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Bringing stroke out of the shadows

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Ahead of a national strategy for stroke, which is due to be published at the end of this year, Clare Lomas asks nurses what they are doing to help improve stroke services

ACCORDING to The Stroke Association, stroke is the third biggest cause of death in the UK and the commonest cause of severe disability. Every year, an estimated 150,000 people in the UK have a stroke, and more than 250,000 are living with
disabilities caused by the condition. Stroke costs the NHS over £2.8bn annually, yet service provision remains inconsistent, varying widely from one area of the UK to the next.

‘Stroke still lags behind cardiac and cancer services and I have been shouting long and hard for some time about the need for development,’ says Jane Williams, chairperson of the National Stroke Nursing Forum. ‘We need an equitable
service as there are still huge variations in care.’

The government has pledged to reduce the death rate from stroke and coronary heart disease in people under 75, by at least 40% by 2010. It is in the process of developing a national strategy on stroke to achieve this. Due to be published at the end of this year, A New Ambition for Stroke aims to modernise service provision and deliver the newest treatments in stroke care.

The national strategy is based on findings and recommendations from the 2006 National Sentinel Audit of Stroke, the latest audit conducted by the Royal College of Physicians. Stroke services provided in 203 trusts to 13,625 patients across the UK were audited against key standards of care, such as patients being treated in a stroke unit during their stay, and spending more than 50% of their time in hospital on such a unit.

Patients who are admitted to Nottingham University Hospitals who have had a stroke go straight to the 16-bed hyper-acute stroke unit. ‘We wanted to improve the stroke pathway so we developed a fast-track system with the paramedics,’
says Dawn Good, clinical stroke lead at the trust. ‘Patients are assessed using the FAST protocol – facial weakness, arm weakness, speech problems and a Glasgow Coma Scale greater than seven. If they have had a stroke they go directly to the
stroke unit rather than A&E.

‘Out of hours, or if the paramedics are unsure, they will take the patient to the emergency department. If a CT scan confirms they have had a stroke they will be on the acute unit within 24 hours. All our patients stay within the stroke service and at least 25% will go home from the unit,’ she adds.

Having a CT scan within 24 hours of a stroke and receiving IV thrombolysis are also key standards of the audit.
At The Royal Free Hospital in London, they have been thrombolysing stroke patients since the summer. ‘The aim is for patients to have a CT within three hours because thrombolysis has to be given within three hours of the onset of stroke symptoms,’ says Pauline Baccarini, senior sister on the stroke ward at the hospital.

Evidence shows that patients who receive thrombolytic treatment within 90 minutes of symptom onset are twice as likely to have reduced disability and lower mortality rates after three months than patients who don’t.

Dysphagia is common following a stroke, so all patients should be screened for swallowing disorders within 24 hours of admission according to the audit. ‘The risks to the patient are great in terms of aspirating,’ says Shaun Marten, matron for elderly medicine at the Royal Sussex County Hospital. ‘Nurses are specially trained in oral assessment and they regularly check the patient’s swallow for safety.’

Earlier this month, the trust also set up a rapid access transient ischaemic attack (TIA) clinic, a nurse-led clinic that operates out of the acute stroke unit. Patients can be referred from GP surgeries or A&E to the nurses who perform assessments, arrange tests and give health promotion advice. They also look at starting the patient on aspirin or statin therapy.

‘The conversion rate from TIA to stroke is relatively high,’ says Mr Marten. ‘TIA is not well managed in the community so the service is a way to refocus.’
Rehabilitation is an essential part of stroke care. In September this year, Trafford General Hospital in Manchester opened a newly refurbished stroke rehabilitation unit. ‘The general rehab unit was not appropriate for stroke patients so we changed the layout so that stroke patients had their own dedicated area,’ says Norah Webster, matron for the rehabilitation directorate.

‘We looked at what we would need to do to accommodate stroke patients. The nine-bed unit has large bed spacings and spacious wet shower rooms with plenty of handrails,’ she says. ‘An ex-patient helped us with the refurbishment and grab rails were one of the things he highlighted,’ she adds.

At the Royal Sussex County Hospital, patients can use the gym, integrated into the stroke unit, as part of their rehabilitation.

The effective discharge of stroke patients back into the community involves the whole multidisciplinary team. At Trafford General Hospital, discharge is done in stages – first the patient will go home for a few hours, then overnight and then for a few days before they are discharged permanently. They will also have a home visit performed by an occupational therapist prior to going home.

The Royal Free also has a supported discharge policy. ‘One third of our patients are suitable for early supported discharge,’ says Ms Baccarini. ‘The best place for rehabilitation is the patient’s home but there are a lot of elderly people
on their own in London who need a lot of support. We have a pathway coordinator who makes sure the discharge runs smoothly and we are forging strong links with the community to tap into the services available,’ she adds.

There are many examples of good practice, and stroke services have improved – the 2006 sentinel audit revealed that 91% of hospitals in England now have a stroke unit.

But there are still areas where the service is way below par. The audit revealed that only 10% of stroke patients were admitted directly to a stroke unit, and a third of patients with swallowing disorders had not been assessed by a speech
and language therapist within 72 hours of admission.

In 2004, 59% of all patients admitted with a stroke had a CT scan within 24 hours, yet by 2006 this figure had dropped to just 42%. And approximately 10% of all stroke admissions were unnecessarily catheterised because of urinary incontinence.

The audit also revealed huge disparities between the specialist stroke services provided in England and Northern Ireland, and the specialist stroke services in Wales, which it said needed urgent attention.

‘To improve things we need to work smarter and together,’ says Ms Williams. ‘We need to look at what works in other specialties and learn from them.

‘There is a growing body of evidence to prove what works – we know what is needed but stroke services need funding and service redesign. The national strategy will provide a lever to local organisations to look at where services need to be developed.’


- All trusts managing patients who have had a stroke should ensure that over 80% spend the majority of their hospital stay on a stroke unit

- All patients should have a CT brain scan within a maximum of 24 hours of admission

- Every SHA and region should develop systems to ensure that all stroke patients have the opportunity to access high-quality acute stroke care, including thrombolysis

- There should be a greater than 90% compliance with the standards for assessments by therapists in the National Clinical Guidelines for Stroke

- There needs to be a major shift in the attitude towards stroke that sees the development of services that can respond appropriately at all times, including nights and weekends

- There should be no patients being catheterised without good reason, and all patients should have adequate assessment for the cause of incontinence and a management plan implemented

- All patients in atrial fibrillation should be anticoagulated unless there are clearly documented contraindications for this

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