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We worked collaboratively with the South West Academic Health Science Network (SW AHSN) and the South West Cardiovascular Strategic Clinical Network (SW CV SCN) to reduce stroke-related disability in the South West by accelerating the real-world implementation of clinical evidence for thrombolysis (clot-busting drugs) after acute ischaemic stroke.
Stroke patients are most likely to recover with minimal disability, if thrombolysis is achieved within 90 minutes from the onset of stroke. Recovering with minimal disability means a better quality of life for the patient, reducing the burden on carers and the long-term costs to health and social services.
There are approximately 3,600 strokes annually in the South West. The ten year target for stroke thrombolysis in the Department of Health’s 2007 National Stroke Strategy was 10% of all acute strokes. There is huge variation in the South West, with some centres with rates as low as 3-4% and long door-to-treatment times.
PenCLAHRCs previous award-winning work, on the emergency stroke pathway at the RD&E, had already achieved a thrombolysis rate of 16% (2013); matching delivery rates for large urban hyperacute centres.
We aimed to repeat this work with other acute providers across the South West. If we saw treatment rates follow the pathway modelled, it was anticipated that 600 stroke patients could be treated annually, giving them the best chance to recover with minimal disability. This would exceed the Department of Health’s national target by over 50%.
The projects overall aim was to reduce stroke-related disability by speeding up the real-world implementation of clinical evidence for thrombolysis for acute stroke. The project objectives were threefold:
Identify process changes within hospitals that minimise the time to thrombolysis treatment in appropriate cases and quantify the disability benefit to patients from changes to the emergency stroke pathway;
Quantify and mitigate the impact of increased travel times when introducing a centralised model of hyperacute stroke care;
Identify and overcome barriers to implementation within emergency stroke centres.
This involved creating a computer model to mimic the flow of patients through an emergency department and stroke unit, using data collected locally from the ambulance service, the hospital’s emergency department and patient administration IT systems. The models were also used to analyse the geographic spread of acute stroke in the region and to investigate the varying approaches to treatment at different centres, taking account of ambulance travel times. This required the collection of appropriate data in each hospital, which was already specified in the national stroke audit (SSNAP), to which all trusts contributed. Additional data, defined as necessary during the early stages of the project, was also included.
The barriers and facilitators were identified through the model development process. Implementation was led by a Stroke Quality Improvement Manager, working with PenCLAHRC’s operational modelling team, local Trust physicians, managers and data analysts to ensure the delivery of effective plans for change.
Thrombolysis significantly increases the chances of surviving free of disability after acute stroke. Project success was measured by observing; (i) the before-to-after change in the proportion of people with stroke who receive thrombolysis and (ii) the reduction in onset to treatment times. By extension, these indicate the resultant reduction in the prevalence of serious disability after stroke.
We explored the potential for relating these benefits to the estimated cost of achieving change in order to estimate the cost-effectiveness of service transformation across the region. It was hoped to calculate this in pounds-per-case of disability prevented. More intangible benefits were likely to accrue through the process of managing and achieving change in collaboration with the dedicated Stroke Quality Improvement Manager. It was anticipated that these might include culture change within each hospital and improved collaboration between departments within hospitals. Finally, improvements in data consistency and quality across Trusts were obtained.
Implementation of research findings at the local trust level were led by the Stroke Quality Improvement Manager, seconded to the South West CV SCN. Their role was to identify local barriers and facilitators to change through engagement around, and delivery of, the stroke modelling project. Close working between the operational researcher, Stroke Quality Improvement Manager and local trust physicians, managers and data analysts was critical to ensure delivery of appropriate, acceptable and realistic plans for change and for achieving these in the shortest possible time. Liaison between the Stroke Quality Improvement Manager and service managers within each trust and across the region was important to enable the management of change and to ensure lessons from each trust were identified and shared across the SW AHSN footprint.
Allen M, Pearn K, Monks T, Bray BD, Everson R, Salmon A, James M, Stein K. Can clinical audits be enhanced by pathway simulation and machine learning? An example from the acute stroke pathway BMJ Open 2019;9:e028296.
Dr Martin James, RD&E; Michelle Roe, SW SCN; Carol Massey - Stroke Quality Improvement Manager, SW CV SCN
South West Academic Health Science Network (SW AHSN)
South West Cardiovascular Strategic Clinical Network (CVD SCN)
NHS Acute Trusts in the South West
South Western Ambulance Service NHS Trust