysis in 6 hoursSTUDY ODDS RATIO

ATLANTIS A

ATLANTIS B

ECASS

ECASS II

MORI

NINDS

TOTAL 95% CI

1 2 1 5 10Favours Treatment Favours Control

0.79 (0.68 - 0.92)

Wardlaw, 2000

Thrombolysis at King’s

• KCH is the busiest centre for acute stroke treatment in England

• Competes with the best across the world (15-20%) and exceeds the National thrombolysis target of 4%

• Scored top (98/100) for stroke care in National Stroke Audit 2008

Jan-Jun 08 Jan-Jun 09 Jan-Mar 2010

All strokes 154 273 236

Within 3 hrs of onset 32 87 100

Within 6 hrs of onset 75 174 156

Thrombolysed 38 80 97

% Thrombolysed (6 hours) 25% 29% 41%

Thrombolysis for Acute Stroke

• Thrombolysis is using drugs to dissolve clots that block blood vessels• The most effective treatment ever for stroke patients• 40% increase in the number of people alive and independent

2 million neurons are lost for every minute of delay in treatment

Left sided weaknessLoss of vision

1 hour 12 hours

Normal

THROMBOLYSIS

Thrombolysis can only be performed at centres with specialist facilities and staff

Intra-arterial Thrombolysis

• Benefits

Increased effectiveness

Increased safety

Longer time window

• Limitations

Neuroradiology access

Training and expertise

Costs

Protocols for malignant stroke

ICH Pathway

Admission to HDU/ITUHourly neuro observations

ICP monitoring

Repeat CT Neurosurgical review

Intraparenchymal haemorrhage

ABC management Assessment for signs of trauma

Blood investigations inc. INR APTT & CBC

Cerebellar haemorrhage

Contact neurosurgeons IMMEDIATELY

Cerebral haemorrhage

Discuss with Neurosurgeons

NOT for surgery

Stroke Unit

May need surgery

Suspected Intracranial Haemorrhage

Subarachnoid haemorrhage

SAH Pathway

Immediate CT scan

Deteriorating GCSNeurologically stable

Improved Deteriorated

SURGERY

SB, 34 yrs old nurse, sudden onset right weakness and unable to speak (7:30 am)Maidstone Hospital 8:15am, transferred KCH 12:50 pm

Door to treatment – 34 minutes “Hole in the heart”

repaired at 24 hours

Making a difference for patients

Rehabilitation on Friends Stroke Unit

What is Rehabilitation?

Rehabilitation is the process that aims to encourage maximum recovery after a stroke. Rehabilitation is a team working process with the patient at the centre. It is very important that that you are actively involved in the your own rehabilitation.

The multi-disciplinary team.

The team mainly includes doctors, nurses, physiotherapists, therapists, stroke specialist nurse, social worker and others depending on your needs.

Goal Setting

One of the main parts of rehabilitation on Friends Stroke Unit is goal setting. The therapists will meet with the patient at the beginning of their treatment to discuss the aims of their rehabilitation whilst an in-patient. The goals made are both short and long term, which will be achieved within two weeks and at the end of rehabilitation respectively.

Family Meeting

The patient/family will be given the opportunity to have a family meeting to discuss treatment and discharge plans. This can involve therapists, doctors, nurses and a social worker in order to facilitate a safe and happy discharge from Friends Stroke Unit.

What is a Keyworker?

A keyworker is the person who will help the patient and carers to co- ordinate the rehabilitation process whilst on Friends Stroke Unit. Part of their role involves communicating with the patient, their relatives and the rehab staff. The keyworker will act as the point of contact if the patient or family members have any queries.

Discharge from Friends Stroke Unit.

Discharge planning is coordinated by the keyworker and the rest of the multi-disciplinary team and an expected discharge date and destination is set within the first week of rehabilitation. Following discharge from Friends Stroke Unit you may have further rehabilitation either as an inpatient or at home.

Advanced imaging for TIA in ED

• 58 y, F, HT, smoker• Suddenly unable to speak• R arm and leg weakness• Improved in 30 minutes• Presented with no deficits to

the Emergency Department

SB, 34 yrs old nurse, sudden onset right weakness and unable to speak (7:30 am)Maidstone Hospital 8:15am, transferred KCH 12:50 pm

Door to treatment – 34 minutes “Hole in the heart”

repaired at 24 hours

Making a difference for patients

UK Firsts in stroke treatment

Themes in Stroke Research

Vascular biology

Cell biology and stem cell

Neuroimaging

7 days after stroke 3 m after stroke

Small vessel disease

Epidemiology and Prevention

Health Services Research

The vision for the future• A Centre of Clinical Excellence

– Provide innovative and high quality stroke care

– Train the best young clinicians and scientists in stroke

– Influence government policies to improve stroke services

• A Centre of Research Excellence

– Improve clinical care and outcome in stroke

– Reduce stroke in African-Caribbean people

– New insights into the causes and prevention of stroke

– Cellular therapies to promote brain repair

– Clinical trials and “first in man” studies for stroke patients

Our goal is to create an internationally recognised centre

of excellence for patient-centred care and research

Achieving the vision: Patients First

Jennifer Whyte, a Wandsworth resident, was brought in as a “blue light” emergency by the London Ambulance services and was given intra-arterial thrombolysis after perfusion scanning. Angiography showed an carotid artery dissection as the cause for stroke for which she was treated.