Stroke is a medical emergency with swift, specialised treatment vital to a good recovery. Every minute and every decision of our health professionals is essential to patient outcomes and we need to better equip and support our acute clinicians to make every action count.
So, how can this best be achieved?
This is a question I have asked myself countless number of times in my years here at the National Stroke Foundation. With each annual audit, with each update of care framework and with every release of new clinical data and research – how can we support the dedicated health professionals around Australia to deliver best practice stroke care? Part of this is where we target our support. On an individual level we can continue to provide education, tools and resources to support busy clinicians get the information at the right time to help their decision making. But health professionals are working within a system that often doesn't facilitate best practice care delivery and if we are going to improve care the more we can lever the system wide changes the better.
Following the release of the 2013 National Acute Audit we set about reflecting its results and recommendations specifically around recommendations we make about the 'system' for stroke care –the nuts and bolts, that is, the infrastructure and resources of stroke systems. In doing this we further analysed the data, reviewed emerging literature, looked at what was happening internationally and consulted extensively with health professionals and consumers in order to provide more up-to-date advice around recommended acute services.
In short, we listened.
As a result we have updated the Acute Stroke Services Framework recommending improved resources and processes for acute stroke services that should be considered as governments and administrators review the way acute stroke services are currently working and what is needed to improve services to provide the best outcomes for patients within available resources.
Highlights of the new Framework include:
- An additional six elements of service to encapsulate the whole stroke care system within the Framework and particularly responding to new evidence for specialist services which remove clots in the arteries in the brain. Good care requires integration across multiple hospitals and importantly involves ambulance and inter-hospital transport coordination;
- Recommended number of beds for Comprehensive Stroke Services (CSS) as some of our larger stroke care services simply don't have the necessary capacity to meet all the demand. This will increasingly need to be addressed with better coordination between small general hospitals which feed into larger primary stroke services which ultimate link to CSS with super specialist services such as clot retrieval interventions;
- Stroke units to be established in hospitals with 75 or more stroke admissions annually (previously this was set at 100). While acknowledging the struggle many small hospitals have in developing and retaining specialist staff our analysis found most of the hospitals seeing 75-99 strokes each year already had dedicated stroke unit care and perform just as well as larger sites. We believe in such a huge country as Australia all patients deserve access to best practice stroke care and several smaller and usually rurally based centres should look to developed specialised services;
- The importance of regional networks in those geographical areas where a CSS is not sustainable; and
- The inclusion of the Acute Stroke Clinical Care Standard Indicator set. The Stroke standards were developed by the Australian Commission for Safety and Quality in Health Care (ACSQHC) and outline minimum required aspects of acute care. The standards have indicators developed to monitor service quality. We strongly feel routinely monitoring care and using this data to improve quality is critical to any dedicated stroke service.
Central to these recommendations is the continued recognition of the importance of people with acute stroke having access to stroke unit care and the recommended systems for this to occur. Stroke unit care should be routinely accessible for the more than 140 people who suffer a stroke every day in Australia. From the 2013 audit, we know that one-third (36%) of stroke patients in specialist centres are being denied access to dedicated stroke units. This is despite the fact that this significantly improves a person's chance of a good recovery and of going home to live independently. Stroke units provide patients with ongoing care by a multidisciplinary team including doctors, nurses, physiotherapists, speech and occupational therapists who can provide active care in the early stages of a stroke. Improving access to stroke units will reduce the number of deaths and disabilities. When you get best practice care in a stroke unit you are more likely to go home alive. You are more likely to go home independent. You are less likely to need nursing home care.
Yet two-in-five (42%) stroke patients continue to be treated on general wards, which appears to be a result of hospitals lacking bed space or encountering problems transferring patients to the specialist unit. This is where advocating for system wide changes can have such a huge difference and exactly why we develop and update the national frameworks and talk to governments and administrators to improve the systems available. We really need to be doing a better job at offering more people access to specialist care on stroke units –international comparisons show this is possible with the UK achieving over 80% access to this service model.
Much has already been made of the revolutionary treatments now proven to double the chance of a good recovery following a major stroke. Research over the last few years including importantly Australian lead research, has now demonstrated mechanical clot retrieval is highly effective and should be offered to more people. Hospitals need to collaborate to identify and treat the best candidates for revolutionary new procedures to literally remove large clots in the larger arteries in the brain. Successfully removing these big blood clots which cause debilitating strokes doubles the chance of a good recovery. The challenge is that such specialist services are rare so solutions to get as many people as possible to these services in a timely manner to benefit is the next big challenge facing acute hospitals.
By updating the Acute Stroke Services Framework we are aiming to describe what is required to be classed as one of the few 'Comprehensive Stroke Services'. The Framework also provides clear recommendations we hope will empower our health professionals, hospital administrators and governments to effectively organise very early hospital services to allow more people to not only survive a stroke but to live well after such an event.
Every moment and every decision counts.
National Stroke Foundation National Manager Clinical Programs Kelvin Hill will present on the new Acute Services Framework at Stroke 2015 (2-4 September 2015) the combined 16th Annual Scientific Meeting of the Stroke Society of Australasia and the 11th Australasian Nursing & Allied Health Stroke Conference SMART STROKES #strokeoz2015
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