GP workshop

Maria Fitzpatrick
Nurse Consultant
Kings College
Stroke Centre

Stroke: the Facts

Every 5 minutes someone in the UK has a stroke
Stroke: the Facts
1 in 4 men and 1 in 5 women will have a stroke
after the age of 45
Mortality is 50% after one year (worse than cancer)
Of the survivors
50% remain dependant on others
25% will have difficulties walking
25% will have problems speaking
33% will suffer depression

Costs UK 4.8 billion a year in cost of care

Little that medicine and nothing that surgery can do in the management of stroke
For every 50 spent on cancer research and 20 on heart disease research,
only 1 is spent on stroke research

Not so long ago

Stroke is a non-acute condition
Hospitalisation for nursing, therapy or social
needs (1988)
CT scan for more than 10% patients needs
justification (1994)
Little acute care can do, emphasis on
rehabilitation (1997)
Move away from hospitals and towards
community care for stroke (2000)

But things have changed..

Developments in neuroimaging (1980-)
Recognition - stroke is complex (1990-)
Pharmaceutical Interest (1990 Proven effectiveness of appropriate
early management (1993)
Introduction of thrombolysis (1995)

The impact of stroke

Every year approximately 150,000 people in England have a stroke.

Stroke is the third largest cause of death in England: 11 per cent of
deaths in England are as a result of stroke.
2030 per cent of people who have a stroke die within a month.
25 per cent of strokes occur in people who are under the age of 65.
There are over 900,000 people living in England who have had a
stroke.
Stroke is the single largest cause of adult disability. 300,000 people
in England live with moderate to severe disability as a result of
stroke.
People from certain ethnic minorities are at a higher risk of stroke.
National Audit Office, 2005, Reducing Brain Damage: Faster access
to better stroke care, London, NAO

Stroke recurrence
The risk of recurrent stroke is greatest
early after the first stroke; about 23% of
survivors of a first stroke have another
stroke within the first 30 days, about 9% in
the first 6 months and 1016% within a
year.

National Audit Office Acute Care

An emergency response to stroke with efficient
and effective acute care is generally lacking
16% hospitals have protocols with ambulance
services for the rapid referral of stroke patients
Rates of thrombolysis in England <1%
Only 41% patients receive specialist care for half
their stay

Potential savings per year of more efficient

practice in London:
20 million in care costs
550 deaths avoided
1,700 people fully recovering from their
strokes

What we know
Variable quality of acute stroke care
Very small proportion of patients admitted
directly to specialist acute stroke unit
Difficulty accessing imaging
Quality of acute stroke units not consistent
(RCP)
Very few patients receiving thrombolysis
All patients should be managed on a stroke unit
(National Clinical Guidelines 2004)

Stroke Strategy

FAST

FAST who does it?

Impact of February FAST campaign

9 in 10 have seen/heard at least 1 part of the campaign.
Stroke is now regarded as the top illness for causing
long standing illness, disability or infirmity among general
population (before campaign regarded as third behind
cancer and heart disease)
Prompted awareness of F.A.S.T. has also increased
significantly (75% compared to 15% of people pre
campaign)
An increase in respondents claiming they would call 999
if they saw a slumped face (64% pre to 87% post);
somebody unable to lift both arms (46% pre to 72%
post) and slurred speech (46% pre to 74% post).

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

Outcome of Acute Unit Care

100%

7
6

12

22

15

80%

11

60%
40%

87
73

67

DOM

TEAM

20%

Dead
Alive but
dependent
Alive and
independent

0%
UNIT

Difference per 100 treated:

SU v DOM: 14 more alive & independent NNT=7
SU v ST: 20 more alive & independent NNT=5

Healthcare for London

Hyper-acute stroke centres (8 centres)
24/7 immediate response, thrombolysis within 30 minutes
At least 6 consultants, on-site middle-grade doctors,
sophisticated imaging and interpretation
Specialist interventions e.g. intra-arterial thrombolysis and
stents.

Local stroke units (20 centres)

Ongoing care after stabilisation, multi-therapy rehabilitation

Transient ischaemic attack services (20 centres)

Rapid assessment and access to a specialist within 24 hours for
high-risk patients

Hyper-acute Stroke Centres

KCH centred network

Key Features

Network between KHP, South London Trust, Lewisham and Kent Hospitals
Delivers excellence in clinical care, training and research across South London and Kent
Enables PCTs to achieve good care for all and not a postcode lottery

Kings Stroke Centre

Covers South East London (1.5 million)
Joint protocols with LAS and ED for rapid
assessment, management and transfer
24/7 service for thrombolysis and
advanced management of hyperacute
patients
Interventional neuroradiology,
neurosurgery, neuro-intensive care
Rapid response TIA services
Joint specialist training programmes with
District Centres
Leadership in research, education and
training

Local Centres
iv thrombolysis at PRUH
Acute and Rehabilitation care
Local TIA services
Multidisciplinary specialist rehabilitation

