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6. STROKE SERVICES
6.1 Stroke services, shaped by the local Managed Clinical Networks, aim to provide evidence based and high quality, patient centred care at all points in the patient pathway - from identification and treatment of a transient ischaemic attack ( TIA) to prevent a stroke, through to the long term support of stroke survivors with complex needs (and their carers) in the community.
Local Services
6.2 Stroke and TIAs are sufficiently common that most stroke services can and should be provided locally. This makes both early access to specialist care and discharge from secondary care back to the community easier.
6.3 About one-fifth of patients who suffer a stroke will have had warning symptoms ( TIAs) in the days or weeks before the onset of a stroke. This offers a unique opportunity to prevent a disabling or even fatal stroke using interventions such as anti-platelet drugs, anticoagulants, cholesterol and blood pressure lowering medication. For every 100 patients treated with this combination in the first day after a TIA or minor stroke one might expect to prevent 5-10 strokes. In some patients, surgery on the carotid artery will further reduce the risk of subsequent stroke.
6.4 Daily TIA clinics and TIA hotlines provide two potential service models which offer the necessary immediate access to clinical assessment and treatments to reduce the risk of future stroke. However, many patients and relatives are unaware of the early warning symptoms of stroke and will therefore stand to benefit from the public awareness campaign being run by Chest, Heart and Stroke Scotland which promotes the Facial, Arm, Speech Test ( FAST).
Stroke Unit Care
6.5 Stroke unit care improves outcomes. For every 100 patients admitted to a stroke unit, about five additional patients will survive to leave hospital free of significant disability. In the six years since the publication of the original strategy, access to stroke unit care has improved greatly. In 2002, there were 31 stroke units and 583 stroke unit beds in Scotland and by 2005, this had increased to 46 units, with a total of 789 designated stroke beds. In 2007, 77% of stroke patients in Scotland were managed in stroke units.
6.6 Despite these successes, however, it remains the case that many hospitals are not yet meeting the standard developed by NHS Quality Improvement Scotland ( NHSQIS), that would see at least 70% of patients with stroke admitted to a stroke unit within the first day. In some areas, this target will require a further increase in the number of stroke unit beds, while in others, the solution lies in collaborative action to reduce delays in accessing investigations, assessments by Allied Health Professionals ( AHPs), early supported discharge and the wider use of community-based rehabilitation services and nursing home beds.
6.7 Achieving NHSQIS standards across Scotland will also require action to meet current difficulties in attracting and retaining appropriately trained staff. The relatively recent recognition of stroke medicine as a sub-specialty for medical training purposes, and the establishment of specialty registrar posts, should help to address current shortages of stroke specialists. A recent survey of medical manpower has, however, identified a shortfall in the number of consultant programmed activities ( PAs) to deliver comprehensive stroke services in most NHS Boards. There are also difficulties in meeting staffing requirements for specialist nursing and AHP staff and action is required to provide higher level specialist training for nurses and increase the range of opportunities for all staff to gain the knowledge and skills required in stroke care. This is particularly important if services such as the triaging of patients in Accident and Emergency centres for possible thrombolytic ("clot dissolving") therapy are to be developed, as this will require the development of more skilled ward nursing staff who can leave their ward base to do this, without compromising the care of patients already on the ward.
Early Supported Discharge
6.8 Patients should only stay in a stroke unit bed as long as they really need it and can benefit from it. There is now reliable evidence from clinical trials that "early supported discharge" from stroke units can achieve not only shorter lengths of stay, but also better clinical outcomes for stroke patients. Currently, access to specialist stroke rehabilitation services for patients outside hospital is patchy and there is a role for Community Health Partnerships to work with Managed Clinical Networks and specialists in secondary care to increase the availability of such services.
Stroke Liaison Nurses
6.9 Leaving hospital can be very stressful for patients and their families, many of whom lack confidence and require information, psychological support and practical advice to help them deal effectively with the consequences of stroke and reduce the risks of further strokes and heart attacks. Many stroke services have employed specialist liaison nurses who meet patients and their families prior to hospital discharge and then follow them up in their own homes during the months after discharge. Patients and their families find these services enormously beneficial and such approaches should continue to be developed either directly or in collaboration with the third sector.
