« Previous | Contents | Next »
Listen
Coronary Heart Disease and Stroke in Scotland
6 Access to Treatment and Care: Stroke
Strategy Recommendations
The stroke component of the Reference Group will be re-constituted as a National Advisory Committee on Stroke.
Each NHS Board will have a Stroke MCN in operation with a Quality Assurance programme agreed with the Quality Standards Board for Health in Scotland [now NHS Quality Improvement Scotland] by April 2004. The Network's functions will cover the complete spectrum of stroke services, the majority of which are provided in the community.
By June 2003, Trusts will ensure that their radiology departments provide the amount of dedicated time each day needed to ensure access to CT brain imaging for acute stroke patients in order to achieve the target times identified in the SIGN Guidelines.
6.1 Scotland is making real progress in reducing premature mortality from stroke. Since 1995 there has been a 34% fall in mortality and this trend is continuing at a time when more patients are being treated at newly established neurovascular clinics and acute stroke and rehabilitation units across the country.
Taking the Strategy Targets Forward
6.2 A joint conference involving 150 stroke physicians and radiologists managing stroke patients throughout Scotland was held in November 2003. The main aim of the conference was to highlight the stroke targets in the Strategy. Particular emphasis was given to providing patients with access to brain imaging; and ensuring that clinicians and radiologists were aware that performance would be monitored through the Scottish Stroke Care Audit and national standards set by NHS QIS. The conference provided many helpful suggestions on making the best use of available resources, including the organization of radiology services so that they can deal with all the competing demands on them. The forthcoming NHS QIS reports on stroke services will indicate whether hospitals are meeting the targets set.
Strategy Funding
6.3 The CHD and Stroke Strategy identified specific services that local MCNs will wish to address in conjunction with their NHS Boards. Funding for individual projects was made available through two rounds of funding, the first in spring 2003 and the second a year later. To date 11m has been dedicated to fund 111 prioritised stroke projects across Scotland. Each bid was individually appraised and particular priority was given to those projects which improved access for patients to one of five services:
acute stroke unit
CT brain scanning
neurovascular clinics (sometimes referred to as TIA clinics)
carotid surgery to reduce the risk of stroke
specialist stroke rehabilitation
Acute Stroke Units
6.4 Research co-ordinated in Scotland has provided strong evidence that people who have suffered a stroke have a better chance of survival, with better quality of life, if their care is organized and delivered by a multi-disciplinary team who have specialised education and training in stroke. The benefits of organised stroke unit care are outlined in the CHD and Stroke Strategy and other documents issued by SIGN, the Royal College of Physicians of Edinburgh and the National Service Framework for Older People in England. These benefits include: more survivors returning home and regaining independence; possible reductions in length of hospital stay and improved long term independence and quality of life.
6.5 In 2002, the Strategy identified an urgent need to ensure that all hospitals in Scotland which admitted patients with an acute stroke could provide immediate stroke unit care. It also highlighted the fact that there was a lack of equity of stroke provision across Scotland. In some NHS Boards such as Highland and Borders there was no provision. In others there were too few designated stroke beds to allow patients early access to a stroke unit. Some hospitals had designated beds but lacked key components of stroke unit care such as a multi-disciplinary team of trained health professionals. Now, all the mainland NHS Boards either have an acute stroke unit in place or are at an advanced stage of planning their implementation. This represents a significant advance on the position in 2002.
Thrombolysis in Stroke
6.6 The CHD Task Force highlighted in 2001 the fact that thrombolytic therapy had revolutionised the management of heart attacks and greatly improved survival rates. Over three quarters of strokes are related to arterial obstruction, often due to a blood clot that may be dissolved by a thrombolytic drug. Recent research concerning the effectiveness of thrombolysis for stroke has concluded that the benefits are promising, especially with early treatment, but unfortunately few patients reach hospital quickly enough for thrombolysis to be safely administered.
6.7 The Task Force took a cautious approach and recommended that thrombolytic therapy for stroke should be reserved for use within the terms of its product licence (i.e. within 3 hours of stroke onset, in specialist units). At present, all patients who receive this treatment in Scotland are entered into a national registry, which will provide data to support a decision on its wider use. Further research is ongoing in this area.
Access to CT Scanning
6.8 For the majority of stroke patients, a routine CT brain scan performed within no more than 48 hours will confirm the diagnosis and accurately distinguish a haemorrhagic from an ischaemic stroke. The CHD and Stroke Strategy recommended that Trusts admitting patients who have had an acute stroke should ensure that radiology departments provide the appropriate amount of dedicated time each day to ensure access to CT scanning.
CASE STUDY
Ayrshire and Arran Feels the Benefits of a Stroke MCN Impact of Increased Stroke Beds Since the increase in the numbers of beds in the acute stroke units in March 2004, stroke patients have benefited by having a more direct method of admission through Accident and Emergency, giving optimum care. The staff feel that the 6 extra beds in 4D at Crosshouse and the 3 extra beds in Station 16 at Ayr are being used appropriately in accordance with the Acute Stroke Protocol. This has improved the flow of patients through the unit with the assistance of the bed managers who can now ensure stroke patients are treated in the acute stroke unit. The multi-disciplinary staff there can offer an improved service to patients in a team environment. |
| Wason McCafferty and Diane Carlin (two young stroke survivors), Fiona Neal (stroke sister) and Karen Barclay (speech and language therapist) |
A View from Speech and Language Therapy Staff Speech and language therapy staff have been pleased to see an increase in therapy sessions in both Ayr and Crosshouse. They report that they feel more focused on stroke and more motivated as a result. The department is developing the use of Care Aims to plan therapy interventions and document outcomes. This has an effect on goal setting and has also encouraged staff to develop reflective practice techniques when planning therapy. The staff are also pleased that there will be opportunities for further training in stroke. Patient and Carers Involvement Group This busy group has been looking at information packs for patients on admission and discharge to tailor them to individual needs. Two patients are co-ordinating a new branch of Different Strokes with help from MCN which has meant they can kick start their exercise and social class for young survivors. |
'One Stop' Neurovascular Clinics
6.9 Well organised stroke services will include rapid access to outpatient assessment, and the approach of MCNs to setting up fast track outpatient clinics is to be commended. The aim of these neurovascular clinics is to see patients promptly at an early sign of stroke related symptoms. Such clinics may provide a full medical assessment, CT scan (if appropriate), carotid Doppler and echocardiography. Ideally these investigations would be available at 'one stop' clinics though this will vary according to local circumstances. The mainland MCNs have been very successful in establishing this important part of the patient journey and the island boards have responded with equally innovative solutions to make sure that patients are seen promptly when symptoms first arise.
