Transforming Stroke Care in London:

The story so farTony Rudd

Clinical Director for Stroke in London

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In 2004 the Sentinel Stroke Audit showed that stroke services in London were poor…

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79Emergency brain scan within 24 hours of stroke%

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Case for change

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More strokes occurred in outer London but most providers were in inner London

GAPS

GAPS

GAPSOVERLAPS

The more intense the red the greater number of providers available to provide service to the area.

Story so far

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The development of the strategy was subject to wide engagement with the model of care agreed by clinicians and user groups

HASUs • Provide immediate response • Specialist assessment on arrival • CT and thrombolysis (if appropriate) within 30 minutes • High dependency care and stabilisation• Length of stay less than 72 hours

Stroke Units • High quality inpatient rehabilitation in local hospital • Multi-therapy rehabilitation• On-going medical supervision • On-site TIA assessment services• Length of stay variable

30 min LAS journey* After 72 hours

Discharge from acute phase

Community Rehabilitation

Services

*This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU

New acute model of care

Prophets of doom predictions• It would not be possible to implement major system

reorganisation in London for a condition as complex as stroke• Staffing requirements would not be achievable• Patients would not accept being taken to a hospital that is not

local to them• It would not be possible to transport people within 30 minutes

to a HASU• Repatriation would fail and HASUs would quickly become full• Trusts would fight to retain services• Even if acute services work it would fail because it would be

impossible to change community services• The new model would be unsustainable

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Following bidding and evaluation a preferred model was agreed and consulted on

London Stroke Care: How is it working?

• 1st February 8 Hyperacute (HASU) stroke units opened taking all patients who might be suitable for thrombolysis

• 19th July all stroke patients taken to one of the HASUs

• Over 400 additional nurses and 87 additional therapists recruited to work in stroke care in London by July 2010

Beds – Open vs PlannedHASU Beds

NWL NCL NEL SEL SWL

Open 36 18 24 22 16

Planned 36 18 24 33 20

SU Beds

Open 130 93 114 57 90

Planned 156 93 114 140 92

London Stroke Care: How is it working?

• Between February and July the proportion of patients admitted directly to a HASU increased from 33% to 69% . Since July over 90%

• The average journey time from home to a HASU is 14 minutes. The HASU with the longest average transfer time was Kings at 17 minutes. The average time from LAS taking the call to arrival at a HASU is 55 minutes

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The number of stroke patients taken by London Ambulance Service to a HASU has been increasing

as implementation progresses

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Non-HASU

HASU

London Stroke Care: How is it working?

• 587 patients thrombolysed in the 5 months between Feb 2010 and June 2010 compared to 174 in the same 5 months in 2009

• The thrombolysis rate for patients brought by LAS to hospital in London is 14%. If use the incidence data of 11,000 strokes per year in London then the thrombolysis rate is 12%. These rates are higher than any reported for a large city in the world

London Stroke Care: How is it working?

• Vital signs performance data– London is performing better than all other SHAs in

England• % of patients spending more than 90% of their hospital

stay on a stroke unit – 48.3% in Q1 08/09– 83.7% in Q1 10/11 (England performance 68.1%)

• % of patients with high risk TIA treated within 24 hours– 48.6% in Q1 08/09– 84.9% in Q1 10/11 (England performance 56.2%)

London Stroke Care: How is it working?

• Average length of stay in a HASU is 3 days. Average length of stay overall has fallen e.g. 24 to 17 days at UCLH

• % of patients discharged home directly from HASU about 40% (predicted 20%)

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Performance data shows that London is performing better than all other SHAs in England

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Thrombolysis rates have increased since implementation began to a

rate higher than that reported for any large city elsewhere in the

world

% of patients spending 90% of their time on a dedicated stroke unit

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% of TIA patients’ treatment initiated within 24 hours

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Efficiency gains are also beginning to be seen

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Average length of stay HASU destination on discharge

• The average length of stay has fallen from approximately 15 days in 2009/10 to approximately 11.5 days in 20010/11 YTD

• This represents a potential saving of approximately [DN - insert figure]

• Approximately 35% of patients are discharged home from a HASU. The estimate at the beginning of the project was 20%.

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Home Other Stroke Unit RIP (blank)

London Stroke Care: How is it working?

• No significant problems with repatriation to SUs. Good exchange of patient information.

• Significantly improved quality of care in SUs• Evidence of constructive collaboration

between hospitals– SU Consultants joining HASU rotas and

participating in post-take rounds and educational meetings

• Very positive anecdotal patient feedback

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Case study

A 73 year old male from Harrow was one of the first patients to be taken to the Northwick Park Hospital HASU after suffering a stroke at home.

He describes the experience as “miraculous”.

He collapsed at home at 2.30am feeling sick and dizzy with weakness in his legs. His wife called an ambulance and paramedics took him to Northwick Park Hospital A&E. He was immediately given a CT scan and subsequently thrombolysis. The patient recalls “It was very serious…My care at the hospital was superb. My speech was slurred before I had the injection but afterwards I was word perfect .It was incredible. After being given the treatment I came round straight away and the next day I woke up and was almost back to normal, had breakfast and went home. I am now completely back to normal and go to the gym twice a week.”

The patient was not unfamiliar with stroke. He had one three years previously following a triple heart bypass and was in hospital following complications for three and a half months. So the experience this time – in and out of hospital in less than two days – was a revelation for him.

Medical Workforce Initiatives

• 1 month intensive training for consultants on HASU rota

• 6 month fast track training post CCST• E learning programme in development• Simulation centre courses being developed

– Senior doctors and nurses– Band 5 nurses

Areas where issues remain

• Acute stroke patients presenting at non HASU A&E departments– Too many– Some difficulties transferring to HASU– Concerns by some SUs that inappropriate to

transfer to HASU and not in patients interest to move

• Out of London patients being brought by ambulance to non HASU A&E departments

Areas where issues remain

• Stroke unit catchment areas• Interventional neuroradiology service• Stroke in children

Areas where issues remain

• Community services in many areas still insufficient– Early supported discharge– Longer term rehabilitation– Vocational rehabilitation

Areas where issues remain

• Collecting data to prove the model is worth it– SINAP– Additional London data items– Economic evaluation

What does the future hold?

• Unlikely enhanced tariff will continue• GP Commissioning: How will this work for the

London stroke model?• Andrew Lansley not convinced that the

London model is the right one• Outcomes framework– Public data being displayed by London Health

Observatory– Need to collect real outcome data

Next steps

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• Assessment of stroke outcomes data from all London units• Appraisal of new financial arrangements to ensure best efficiency and value for money• Improve availability on stroke outcomes data to patients and the public• More focus on life after stroke and long term care

•Longer term commissioning strategy...............