National Stroke Strategy Research Articles

Profiling the characteristics of people after stroke in Ireland discharged home with and without Early Supported Discharge: Analysis of a nationally representative cohort study

Background Early Supported Discharge (ESD) after stroke has demonstrated cost savings, reducing hospital length of stay (LOS) and long-term dependency. ESD discharges people after stroke from hospital earlier than conventional care with rehabilitation continuing at home. The Irish National Stroke Strategy 2022–2027 aims for ESD to be available to 92% of the stroke inpatient population. This study aims to profile the clinical characteristics and rehabilitation needs of those referred to ESD on discharge versus those discharged home without it in Ireland. Methods This study represents secondary analysis of an anonymised nationally representative prospective cohort study; the Irish National Audit of Stroke (INAS). Data were retrieved for 2018–2020 inclusive. A subset of 20 variables were used to profile the clinical characteristics and rehabilitation needs of those referred to ESD on discharge versus those discharged home without it. Data were analysed descriptively. Results In 2018, 139 people were discharged home with ESD, representing 3.8% of all people after stroke discharged home. This increased to 207 (4.9%) in 2019 and to 325 (6.6%) in 2020. More men were discharged home with and without ESD. Those aged 65–79 years represented the largest proportion of those discharged home with and without ESD. For those discharged with ESD, the mean LOS reduced each year from 17 days (SD=20) in 2018, 16 days (SD=16) in 2019 to 13 days (SD=13) in 2020. Those with a modified Rankin Scale score of 1, 2 at discharge represented the highest proportion of those returning home with ESD (59.3%) and without ESD (40.8%). Of those returning home with ESD, 10.8% were seen by a psychologist. Conclusions There is a need for significant scale-up of ESD to meet National Stroke Strategy targets. Consensus on ESD eligibility criteria nationally needs to be established and access to psychology services for people after stroke needs expansion.

23 Rapid access stroke prevention clinic, are we adhering to international recommendations?

Abstract Background Transient Ischaemic attack (TIA), accounted for over 2000 hospital admissions in Ireland in 2020. 25% of all TIA presentations develop stroke. The European Stroke Organisation (ESO) and National Stroke Strategy have recommended the development of rapid access stroke prevention (RASP) clinics, to reduce morbidity associated with devastating stroke event and reduce unnecessary hospital admissions. This project reviews the functionality of a RASP clinic in an Irish hospital and compares it to international recommendations. Methods A retrospective chart review of patients who had been referred to the clinic over a three month period was performed. The initial referral date, clinic review date, date of any appropriate investigations and final diagnosis were collected and compared against the current recommendations. Quantitative analysis was performed on this data. Results A total of 43 patients were included, 18 were referred by the emergency department (ED), 25 by general practitioners (GP). On average GP referrals were waiting 5.8 days, and ED referrals 3.5 days, to be seen by a specialist. Current ESO recommendation is for specialist review within 24 hours. Of those referred, 34 underwent the recommended carotid imaging. 7 of the 43 were diagnosed with TIA, highlighting the poor sensitivity of the current risk stratification tool (ABCD2). The average time from symptom onset to referral was 3.7. With 15 patients waiting 35 days prior to seeking medical advice. Conclusion It is clear that, at present, the RASP clinic is not meeting the international recommendations. A number of improvements to the referral process have been proposed. The move to an electronic referral process would reduce unnecessary steps in the current pathway and would ensure the appropriate investigations were carried out, at the time of initial contact. Improved patient education on symptoms of TIA is needed. A repeat audit will take place to review if these changes have had a significant impact.

