Better Community Care Needed To Help Stroke Victims Recover

For the first time the Sentinel Stroke Audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP), has investigated the follow-up care that patients receive when they are discharged from hospital. It shows that while many aspects of acute care have improved, post acute services have not kept up and there is a lack of access to long term rehabilitation services, particularly to help people return to work.

Over one in ten people in the UK die from a stroke, and every year an estimated 150,000 people have a stroke. It is the third largest cause of severe disability with 250,000 people living with a severe disability caused by stroke.

100% of eligible services in England, Wales and Northern Ireland took part in the audit which is in its twelfth year. The audit shows a dramatic increase in the number of units providing 24 hour, seven day a week access to thrombolysis. There has also been  a five-fold improvement in the number of stroke patients receiving thrombolysis over last year’s figures but this is still only 4%  compared to the  10-15% figure being aimed for. Fast access is vital to gain the greatest benefit from this treatment which is to prevent long term disability. With further improvements in thrombolysis services, another four to five people every day could expect to survive their stroke without long term disability if they had access to the right specialist treatment at the right time.

There is a major concern that many patients are being transferred from stroke units to non specialist beds in community hospitals where there is no access to the type of specialist multidisciplinary stroke care that has been shown to reduce disability and mortality. This is presumably being done to reduce costs but is likely to be resulting in exactly the opposite with less effective rehabilitation and more long term dependency.

Fewer than half of hospitals have access to stroke-specific services known as Early Supported Discharge (ESD), despite evidence showing that patients fare significantly better when such services are available. Where ESD is in place the care being offered is not timely.  Just over half of stroke units have access to longer term community rehabilitation services. Failure to support people who have suffered a stroke impacts upon the extent and speed of their recovery, putting pressure on the welfare system and causing misery to them and their family and carers..

There continues to be a problem ensuring that patients are admitted directly to stroke units instead of being treated on general wards where the care is significantly worse than on specialist acute wards. For example, patients are reviewed more frequently and nurses on specialist wards are trained to perform screening for safe swallowing after stroke which is not the case on general wards.

This report also shows there has been progress in the care given to people who have suffered a Transient Ischaemic Attack (TIA) or mini stroke, but many areas are still too slow and there is a lack of scanning to identify whether urgent Carotid Endarterectomy (CEA) is necessary as stated in NICE guidance. Many hospitals are still not achieving this standard.

The key findings of the report include:

• 74% of patients are now getting some access to thrombolysis
• While 98% of hospitals now have a neurovascular clinic, the median wait from referral to being seen in one is 3 days.
• 36% patients are still being treated on a general assessment ward 24 hours after being admitted to hospital with a new stroke.
• Almost half of sites report the need to admit patients to non-specialist wards because of bed shortages.
• 44% of stroke services have an available specialist ESD team.
• 28% of patients discharged to specialist ESD teams are still waiting over 48 hours for physical therapy, occupational therapy or speech and language therapy.
• 55% of stroke services have access to specialist community rehabilitation team.
• 43% of high risk patients with suspected TIA are seen on the same or the next day.
• 85% of low risk patients with suspected TIA are seen within a week.

Key recommendations include:

• Patients with acute stroke should be admitted directly to a specialist stroke unit and have access to continuous physiological monitoring. General assessment units are not an adequate substitute.
• Standards of care offered in all specialist stroke beds should meet those defined in the National Clinical Guidelines for Stroke 2008.
• Stroke services should be organised to deliver thrombolysis to all appropriate patients regardless of where they live or the time of day or week they present.
• Patients requiring end of life care should be able to receive such care to a high standard on a stroke unit.
• Vocational rehabilitation should be made available to all stroke patients wishing to return to work.
• Care of stroke patients transferred to community hospitals should meet the standards defined for specialist stroke unit care set out in the National Clinical Guidelines for Stroke 2008.
• All services should be able to deliver high quality specialist early supported discharge to appropriate patients.
• High quality longer term rehabilitation should be provided to all patients who require on-going treatment without undue delay.
• Facilities to investigate high risk patients after TIA should be available at all times including weekends.
• Information provision should be improved to provide universal access to all in-patients and out-patients.

Dr Tony Rudd, Chair of the Intercollegiate Stroke Working Party, said: ‘This report shows how much progress has been made in many aspects of stroke care around the UK over recent years. I think the most concerning aspect of the report is the previously unreported heavy use of intermediate care beds instead of keeping patients in specialist stroke units or discharging them home to be managed by specialist stroke teams in the community. We should be using the processes that we know from research are effective at reducing death and disability.’

Notes

1. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices.  Its aim is to promote quality improvement, particularly the impact clinical audit has on healthcare quality in England and Wales.  HQIP manages and develops the National Clinical Audit and Patient Outcomes Programme (NCAPOP), which currently comprises 30 clinical audits covering an extensive range of medical, surgical and mental health conditions.
2. The full report can be found here: http://www.rcplondon.ac.uk/CLINICAL-STANDARDS/CEEU/CURRENT-WORK/STROKE/Pages/Audit.aspx