The Challenge for Small Stroke Units

Dr Phil Jones

Ceredigion Division,

Hywel Dda

The Ceredigion Challenge

Catchment population around 100,000

Catchment population ranges from South Gwynedd to South Ceredigion and across to Rhayader

Annual stroke admissions about 120

Plus attendances at rapid access stroke service

The Ceredigion Challenge

Travel Times to admitting DGH (Bronglais, Aberystwyth) variable:

short for local patients

2 hours plus for more distant residents

The Ceredigion Challenge

Local service infrastructure:

4 acute monitoring beds

11 rehabilitation beds in BGH

Staffing

Physio, OT, SALT, nursing staff, consultant

others as required

The Ceredigion Challenge

What we don’t have:

Specialist nurse/therapist

Community based stroke service

Thrombolysis service

Commissioned services for stroke patients

The Ceredigion Challenge

Participation in Sentinel audit since inception.

Organisational change as far as possible.

The Ceredigion Challenge

How did we do in the 2006 RCP Audit?

Standards 1 + 2

1 More than 50% of stay is in Stroke Unit We do not have a designated stroke unit, we

are classed as stroke and rehabilitation.

2 Treated in Stroke Unit at some point during stay 25% treated outside of Ystwyth 75% treatment included stay on Ystwyth

Assessment and Diagnosis Standards 3+4

3 Swallowing assessed within 24 hours of admission National Average 66% Our site 88%

4 Brain scan within 24 hours of stroke National Average 42% Our Site 30% (median = 27 hours) (within 3 hours = 10%)

Brain scan within 24 hours of admission National Average 53% Our Site 74%

Secondary Prevention (10 and 5)

5 Receiving aspirin by 48 hours after stroke National Average 60% Our Site 83%

10 on any antithrombotic agent by discharge National average 100% Our site 100%

On 1 or more antihypertensives by discharge National Average 88% Our Site 91%

On warfarin for AF by discharge National Average 92% Our Site 100%

On lipid lowering therapy by discharge National Average 79% Our Site 69%

Multidisciplinary Assessment (6 + 7)

6 PT assessment within 72 hours of admission National Average 71% Our Site 63%

7 OT assessment within 7 days of admission National Average 68% Our Site 57%

Communication assessed by SALT within 7/7 National Average 69% Our Site 79%

Social Work Assessment within 7/7 of referral National Average 56% Our Site 14%

Risk factor management

Underlying cause for stroke identified National Average 73% Our Site 88%

Smoking Cessation (N=1) National Average 79% Our Site 100%

Alcohol Reduction (N=1) National Average 80% Our Site 0%

Exercise (N=6) National Average 41% Our Site 50%

Diet (N=16) National Average 42% Our Site 25%

Research

Patients entered into research trial National Average3% Our Site 20%

The Thrombolysis Challenge

100% of stroke patients require the basic assessment and rehabilitation services at a local level.

2006 RCP audit shows that 0.2% of patients were thrombolysed in that round of audit. 40 sites across Engalnd and Wales offered the services, 25% did not thrombolyse in 12 months. 2 patients were thrombolysed in Wales.

We must not confuse the thrombolysis issue with the holistic management of stroke.

Ceredigion Position

Emergency services:

Consultant led 0900-1700.

Speciality doctor led 1700-0900 and at weekends.

Rapid local access to CT scanning services in hours and out of hours.

Provision of acute monitoring facilities.

Complete lack of commissioning intent.

The NHS in Wales Challenge

NHS ethos of care is free at point of delivery and local access to services.

Moving away from the “post-code” lottery.

The challenge for the NHS in Wales is to support these principles through support for local care where it can be effectively delivered.

The SITS-MOST data demonstrates that experience and high volume of activity does not confer a significant advantage in the area of thrombolysis.

Conclusion

The challenges facing smaller stroke units are different to those facing larger stroke units.

Where is the evidence that smaller stroke units provide an inferior level of care to larger stroke units?

Services should be judged/commissioned on quality

not quantity