230 DEVELOPMENT AND IMPLEMENTATION OF A STROKE PASSPORT IN THE HYPER-ACUTE STROKE UNIT: SUPPORTING PEOPLE POST-STROKE

Abstract Background A Multi-Disciplinary Team (MDT) approach is instrumental to post-stroke management in the Hyper Acute Stroke Unit (HASU). There is strong evidence highlighting the importance of patients’ social needs post-stroke (UK National Clinical Guideline for Stroke, 2016) and the need for a clear plan and resource combining both health and social care. This is outlined in the National Stroke Strategy (2020-2025). Stroke care involves a cohesive multi-disciplinary approach. In 2021, members of the MDT in HASU identified a service gap and implemented a unified tool. The aim of this project was to develop a user-friendly resource “Stroke Passport” to ensure the patient was central to their own stroke journey. Methods National and international guidelines were reviewed and benchmarking of other acute services was completed. The Stroke Passport was specialised to the HASU to include key stakeholders including stroke Consultant, stroke MDT and stroke Nursing Staff. Key stakeholders contributed to the development and adjustments were made after feedback. A sample of stroke patients piloted the passport (n=10). Education was provided for staff and patients through information sessions. Results This project resulted in the development of a resource that captured the following key areas:(i)Causes of Stroke (ii) Risk Factors (iii) Stroke Team (iv) Rehabilitation Goals (v) Useful Contacts (vi) and Medication List (vii). Qualitative feedback from the pilot study included: consistent awareness into stroke type, rehabilitation goals and discharge plan. The passport was successfully implemented to meet the organisational demands of the service while including the patient’s voice and is now embedded into standard practice in the HASU. Conclusion The development and implementation of a Stroke Passport ensured inclusion of the patient central to rehabilitation goal setting and discharge planning. The project supports an integrated approach to care and allows for patient centred care from admission to safe discharge.

Level 1 Evidence on Timing from Most Recent Cerebral Event to Carotid Revascularization, A Wakeup Call

Introduction - The indication for carotid revascularization has largely been based on symptomatology in combination with the degree of stenosis in the ipsilateral carotid artery. More recently, the role of timing in the prevention of recurrent stroke in symptomatic patients has gained interest. Current guidelines recommend that “Carotid endarterectomy (CEA) should be performed within two weeks (European Society for Vascular Surgery (ESVS)), or even within 48 hours of symptom onset (National Stroke Strategy, United Kingdom)[1,2].

A sustainable stroke nursing workforce requires a clear pathway for career progression

British Journal of Neuroscience NursingVol. 13, No. 6 CommentA sustainable stroke nursing workforce requires a clear pathway for career progressionLiz LightbodyLiz LightbodySearch for more papers by this authorLiz LightbodyPublished Online:20 Dec 2017https://doi.org/10.12968/bjnn.2017.13.6.295AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Bray D, Ayis S, Campbell J et al.. Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study; 2014. PLOS. https://doi.org/https://doi.org/10.1371/journal.pmed.1001705 (accessed November 2017) Crossref, Google ScholarDepartment of Health. National stroke strategy; 2007. https://tinyurl.com/huvedz2 (accessed November 2017) Google ScholarDepartment of Health. A high quality workforce. NHS next stage review. London, Department of Health; 2008 Google ScholarDepartment of Health. Advanced level nursing: a position statement; 2010. https://tinyurl.com/pbtt9b8 (accessed 4 October 2016) Google ScholarGuardian. More nurses and midwives leaving UK profession than joining, figures reveal; 3 July 2017. https://tinyurl.com/y72dgd39 (accessed November 2017) Google ScholarNursing and Midwifery Council. Increasing number of nurses and midwives leaving profession ‘highlights major challenges faced by health and care sectors’; 2017. https://tinyurl.com/ycbj4htb (accessed November 2017) Google ScholarPhilippou J. Employers' and employees' views on responsibilities for career management in nursing: a cross-sectional survey. J Adv Nurs. 2015;71(1):78–89. http://onlinelibrary.wiley.com/doi/10.1111/jan.12473/abstract (accessed November 2017) Google ScholarRafferty AM, Xyrichis A, Caldwell C. Post-graduate education and career pathways in nursing: a policy brief. London, King's College London; 2015. Google Scholar FiguresReferencesRelatedDetails 2 December 2017Volume 13Issue 6ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 20 December 2017 Published in print 2 December 2017 Information© MA Healthcare LimitedPDF download

Delays in the presentation to stroke services of patients with transient ischaemic attack and minor stroke.

