Stroke Services. Maria Fitzpatrick Consultant Nurse

Transcription

1 Stroke Services Maria Fitzpatrick Consultant Nurse

2 WHO Definition: Stroke definition rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin TIA is a clinical syndrome characterised by an acute loss of focal cerebral or ocular function with symptoms lasting less than 24hrs.

3 Epidemiology third commonest cause of death worldwide after coronary heart disease and all types of cancer combined (Warlow et al, 2003). It also causes a greater range of disabilities than any other condition and is the leading cause of long-term disability in the developed world (Adamson et al, 2004).

4 Incidence Each year approximately 150,000 people in England and Wales will have a stroke of which 87,700 are first strokes and 53,700 recurrent strokes (Office of National Statistics, 2001). The number of TIAs occurring each year in England alone is estimated to be 20,000 (NAO, 2005).

5 Mortality Stroke causes over 60,000 deaths each year in the UK and in 2004 stroke caused 8% of deaths in men and 12% of deaths in women (Allender et al, 2006). two-thirds of deaths occur within the first week after a stroke

6 Burden of stroke At one year after stroke 30% of patients will be dead, & 40% of survivors will be dependent on others (Warlow et al, 2001). In the UK it has been estimated that one in five acute hospital beds and a quarter of places in residential or long-term care are occupied by patients with stroke. The costs of direct care are 2.8 billion a year; 1.8 billion in lost productivity and disability, and 2.4 billion in informal care costs a total of 7 billion a year (DH, 2007).

7 Aetiology About 69% of strokes result from ischaemia and infarction of brain tissue caused by diminished blood flow due to thrombotic or embolic complications of atheroma. The remaining 13% of strokes are caused by a primary intracerebral haemorrhage (PICH), and 12% are of an uncertain type

8 Signs and symptoms of stroke Motor deficits: facial weakness, focal limb weakness, loss of fine finger movement Altered sensation: numbness, tingling Disturbance of conscious level Acute memory impairment Altered higher cerebral function: orientation Disorders of speech and language Visuospatial dysfunction: neglect, inattention Apraxia (loss of the ability to perform learned movements) Visual disturbance: diploplia, homonymous hemianopia, loss of vision Disturbance of hearing Loss of balance, vertigo Ataxia: poor co-ordination Nausea, vomiting Headache

9 The Principles of Immediate Stroke Care The acute stroke patient must be recognised as an urgently ill medical patient - Time is brain Possible later complications must be recognised early. Admit ALL patients to a Stroke Unit reduce mortality and disability Early CT scan start aspirin. Physiological Monitoring Early mobilisation Timely swallow assessment Early onset of rehabilitation, within 24 hours of onset of symptoms.

10 Diagnostic tests Computerised Tomography (CT) Scan (Perfusion scanning) Magnetic Resonance Imaging (MRI) NICE recommendations for all TIA pts Electrocardiogram (ECG) Ultrasound studies Laboratory tests

11 Stroke 150,000 people a year, per 100,000 TIA 35 people per 100,000 1 every 5 minutes The most common cause of long term disability

12 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

13 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.

14 The aims of our stroke services are to Provide a comprehensive integrated quality service to stroke patients irrespective of background or age. Provide a service, which is seamless across specialities and disciplines. Local population Southwark population = Lambeth population =

15 Differences from other districts 25% are African American in origin Younger by about 10 years Higher number of bleeds so tend to be sicker

16 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

17 Stroke Strategy

18 Main themes in the Strategy Emergency Response to Stroke Management of TIA Rehabilitation Stroke Networks Prevention and Social Integration

19 Emergency Response Category A response by ambulance services Trained in stroke recognition blue-light response Pre-notification to receiving hospital Immediate transfer to a centre providing acute stroke services Availability of thrombolysis throughout the 24-hour period Immediate expert clinical assessment Urgent imaging Prompt access to high quality stroke specialist acute care Rapid availability of specialist neurointensivist care in some cases

20 Delivery of Care: Emergency Response The KCH Model Close partnerships with LAS Training activities for LAS crews (4/year) Feedback of blue light calls Monthly audit of all stroke arrivals <6hrs Joint service development Patient feedback

21 Achieving the vision: Ambulance response At King s College Hospital: Close partnerships with LAS Simple, clear guidelines applicable 24/7 Training activities for LAS crews (4 times a year) Feedback of blue light calls Monthly audit of all stroke arrivals <6hrs Patient feedback Joint service development

22 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)

23 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

24 Outcomes: 0-3 v 3-6 hours 0-3 hours (n=59) 3-6 hours (n=41) Mean Age (years) 72.2(15.7) 66.8 (12.1) Male Gender (%) 32 (54%) 25 (61%) Mean NIHSS score at baseline 12 (9-17) 9 (7-16) SITS Outcome - Much better 26 (44%) 23 (56%) SITS Outcome better or unchanged 26 (44%) 15 (37%) SITS Outcome worse 4 (7%) 2 (5%) Intracranial Haemorrhage (any type) 6 (10%) 2 (5%) Intracranial Haemorrhage (significant) 2 (3%) 0 Mortality (%) 3 (5%) 1 (2%)

25 Thrombolysis pathway: summary Sudden onset of left sided weakness sensory deficit visual inattention (2 hrs) Thrombolysis in A&E No deficits at 24 hours

26 Achieving the vision Thrombolysis at King s College Hospital Thrombolysis approved 1995 Introduced at KCH 2002 Thrombolysis rates (all strokes) England as a whole <1% North America 5-8% Europe 8-10% Best centres 15-20% NSS Target 4% KCH % Jan to June % July to Oct % Fewer bleeding and other complications compared with the international SITS database

