Governance of a Stroke Thrombolysis Service

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Governance of a Stroke Thrombolysis Service

• Barry Moynihan

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Framework

• Pathway
• Protocols
• Outcomes
• Process
• Clinical
• Monitoring
• Local MM
• SITS/NICE

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and of course.Training 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 all
• 1 No significant disability despite symptoms
  able to carry out all usual duties and activities
• 2 Slight disability unable to carry out all
  previous activities, but able to look after own
  affairs without assistance
• 3 Moderate disability requiring some help, but
  able to walk without assistance
• 4 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
• There was a trial of therapy at 3-4 hours
• 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
27369(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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Process
Time delay (minutes) NOW Time delay (minutes) NOW Center UK All centres
Onset to AE 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
Time delay (minutes) PREVIOUS Time delay (minutes) PREVIOUS Center UK All centres
Onset to AE 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
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Clinical Outcome
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NICE 2007
This 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 gt 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/module
  s/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/ceeu
  /Current-work/stroke/Pages/SINAP.aspx