The UK National Institute for Health and Care Excellence (NICE) guidelines state that carotid endarterectomy should be scheduled within 2 weeks of symptoms. The recent National Stroke Strategy has reduced the time interval to 48 h. This study aimed to review the possible delays. This study analysed patients with confirmed transient ischaemic attack (TIA) or minor stroke, referred to a single tertiary centre clinic and followed up 1 month after the event. A questionnaire was used to collect data on the rapid-access clinic pathway, and details of previous medication and treatment. Some 150 patients presented with a confirmed TIA or minor stroke during a 5-month interval (June to October 2014). Fifty-one (34·0 per cent) had a history of TIA or stroke and 35 (23·3 per cent) had undergone an 'index' event in the 5 days before presentation. Forty-five patients (30·0 per cent) experienced a reduction or loss of vision. Of this group, 32 had a deficit in vision only, none of whom attributed these symptoms to a cerebrovascular event. Overall 92 (61·3 per cent) of the 150 patients had a delay in presentation to medical services. Forty-seven (31·3 per cent) had residual symptoms at the clinic appointment. Eighty-eight patients (58·7 per cent) did not think they were having a stroke and 54 (36·0 per cent) were unaware of the National Stroke Strategy (FAST campaign-Face, Arm, Speech, Time). Two-thirds of patients were not aware they were having a stroke, one-third were unaware of the FAST campaign and nearly one-third presented with eye symptoms. Inclusion of eye symptoms and reaffirmation of the need to react might avoid unnecessary delays in the presentation of patients with TIA and minor stroke.

Education

Introduction: The National Stroke Strategy, and the development of the Stroke-Specific Education Framework, emphasised the need for a skilled and knowledgeable workforce. The Francis and Keogh reports highlighted the importance of on-going continuing professional development. However, key policies do not cite explicit evidence of the value of education and training. This study aimed to systematically review the literature exploring the impact of healthcare professional education and training on the process and outcome of stroke patient care. Methods: An integrative review approach was used to summarise the literature. A search strategy including the MeSH terms stroke, education and health personnel was developed and adapted to search bibliographic databases. The search strategy's quality was tested using backwards and forwards citation searches. Results were screened on title, abstract, and full paper. Systematic data extraction and synthesis were conducted. Results: Following screening, 23 studies met the inclusion criteria. Staff group varied: pre-hospital staff (n=4), healthcare assistants, student nurses and nurses (n=10), multi-disciplinary teams (n=8), pharmacists (n=1); as did settings; pre-hospital and hyperacute (n=7), acute and rehabilitation (n=15), and community (n=1). The majority, 17 studies, demonstrated that education and training had a positive impact on a range of patient and process outcomes, however, methodological quality was variable ranging from single centre observational studies to cluster RCTs. Conclusion: Robust studies are needed to explore the impact of stroke education and training of health care staff on patient care so that investment in education and training can be more clearly linked to optimum health outcomes

Hyper-acute stroke treatment: the first 48 hours

Every year, 150000 people in the UK suffer a stroke. This works out at one every five minutes ( Townsend et al, 2012 ). Stroke is the single largest cause of disability and the third largest cause of deaths in England. Stroke costs the NHS over £2.8 billion and can lead to death or severe disability ( Mant et al, 2004 ). The National Stroke Strategy launched in 2007 outlined a 10-point strategy to develop stroke services, reduce death and disability and to improve care ( Department of Health (DH), 2007 ; 2008 ). One of the most important aspects of stroke care is ensuring that stroke is recognised and that everyone acts quickly to preserve brain function and minimise disability. Healthcare professionals and the public need to be able to recognise stroke and to act appropriately when stroke occurs. This article aims to enable readers to recognise acute stroke and to act quickly and appropriately when stroke occurs

The nursing role in thrombolysis treatment for acute ischaemic stroke: an overview

Clot-busting thrombolysis treatment is recommended for some patients with stroke if it can be administered within 4.5 hours of stroke onset. Over the past few years, initiatives across the UK stemming from the Department of Health's (2007) National Stroke Strategy have attempted to improve various aspects of stroke treatment, including rates and speed of administration of thrombolysis ( NHS Improvement, 2010a ; 2010b ). Specialist stroke nurses have played an important part in these efforts, but there is a limited amount of literature defining the nursing role in thrombolysis treatment. This article provides an overview of the nursing role in delivering thrombolysis treatment in acute ischaemic stroke and the factors that affect it.

