Innovations in Stroke Services in the United Kingdom

Dr Ben Bray Quality Improvement Fellow, Royal College of Physicians Clinical Lead (Stroke), Cardiovascular Intelligence Network, Public Health England

Innovations in Stroke Services in the United Kingdom*

Dr Ben Bray Quality Improvement Fellow, Royal College of Physicians Clinical Lead (Stroke), Cardiovascular Intelligence Network, Public Health England *Mainly England

Outline

• • • • Where have we come from?

Audit and quality improvement Changing services: 7 day working, reconfiguration Current priorities and future directions

Stroke Services

Where have we come from?

• • • • • • • • •

What has happened in the past 30 years?

Stroke unit based care Thrombolysis services Stroke specialist training for physicians Development of multidisciplinary teams Early supported discharge Rapid TIA services Much better imaging Secondary prevention Primary prevention, especially atrial fibrillation

“The performance of the UK in terms of premature mortality….is below the mean of the EU15+…….further progress will require improved public health, prevention, early intervention and treatment activities……and deserves an integrated and strategic response”

Changes in Stroke Mortality 1968 2006

Mortality: Ischaemic stroke

30 day mortality: Ischaemic 15 10 5 30 25 20 0 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 Year 20 06 20 07 20 08 20 09 20 10 20 11 20 12 95%CI Audit 95%CI SLSR Source: SINAP

Mortality: Primary intracerebral haemorrhage

30 day mortality: ICH 60 55 50 45 40 35 30 25 20 15 10 5 0 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 Year 20 06 20 07 20 08 20 09 20 10 20 11 20 12 95%CI Audit 95%CI SLSR Source: SINAP

Mortality: Older people

30 day mortality: Age 80+ 40 35 30 25 20 15 10 5 0 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 Year 20 06 20 07 20 08 20 09 20 10 20 11 20 12 95%CI Audit 95%CI SLSR Source: SINAP

Thrombolysis

15 0.7

.

2.2

10 7.3

9.6

11.8

11.2

5 0 ...

20 04 Sentinel 20 08 SINAP 20 10 20 11 20 12 20 13 SSNAP Source: SINAP/SSnap

Appropriate place of care

Source: SINAP/SSNAP

Access to physiotherapy

Source: SINAP/SSNAP

Proportion of patients (by age band) receiving a scan within 24 hours of admission after stroke

Audit & Quality Improvement

Admission to acute stroke service Transfer to in patient rehabilitation Discharge to community rehabilitation team 6 month review

Complete pathway record

Reorganising services

Strokes happen on weekends!

3000 Hospital arrival - Day of the week 2000 1000 0 Mon Source: SSNAP Jul-Sep 2013 National level results Tues Wed Thur Day of the week Fri Sat Sun

Differences in the processes of care for patients admitted in normal working hours and out of hours Eligibility for and compliance with process measures for normal hours and out of hours patients (adjusted odds ratios)

Campbell et al. PLOS One 2014

7 day working - thrombolysis

300 Thrombolysis - Day of the week 200 100 0 Mon Source: SSNAP Jul-Sep 2013 National level results Tues Wed Thur Day of the week Fri Sat Sun

7 day working – occupational therapy

Overall OT assessment - Day of the week 3000 2000 1000 0 Mon Source: SSNAP Jul-Sep 2013 National level results Tues Wed Thur Day of the week Fri Sat Sun

7 day working - physiotherapy

Overall PT assessment - Day of the week 3000 2000 1000 0 Mon Source: SSNAP Jul-Sep 2013 National level results Tues Wed Thur Day of the week Fri Sat Sun

Risk of death by 30 days and weekend ratio of trained nurses per 10 stroke beds, by day of admission

Higher nurse:bed ratio

Adjusted for patient level prognostic variables, stroke service characteristics, consultant and care assistant staffing levels and care quality

Bray et al. Submitted to PLOS Medicine

Median arrival-tPA time by annual thrombolysis volume

Bray et al. Stroke 2013

Arrival-tPA for each volume group

Bray et al. Stroke 2013

Thrombolysis rate by onset-arrival time

Bray et al. Stroke 2013

London Stroke Reconfiguration

• 28 stroke units  8 hyperacute SU and 20 post acute SU • 11,500 strokes a year in London – 2,000 deaths 38

Percentage of all stroke admissions thrombolysed in London

20,00% 18,00% 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% Feb-July 2009 Feb-July 2010 Jan-March 2011 Jan-July 2012 Jan-March 2013

Risk adjusted mortality by quarter at 30 days in London, Manchester and the Rest of England

Current priorities

• • • • Intermittent pneumatic compression for VTE prevention (CLOTS 3 Trial) Evidence based care: AF, acute stroke, TIA management, thrombolysis pathway Integration across cardiovascular diseases Psychological, mental health and cognitive impairment after stroke

Vascular Disease – One Event Leads to Another Having a stroke

• •

increases your chance of: Heart attack by 2-3 times Another stroke by 9 times

• •

Having Chronic Kidney Disease increases your chance of: Heart attack by 2 times Stroke up 50%

•

Having a heart attack

•

increases your chance of: Having another heart attack by 5-7 times Stroke by 3-4 times

• •

Having PAD increases your chance of: Heart attack by 4 times Stroke by 2-3 times Diabetes (type 2) Because of the increased risk associated with diabetes the risk is equivalent to having a heart attack

Data is increased risk vs general population (%) *Includes angina and sudden death. Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD) **Includes only fatal heart attack and other CHD death; does not include non-fatal heart attack, + Includes death ++Includes TIA

1.

Adult Treatment Panel II.

Circulation

1994; 89:1333 –63.

2.

Kannel WB.

J Cardiovasc Risk

1994; 1: 333 –9.

3.

Wilterdink JI, Easton JD.

Arch Neurol

1992; 49: 857 –63.

4.

Criqui MH

et al. N Engl J Med

1992; 326: 381 –6.

Cardiovascular Integration

• • • • Prevention Cardiopulmonary rehabilitation after stroke and TIA Shifting care where appropriate to community and primary care Joining cardiovascular datasets for clinical care, quality improvement and research

Thank you

benjamin.bray@kcl.ac.uk