National Acute Stroke Services

Transcription

1 National Acute Stroke Services Framework

2 Introduction Delivering otimal stroke services equitably across Australia remains a challenge with variable access to best ractice stroke services, articularly in rural and regional areas. One of the most effective ways of reducing death and disability following a stroke is to rovide evidence-based, dedicated hosital services. Caacity to lan, deliver and evaluate high quality acute stroke services is essential for imrovement of health care delivery and atient outcomes. A framework to guide the establishment of aroriate stroke services to suort delivery of best ractice care as outlined by clinical guidelines was first develoed by the National Stroke Foundation (NSF) (with suort from the Australian Government Deartment of Health and Ageing) in This was reviewed in 2008, following an udate of the Clinical Guidelines for Acute Stroke Management (2007) and again in 2011 following the udate and amalgamation of the Clinical Guidelines for Stroke Management (2010). In 2013 the National Stroke Audit Acute Services recommended a review of the Framework to exlore aroriate models of stroke care for hositals of varying size and location (secifically hositals that admit under 100 strokes er year and hositals that manage large number of strokes annually [>350]). Subsequently, the National Stroke Services Rehabilitation Framework was ublished reinforcing the need for rehabilitation assessment to commence during the acute hase of stroke care. It also highlighted the need for the links between the two frameworks to be strengthened. Finally, a number of key aers referenced in the 2011 Acute Stroke Services Framework have been subsequently udated and ublished and new research on endovascular techniques was released in 2015 with significant imlications for stroke care infrastructure. This document outlines the third iterative udate of the Acute Stroke Services Framework that was initially develoed as art of the Australian Government funded National Stroke Unit Program (2002). The current review rocess has included a: a) Literature review (from June 2010 to December 2014). b) Sub-analysis of the data from the 2013 National Stroke Audit Acute Services. c) Review of information from international work and systems. d) Targeted consultation about the scoe of the review. e) Further targeted consultation on the revised draft framework. Aims of the framework The framework aims to imrove the quality of Australian acute stroke services by outlining recommended structures, networks, settings and criteria for monitoring. The intended use of the framework is to: 1. Outline where stroke services should be develoed and what such services should include in order to assist lanning of stroke services. 2. Provide a basis for measuring adequacy of current structures and resources for best ractice stroke care. 3. Make information available to be used to advocate for imroved services where gas are identified. 4. Guide decisions about resource requirements (including minimum stroke unit bed numbers in comrehensive stroke services). 5. Provide an outline for monitoring quality of care delivered by stroke services. The framework has not been develoed for use for accreditation uroses.

