governance of a stroke thrombolysis service barry moynihan
TRANSCRIPT
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Governance of a Stroke Thrombolysis Service
Barry Moynihan
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Framework
• Pathway
• Protocols
• Outcomes– Process– Clinical
• Monitoring– Local M&M– SITS/NICE
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and of course………………….Training & EducationTraining & Education
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Pathway
• Mapping
• Geography & People
• Where the drug is given
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Protocols
• Pre-hospital• Hospital assessment & administration
– Inclusion/exclusion checklist– Thrombolysis proforma
• The 1st 24 hours– Nursing care plan– What to do about deterioration– Repeat brain imaging
• Outcomes
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Outcomes
• Process– ‘door to needle time’
• Clinical– Death– Haemorrhage– NIHSS– Modified Rankin Score
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Haemorrhage after stroke rtPA
• Extracranial
• Intracranial– Symptomatic– Asymptomatic
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NIHSS
• National Institutes of Health Stroke Scale
• 15 point clinical scale
• Predicts lesion size & outcome
• Validated
• Requires certification
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Modified Rankin Score (mRS)
0 No symptoms at all1 No significant disability despite symptoms; able to carry
out all usual duties and activities2 Slight disability; unable to carry out all previous activities,
but able to look after own affairs without assistance3 Moderate disability; requiring some help, but able to walk
without assistance4 Moderately severe disability; unable to walk without
assistance and unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 Dead
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Monitoring
• Local– Clinical Networks
• National– SITS– NICE– SINAP
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What is SITS?
• 2000: SITS set up in Sweden for local purposes
(Svenska Implementeringskommittén för Trombolys vid Stroke)
• 2001: EMEA licensed Alteplase until 2005 on 2 conditions:
1. There was a trial of therapy at 3-4 hours
2. All patients were entered onto the SITS register.
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Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study
(SITS-MOST): an observational study. Lancet. 2007 Jan 27;369(9558):275-82
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SITS (Safe Implementation of Thrombolysis in Stroke)
prospective internet-based audit of the International Stroke Thrombolysis Registry (ISTR)
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Time delay (minutes): PREVIOUS Center UKAll
centres
Onset to A&E time Median 66 69 65
Door to imaging time Median 39 36 25
Imaging to report time Median 0 5 5
Door to needle time Median 62 70 66
Onset to needle time Median 139 155 145
Time delay (minutes): NOW Center UKAll
centres
Onset to A&E time Median 62 70 64
Door to imaging time Median 28 30 24
Imaging to report time Median 0 6 6
Door to needle time Median 50 58 65
Onset to needle time Median 130 135 145
Process
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Clinical Outcome
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NICE 2007This appraisal covers the use of Alteplase in acute ischaemic stroke.
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None of these criteria are available from SITS
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SINAP April 2010
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SINAP April 2010
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SINAP Local Monthly Report Feb 2011• Admissions
– Total: 134– Stroke: 77 (57%)– TIA: 22 (16%)– Non Stroke: 35 (26%)
• Thrombolysis– Total Thrombolysed: 7 (9% of patients with a
diagnosis of stroke – one as part of IST3)– 100% eligible cases– Mean DTN time 49 mins (32 minutes Feb 2012)– DTN > 60 mins exceptions
• IST3 70 mins• 90 mins (45 mins to confirm time of onset in aphasic pt)
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Second National SINAP report (Feb 2011)
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Summary
• Pathway
• Protocols
• Outcomes
• Monitoring
• Training
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Useful Links
• http://nihss-english.trainingcampus.net/uas/modules/trees/windex.aspx
• http://www.rankinscale.org/links.shtml• http://www.acutestroke.org/• http://www.nice.org.uk/guidance/TA122• http://www.rcplondon.ac.uk/clinical-standards/c
eeu/Current-work/stroke/Pages/SINAP.aspx