Opportunistic screening for atrial fibrillation should be carried out for all people aged 65 years and over in Ireland

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Joseph Harbison
Prof Joseph Harbison

Opportunistic screening for atrial fibrillation (AF) should be carried out for all people aged 65 years and over in Ireland and the number of stroke unit beds in the country should be increased so that at least 90% of patients with a stroke are cared for in a stroke unit, the latest report of the Irish National Audit of Stroke (INAS) has recommended,

The report, covering the year 2022 and published in December, 2023, also recommended that  clinicians and patients should be provided with guidance as to the importance of good adherence to anticoagulation therapy in order to avoid strokes, all hospitals should review their own performance against the national standards and identify quality improvement opportunities in order to improve the quality of care they are providing and all hospitals should be resourced to participate fully in the fourth Irish National Audit of Stroke (INAS).

Key Findings of the Irish Stroke Audit included:

  • There was no significant change in the demographic profile of stroke patients –  57% male (average age 70) and 43% female (average age 75).
  • Fifty per cent of patients arrived at hospital within three hours of symptom onset, 28 minutes faster than 2021.
  • Forty-seven per cent of patients with a stroke were seen by a medical team within 10 minutes of hospital arrival.
  • Fifty per cent of patients received a brain scan within one hour of hospital arrival.
  • The number of admissions to a stroke unit remained unchanged at 69%, and of those admissions, 68% of the total hospital stay was spent in a stroke unit.
  • Eighty-nine per cent of patients with a stroke were assessed by a health and social care professional.
  • The prevalence of known atrial fibrillation in patients admitted with stroke was 18%, with an additional 10% only diagnosed with AF after their stroke. The in-hospital mortality rate for 2022 was 10.8%, lower than the UK rate of 13.8%.

Launching the report, Prof. Joseph Harbison, Clinical Lead of the Irish National Audit of Stroke (INAS) said, “The notable reduction in the time it takes for stroke patients to arrive at hospitals is a pivotal achievement outlined in the INAS National Report 2022. This improvement signifies a crucial step forward in stroke care. Equally promising is the increase in the number of patients arriving within the critical three-hour window, a key predictor of positive outcomes. Early intervention is paramount in stroke management, and these findings underscore the strides we are making to enhance patient outcomes through timely and effective treatment.”

 The report provides data on 90% of all stroke activity in 2022, accounting for 4,999 patients in 21 hospitals. Three hospitals were not included for this reporting period due to low levels of data submission.

Stroke remains the second leading cause of death in middle- to higher-income countries, and it stands as the leading cause of acquired adult neurological disability in Ireland.

There was a 7.1% increase in the number of patients with a stroke admitted to hospital between 2020 and 2021, and although the number of admissions continued to rise in 2022, it was a lower increase (3.0%) than in previous years. There was no change in the demography of patients with a stroke from previous years  Male stroke patients had  a mean age of 70 years, female stroke patients had  a mean age of 75 years. Males had a stroke at a younger age compared with females: 33% of males had a stroke aged 65 years or under, compared with 22% of females.

The thrombolysis rate,  at 10%, remained unchanged from 2021 and below the 12% target. A spotlight audit on thrombolysis will be undertaken to assess the factors that impact on treatment with thrombolysis. The rate of thrombectomy also remained unchanged at 9%. There was variation between all hospitals in these results.

The report also presented data on the findings of a spotlight audit on atrial fibrillation (AF) carried out in 2022. It suggested that the management of AF was relatively good. The prevalence of known AF in patients admitted with stroke was 18%, with a substantial number of patients (10%) diagnosed with AF after their stroke. While the great majority of patients were on the correct dose of anticoagulation medication on admission, 23% of those prescribed anticoagulants either were on an inadequate dose, had paused their medication or regularly forgot to take it.

Eighty-five per cent) of cases had a principal diagnosis of ischaemic stroke, and 15% had a principal diagnosis of haemorrhagic stroke.   As in 2021, 88% of cases were admitted from home and 3% from long-term care.

Date and time of onset of stroke symptoms were known in 61% of cases.  For those cases where the time that elapsed from onset of stroke symptoms to hospital arrival was available, (61%), the median interval was 3 hours and 2 minutes (IQR: 1 hour and 38 minutes to 9 hours and 25 minutes). This was a decrease from 3 hours and 30 minutes in 2021, which was a statistically significant decrease.

The median time between hospital arrival and review by a medical team was 14 minutes (IQR: 0–120 minutes) in 2022, an increase from the median time of 12 minutes in 2021, which was statistically significant. Forty-seven percent  of patients with a stroke were seen by a medical team within 10 minutes of hospital arrival in 2022, which was unchanged from 2021. This result varied between hospitals.

The median time between hospital arrival and brain imaging is a KQI that is reported quarterly in all hospitals. The median time between hospital arrival and brain imaging in 2022 was 59 minutes (IQR: 25–281 minutes). The variation between hospitals ranged from 29 minutes to 867 minutes.  The proportion of cases who received brain imaging within 1 hour of hospital arrival increased from 48% in 2021 to 50% in 2022, which was a statistically significant difference.

The report said  all hospitals should monitor the time from hospital arrival to brain imaging and implement an improvement plan to manage this process if required.

The time of a patient’s arrival at hospital and the time they receive thrombolysis varied between hospitals and the report said all hospitals should monitor the time from arrival to thrombolysis and implement an improvement plan to manage this process, if required.

The report identified several positive trends in stroke care. Time to hospital admission had decreased, and the speed of assessment post-arrival had improved. However, it stated that the fact that the rate of the most common acute intervention, intravenous thrombolysis, continued to be below expected levels remained a concern. There were a number of potential reasons for this, including the increased use of anticoagulants in the community identified in this report. The INAS Governance Committee had determined that a spotlight audit of why patients were not being thrombolysed, despite potentially lengthening treatment windows permitted by the availability of advanced imaging, should be conducted. This audit is under way, and the results will be published in the 2023 INAS annual report.

The report said it was also encouraging to see the significant increases in the proportion of patients with a stroke being screened for mood disorders (which may affect two-thirds of stroke survivors) and for swallowing difficulties and dysphagia. However, while the increase in screening was welcome, the proportion of people who were not being screened remained high, and rates of screening within four hours of hospital admission remained low.

The continued failure to admit a large proportion of people with a stroke to a stroke unit was a concern, and the report  recommend that the National Stroke Strategy 2022-2027 and its recommendations for increasing resources and clinical facilities for stroke be fully implemented. “In an environment where the number of strokes continues to increase due to demographic trends, the health service must likewise continue to increase the number of stroke unit beds in order to avoid a deterioration in the admission to a stroke unit national KPI.”

The report said that the number of hospitals meeting criteria for entry in this 2022 audit had declined, largely due to the unavailability of key data collection staff. “Clinical audit is a key means of maintaining quality and safety of services across the health system. These data are typically collected by clinical nurse specialists in stroke, and the absence of these important staff members can potentially lead not only to a lack of data but also to a deterioration in the quality of service and care provided to patients with a stroke. This report, like other NOCA reports, strongly recommends and advocates for the prioritisation of the collection of these data, even when the person who ordinarily does it is not available.”