Carotid Endarterectomy
6.10 A minority of patients who have previously experienced a stroke or TIA have a narrowing located within a carotid artery. Such narrowings are detectable by ultrasound or magnetic resonance imaging. If the narrowing is severe then surgical treatment (carotid endarterectomy) has been shown to reduce the subsequent risk of a stroke, but surgery is not without risks and these must be balanced against the potential benefits of intervention.
6.11 Recent evidence has indicated that surgery is of greatest benefit if performed within a few weeks of the TIA or minor stroke. Those responsible for coordinating neurovascular clinics and arranging surgery are working hard to minimize the delays to surgery.
Rehabilitation after Stroke
6.12 The Task Force Report recommended that Stroke MCNs should pay particular attention to co-ordinated stroke rehabilitation and integrated discharge planning, regardless of the setting in which this is delivered.
6.13 Rehabilitation is an essential part of the recovery process and is ongoing from admission to discharge from hospital and beyond. It helps build the patients' strength, co-ordination, endurance and confidence. The goal of stroke rehabilitation is to help patients make the best possible recovery and promote independence after a stroke. The interdisciplinary rehabilitation team works closely with each stroke survivor and their family to enable them to take part more fully in family, social, leisure and work activities. The goal to achieve the best level of quality of life and life satisfaction for the patient and their family is at the heart of this process.
CASE STUDY
Tayside Dedicated Acute Stroke Unit NHS Tayside opened a dedicated acute stroke unit in Ninewells Hospital on 16 August 2004. The unit has 18 beds managed by a multi-disciplinary team to optimise recovery and outcome of patients in the immediate period after a stroke. The opening of the new unit should result in better outcomes for patients as a result of preventing stroke progression in the early stages. Strategy funding has helped in this first phase of redesign of stroke services. Service mapping of the acute phase of the patient journey has identified the need to enhance the existing nursing team - both in terms of boosting numbers and improving the skill mix. Additional allied health support in the multi-disciplinary teams was also identified as an essential component for an acute stroke unit. The unit now has six additional trained nursing staff, senior dieticians, a speech and language therapist and an assistant. A framework for acute stroke nursing has been developed to define the nursing role. This new framework has given purpose to activities, identified contribution and effectiveness, identified the learning needs of staff and will guide future development. The team has worked hard to produce clear protocols for the standardised approach to care and the admission criteria for the unit. Patients with a neurological deficit consistent with acute stroke are admitted initially to the acute general receiving unit. The stroke acute response team will be notified of all acute strokes and will make a rapid assessment with respect to further management. Staff within the unit will be supported by the Managed Clinical Network to undertake further stroke training through the accredited CATS module of stroke care at Dundee University. Unqualified staff will also be supported to undertake training in stroke care. Multi-disciplinary team meetings are held weekly introducing patients to the team and providing a forum for assessment and goal setting before the patient begins rehabilitation. Though the unit has been opened only a few weeks, clear benefits are already being seen. Audit figures show that the patient journey within Ninewells Hospital was often erratic with patients being admitted to many different specialities and wards within the hospital. Since the unit opened, there have been fewer inappropriate admissions and Tayside is on track to meet the target of 70% of stroke patients being admitted to the stroke unit within 24 hours of presentation at hospital. |
6.14 The process of stroke rehabilitation is therefore integral to the functioning of acute stroke units and has been a focus for service development over the last two years. Scottish Stroke MCNs have invested more than 5.5m of strategy funds into acute stroke care pathways and this includes the establishment of stroke units and the provision of community based rehabilitation services. This now means that any patient presenting with a stroke in Scotland should receive dedicated multi professional rehabilitation as part of their care package.
NHS Quality Improvement Scotland Stroke Standards
6.15 NHS Quality Improvement Scotland (NHS QIS) published the
"Clinical Standards for Stroke Services: Care of the Patient in the Acute Setting" in March 2004. The standards apply to stroke, transient ischaemic attack (TIA), rehabilitation, secondary prevention and discharge. They will reinforce the requirement for the local provision of: acute stroke units; access to CT scanning; neurovascular clinics; and rehabilitation services.
6.16 The standards were developed by a multi-disciplinary project group including representatives from healthcare professions, patients, carers and voluntary organisations. The wider service was involved through a full consultation exercise, including open meetings in March and April 2003, and through piloting the standards in various NHS sites across Scotland.
6.17 Since publication of the standards, all relevant sectors of NHSScotland have been building up their self-assessment audit data. NHS QIS review teams have started a programme to visit each NHS Board to follow up this self-assessment exercise with an external peer review of performance in relation to the standards. Following each visit, a local report is being sent to each NHS Board and a national overview of the findings will then be published by NHS QIS in November 2005.
« Previous | Contents | Next »