3 Section 1: Recommended stroke services a) General hosital service Services admitting less than 75 stroke atients generally do not have sufficient demand to justify secialised inhosital resources such as a stroke unit, clinicians with stroke exertise or advanced neuroimaging, nor do they have essential infrastructure. Given that stroke unit (SU) care should be offered to all eole with acute stroke, these services should have formal networks and written agreements in lace to transfer stroke atients to a comrehensive or rimary stroke service (PSS) (hubs) or suort (e.g. via telemedicine) where there is a decision to not transfer the atient (e.g. due to atient reference or alliation). In regions where a PSS is accessible within reasonable transort time, ambulance services should byass basic services and deliver susected stroke atients to the rimary or comrehensive stroke service. b) Primary stroke service (PSS) All services with 75 stroke atients er year should be a rimary stroke service. Primary stroke services have a dedicated stroke unit with clinicians who have stroke exertise; written stroke rotocols for emergency services, acute care and rehabilitation; CT/ CT angiograhy caability; ability to offer thrombolytic theray at least during normal business hours and referably 24/7 (either via onsite secialist or suorted by telehealth); rotocols to transfer aroriate atients to a comrehensive stroke service as needed (e.g. for neurointerventional or neurosurgical services); timely neurovascular imaging and timely access to exert interretation; telemedicine services and coordinated rocesses for atient transition to ongoing rehabilitation and secondary revention services. Deending on local factors (revious and existing services, geograhy etc) these services may have some of the additional elements of comrehensive stroke services and or resonsibility for regional coordination of stroke services. c) Comrehensive stroke service (CSS) Comrehensive stroke services have highly secialised resources and ersonnel available (24 hours a day, 365 days a year). These services are located in large, tertiary referral services which see high volumes of stroke atients (usually over 350 annual admissions) including the most comlex resentations. These services have a dedicated stroke unit, established well organised systems to link emergency services, hyeracute care, coordinated rocesses for ongoing inatient rehabilitation, secondary revention (e.g. clinic or follow u service), and community reintegration (e.g. early suorted discharge). Such services have timely neurovascular imaging and exert interretation (including advanced imaging caability) and offer thrombolysis, endovascular theray and neurosurgery (24/7), along with links to other secialist services such as cardiology and alliative care. These services have a leadershi role in establishing artnershis with other local hositals for suorting stroke care services (e.g. formal networks, secialist education and clinical advice including outreach visits or telemedicine links) and leading clinical research. CSS are located to allow the greatest equity of access to highly secialised interventions. CSS have a minimum of eight dedicated stroke beds in their stroke unit for centres admitting 350 stroke atients annually increasing to a minimum of 12 dedicated stroke beds for services that see >600 stroke admissions. Recommended bed numbers are for acute stroke units only (not combined acute/ rehabilitation units) with the actual caacity of a CSS stroke unit deendent on local factors including referral atterns, case mix and efficient access to further rehabilitation services. Deending on local factors (revious and existing services, geograhy etc) these services will commonly have resonsibility for regional coordination of stroke services.

4 Table 1. Elements of stroke services for comrehensive and rimary stroke services Element of service Organised re-hosital services (includes use of validated screening tools by aramedics, aroriate re-notification systems). Coordinated emergency deartment systems (includes use of validated screening tools; agreed triage categories; rotocols for tpa intervention e.g. Code Stroke ; athways to facilitate urgent access to imaging etc). Coordinated regional stroke systems (includes rotocols for hosital byass, transfer from non-stroke hosital to PSS or CSS, and between a PSS and CSS). Primary stroke service Comrehensive stroke service Stroke unit. Onsite CT brain (24/7) including CT angiograhy. * Carotid imaging. Advanced imaging caability (e.g. MRI/MRA, catheter angiograhy). Otional On-site endovascular stroke theray. r 24/7 On-site neurosurgical services (e.g. for hemicraniectomy due to large middle cerebral artery infarcts). Otional Delivery of intravenous tissue lasminogen activator (tpa). # 24/7 Ability to rovide acute monitoring (telemetry and other hysiological monitoring) for at least 72 hours. Acute stroke team (see Table 2). Dedicated stroke coordinator osition. Dedicated medical lead. ^ Access to HDU / ICU (for comlex atients). Raid (within 48 hours) Transient Ischaemic Attack (TIA) assessment clinics/ services. Provision of telehealth services for acute assessment and treatment. Otional Coordination with rehabilitation service roviders (this should include a standardised rocess, and/or a erson, used to assess suitability for further rehabilitation). Early assessment using standardised tools to determine individual rehabilitation needs and goals (ideally within hours). There should also be standardised rocesses that ensure ALL stroke atients are assessed for rehabilitation. Routine involvement of carers in the rehabilitation rocess. Routine use of guidelines, care lans and rotocols. Regular data collection and stroke secific quality imrovement activities. Access and collaboration with other secialist services (cardiology, alliative care, vascular). Otional Regional resonsibility (e.g. coordination across a local health district). Otional Commonly # tpa rovided at least during business hours (onsite including via telehealth). requires clear transfer arrangements to services with this caacity if not available onsite. ^ Dedicated medical lead who has rimary focus on stroke (stroke service director). * CTA should be at least available during business hours for PSS with non-contrast CT 24/7.

