Good news for optimal stroke care

Stroke care has been a ‘good news’ story among all the negative reports on aspects of healthcare in Ireland in recent years. This was the overwhelming message from the Irish Heart Foundation’s recent Annual Stroke Day conference for health professionals, held in Croke Park.

While it was acknowledged that much more needs to be done, it was clear that  targeted resourcing, service reorganisation, data collection, technical innovation and research has done much to improve stroke care. 

Dr Joe Harbison, national lead of the HSE’s Stroke Programme, pointed out to the conference that for the first three quarters of 2014, Ireland had its lowest ever mortality rate from stroke.

On the innovations front, Prof David Williams, associate professor in geriatric medicine at the RCSI/Beaumont Hospital, updated the conference on the results of the ESCAPE trial. This is a multicentre international study which was carried out at 22 centres worldwide and included patients referred to Beaumont Hospital from 10 centres in Ireland.

The trial aims to understand whether endovascular clot removal (thrombectomy, the mechanical removal of a clot by capturing and removing it using a stent) can be added to the current standard of care to improve stroke outcomes. This procedure has been used at Beaumont through its neuroradiology service since 2011.

Irish results in ESCAPE trial

As part of the ESCAPE trial, 34 Irish patients were recruited to the study. The trial randomly assigned patients to receive standard care or standard care plus endovascular treatment with the use of available thrombectomy devices. Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded.

The trial results proved very positive as regards the efficacy of thrombectomy over conventional therapy. There was a significant improvement in mortality and disability in patients who received the interventional therapy, Dr Williams told the meeting. In fact, the ESCAPE trial was recently halted because of this efficacy.

Overall, positive outcomes from patients receiving the thrombectomy treatment increased from 30% to 55%, and the overall mortality rate was reduced by 50% compared to standard therapy. Prof Williams said ESCAPE had concluded that endovascular thrombectomy had been shown to be a safe, highly effective procedure that saves lives and dramatically reduces disability. He stressed that patients must be carefully selected for this treatment by imaging to identify and include patients with proximal occlusions and exclude large infarct core or poor collateral occlusion.

Prof Williams stressed that endovascular thrombectomy must be delivered very rapidly following imaging. He felt that thrombectomy represented a sea change in the acute management of stroke, and was indicative of how stroke care in Ireland had been improving in recent years.

National Stroke Audit

Dr Paul McElwaine outlined progress on the latest Irish Heart Foundation/HSE National Stroke Audit. The project has two specific parts – firstly, an organisational examination of services, and secondly a clinical audit of patient management.

Dr McElwaine, who is a stroke research fellow with the HSE National Stroke Programme, told the conference that the organisational review in the audit encompasses 37 hospitals around the country, all of which will be visited; the review will include staff interviews and chart audits. He stressed the key role of nurse specialists in stroke care in Ireland, and their input will form an important part of the audit.

The full results of the stroke audit will be published before the end of the year. Dr McElwaine said future plans include an audit of stroke rehabilitation services and stroke services in the community.

National Stroke Register

Prof Emer Shelley, specialist in public health medicine with the HSE, updated the meeting on the National Stroke Register, which was developed in 2011 by the HSE’s National Clinical Programme for Stroke to monitor access to and quality of hospital services for patients with acute stroke.

Currently, around 12,200 patient stroke episodes have been recorded on the register, Prof Shelly told. Data is collected about stroke onset, admission, treatment, discharges, rehabilitation outcomes and other areas, and measures key performance indicators (KPIs) as set out by the National Programme.

The overall aims include maximising the numbers of patients discharged home, minimising the numbers discharged to nursing homes, and reducing mortality levels.

Collecting high-quality data is essential in striving for reduced mortality and morbidity from stroke, she said. Currently, 26 hospitals are actively participating in the register. The latest figures from the register, for the second quarter of 2014, show that 68% of stroke patients are being admitted to an acute unit, against a target of 50%, with a thrombolysis rate of 12%, against a target of 9%.

According to the register’s most recent annual report, for 2013, based on data from 10 hospitals, 50% of patients were being discharged home following acute care, with 18% being discharged to nursing homes. A mortality rate of just under 14% during the acute stroke in patient episode was recorded, Dr Shelley said.

Interestingly, it was found that 37% of cerebral infarction stroke patients had either a history or new diagnosis of atrial fibrillation (AF), and of these 73% were prescribed anticoagulants.

Prof Shelley referred to some issues relating to improving the quality of data for the register. There is an issue, for example, with coverage, in terms of the percentage of cases discharged from hospital with a Hospital Inpatient Enquiry system (HIPE) principal diagnosis of cerebral haemorrhage or cerebral infarction that are entered onto the stroke register. Under this heading some hospitals had consistently high coverage, but there was wide variation between hospitals.

Dr Shelley said regular communication between stroke teams and coding staff is important to ensure accuracy of stroke diagnoses in the HIPE system. She said as far as is possible, prior to analysis of 2014 data, the register will seek additional information from units where the diagnosis is unclear. 