The 2010 British Association of Stroke Physicians Survey of Interventional Treatments for Stroke in the United Kingdom

The UK National Stroke Strategy (Department of Health 2007) states that patients should have access to a stroke service with neurointerventional capacity. This survey was conducted by the Clinical Standards Committee of the British Association of Stroke Physicians to get a snapshot of the availability of interventional treatments for stroke in the United Kingdom. Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy. Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2-20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5.2 (2-12) stroke physicians, 2.3 (0-4) interventional neuroradiologists, and 3.6 (0-9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists. Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.

Thrombolysis in acute ischemic stroke in centers lacking a stroke unit: Referral to reference center or on-site treatment?

ObjectiveTo assess the clinical impact of on-site thrombolysis vs referral to another hospital in patients with ischemic stroke attended in a hospital lacking a stroke unit. DesignExpected value decision analysis and Monte Carlo simulation. Patients and settingDecision analysis based on a cohort study (SIT-MOST) and a meta-analysis of randomized trials of thrombolysis vs placebo in patients with acute ischemic stroke. InterventionsOn-site thrombolysis (in hospitals lacking a stroke unit) vs delayed thrombolysis in a reference hospital. Main outcomesNeurological outcome (modified Rankin scale) three months after admission according to the delay in the introduction of thrombolysis. ResultsAt baseline (initial delay of 135min, travel time 60min), on-site treatment was more effective than referral to another hospital (number of patients with favorable neurological outcome 45.3% vs 41.3%). In patients seen within 45min of the onset of symptoms, for every 10 patients transferred there was an additional case with an unfavorable neurological outcome that could have been avoided with on-site thrombolysis. In the Monte Carlo analysis, biased against on-site treatment by a reduction in effectiveness of 30%, on-site treatment was superior to patient referral in 77.2% of the cases. ConclusionsThe available evidence does not support the recommendations of the national stroke strategy or some regional plans that discourage the administration of thrombolysis in hospitals without stroke units.

Promoting stroke-specific education

Stroke is the most common cause of adult neurological disability in the UK. This article describes the reasons for the establishment of the UK Forum for Stroke Training and the Stroke-Specific Education Framework. It illustrates how these initiatives can be used to access a range of endorsed, stroke-specific courses to develop excellence in stroke care and multidisciplinary teamwork, as demanded by the Department of Health's National Stroke Strategy.

Trombolisis en el ictus isquémico agudo en centros sin unidad de ictus: ¿derivación a centro de referencia o tratamiento in situ?

ObjectiveTo assess the clinical impact of on-site thrombolysis versus referral to another hospital in patients with ischemic stroke attended in a hospital lacking a stroke unit. DesignExpected value decision analysis and Monte Carlo simulation. Patients and settingDecision analysis based on a cohort study (SIT-MOST) and a meta-analysis of randomized trials of thrombolysis versus placebo in patients with acute ischemic stroke. InterventionsOn-site thrombolysis (in hospitals lacking a stroke unit) versus delayed thrombolysis in a reference hospital. Main outcomesNeurological outcome (modified Rankin scale) three months after admission according to the delay in the administration of thrombolysis. ResultsAt baseline (initial delay of 135min, travel time 60minutes), on-site treatment was more effective than referral to another hospital (number of patients with favorable neurological outcome 45.3% versus 41.3%). In patients seen within 45minutes of the onset of symptoms, for every 10 patients transferred there was an additional case with an unfavorable neurological outcome that could have been avoided with on-site thrombolysis. In the Monte Carlo analysis, biased against on-site treatment by a reduction in effectiveness of 30%, on-site treatment was superior to patient referral in 77.2% of the cases. ConclusionsThe available evidence does not support the recommendations of the national stroke strategy or some regional plans that discourage the administration of thrombolysis in hospitals without stroke units.

Will telemedicine facilitate access to hyper acute stroke care across the UK?

