Good stroke care is not just about the acute stage - services must be designed from the paramedic through to social care post-discharge.
The first few hours after a stroke are critical in terms of making a diagnosis, doing the appropriate investigations and keeping the patient stable, which is why it is important for hospitals to have a stroke unit and reserve beds for stroke patients.
It is one of the top priorities coming out of this year’s national sentinel stroke audit, which shows that one quarter of patients never get to a stroke unit at all during their admission. That increases their chance of disability and death. This is due to a lack of organisation, rather than a lack of beds, says intercollegiate stroke network chair Tony Rudd.
“Overall there are probably about the right number of stroke unit beds, we’re just not using them efficiently,” Dr Rudd says. “Even in my own hospital it’s a constant struggle to prevent the bed managers putting in inappropriate patients and then being reluctant to move those patients out when I do get a stroke patient that I need to admit.”
His advice is to keep empty beds waiting for stroke patients, so they can be admitted immediately. That can be accomplished by having a meeting in the morning to discuss how to create the beds for that day.
“Speed is the essence of the game in terms of the acute pathway,” says national director for heart disease and stroke Roger Boyle.
“We need to get the stroke units really working exactly like a coronary care unit works so that patients are admitted to it as quickly as possible.”
Thrombolysis can only be given in time if a brain scan is given quickly but, while there have been improvements, there are still a large number of patients who do not get a scan within 24 hours, which is the maximum length of time they ought to be waiting.
“We’ve got to stop thinking about hospitals as being places which operate actively between nine and five, Monday to Friday and then packing up in the early evening and at weekends and nothing very much happens in between times,” says Dr Rudd.
“It’s no longer acceptable to admit someone on a Friday afternoon and only start actively investigating and treating them on a Monday morning, for example.”
The data shows that there is no shortage of brain scanners. The problem is that scanners are lying idle for a large part of the day. What is needed is for all radiographers to be trained to use them.
Dr Rudd says: “I still find it absolutely incredible that there are radiographers around in this day and age who don’t know how to switch the CT scanner on.”
Most hospitals have a radiographer on staff 24 hours a day, so with appropriate training that would mean patients could be scanned at any hour of the day.
Access to thrombolysis is still patchy across the country, and services need to be developed in some areas. Different models will be required, such as the hub and spoke model being planned for London, where a small number of centres do all the hyperacute work. Rural parts of the country, such as Cornwall, will need a model that incorporates telemedicine.
Ensuring that long term support arrangements are in place is another priority, says Professor Boyle.
“That means much more partnership working between the NHS and local authorities so the overall needs that people have to return to an independent life are jointly met. It’s not just a health issue.”
Social care support may be needed, along with minor alterations to the home to allow people to return there to live. People’s needs should be reviewed regularly so they are not lost from the system.
Having a top notch stroke service is about planning the whole range of services strategically, which stretches from how the paramedics respond through to social care post discharge, says Healthcare Quality Improvement Partnership chief executive Robin Burgess.
“If care focuses on the management of the acute episode, it’s missing half the point. You need a local strategy which brings in social care people, which brings in ambulance trust people, and you plan what’s needed across the whole [pathway]. That might be training, that might be protocols, whatever.”
Top five priorities for improving stroke services
- Stroke unit with beds reserved for stroke patients
- Comprehensive thrombolysis services
- Quick access to brain scanning
- Long term support with local authorities
- Strategic planning of the whole stroke pathway