She said the stroke register was providing valuable information to monitor access to evidence-based care for stroke patients, and stroke care teams should receive as much support as possible to improve and maintain data coverage.

Improvements in stroke care

Nora Cunningham, clinical nurse specialist, outlined the improvements in stroke care that have come about in the mid-west since the implementation of the National Clinical Programme for Stroke in University Hospital Limerick (UHL) in 2012.

Prior to the programme, UHL had four designated stroke beds within a medical ward and the thrombolysis rate was 1%. Since then resources and infrastructure of stroke services have improved significantly, with the thrombolysis rate increasing to 13.6%. The development of an acute stroke unit in line with a thrombolysis protocol has led to reduced length of stay and positive outcomes for patients, including improved post-stroke function.

Research showed that there had been marked improvements in many aspects of stroke care in Limerick between 2008 and 2012, including the numbers of patients treated in a designated stroke unit, the numbers given brain scans, thrombolysis rates, and the numbers screened for swallow. There had also been improvements in recent years in median door-to-needle time.

Opportunistic screening

Dr Breda Smyth, public health specialist with the HSE, presented findings from a new study on the feasibility of opportunistic screening for AF in general practice in Ireland. The study involved Galway University and Sligo Regional Hospitals and 39 practices with 89 GPs based in the Galway and Sligo regions, whose practices covered 170,000 patients. The hospitals provided clinical and diagnostic support for the GPs in the screening study.

A total of 7,262 patients were screened for AF in the general practices through pulse-taking. It was found that 87% of screened patients had a regular pulse, with just under 13% having an irregular pulse.

It was found that 6% of patients detected as having irregular pulse had newly detected AF. It was found that females with AF had higher levels of common risk factors than males, such as smoking, heavy drinking or were overweight or obese. 

It was found that 22.6% of AF patients had systolic blood pressure of greater than 140 and 9.4% had a diastolic greater than 90, and these were predominantly female.

The study, which is regarded as unique in this area, produced useful data on the detection of AF in general practice and on the care of AF patients in both primary care and hospital settings.

‘Get with the Guidelines’

A key speaker at the conference was Prof Lee Schwamm of Harvard Medical School, who leads the American Heart Association’s ‘Get with the Guidelines’ (GWTG) Stroke Program, launched in 2000. 

This is a programme aimed at improving stroke care by promoting consistent adherence to the latest clinical treatment guidelines and supporting hospitals in a number of ways to improve care. There is now extensive hospital participation in the programme, which has led to some major improvements in stroke care.

He provided an interesting overview to the conference on what we can learn from the results of the program.

There has been a particular emphasis on improving ‘door to needle’ TPA treatment times. There has been an increased number of hospitals in the US, with 50% or more of their TPA-treated patients now with door-to-needle times of 60 minutes or less. Prof Schwamm said 45% of all strokes in the US are captured in the GWTG-Stroke Program.

Data from the programme has shown that more stroke events occur in women than in men, and women have higher stroke mortality. Prof Schwamm pointed out that even though stroke mortality is dropping in the US, the number of strokes is rising. He said there was a need for more patient-centred care and patient-centred outcomes measurement. For example, in terms of data measurement, focusing on mortality alone may obscure large differences in regaining post-stroke function. He said patients should be followed up and listened to post-hospitalisation.

Exercise after stroke

Prof Gillian Mead of the University of Edinburgh, addressing the meeting on exercise after stroke, pointed out that an increasing body of evidence shows that physical training after stroke can improve physical fitness and reduce disability. She stressed that fitness training programmes specifically adapted for stroke survivors to accommodate a large range of neurological deficits are feasible and acceptable.

Prof Mead, a stroke medicine specialist, described how she had helped develop a training programme for exercise professionals to enable them to run safe and effective exercise-after-stroke services in the community, analogous to those provided for people with coronary disease.

Community exercise programmes for stroke survivors are now being developed throughout the UK.

Cognitive impairment after stroke and TIA

Other speakers at the conference included Prof Sarah Pendlebury of John Radcliffe Hospital, Oxford, who spoke on measurement and management of cognitive impairment after stroke and TIA.

She pointed out that measurement of cognitive defects in the immediate post-stroke period is difficult due to the presence of acute stroke effects. Ease of measurement varies depending on type of stroke, the length of time post-stroke and particular after-effects of the stroke. Prof Pendlebury said early identification of cognitive impairment may enable targeting of preventive strategies in those at risk.

The development of risk scores to further identify those at high risk may help selection of patients for clinical trials of interventions to prevent cognitive decline.

The meeting also heard presentations from Prof Katherina Stibrant Sunnerhagen of the University of Gothenburg, Sweden, on a Swedish database for quality control in post-stroke rehabilitation, and from Thomas Hope, of University College London on a UK study on predicting language outcomes and recovery after stroke.