Stroke Improvement Plan

3. Stroke Care in Scotland: Priorities for Improvement and The Stroke Care Pathway

Priorities for Improvement and the Stroke Care Pathway

39. The Stroke Improvement Plan 2014 identifies eight priority areas for improvement linked by an overarching aim that are fundamental to success. Together, these contribute towards the prevention, detection, treatment and after care of stroke and patients with stroke. These priorities are summarised in Figure 3 below followed by a more detailed outline of each priority and its corresponding actions.

40. These priorities have been identified to improve the experience and clinical outcomes for patients living with stroke across Scotland by supporting the community to adopt a seamless approach to the delivery of care across the whole care pathway for stroke as set out in Figure 2 below. It reflects the priorities, best practice and emerging evidence to continually improve stroke care for patients regardless of where they live or are treated in Scotland.

Figure 2 Stroke in Scotland: Priorities for Improvement

Figure 3 Stroke in Scotland: Stroke Care Pathway

Priority 1: Early recognition of Transient Ischaemic Attack (TIA) and stroke by the general public, Scottish Ambulance Service (SAS), NHS 24, primary care hospital front door services and social care staff.

Aim: To maximise access to effective treatments, including early thrombolytic (clot busting) therapy for ischaemic stroke in order to optimise recovery and treatments to reduce the risk of further stroke. Maximising access to acute treatment through local protocols will help ensure recovery.

Background: Raising awareness of the signs and symptoms of stroke remain a priority since 2009. Greater awareness helps to ensure that medical advice is sought at the earliest opportunity and in doing so that treatment can be commenced as soon as possible. Much work has been done for example through continuing support to deliver the FAST campaign - this priority recognises the on going need to maintain this work.

Actions:

1. Public campaign to raise awareness of stroke symptoms (Face Arm Speech Time (to call 999) (FAST)) - Deliver public education to increase awareness of common symptoms of stroke and TIA, and the need to seek emergency medical care.

2. Improve early identification of stroke and TIA by SAS/NHS24, primary care and hospital emergency departments.

• Call handlers for NHS 24 trained to recognise stroke and TIA (e.g. FAST test) and those with stroke should be re-directed to the SAS;
• Call handlers for the SAS, paramedics and staff dealing with patients' calls in primary care trained to recognise stroke and TIA, treat those with stroke as Category B emergencies and be aware of local protocols to access early hospital care; and
• Staff working in hospital emergency departments receive training to identify strokes and TIA (e.g. Stroke and TIA Assessment Training (STAT)) and to follow local protocols for assessment, referral and treatment.

Priority 2: Appropriate pre-hospital protocols to ensure rapid admission, early diagnosis and treatment.

Aim: To ensure that appropriate treatment is delivered as quickly as possible to all stroke patients to reduce the risk of future strokes and to maximise recovery by: rapidly distinguishing stroke from non stroke, ischaemic from haemorrhagic stroke with brain imaging; identifying patients with symptomatic tight carotid stenosis who require urgent carotid endarterectomy and ensuring thrombolytic treatment is given to appropriate patients, as early as possible.

Background: Thrombolysis has emerged from the 2009 plan through the on going refresh process. In 2009 the aim was to record the number of people being thrombolysed and that this was at least 5 per 100,000 of the population each year in line with the guidance published at the time and that the right people were being thrombolysed. The priority for this plan now focusses on specific actions to improve the door to needle time for patients who receive thrombolysis. The stroke community started to work with the SAS and front door hospital services some time ago - the initial work has been done allowing this priority to now be measured.

Actions:

1. Pre-alert by SAS - The SAS should pre alert Emergency Departments of the arrival of stroke patients who might potentially benefit from thrombolysis.

2. Early imaging - Imaging services should work with stroke services, Emergency Departments, and other services where patients with stroke/TIA may present, to provide rapid access to CT or MR brain imaging (as appropriate) for all patients with suspected stroke, and those patients with TIA in whom brain imaging is clinically indicated; timely access to carotid imaging for patients with TIA and minor stroke should also be provided.

3. Thrombolysis teams - Develop local teams and protocols to ensure that intravenous thrombolysis is offered to all eligible acute stroke patients with the minimum possible delay.

Priority 3: Delivery of Stroke Care Bundle

Aim: To ensure that all appropriate patients receive timely access to key interventions to optimise survival and minimise disability and risk of complications. Outcomes for acute stroke patients are improved with admission and care in a stroke unit. All patients who may benefit are admitted to a stroke unit as quickly as possible. Early identification of swallowing problems and aspiration risk, prior to any oral intake, is important to avoid pneumonia.

