Stroke care improves but concerns remain

Twelve years after the start of the National Sentinel Stroke Audit, the recently published 2010 report shows that care for patients with stroke is still improving. 88% of patients now spend at least some time on a stroke unit, which is good progress, compared to previous audits. However, even though around two-thirds of patients spend more than 90% of their hospital stay in a stroke unit, the audit has identified that there are still too many patients who spend the majority of their time on a general assessment unit where stroke specialist care is not carried out quickly enough, putting patients at a greater risk of later complications. Patients on stroke units are now reported to have better outcomes than those admitted to, and treated on, general wards. Patients admitted to a stroke unit within four hours have a median length of stay of nine days, compared to 12 days for those who were not directly admitted to a stroke unit. The audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP), was carried out on behalf of the Intercollegiate Stroke Working Party by the Royal College of Physicians’ Clinical Standards Department, using statistics from 100% of eligible hospitals across England, Wales and Northern Ireland. From 2012 onwards stroke audit will be carried out in a different way and it is expected that there will be a national prospective stroke audit, covering information needed by NICE, the Stroke Improvement Programme, Department of Health Vital Signs and the NHS Outcomes Framework. Professor Tony Rudd, chair of the Intercollegiate Stroke Network and trustee for The Stroke Association, said: “Stroke care has dramatically improved since we first started measuring the quality of care. In many areas of management we perform as well or better than other countries in Europe and America. The National Stroke Strategy and the subsequent work undertaken by the Stroke and Cardiac Networks have been the most important factors leading to this improvement. However, there are still many aspects of care, particularly in rehabilitation and longer term management, that need to be developed. It is vital that we continue to develop national policies to encourage these changes to occur and that we also continue to monitor both processes of care and patient outcomes.” The audit has indicated that patient outcomes are improving, with a reduced 30-day mortality of 17% in the 2010 audit compared to 20% in the 2008 audit. There has been a reduction in the length of hospital stay in the last two years from a mean 23.7 days (median 12 days) in 2008 to a mean 19.5 days (median 9 days) in 2010. There has been no change in discharge disability scores over the past two years. It must be hoped that patients are not being sent into the community without having had sufficient opportunity in hospital or to have adequate access to ongoing specialist rehabilitation in the community. The institutionalisation rate has also remained constant, at 10%. However, the audit did highlight the fact that more than one in 10 patients are transferred to nursing home care with little or no hope of receiving ongoing specialist stroke care and rehabilitation within two weeks of suffering a stroke. One particular area of concern for clinicians, identified by the audit, was the fact that the 5% of stroke patients audited who were already hospital inpatients at the time of their stroke appeared to fare worse than those who had a stroke outside of the hospital environment. This is a pattern that has also been highlighted in previous audits. Rapid recognition of stroke and access to specialist stroke care are vital for all patients, regardless of when or where the stroke occurred. Patients already in a hospital should not end up with worse care than patients who have their stroke at home and this is an area that needs to be urgently addressed.

Acute management

Most of the audited sites continue to provide care for acute stroke patients. However, there are still some parts of the country where systems are not in place with the ambulance service to identify acute stroke patients and transfer them rapidly to hospital. It would appear that ambulance services are still not routinely using a validated tool to screen for stroke and one in three patients have no ambulance record available in their hospital records. Only 36% of stroke patients are admitted directly to a stroke unit, with 38% reaching the stroke unit within four hours. 82% of eligible patients received a brain scan within 24 hours of stroke. However, only 25% are scanned within three hours of stroke. The audit identified an increase in the number of units that provide a 24 hour, 7 day a week thrombolysis service for their population. The last year, in particular, has seen a major improvement in thrombolysis provision, with patients in 88% of Trusts being able to access treatment. However, there are still improvements to be made as a 24/7 service is only available in 50% of centres. Over half of them had an on-site service in April 2010, with the other sites offering a 24/7 service via arrangements with neighbouring sites. Of all patients in the audit sample 5% received thrombolysis, also an increase over the last audit, but this figure is still only one-third of the patients who should receive it. Infection rates as a complication of acute stroke have also decreased by 3% to 13% for pneumonia and 6% for urinary tract infection.