National Sentinel Stroke Audit 2010: an organisational audit/UK

The Royal College of Physicians London has published on line the full public report of the 7^th round of the sentinel stroke audit which is prepared on behalf of the intercollegiate stroke working party and commissioned by the Healthcare Quality Improvement Partnership (HQIP). The main focus of this audit is the organisational structure for stroke care in the country.  It investigated for the first time the follow-up care that patients receive when they are discharged from hospital. It shows that while many aspects of acute care have improved, post acute services have not kept up and there is a lack of access to long term rehabilitation services, particularly to help people return to work. With regards of the thrombolysis service for ischaemic stroke victims the audit mentioned that there has been a dramatic increase in the number of units providing a 24 hour, 7 day a week thrombolysis service for their population. Progress in Wales and Northern Ireland in delivering comprehensive acute stroke care including thrombolysis is however too slow.

Fewer than half of hospitals have access to stroke-specific services known as Early Supported Discharge (ESD), despite evidence showing that patients fare significantly better when such services are available.

This audit has addressed for the first time the issue of stroke care in the young or in the working age group with a key message stating that vocational support for stroke patients of working age should be regarded as a core element of all stroke services. Less than half of services in Britain specifically provide a service that involves educational or vocational training.

The key findings of the report include:

• 74% of patients are now getting some access to clot-busting drugs (thrombolysis)
• While 98% of hospitals now have a neurovascular clinic, the median wait from referral to being seen in one is 3 days.
• 36% patients are still being treated on a general assessment ward 24 hours after being admitted to hospital with a new stroke.
• Almost half of sites report the need to admit patients to non-specialist wards because of bed shortages.
• 44% of stroke services have an available specialist ESD team.
• 28% of patients discharged to specialist ESD teams are still waiting over 48 hours for physical therapy, occupational therapy or speech and language therapy.
• 55% of stroke services have access to specialist community rehabilitation team.
• 43% of high risk patients with suspected TIA are seen on the same or the next day.
• 85% of low risk patients with suspected TIA are seen within a week.

Key recommendations include:

• Patients with acute stroke should be admitted directly to a specialist stroke unit and have access to continuous physiological monitoring. General assessment units are not an adequate substitute.
• Standards of care offered in all specialist stroke beds should meet those defined in the National Clinical Guidelines for Stroke 2008.
• Stroke services should be organised to deliver thrombolysis to all appropriate patients regardless of where they live or the time of day or week they present.
• Patients requiring end of life care should be able to receive such care to a high standard on a stroke unit.
• Vocational rehabilitation should be made available to all stroke patients wishing to return to work.
• Care of stroke patients transferred to community hospitals should meet the standards defined for specialist stroke unit care set out in the National Clinical Guidelines for Stroke 2008.
• All services should be able to deliver high quality specialist early supported discharge to appropriate patients.
• High quality longer term rehabilitation should be provided to all patients who require on-going treatment without undue delay.
• Facilities to investigate high risk patients after TIA should be available at all times including weekends.
• Information provision should be improved to provide universal access to all in-patients and out-patients.