GP workshop. Maria Fitzpatrick Nurse Consultant Kings College Stroke Centre

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1 GP workshop Maria Fitzpatrick Nurse Consultant Kings College Stroke Centre

2 Stroke: the Facts 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

3 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)

4 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)

5 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 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

6 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.

7 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

8 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)

9 Stroke Strategy

10 FAST

11 FAST who does it?

12 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).

13 KCH stroke management Delivered 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

14 Outcome of Acute Unit Care 100% 80% 60% 40% 20% Dead Alive but dependent Alive and independent 0% UNIT DOM TEAM Difference per 100 treated: SU v DOM: 14 more alive & independent NNT=7 SU v ST: 20 more alive & independent NNT=5

15 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

16 Hyper-acute Stroke Centres

17 KCH centred network Key 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 neurointensive care facilities Management of complex patients

18 Pathogenesis of ischaemic stroke Penumbra Infarction

19 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

20 Thrombolysis in 3 hours Alive and independent Alive but dependent Dead Thrombolysis 18.4 Control Differences/1000: 141 extra alive and independent (P<0.01) 130 fewer dependent survivors (P<0.01)

21 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 disability ECASS investigators, NEJM 2008

22 Thrombolysis in 6 hours STUDY ODDS RATIO ATLANTIS A ATLANTIS B ECASS ECASS II MORI NINDS TOTAL 95% CI 0.79 ( ) Favours Treatment Favours Control Wardlaw, 2000

23 Thrombolysis at King s Jan-Jun 08 Jan-Jun 09 Jan-Mar 2010 All strokes Within 3 hrs of onset Within 6 hrs of onset Thrombolysed % Thrombolysed (6 hours) 25% 29% 41% 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

24 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 1 hour 12 hours THROMBOLYSIS Left sided weakness Loss of vision Normal 2 million neurons are lost for every minute of delay in treatment Thrombolysis can only be performed at centres with specialist facilities and staff

25 Intra-arterial Thrombolysis Benefits Increased effectiveness Increased safety Longer time window Limitations Neuroradiology access Training and expertise Costs

26 Protocols for malignant stroke

27 ICH Pathway Suspected Intracranial Haemorrhage ABC management Assessment for signs of trauma Blood investigations inc. INR APTT & CBC Immediate CT scan Subarachnoid haemorrhage Intraparenchymal haemorrhage SAH Pathway Cerebral haemorrhage Cerebellar haemorrhage Neurologically stable Discuss with Neurosurgeons Deteriorating GCS Contact neurosurgeons IMMEDIATELY NOT for surgery Stroke Unit Improved May need surgery Admission to HDU/ITU Hourly neuro observations ICP monitoring Deteriorated Repeat CT Neurosurgical review SURGERY

28 Making a difference for patients 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

29 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. Rehabilitation on Friends Stroke Unit The multi-disciplinary team. The team mainly includes doctors, nurses, physiotherapists, therapists, stroke specialist nurse, social worker and others depending on your needs. What is a Keyworker? A keyworker is the person who will help the patient and carers to coordinate 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. 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. 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.

30 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

31 Making a difference for patients 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

32 UK Firsts in stroke treatment

33 Themes in Stroke Research Vascular biology Epidemiology and Prevention 7 days after stroke 3 m after stroke Neuroimaging Small vessel disease Cell biology and stem cell Health Services Research

34 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

35 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.

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