5 Section 2: Stroke unit care definition Section 3: Regional stroke resonsibility The foundation of any stroke service is the rovision of SU care. To ensure SU care is consistent across Australia, it is imortant that each SU comonent be defined and measurable. Furthermore the most imortant recommendations from the national stroke guidelines (accessible from state: 2.1 Stroke unit care a) All eole with stroke should be admitted to hosital and be treated in a stroke unit with a multidiscilinary team. b) All eole with stroke should be admitted directly to a stroke unit (referably within three hours of stroke onset). Some services will take on resonsibility for lanning and coordination of stroke services for a designated local area (e.g. health district) and rovide a hub for less secialised stroke care at other services. In metroolitan areas these services may be comrehensive stroke services as described above. However, in regional and rural areas sites with regional resonsibility they may be rimary stroke services but only as long as they have formal links to a comrehensive stroke service. Where a stroke service has regional resonsibility, additional resources should be allocated to coordinate care in and from soke sites. Elements of care secific to services with resonsibility for regional coordination are listed in table 2. c) Smaller hositals should consider stroke services that adhere as closely as ossible to the criteria for stroke unit care. Where ossible, atients should receive care on geograhically discrete units. d) If eole with susected stroke resent to non-stroke unit hositals, transfer rotocols should be develoed and used to guide urgent transfers to the nearest stroke unit hosital. Table 2. Stroke unit definition Minimum criteria: 1. Co-located beds within a geograhically defined unit. 2. Dedicated, interrofessional team with members who have a secial interest in stroke and/or rehabilitation. The minimum team would consist of medical, nursing and allied health (including OT, PT, SP, SW & DT). 3. Interrofessional team meet at least once er week to discuss atient care. 4. Regular rograms of staff education and training relating to stroke. (e.g. dedicated stroke inservice rogram and/or access to annual national or regional stroke conference). Table 3. Regional or hub service features Resonsibility for regional stroke lanning and local stroke network (this may be coordination across a local health district). Extra caacity for secialist clinical suort (outreach or via telemedicine). Extra caacity for educational outreach (including medical, nursing [educator or consultant], allied health and research). Extra caacity to resond to/accet additional transfers. Dedicated stroke coordinator osition to coordinate care between sites. Regional coordination of hyeracute theray. Use of telemedicine links to comrehensive stroke services (for rimary stroke services).

6 Section 4: Workforce requirements Skilled inter-rofessional stroke teams are an essential comonent to best ractice stroke care. Staffing levels are exected to vary deending on local considerations such as hosital service and clinical rofile. It is imortant to note that other essential considerations in determining the most aroriate stroke unit staffing levels include skill mix (i.e. adequate numbers of ermanent highly skilled and senior/ exerienced staff who can suort any junior or new staff), caacity within stroke unit and cross-cover with other nonstroke services (e.g. stroke teams asked to review outlying stroke atients not on the stroke unit), weekend cover, and additional time allocated to rofessional develoment, research and quality imrovement activities. Section 5: Safety and quality imrovement Caacity to evaluate the quality of health care delivery is essential for informing clinical ractice and imroving atient outcomes. Over the ast five years a significant amount of work has occurred to develo national clinical indicators for stroke. Figure 1 below shows the links between the different indicator sets and the nature and urose of each. As a minimum all hositals should articiate in routinely collecting and monitoring a small data set and eriodic national organisational survey. In addition, comrehensive and rimary stroke services should routinely be involved in eriodic detailed data collection (clinical audit) and articiate in ongoing quality imrovement rograms. Further work to determine the workforce requirements for roviding best ractice care is clearly needed and lanned to occur by the end of 2016 with this information to be included when available. Figure 1: Links between stroke data sets Minimum data set (MDS) 2 items: SU care, tpa. Embedded, continuous, rosective. AuSCR 4 items: (MDS lus antihyertensive on D/C, care lan on D/C) Embedded, continuous, rosective. National Performance Indicator Set (NPIS) 8 items: (AuSCR lus swallow screen, asirin, PT assessment, brain imaging within 24hrs). Voluntary, continuous collection or eriodic on cohort. Acute Stroke Clinical Care Standard Indicator Set 19 items: questions linked to Acute Stroke Clinical Standards many of which overla with NPIS. Periodic collection on cohort of atients. National Audit rogram NPIS & Standard Indicators lus questions linked to clinical guidelines. Periodic collection on cohort of atients.