Long Term Services for Stroke
6.10 About a third of people who have a stroke will be faced with adapting to a life with a long-term disability. The effects of a stroke are wide ranging and can include physical and mental health problems which have a profound impact on the everyday activities of the affected individual, their family and carers.
6.11 Health, social care services, the voluntary sector, individuals and carers need to work together to develop good quality, innovative long-term solutions to stroke, which reflect the shared principles of the Delivery Framework for Adult Rehabilitation in Scotland and other key statements of Scottish Government policy. These offer the potential to deliver services which suit the needs of individuals at all stages of the recovery process, particularly following discharge from hospital. Coordinated community care via MCNs will provide the necessary multi-agency approach to create robust local support networks for stroke survivors. The provision of information in a wide variety of formats suitable for people with cognitive and communication difficulties should be a key aim of such networks.
Thrombolysis
6.12 As with TIAs, patients experiencing symptoms of stroke need to seek immediate medical advice and get rapid access to services at local or regional level. This is particularly important if treatment with thrombolytic drugs is being considered, because these need to be given within three hours of first symptom onset, with even greater benefits if the treatment is given in the first hour or two. For every 100 patients treated with early thombolysis, one would expect that 10 to 20 would avoid long term disability. This requires joint planning and collaboration between primary care, NHS 24, the Scottish Ambulance Service and Emergency Admission Units.
6.13 Despite reliable evidence from randomised controlled trials supporting its effectiveness, fewer patients in the UK receive thrombolysis for stroke than in most countries in Western Europe.
6.14 The safe delivery of thrombolysis requires the patient to be assessed by an experienced clinician and to have access to an immediate brain scan. Specialist on-site cover is not available 24/7 in every hospital that admits acute stroke patients and therefore two complementary models of collaborative working are developing across Scotland. The first relies on early recognition of suitable patients by GPs and paramedics and diversion of the patient to the nearest appropriate centre with the necessary staffing and facilities. The second involves patients going to the nearest hospital with a brain scanner and stroke unit, with specialist assessment provided remotely via a telemedicine link when necessary.
Scottish Hyper-acute Stroke Assessment and treatment (Rx) Evaluation - ( SHARE)
6.15 The development of hyper-acute stroke care is a priority for future stroke service development. Currently, the information on hyper-acute stroke care treatment until thrombolysis is collated in a variety of different ways. The SHARE project is therefore designed to allow a more consistent approach to the monitoring and evaluation of hyper-acute stroke services in Scotland. It will comprise a national registry of treated patients which will enable it to monitor whether this treatment is provided equitably and safely across Scotland. It is anticipated that this will eventually form part of the Scottish Stroke Care Audit.
6.16 To improve access and equity, thrombolysis services will need to be planned on a regional basis. This will require the development of regional on-call rotas for stroke specialists and the introduction of telemedicine networks to reduce delays to treatment and avoid prolonged journeys in ambulances.
6.17 Some patients with stroke may benefit from a number of other specific interventions (e.g. decompressive craniectomy, evacuation of haematomas, intra-arterial thrombolysis, management of arteriovenous malformations, clot pulling and stenting). These require a neurosurgical or interventional neuroradiological team (comprising neurosurgeons, radiologists, anaesthetists and intensivists) and can therefore only be provided in regional centres. MCNs need to develop referral criteria and pathways to ensure patients have access to these interventions when needed. The regional telemedicine networks should also help coordinate the transfer of small numbers of patients to a regional centre for these more specialist treatments.
Carotid Surgery
6.18 About 500 patients each year undergo carotid endarterectomy to treat narrowing of their carotid artery and reduce the risk of subsequent stroke. If this operation is performed within a week or two of a TIA or minor stroke, there is very good evidence that major stroke can be prevented. If operated on within this period, one would expect to avoid at least 20 strokes for every 100 patients treated. Currently most operations in Scotland are not done within the optimal waiting time of 14 days described in the SIGN guideline, so that some potentially avoidable strokes are not prevented and the effectiveness of the surgery is reduced.
6.19 The patient pathway to carotid surgery needs to be greatly speeded up. This will reduce delays in:
- patients seeking medical help;
- access to specialist assessment and appropriate investigation;
- referral to surgeon;
- assessment by surgeon; and
- time to surgery.
ISSUES TO CONSIDER
What further actions should we take to improve the range and quality of stroke services in Scotland and how should these actions be prioritised?
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