Stroke :: More patients getting into stroke units but 21st century care still lacking

The results of the 2006 National Sentinel Audit for Stroke show that patients are spending more of their time on stroke units, but there are still unacceptable waits for brain scans and starting treatment.

Results from Wales are still falling behind those from England, and are a major cause for concern. A separate release on the Welsh results is available.

The Audit, funded by the Healthcare Commission, was carried out on behalf of the Intercollegiate Stroke Group by the Royal College of Physicians? Clinical Effectiveness and Evaluation Unit (CEEu), and covers 100% of eligible hospitals in England and Wales.

Headline results:

62% of patients were admitted to a stroke unit at some point in their stay, compared to 46% in 2004. 54% spent over half their stay in a stroke unit (40% in 2004). This is a significant and welcome improvement, as now 91% of hospitals have a stroke unit (79% in 2004) but there is still a lack of capacity

The most dramatic rise in stroke units was in England, which improved from 82% in 2004 to 97% in 2006, while in Wales the number of stroke units is 9 (45%), the same as in 2004

Patients managed on stroke units have much better results than patients looked after in other settings ? they are much more likely to have had their ability to swallow checked, to have started aspirin within 48 hours, been assessed by therapists within the recommended times; had rehabilitation goals documented and have a home visit performed before discharge

76% of patients with minor stroke in hospital for less than 2 days are not being managed on specialist units. These patients have a high risk of having another stroke and should receive expert care and investigation

Mean length of stay has fallen considerably over the last two cycles of audit from 27.9 days in 2004 and 34 days in 2001, to 25.4 days in 2006. These shorter lengths of stay are not due to patients being moved too early into care homes, as the audit measures transfer to care homes separately and there is no change from the 2004 figure of 13%.

The proportion of patients with mild stroke has fallen from 29% in the 2004 audit to 24% in 2006, suggesting that such patients are being discharged earlier without the opportunity to complete their rehabilitation ? this is worrying as there has been no significant increase in specialist community rehabilitation teams

Early access to a stroke unit has improved since 2004, but only 15% of patients are admitted to a stroke unit on the same day and only 12% of patients are being admitted directly to a stroke unit (within 4 hours of arrival at hospital)

Only 42% of patients had brain imaging to confirm their diagnosis within 24 hours of the onset of symptoms. This figure is unacceptably low and must be improved. Patients need a brain scan to determine if it is appropriate to prescribe aspirin ? if given within 48 hours of the stroke this can save lives and reduce disability

Only 9% of patients were scanned within 3 hours of stroke ? if not scanned on the day of admission, they normally have to wait until the next working day – this is a particular problem if admitted at the weekend as very few scans are performed outside the hours of 8.00 am-6.00 pm

Problems remain with stroke patients getting access to therapists and social workers ? a third of patients who have difficulty swallowing have not been assessed by a Speech and Language Therapist within 72 hours of admission or within 7 days for those having difficulty communicating. The situation is similar for physiotherapy and for occupational therapy and social work it is even worse

Assessment of carer needs is one of the areas of practice that has improved most since the last audit, from 43% to 68%, but there has been no improvement in discussing the diagnosis and likely progress with patients

The audit concludes:

“Stroke clinicians, managers and politicians can feel proud of the advances that have been made over the last ten years – there are few other conditions that have progressed as rapidly. However there are still many areas of care that need to be improved and some hospitals that have failed to recognise that their stroke patients need 21st century management.”

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