It is the nature of a stroke to partly take away the use of a man s limbs and to throw him onto the parish if he had no children to look to
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1 It is the nature of a stroke to partly take away the use of a man s limbs and to throw him onto the parish if he had no children to look to George Eliot
2 The Cripples (1949)
3 All cerebrovascular events in OXVAS (Rothwell et al. Lancet 2005; 366: ) Rates / 1000 / yr
4 STROKE Sudden onset Focal neurological deficit Of presumed vascular origin Symptoms lasting more than 24 hours or leading to death
5 TRANSIENT ISCHAEMIC ATTACK Sudden onset Focal neurological deficit Of presumed vascular origin Symptoms lasting less than 24 hours
6
7 Strategies to reduce the burden of stroke Primary prevention Secondary prevention Acute treatment Rehabilitation Reintegration
8 Risk of stroke (%) Cumulative risk of stroke following a TIA or minor stroke in OXVASC BMJ 2004; 328: TIA Log rank p = 0.8 Minor stroke Days
9 Atrial Fibrillation
10 Annual risk of recurrent stroke in patients who are in atrial fibrillation 15% 10% [VALUE] 5% [VALUE] 0% Warfarin Control Compared with aspirin about 90serious vascular events are avoided each year for every 1000 treated (NNT = 11)
11
12 Carotid Ultrasound
13 CT Angiography
14
15 ABCD2 Age > 60 years 1 BP > 140 / 90 mmhg 1 Clinical Duration Unilateral weakness Speech disturbance > 60 mins mins < 10 mins Diabetes Yes
16 Risk of stroke after a TIA ABCD 2 2 days 7 days 90 days Low risk < 4 Mod risk 4 5 High risk >5 1% 1.2% 3.1% 4.1% 5.9% 9.8% 8.1% 11.7% 17.8%
17 The LTHT TIA Pathway High risk (ABCD2 > 3) Direct to LGI A&E -> CDU Assessed by Brain Attack Team nurse (7 day) Investigations Reviewed by Consultant Stroke Physician (7 day) Treatment initiated Aim is all < 24 hours
18 The LTHT TIA Pathway Low risk (ABCD2 < 4) Fast track TIA clinics (5 day) LGI, SJUH, CAH, SFT Seen by Consultant Stroke Physician Investigations ordered Treatment initiated Aim is all < 7 days
19 John Hughlings Jackson He who treats apoplexy with potions or medicaments is wasting his time he is treating a hole in the brain!
20
21 Sir Godfrey Hounsfield
22 Infarction (85%) Haemorrhage (15%)
23
24 Lancet 2014
25 Public Education
26 The LTHT Acute Stroke Pathway All FAST +ve patients direct to LGI A&E Pre-alert to Brain Attack Team nurses (24/7) If potential thrombolysis direct to CT scan Review by Consultant Stroke Physician including the use of telemedicine (24/7) Between 10% and 15% patients thrombolysed Median door to needle time 44 minutes
27 SSNAP October December 2015 Individual Team Slideshow
28 2 Median time from clock start to stroke nurse (hh:mm) 1 1:06 0:47 0:37 0:33 0:45 0:42 0:37 0:34 0:34 0:46 0:23 0:25 0 Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 4.4B Team 189
29 % Scan within 12 hours Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 1.2B Team 189
30 % 100 Stroke consultant within 24 hours Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 4.1B Team 189
31 The LTHT Acute Stroke Pathway On site availability Neuroradiology Neurosurgery Neuro critical care Vascular surgery
32 Large Vessel Occlusion
33 Proximal anterior circulation large vessel occlusion (ICA / M1) accounts for 18% - 25% of all ischaemic stroke but 60% - 70% of deaths or severe disability.
34
35 Benefits of stroke unit care 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Death Stroke Unit General Ward Death or Institutional Care
36 The LTHT Stroke Wards Hyper-acute stroke unit (L 21) 8 beds Acute stroke unit (L 21) 25 beds Rehabilitation stroke unit (L 12) 27 beds Rehabilitation unit (CAH 1) 8 beds
37 % 100 Stroke unit within 4 hours Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 2.1B Team 189
38 % 100 At least 90% of stay on a stroke unit Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Patient-centred results at team level for Key Indicator 2.3A Team 189
39 % 100 OT assessment within 72 hours Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 8.1B Team 189
40 % 100 PT assessment within 72 hours Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 8.3B Team 189
41 % 100 SALT communication assessment within 72 hours Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 8.5B Team 189
42 Standards by Discharge 60 Your score Team-centred Domain 9 score Source: SSNAP Oct-Dec 2015 Team-centred results for Domain 9 Team 189
43 Discharge Process 60 Your score Team-centred Domain 10 score Source: SSNAP Oct-Dec 2015 Team-centred results for Domain 10 Team 189
44 % 100 Discharged with stroke skilled ESD team Jan 2015 Apr 2015 Jul 2015 Oct 2015 Source: SSNAP Oct-Dec 2015 Team-centred results at team level for Key Indicator 10.2B Team 189
45 Success is a journey not a destination
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