Background: The Better Heart Disease and Stroke Care Action Plan recognised that the key action to deliver improved outcomes for people with stroke was early admission to a stroke unit and for these to be established in every NHS Board. The updated clinical standards published in 2009 and 2013 set targets for the provision of swallow screening, timely administering of aspirin and thrombolysis. NHS Boards have continued progress towards these targets however emerging evidence indicated that survival outcomes would significantly improve with focus on the provision of all four of these elements of care. The Stroke Care Bundle was developed to ensure the delivery of these elements - access to a stroke unit, swallow screen test, CT scanning and aspirin.

Actions:

1. Ensure early access to stroke unit - Acute stroke patients will be admitted rapidly to a stroke unit and remain in that care setting for as long as is clinically necessary.

2. Swallow screen - Stroke services should ensure swallow screening is part of the stroke admission protocol and provide a programme of education to support delivery.

• Swallow screening is a pass/fail procedure to rapidly identify patients who require referral for comprehensive swallowing assessment to inform appropriate management;
• Keeping patients nil by mouth for extended periods pending screening reduces patient satisfaction and may present other health risks such as missed medications; and
• The swallow screening procedure requires close observation of both non-swallowing and swallowing behaviours that require sound clinical judgement and competence to practice.

3. Evidence based interventions - Ensure that protocols are in place and effectively implemented to guide the appropriate use of:

• Thrombolysis with alteplase for selected patients with ischaemic stroke;
• Aspirin in patients with acute ischaemic stroke; and
• Intermittent Pneumatic Compression (IPC) for venous thromboembolism prophylaxis in patients who are immobile after a stroke.

NB - the fourth element of the Stroke Care Bundle (CT scan) is listed under priority 2, action 2.

Priority 4: Developing a skilled and knowledgeable workforce

Aim: A trained and competent workforce ensures health and social care staff in contact with people affected by stroke have the knowledge and skills to deliver person-centred, safe and effective stroke care.

Background: The 2009 clinical standards recognised the need for stroke units to be able to demonstrate that their staff underwent appropriate training. This priority builds on this further recognising the need for appropriate levels of training across the wider health and social care workforce. A current project led by the National Advisory Committee for Stroke (NACS) and the Stroke Improvement Team to measure the correlation between training provision and performance of the Stroke Care Bundle and door to needle time will provide evidence on training provision.

Actions: Health and social care staff in hospital and community settings are trained to an appropriate level depending on whether their contact with people affected by stroke is: occasional (stroke awareness), regular (core competencies) or in the context of specialist services (specialist competencies).

• All NHS Boards utilise the education training template to accurately identify training delivery and demonstrate appropriate level of training; and
• NHS Boards use the information collated from the education template to identify and address training needs at all levels.

Priority 5: Early diagnosis and treatment for non-admitted patients

Aim: To ensure access to specialist advice to confirm diagnosis and timely access to appropriate treatment. By ensuring that patients with TIA/stroke are started on treatments such as aspirin, clopidogrel and statins to reduce their risk of stroke at the earliest possible time and that only patients with definite or probable TIAs and strokes receive lifelong treatment with secondary prevention. Also, to rapidly investigate the underlying cause of any TIA/stroke (e.g. carotid disease, cardiac embolism) to refine the treatment options and ensure that delays to starting these treatments (carotid surgery, anti-coagulation) are minimised.

Background: The 2009 clinical standards recognised that the risk of early stroke recurrence is high in all patients who have had a TIA or stroke. Therefore, early rapid specialist assessment of patients is important for accurate diagnosis and secondary prevention in those patients not requiring admission to hospital. This priority re-enforces the need for treatment to be given very early after a TIA/stroke, when the risk of stroke is at its highest, as it is much more effective than that given later.

Actions:

1. A specialist service to deliver immediate specialist advice - Stroke services should provide GPs, Emergency Departments and other services where patients with TIA/stroke may present with immediate access to advice from a specialist stroke physician.

2. Service to provide early access to confirmatory clinical assessment - A specialist service should be available to confirm the diagnosis of TIA/stroke, to differentiate these from mimics and to provide early access to brain and vascular imaging.

Priority 6: Appropriate secondary prevention

Aim: To improve the identification of Atrial Fibrillation (AF) which is a significant risk factor for stroke, ensuring appropriate treatment with anti-coagulation and to reduce the risk of a patient having a stroke whilst waiting for carotid surgery, and to maximise the effectiveness of the surgery.

