Phil Jones The Challenge for Small Stroke Units.pp

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 Our site

66% 88%

4 Brain scan within 24 hours of stroke   

National Average Our Site (within 3 hours = 10%)

42% 30% (median = 27 hours)

Brain scan within 24 hours of admission  

National Average Our Site

53% 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%

Our Site

100%

80%

Our Site

0%

41%

Our Site

50%

42%

Our Site

25%

Smoking Cessation (N=1) 

National Average

79%

Alcohol Reduction (N=1) 

National Average

Exercise (N=6) 

National Average

Diet (N=16) 

National Average

Research Patients entered into research trial 

National Average 3%

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