An Essex trust is proving what fast stroke response can achieve, by introducing a specialist acute unit. Mark Hunter explains
Acute stroke care is undergoing a transformation. The most obvious sign of this improvement is in the provision of specialist acute stroke care.
In England 96 per cent of hospitals now offer specialist acute stroke care, with 54 per cent having an acute stroke unit and 47 per cent a combined stroke unit. It is well established that patients with acute ischaemic stroke (AIS) who present rapidly to a specialist service are most likely to receive treatment, such as thrombolysis, that reduces the risk of death or long term disability (better control of unstable physiology and prevention of early complications).
There is, however, little room for complacency. Despite the wider availability of specialist stroke care, the report notes that 81 per cent of stroke patients are still initially admitted to a general rather than an acute stroke unit. The number of patients receiving thrombolysis has increased fourfold since 2006, but this still only accounts for 0.8 per cent of stroke admissions.
The Department of Health has estimated that if just 10 per cent of AIS patients were to receive thrombolysis, more than 1,000 people would regain their independence rather than die or face long term dependency.
The 10-year national strategy on stroke published last year urged trusts to introduce "hyper acute" stroke care including 24-hour access to a stroke specialist, urgent CT scans with expert interpretation, and fast track thrombolytic treatment.
But is such a service feasible in the UK's cash-strapped and overstretched general hospitals?
If the experience at Southend University Hospital foundation trust is anything to go by then the answer is emphatically yes.
In July last year Southend introduced a specialist acute stroke unit offering fast-track thrombolysis to all eligible patients with AIS. In its first year the service has thrombolysed 56 of the 379 stroke admissions, a rate of 15 per cent compared with the national average of less than 1 per cent.
"Of the 56 patients we have thrombolysed this year, 14 have walked out of the hospital with no disability whatsoever and 55 per cent have had a positive outcome," says Anthony O'Brien, stroke clinical lead consultant at Southend.
"The length of hospital stay has decreased from 28 days to 18 days, so we've not only improved patients' lives we've also saved resources."
The service incorporates a rapid "blue light" transfer from the ambulance service. Paramedics are fully trained to recognise the early signs of stroke. The paramedics, along with local GPs, district nurses and allied health professionals, are trained in the "FAST" protocol for recognising stroke:
test all three and dial 999 if they point to a stroke.
Waiting at the hospital is a multidisciplinary team with 24-hour access to a stroke specialist. CT scans are prioritised and all eligible patients admitted within three hours of the onset of symptoms are offered the thrombolytic agent alteplase.
The stroke unit comprises 14 acute beds and 27 rehabilitation beds. Routine testing is done for neurological function, blood pressure, cardiac rhythm, respiratory function, oxygen saturation and blood glucose. There is a daily TIA (transient ischaemic attack) clinic to identify high risk patients and rehabilitation services include physiotherapy (including respiratory physiotherapy), speech and language therapy (including swallowing), dietetic services (including nutrition screening) and critical care for stroke patients who require enhanced monitoring or who develop complications.
"Setting up the unit has cost us around£800,000," says Dr O'Brien. "But half of that was for a new gym. We also had to relocate the ward which, incredibly for a stroke unit, used to be on the sixth floor. Given the results we've achieved, it's been worth every penny."
Nevertheless, it took Dr O'Brien and his colleagues several years of lobbying and required a cast-iron business case before the resources were made available.
"It's been a long process," he says. "When I took up post in 2004, the management of stroke was spread across at least three different departments - neurology, gerontology and general medical - and each had a different approach. There was a lot of disparity that had to be sorted out. Also, the whole focus was on rehabilitation with very little attention paid to acute care.
"Someone had to grasp the nettle and become a champion for stroke."
Change of focus
Having duly grasped that nettle, Dr O'Brien's first step in preparing the case for an acute stroke unit was to collect examples of best practice from units around the country.
"While I was visiting Addenbrooke's Hospital it just so happened that a stroke case came in and I was able to follow it all the way through. The patient was admitted, diagnosed and thrombolysed extremely quickly and was able to make a complete recovery. It was incredibly life-enhancing to watch. So when I got back to Southend I went straight to my medical director and said we have got to do this. He agreed. I think his exact words were: 'Let's put some passion back into medicine.'"
It became clear early on that the unit would only ever be as good as the people working in it, so a lot of time and effort was put into training staff. A second stroke specialist, Paul Guyler, was hired in 2006.
"The acute unit required a complete change of focus for the nursing staff," points out Dr O'Brien. "It was no longer all about rehabilitation so we had to do a lot of training on acute management."
The results at Southend have been so impressive that the Essex cardiac and stroke network is now seeking to extend the approach across the county and Dr O'Brien has recently been appointed lead stroke consultant for all of Essex.
By the end of this year he expects each of the five acute trusts in Essex to have set up a hyper acute service that provides 24-hour access to brain imaging, expert interpretation, specialist nursing and monitoring; with thrombolysis to be given to all those who will benefit.
"Of course, the model for all this is the acute care of myocardial infarction," says Dr O'Brien. "Basically it's the same disease."
He believes the success achieved at Southend should be within the scope of most general hospitals.
"There are a lot of drivers to make this happen," he says.
"There's the national stroke strategy, the operating framework, the Royal College of Physicians audits and National Institute for Health and Clinical Excellence guidelines. So it's not hard to make a business case."
"There's nothing particularly special about Southend," he continues. "We've probably got a slightly higher elderly population than average and we are lucky the hospital does have a well established central role within the community. But before we developed the service we were ranked 228th out of 244 [in the National Audit Office organisational audit of stroke services]. We are now third. If we can do it, anyone can."