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

28 Protocols for malignant stroke

29 Intracranial haemorrhage 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

30 TIA Immediate referral of all TIA or minor stroke patients for appropriately urgent specialist assessment and investigation Agreement of local referral protocols between primary and secondary care: Transfer by ambulance to an acute stroke service of anyone whose stroke symptoms have not resolved or at high risk of stroke Asessment and treatment of all patients with high-risk patients with TIA within 24 hours Investigation within seven days of all other lower risk TIA or minor stroke patients

31 Transient Ischaemic Attack 26% strokes preceded by TIA 10-20% pts have a stroke within 3 months of TIA Up to 40% of high risk patients with TIA have stroke within 1-2 days

32 VASCULAR REFERRAL Asymptomatic carotid stenosis Further Investigations CEA within 48 hours >70% stenosis - all >50% stenosis selected Clinic FU Management pathway for TIA Rapidly resolving neurological deficit of acute onset suggestive of TIA If symptoms fully resolved: Start Aspirin 300mg or Clopidogrel 75mg daily Urgent Referral to hospital (high risk) or TIA clinic (low risk) Blood tests, ECG MRI with DWI and Carotid Dopplers If dopplers inconclusive, CT Angiogram Ipsilateral >50% carotid stenosis NO significant carotid stenosis 24 hrs Corresponding Clinical History Clinical History NOT of TIA Clinical history of TIA MRI +ive or ive MRI ive MRI ive

33 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.

34 Early Rehabilitation Availability of high-quality stroke specialist rehabilitation at all stages of the pathway Stroke units, early supported discharge, intermediate care units, community stroke teams Seamless transfer of care from hospital to home or care home Review within 6 weeks, 6 months and annually after discharge from hospital to facilitate pathway back to specialist services if required

35 HOSPITAL COMMUNITY SERVICES HOME MDT Assessment rehab referral: Psychological Impairment Communication Cognitive impairment Motor Impairment Sensory Impairment Functional rehab interventions Swallowing, feeding, nutrition Prevention of complications Self Care Continence Named person identified Intensive inpatient rehab Clear criteria for referral to appropriate community setting/ model Neuro specific community based rehab Intermediate care Intermediate domiciliary care rehab inpatient rehab Regular contact with service-user Intensive Community Rehab/ Early Supported Discharge Support from Social Care Services if required MDT Goal Settings Discharge Planning: Full involvement of patients/families GPs, Primary health teams, Social Services informed Equipment and support services in place Patients receive info on local voluntary and statutory agencies Training and equipment for carers Post discharge MDMs: Goal Setting and discharge planning As acute but add: Return to work/leisure Driving Housing Sexuality Respite for carers MDM review: 6-8 weeks 6 months 12 months Appropriate intervention Review/ revise goals Discharged to GP Annual Review Management of secondary prevention issues and medical review: Cholesterol Blood Pressure Antiplatelets/Anticoagulants Carotid stenosis Smoking Other risk factors e.g. alcohol, diet, exercise, diabetes.

36 Delivery of Care: Stroke Pathway Primary Prevention Rapid detection Thromb -olysis Stroke Unit care Tailored Community rehab Self care/ Peer support Sign posting Access to leisure, Employment, Other opportunities Quality information for users and carers Quality information for professionals A workforce skilled in working with people with stroke Preventing a further stroke or TIA Acute phase recovery Learning to live with a disability Living with a disability

37 Service and patient Audit Over 94% get access to stroke unit Over 90% have a scan with in 24 hours 45% go home from acute services Areas for improvement door to needle time of 30 minutes Psychological assessment / support Daily review / telemedicine Nurse led Thrombolysis

38 Presentation I Mrs S B, 34 yrs old oncology nurse specialist No vascular risk factors, family history Ex-smoker 5/day Stopped 1 yr ago On OCP Presented to Maidstone Hospital (9:15) Sudden onset R weakness (7:30) Unable to speak

39 Clinical Examination HR 76/min reg, BP 118/75 R Facial droop Expressive dysphasia RUL 0/5, RLL 3/5 Decreased sensation on R side Left MCA territory stroke

40 Further Management (Maidstone) 10:35 (3h) CT scan -Infarct left putamen 11:25 (4h) KCH contacted for specialist management 12:51 (5.5 h) Arrived at KCH

41 Initial Assessment at KCH (12:55) HR 76/min regular, BP 130/79, BM 5.3 Aphasic R Neglect, Eyes deviated to L R UL 0/5, R LL 3/5 5.5 hrs post onset Outside the 0-3 hr time window for routine thrombolysis but still within 6 hrs

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43 Management at KCH Proximal MCA occlusion with significant mismatch Decision to proceed to intra-arterial thrombolysis Location of occlusion (proximal) Duration since onset (>3 hours) Loading dose given at 13:25 (5:55 h post onset) Door to Needle 34 minutes (gold standard 45 min)

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45 Excellent recovery, full power in all limbs Independent next morning Residual mild expressive dysphasia Capsular haemorrhage (recanalisation) Post- thrombolysis

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47 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.

48 References Department of Health (2007) National Stroke Strategy, London, DoH. National Audit Office (2005) Reducing Brain Damage: Faster access to better stroke care. The Stationery Office: London World Health Organisation (1988) World Health Organisation MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. Journal of Clinical Epidemiology: 41;

49 References Burton, C and Gibbon, B (2005) Expanding the role of the stroke nurse: a pragmatic clinical trial. Journal of Advanced Nursing, 52(6), Thomas, L; Cross, S; Barrett, J; French, B; Leathley, M; Sutton, C; Watkins, C (2008) Treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews, 2008 (1), CD