7 Descrition of stroke data sets Minimum data set (MDS): collected on all atients as art on ongoing data collection to monitor health system erformance as it relates to stroke. Aim is to have these two indicators collected and reorted by government as art of ongoing and routine data collection (embedded and collected on all atients). Australian Stroke Clinical Registry (AuSCR): Four rocess indicators. To be collected on all atients in a rosective manner (aim to draw the MDS from routine data collection systems into the AuSCR data set). National Performance Indicator set: Eight indicators. Collected voluntarily and usually retrosectively on all or some atients (although may be mandated by a state for regular collection). Provides broader data (i.e. more reresentative of the interrofessional nature of stroke than two datasets above) by which to monitor quality of care and may be useful for accreditation of hositals if it is done as art of ACHS Clinical Indicator Program. Acute Stroke Clinical Care Standard Indicator Set: The Australian Commission on Safety and Quality in Health Care (ACSQHC) has recently develoed national Standards for Stroke Care and recommended indicators that can be used which link to each of the standards. Most of the indicators are already used within the existing stroke data sets described above. National Audit: large data set including questions measuring many rocesses across all dimensions of care. Drawn from and linked to the Clinical Guidelines and forms foundation of all other data sets as well as acting as the basis for multidiscilinary quality imrovement activities. Collected eriodically (every two years) and retrosectively on small cohort of atients (size may vary) but the webtool and data set are available to be used by hositals to collect all (or subset of the data) at any oint in time. This means it may be used to collect the National Performance Indicator Set on an ongoing basis. Section 6: Conclusion All efforts should be made to imrove atient access to evidence-based acute stroke care in Australia. Caacity to evaluate the quality of acute stroke services is essential for imrovement of health care delivery and atient outcomes. The roosed framework should be used by olicy makers, administrators and the clinician to identify gas in recommended evidence-based service rovision for stroke or lan for new services. It is recommended that for acute hosital stroke services: All hositals that admit 75+ stroke atients each year should be a Primary stroke service. Comrehensive stroke services should be established so that equitable access to highly secialised, hyeracute interventions is ensured. It is recommended lanning be undertaken using a regional aroach. All hositals managing acute stroke should be collecting data that monitors the care rovided. A broad set of clinical indicators (e.g. the national stroke audit) should also be used routinely (at least every second year) to monitor imortant rocesses of care involved in acute stroke services. Primary and comrehensive stroke services should also rosectively monitor acute stroke care using a minimum number of rocess indicators (e.g. AuSCR or the National Performance dataset). Finally, this framework should be used in conjunction with the most recent Clinical Guidelines for Stroke Management to increase access to evidence-based stroke care throughout Australia. It is recommended for the collection of any stroke data that the Australian Stroke Data Tool (AuSDaT) be used to enable efficient entry of data across various data collection activities.