Background: Secondary prevention to reduce the risk of further stroke are key aims which remain current since the 2009 plan and are relevant across the priorities in this plan. The identification and diagnosis of AF is recognised as a specific priority in both this plan and at Priority 6 of the Heart Disease Improvement Plan. Appropriate treatment with anti-coagulants reduces the risk of recurrent stroke by two-thirds in patients in AF. This plan also provides specific focus on provision of carotid surgery as the number of strokes prevented by surgery is much higher if it can be performed within 14 days of the index TIA/stroke event.

Actions:

1. Anti-coagulation for patients in AF - To develop and implement a local protocol to:

• Identify people with atrial fibrillation and assess their risk of ischaemic stroke and bleeding to determine whether they would benefit from anti-coagulation;
• Identify persistent and paroxysmal AF in patients with ischaemic stroke and TIA; and
• Ensure that patients' risks of ischaemic stroke and bleeding on anti-coagulants are assessed to maximise the number of appropriate patients with AF receiving anti-coagulants.

2. Carotid endarterectomy for patients with recently symptomatic carotid stenosis - To modify the patient pathway to ensure that at least 80% of patients undergoing carotid endarterectomy for symptomatic carotid stenosis have the procedure within 14 days of their index TIA/stroke event (see details of Scottish Stroke Care Standards in Annex 2).

Priority 7: Transition to the community

Aim: To support patients living with stroke to live longer, healthier and independent lives by ensuring that: specialist stroke rehabilitation, is started early after stroke; patients with visual problems after stroke (i.e. eye movement disorders, visual field loss, visual perceptual dysfunction and low vision) are identified early and offered appropriate support; people with cognitive, emotional and psychological issues following stroke have access to psychology services for assessment and treatment of on-going needs; people have access to an assessment of their ability to return to safe and effective driving after stroke.

Background: The 2009 standards recognised the need for good discharge planning with provision of appropriate advice and support. This priority emphasises the need for specialist stroke rehabilitation provided with sufficient intensity and duration to reduce mortality and long-term disability. Appropriately resourced stroke specialist early supported discharge and community teams will optimise patients' personal outcomes and reduce lengths of hospital stay.

Actions:

1. Access to stroke rehabilitation services - Acute therapy assessment is provided within 24 hours of having a stroke. Stroke rehabilitation should be delivered by stroke specialists at an appropriate intensity and duration based on the needs of the individual in hospital, early supported discharge teams and community settings.

2. Person-centred approach - Stroke services should implement a person-centred approach including goal setting where practical in hospital and community services. To ensure that rehabilitation is planned according to the person's individual needs and preferences by agreeing what they will work on with the multidisciplinary stroke team over an agreed period of time.

3. Access to specialist services - Patients with stroke are assessed for visual, cognitive, emotional and psychological issues and have access to services such as orthoptics and psychology for specialised assessment and intervention. This will include provision of advice, information, support and referral for driving assessment for patients who drove previously and who have residual deficits which require specialised assessment before returning to driving.

Priority 8: Supported self management and living with stroke

Aim: To improve wellbeing and quality of life for people affected by stroke by ensuring the provision of supported self management approaches, appropriate advice and signposting to physical activity and vocational rehabilitation.

Background: As the acute care of stroke continues to improve this Plan recognises the need for the delivery of services to support people living with stroke and their families, to optimise quality of life. It focuses on the need to improve the provision of supported self management, physical activity and services to support people wishing to return to work. Increased levels of physical activity resulting in improved physical fitness contribute to secondary prevention of stroke and improved levels of function.

Actions:

1. Self management post discharge support - Multidisciplinary stroke teams offer a range of supported self management approaches including individual and group support, written and on-line resources including:

• Self Management tools;
• Web sites;
• Information in different formats, including aphasia accessible;
• Support services (life style classes, communication support services, exercise groups and peer support); and
• Professional advice (primary care, NHS 24 and Third Sector help lines).

Patients and their carers are provided with a key contact on discharge from hospital, available for up to 12 months post discharge.

Patients and families/carers are supported during their transition from hospital care to the community and engage with supported self management to ensure they have the confidence, control and coping mechanisms to live life to their full potential.

2. Exercise - Stroke patients being discharged home from hospital should have access to appropriately resourced, evidence-based exercise after stroke services; and patients with stroke are given advice about increasing their physical activity levels where appropriate.

3. Living with stroke - vocational rehabilitation - Stroke services should ensure that people of working age who wish to return to paid or unpaid work or voluntary work are signposted to vocational rehabilitation services.

• People who wish to return to work are assessed with regards to their capacity to do so; and
• Vocational rehabilitation services are available if further advice and support is required.