Ireland’s mortality rate from stroke had fallen from 19% to 8% without an increase in nursing home discharge over the last decade, Prof. Ronán Collins, National Clinical Lead for Stroke and consultant in geriatric and stroke medicine at Tallaght University Hospital, told the Conference.
Speaking on “Stroke: our Joint Journey” he said that in the same period provision of thrombolysis in Ireland had increased from 1% to 12%, the number of stroke units increased from 1 to 21 sites across 27 acute hospital and, an early supported discharge service was piloted and rolled out in six sites.
It was also now possible to get stroke rehabilitation at home, telemedicine had been piloted and was active in two networks and Ireland had become an international leader in the provision of a stroke thrombectomy service.
He said “Nothing happens through clinicians alone. This happened by our working together. We have set about tackling stroke in the way we needed to by first understanding our deficits through audit and making stroke part of national health policy in the 2010 Cardiovascular Strategy. Then through a joint clinical and managerial leadership for stroke services with set KPIs requiring appropriate institutional investment and regular re-audit. The National Stroke Programme has not been without its’ hiccoughs but it is delivering tangible results,” he said.
There are about 7,500 strokes a year in Ireland at present, Dr Collins said. Explaining stroke in its’ most basic, he said put simply stroke was brain damage due to an occluded or ruptured blood vessel. It was the second leading cause of death in the western world and the leading cause of acquired adult neurological disability. It was also a major cause of depression and dementia in later life and a disease with major institutional, societal and personal costs.
The situation had not been good in Ireland in 2008. We had no pathways in primary care for rapid access stroke prevention , only 50% hospitals had a stroke prevention clinic, there was just one stroke unit in the country, less than 1% of acute stroke patients received thrombolysis, mortality was 19% and almost 30% of patients went to nursing homes. Thirty per cent of hospitals had no routine access to CT and there was no organised MDT system of assessment or rehabilitation for stroke patients, he said.
In 2010, The National Stroke Programme commenced. A joint consultant lead from neurology and geriatric medicine was appointed, and a Clinical Advisory Group of consultants was established to monitor and advise on strategy implementation. A Working Group of multidisciplinary team members was set up to review and devise new guidelines and policies on critical aspects of stroke care and advise on staffing, new service initiatives.
The goals were, “to reduce one death and disability from stroke each day and to prevent one stroke each day.”
The following were among the recommendations adopted as part of the National Cardiovascular Health Policy 2010 – 2019.
Dr. Collins said ‘data drives change’ and the need for data was the genesis of a National Stroke Registry. Reporting sites had to capture additional data on at least 80% of HIPE coding cases of stroke at that site.
It was also decided to focus on a series of progressive KPIs, such as the rate of thrombolysis (which was increased as a KPI from 9% to 12% in 2016), admission to a stroke unit (changed from 50% to 90% in 2016) and the percent of a patients admission spent in a stroke unit (increased from 50% to 90% in 2016).
“Between the two Irish heart foundation audits of stroke care in 2008 and 2015, the number of sites with stroke specialists has increased from 33% to 85% and mortality had come down 5% from 19% to 14% in the seven years. This has fallen further still and this is a huge achievement for us to celebrate. In addition we have an expanding stroke telemedicine network in Dublin Mid-Leinster, a high level thrombectomy service that has provided significantly life-changing treatment to almost 7% of ischaemic strokes and an early supported discharge service.”
Dr Collins said the National Stroke Register 2018, had just been published. It showed the mortality from ischaemic stroke was down to 7.8%, a historic low. More work had to be done medically with haemorrhagic stroke, because we didn’t have a therapy currently, but he thought that recent research pointed to an imminent development for acute strokes due to bleeds. There were 320 thrombectomies carried out in 2018 (almost 7% of ischaemic stroke patients) compared to 120 in 2016. Thrombectomy would drive reconfiguration of stroke services in the same way as the cancer programme. Our record for stroke, cardiovascular disease and cancer sat very well in Europe.
The mortality from ischaemic stroke was down to 7.8%, a historic low
“We must engage with the public because programmes will not run unless the public are aware of them. Public awareness is needed again around the concept ‘time is brain’ and I would l like to see the stroke awareness advertisement reinstated. Also, our stroke unit capacity is poor for the demography and numbers and it is not acceptable that only 70% of patients are getting into a stroke unit.
“We are delighted that NOCA will bring our clinical audit in under its auspices. This will make information available to clinicians and health managers.”
Dr Collins said he believed as all physicians in ‘equity of access’, but that a ‘public only’ dictat to our public hospitals ran the risk of significant underfunding and investment and the real risk of our teaching hospitals falling further behind the curve in terms of estate and equipment. “This is already a reality and we must encourage people also who have insurance to consider spending their insurance with our ‘not for profit’ public health system too, while ensuring equity of access in our teaching hospital system. It was a fallacy, he said, to assume that a public only system would cure waiting lists and he had also seen inequities and economic injustices with the NHS, when he worked in the UK. “A conformist acceptance of a proposal as contained in Sláinte Care without further discourse and debate is unhealthy and will lead to a poor system. Healthcare is not static and our challenges in the health service and solutions to them must be openly and continually discussed and thought through.”
The priorities for phase II national stroke programme were:
- Access to Stroke Unit Care in all acute hospitals receiving acute stroke
- To support and develop the thrombectomy service and QI programme
- Develop and promote ESD as model of care
- To develop an Irish National Audit in Stroke with NOCA as the single repository for stroke data.
- Top develop a realistic five year strategy that aims to make big stroke history.