8 Acknowledgements The National Stroke Foundation gratefully acknowledges the significant inut from many key eole who have heled shae this document including: The National Stroke Foundation Clinical Council. Members of the Australian Stroke Coalition. Dominique Cadilhac and staff at Translational Public Health and Evaluation Division, Stroke & Ageing Research Centre Monash University who undertook the analysis of the audit data. State and national reresentatives who have contributed to this udate and revious versions of the framework. References Alberts MJ, Latchaw RE, Jagoda A, Weschler LR et al. Revised and Udated Recommendations for the Establishment of Primary Stroke Centers. A summary statement from the Brain Attack Coalition. Stroke. 2011; 42: Alberts MJ, Latchaw RE, Selman WR, Shehard T, Hadley MN, Brass LM, et al.; Brain Attack Coalition. Recommendations for comrehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke Jul;36(7): Bae HJ, Kim DH, Yoo NT, Choi JH, Huh JT, Cha JK, Kim SK, Choi JS, Kim JW. Prehosital notification from the emergency medical service reduces the transfer and intra-hosital rocessing times for acute stroke atients. J Clin Neurol. 2010;6: Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372: Cadilhac D, Kilkenny M, Churilov L. Deriving a subset of rocess indicators from the National Stroke Foundation acute stroke services audit. Results of statistical analyses. National Stroke Research Institute. Unublished reort; Cadilhac DA, Moodie ML, Lalor EE, Bilney LE, Donnan GA; National Stroke Foundation. Imroving access to evidence-based acute stroke services: develoment and evaluation of a health systems model to address equity of access issues. Aust Health Rev Feb;30(1): Cambell BCV, Mitchell PJ, Kleinig TJ et al; EXTEND-IA Investigators. Endovascular Theray for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med 2015; February 11, 2015DOI: / NEJMoa Candelise L, Gattinoni M, Bersano A, Micieli G, Sterzi R, Morabito A; PROSIT Study Grou. Stroke-unit care for acute stroke atients: an observational follow-u study. Lancet Jan 27;369(9558): Douglas VC, Tong DC, Gillum LA, Zhao S, Brass LM, Dostal J, Johnston SC. Do the Brain Attack Coalition s criteria for stroke centers imrove care for ischemic stroke? Neurology Feb 8;64(3): Foley N, Salter K, Teasell R. Secialized stroke services: a meta-analysis comaring three models of care. Cerebrovasc Dis. 2007;23(2-3): Govan L, Langhorne P, Weir CJ; Stroke Unit Trialists Collaboration. Does the revention of comlications exlain the survival benefit of organized inatient (stroke unit) care?: further analysis of a systematic review. Stroke Se;38(9): Goyal M et al. Randomized assessment of raid endovascular treatment of ischemic stroke. N Engl J Med Feb 11 [Eub ahead of rint]. Grimley, R. & Middelton, S.M. (on behalf of the Australian Stroke Coalition). 48 hours: Imroving stroke management in the critical window. Accessed on 24 June 2014 htt://australianstrokecoalition.com.au/rojects/first-48- hours-of-stroke-care/ Higashida et al on behalf of the American Heart Association Advocacy Coordinating Committee. Interactions Within Stroke Systems of Care - A Policy Statement From the American Heart Association/American Stroke Association. Stroke. 2013; 44: Kim SK, Lee SY, Bae HJ, Lee YS, Kim SY, Kang MJ, Cha JK. Prehosital notification reduced the door-to-needle time for IV t-pa in acute ischaemic stroke.. Eur J Neurol. 2009;16: Langhorne P, Pollock A in collaboration with The Stroke Unit Trialists Collaboration. What are the comonents of effective stroke unit care? Age and Ageing 2002;31: Leys D, Ringelstein EB, Kaste M, Hacke W; Euroean Stroke Initiative Executive Committee. The main comonents of stroke unit care: results of a Euroean exert survey. Cerebrovasc Dis. 2007;23(5-6): Morris et al. Imact of centralising acute stroke services in English metroolitan areas on mortality and length of hosital stay: difference-indifferences analysis. BMJ 2014;349:g4757. National Stroke Foundation. Stroke Services in Australia: National Stroke Unit Program Policy Document. NSF: Melbourne National Stroke Foundation. Clinical Guidelines for Stroke Management Melbourne, Australia. National Stroke Foundation. National Rehabilitation Stroke Services Framework Melbourne, Australia. National Stroke Foundation. National Stroke Audit - Acute Services Organisational Survey Reort Melbourne, Australia. National Stroke Foundation. National Stroke Audit Clinical Audit Reort Acute Melbourne, Australia. Saosnik G, Baibergenova A, O Donnell M, Hill MD, Karal MK, Hachinski V; Stroke Outcome Research Canada (SORCan) Working Grou. Hosital volume and stroke outcome: does it matter? Neurology 2007, 69(11): Standards for Rehabilitation Medicine Services in Public and Private Hositals Australasian Faculty of Rehabilitation Medicine, RACP. Stroke Unit Trialists Collaboration. Organised inatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD DOI: / CD ub3. National Stroke Foundation National Office Level 7, 461 Bourke Street Melbourne VIC 3000 Phone: admin@strokefoundation.com.au We have offices in Brisbane, Canberra, Hobart, Sydney and Perth.