Delayed and inconsistent adoption of telemedicine among many acute stroke services is undermining recent advances in acute stroke care. Widespread use of telemedicine will be required for stroke care to achieve the standards demanded by the National Stroke Strategy.

The role of specialist palliative care services in stroke – views from an acute stroke unit

BackgroundStroke is the third commonest cause of death and causes significant symptoms and disability. In the UK, acute stroke care occurs in hospital. National Stroke Strategy guidelines recommend that patients...

Stroke care in Spain. What do we have? What do we need?

The high level of scientific evidence which supports the recommendations for the care of acute stroke in stroke units (SUs) with a good health care network, does not correspond to the level of introduction in Spain. In this regard, the Cerebrovascular Diseases Study Group (GEECV) of the Spanish Society of Neurology has taken the initiative to conduct the “National Survey of Stroke Care” that will help to determine the real situation in acute stroke management in Spain just before the approval of the National Stroke Strategy (NSS) by the Ministry of Health and concludes that in the first semester of 2009 there were 39 SUs, unevenly distributed with higher concentration in Madrid and Barcelona. Although the approval of the NSS was a major achievement, much remains to be done to meet the objectives. We thank the GEECV's initiative, which gives us an “X-ray” of the, not very satisfactory, state of stroke care in Spain in December 2008, highlighting some achievements and the many shortcomings. Therefore, we must continue to improve, refine our data collection with records that include all available resources and all the stroke patients attended. We invite GEECV to carry out a second study to evaluate the impact of NSS and to serve as a stimulus to achieve a substantial improvement in stroke care in Spain, closer to the recommendations of the new PASI document.

Situación asistencial del ictus en España. ¿Qué tenemos? ¿Qué nos falta?

The high level of scientific evidence which supports the recommendations for the care of acute stroke in Stroke Units (SU) with a good health care network, it does not correspond to the level of introduction in Spain. In this regard, the Cerebrovascular Diseases Study Group (GEECV) of the Spanish Society of Neurology has taken the initiative to conduct the «National Survey of Stroke Care» that will help to determine the real situation in acute stroke management in Spain just before the approval of the National Stroke Strategy (NSS) by the Ministry of Health and concludes that in the first semester of 2009 there were 39 SUs, unevenly distributed with higher concentration in Madrid and Barcelona. Although the approval of the NSS was a major achievement, much remains to be done to meet the objectives. We thank the GEECV́s initiative, which gives us an «x-ray» of the, not very satisfactory, state of stroke care in Spain in December 2008, and highlighting some achievements and the many shortcomings. Therefore, we must continue to improve, refine our data collection with records that include all available resources and all the stroke patients attended. We invite GEECV to carry out a second study to evaluate the impact of NSS and to serve as a stimulus to achieve a substantial improvement in stroke care in Spain, closer to the recommendations of the new PASI document.

Spotting and treating a stroke

Stroke management in the UK has only moved to the forefront of medicine in the recent past. Stroke is the third most common cause of death after heart disease and cancer and has an estimated total cost to the economy of approximately £9 billion per year. Almost 20% of ischaemic strokes are cardioembolic in origin and potentially treatable. With the publication of the National Stroke Strategy in 2007 and the establishment of hyper acute stroke units, the NHS hopes to deliver a world class service for the treatment of strokes.

Supporting life after stroke

The National Stroke Strategy (Department of Health (DH), 2007) was developed by six expert groups representing health and social care professionals, non-statutory organizations and carers, to ensure that appropriate and effective treatment and ongoing support is available to individuals who have had a stroke. While prevention is considered the first line of defence, the importance of rapid treatment and ongoing support after the initial event should not be underestimated.

Evolutions in stroke care: the significance

Stroke is the third biggest cause of death in the UK and the largest single cause of severe disability. In 2001, the Department of Health recognized the importance of developing better stroke services by including specific milestones, targets and actions in the National Service Framework (NSF) for Older People. In 2007, the Government launched the National Stroke Strategy to modernize service provision and deliver the newest treatments for stroke. Here, Andrew Volans, Consultant in Emergency Medicine, looks at some of the strategy intentions and describes some of the developments in the acute care sector. Email for correspondence: andrew.volans@acute.sney.nhs.uk