Research and Academic at KCL

Epidemiology, Prevention, Ethnicity
Complex Interventions, HSR Research
Imaging, cortical plasticity, rehabilitation
Tertiary Services for Kent
24/7 neurosciences service
Diagnostic, interventional and neurointensive care facilities
Management of complex patients

Pathogenesis of ischaemic stroke

Penumbra
Infarction

What needs to be in place

Red phone / bleep system / team in ED

Protocols with paramedics (FAST)
Protocols with A&E (ROSIER)
National Institutes of Health Stroke Scale (NIHSS) (all
stroke team trained)
Protocol with radiology
Acute stroke bleep / rota
Agreement with bed management
Identified monitored bed
Trained nurses (rt-PA & acute skills)
Protocols of care, guidelines

Thrombolysis in 3 hours
Alive and
independent

100
80

30.2

44.3

60
40

51.4

38.4

Alive but
dependent
Dead

20

17.3

18.4

Thrombolysis

Control

Differences/1000:

141 extra alive and independent (P<0.01)

130 fewer dependent survivors (P<0.01)

ECASS III
The European Cooperative Acute Stroke
Study
Randomized, placebo-controlled, phase 3
trial
Test efficacy of alteplase administered in
patients with acute ischemic stroke in an
extended time window of 3 to 4.5 hours
Primary efficacy outcome: 90 day disability
ECASS investigators, NEJM 2008

Thrombolysis in 6 hours
STUDY

ODDS

RATIO

ATLANTIS A
ATLANTIS B
ECASS
ECASS II
MORI
NINDS
0.79 (0.68 - 0.92)

TOTAL 95% CI

1
2
Favours Treatment

5
10
Favours Control
Wardlaw, 2000

Thrombolysis at Kings
Jan-Jun 08

Jan-Jun 09

Jan-Mar 2010

All strokes

154

273

236

Within 3 hrs of onset

32

87

100

Within 6 hrs of onset

75

174

156

Thrombolysed

38

80

97

25%

29%

41%

% Thrombolysed (6 hours)

KCH is the busiest centre for acute stroke treatment

in England
Competes with the best across the world (15-20%)
and exceeds the National thrombolysis target of 4%
Scored top (98/100) for stroke care in National
Stroke Audit 2008

Thrombolysis for Acute Stroke

Thrombolysis is using drugs to dissolve clots that block blood vessels

The most effective treatment ever for stroke patients
40% increase in the number of people alive and independent
1 hour

12 hours

THROMBOLYSIS

Left sided weakness

Loss of vision

Normal

2 million neurons are lost for every minute of delay in treatment

Thrombolysis can only be performed at centres with specialist facilities and staff

Intra-arterial Thrombolysis

Benefits
Increased effectiveness
Increased safety
Longer time window

Limitations
Neuroradiology access
Training and expertise
Costs

Protocols for malignant stroke

ICH Pathway
Suspected Intracranial Haemorrhage
ABC management
Assessment for signs of trauma
Blood investigations inc. INR APTT & CBC

Immediate CT scan
Subarachnoid haemorrhage

Intraparenchymal haemorrhage
Cerebellar haemorrhage

Cerebral haemorrhage

SAH Pathway

Neurologically stable

Deteriorating GCS

Contact neurosurgeons
IMMEDIATELY

Discuss with Neurosurgeons

NOT for surgery

Stroke Unit

SURGERY

May need surgery

Admission to HDU/ITU
Hourly neuro observations
ICP monitoring
Improved

Repeat CT
Neurosurgical review

Deteriorated

Making a difference for patients

SB, 34 yrs old nurse, sudden onset right weakness and unable to speak (7:30 am)
Maidstone Hospital 8:15am, transferred KCH 12:50 pm

Door to treatment 34 minutes

Hole in the heart

repaired at 24
hours

Rehabilitation on Friends Stroke Unit

The multi-disciplinary team.

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.

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.

Discharge from Friends Stroke

Unit.

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 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.

Advanced imaging for TIA in ED

58 y, F, HT, smoker
Suddenly unable to speak
R arm and leg weakness
Improved in 30 minutes
Presented with no deficits to
the Emergency Department

Making a difference for patients

SB, 34 yrs old nurse, sudden onset right weakness and unable to speak (7:30 am)
Maidstone Hospital 8:15am, transferred KCH 12:50 pm

Door to treatment 34 minutes

Hole in the heart

repaired at 24
hours

UK Firsts in stroke treatment

Themes in Stroke Research

Vascular biology
Epidemiology and Prevention
7 days after stroke

3 m after stroke

Neuroimaging

Cell biology and stem cell

Small vessel disease

Health Services Research

The vision for the future

A Centre of Clinical Excellence

Provide innovative and high quality stroke care

Train the best young clinicians and scientists in

stroke

Influence government policies to improve stroke

services

A Centre of Research Excellence

Improve clinical care and outcome in stroke

Reduce stroke in African-Caribbean people

New insights into the causes and prevention of

stroke

Cellular therapies to promote brain repair

Clinical trials and first in man studies for stroke

patients

Our goal is to create an internationally recognised centre

of excellence for patient-centred care and research

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.