Stroke care pathway from the emergency department to CT and the improvement of patient time from CT scan to thrombolysis

Sentinel Stroke National Audit Programme (SSNAP) data for the Trust from April 2015 to March 2016 showed that only 9.7% of patients received thrombolysis within one hour of arrival to the emergency department (ED), with only 44.4% of patients receiving a CT scan within one hour of arrival to ED.

In light of this, the overall aim of our project was to compare data to highlight improvement percentages of patients’ receiving CT imaging within 1 hour and up to 12 hours, and to re-evaluate and confirm recommendations for further service improvement.

Annually there are over 100,000 strokes in the UK (State of the National Stroke statistics - January 2017). The number of reported stroke patients that attended Plymouth Hospital between April 2016 - March 2017 was 862.

NICE Guideline NG128 recommendation 1.3.2 states that brain imaging should be performed immediately for people with acute stroke if any of the following apply:

• Indications for thrombolysis or early anticoagulation treatment.
• On anticoagulant treatment.
• A known bleeding tendency.
• A depressed level of consciousness (GCS <13).
• Unexplained progressive or fluctuating symptoms.
• Papilloedema, neck stiffness or fever.
• Severe headache at onset of stroke symptoms.

For all people with acute stroke without indications for immediate brain imaging, scanning should be performed as soon as possible (NICE CG68 recommendation 1.3.3). 'Immediately' is defined as 'ideally the next slot and definitely within 1 hour, whichever is sooner', in line with the National Stroke Strategy.

This poster presentation was made as a compilation of data collected for the SSNAP from Plymouth Hospital, directly analysing the stroke care pathway that is provided, noting statistical improvements since 2013. There is emphasis on time frames between patient arrival in the emergency department to CT and how this impacts the rate of suitable thrombolysis patients receiving thrombolysis within the recommended 4.5 hour window.

Our data collection has been measured against the SSNAP, of which there are three main components: the clinical audit, acute organisational audit, and post-acute organisational audit. CT imaging is under clinical audit, which summarises the hospitals’ performance across 10 key aspects of stroke care and then an overall SSNAP score is given. There are 3 reporting periods throughout the year through SSNAP, with an annual report being made available. We compared Trust performance using maps, patient questionnaires and statistics collected by our stroke nurses. This is a great tool for staff and the public to review, national, regional and hospital specific results and improvements.

• It was recommended by CQC to implement a ‘Thrombolysis bag’ to aid in reducing delays in administering IV TPA. This has allowed for an increase of patients receiving thrombolysis on the CT scanner (when sufficient history and blood pressure etcetera has also been checked). This directly reduces the time delay of receiving thrombolysis and allows treatment as early as possible using Alteplase as per recommendation 1.4.1 in NICE NG128.
• Routine tasks such as ECG, changing patients’ clothes etc. should be postponed until after thrombolysis. This is being carried out in addition to the assessment of the patient outside CT scanning room when in use and on entering CT scanning room.
• Weekly meetings are held maximising review and feedback to all departments through clinical leads.
• Current employment of 3 specialist stroke nurses (in-hours, with view to increase numbers).
• Stroke nurse presence extended out-of-hours. Band 6 nurse from stroke ward to accompany patient from ED via bleep call. This reduces the reliance on the on-call medical SpR, which limits the delays in organising and allocating patients’ onto a stroke pathway if required.
• Education and awareness of the urgency of strokes (treated as urgent as trauma patients) amongst the imaging and emergency team through staff meetings and CME lectures).

Every stroke patient across the UK should have documentation of their arrival to a specialist acute stroke unit, where a stroke pathway has been implemented. Documentation should also include that of when they are no longer a part of the stroke pathway and move into another e.g. oncology. This is a key point, as the need for patients to be assigned onto the correct healthcare pathway for their treatment and improved recovery outcome is vital.

Non-thrombolysis (CT head non-contrast only) should therefore, also be scanned on an urgent basis, as we do for positive thrombolysis patients. SSNAP data shows that between April 2016- March 2017 862 patients presented to Plymouth Hospitals NHS Trust (patient centred results -72 hour cohort), with 57.7% of those patients being scanned within 1 hour of timed arrival.

As a department we have dramatically increased our SSNAP category score over the past 3 years.

• Jan-March 2014 scanning wise, CT achieved a score of ‘C’ with Derriford stroke service as a whole scoring ‘D’
• Jan-March 2015 scanning wise, CT achieved a score of ‘C’ with Derriford stroke service as a whole scoring ‘D’
• Jan- March 2016 scanning wise, CT achieved a score of ‘A’ with Derriford stroke service as a whole scoring ‘D’
• Dec 2016-March 2017 scanning wise, CT achieved a score of ‘A’ with Derriford stroke service as a whole scoring ‘B’. The median time for patient to be scanned within 1 hour in July-September 2013 was 1hour 43minutes. This reduced to a median of 35minutes between December 2016 – March 2017.

Building a good, clear communication platform amongst the stroke team, consisting of specialist stroke nurses and registrars, with the CT department has allowed for a smoother transition for patients’ from the emergency department to arrival and completion of their CT scans. A stroke bleep is kept within the CT viewing area of the ED/Inpatient scanner and is tested via switchboard daily. Radiologist and radiology registrars are aware of the urgency in e-vetting requests and the stroke nurse and registrars are aware of the current pathway that is in place to allow timely scans.

CT radiographers have been encouraged to document in the event comments of the imaging system CRIS, any delays or changes in circumstances as patterns can be highlighted and practices changed if necessary to further reduce delays. This is currently discussed at a weekly stroke meeting involving the CT superintendent, radiologists, stroke lead and ED consultants.

Administration of Alteplase should be as early as possible and within 4.5hours of onset of stroke symptoms. (NG128 recommendation 1.4.1). Therefore it is crucial to document and monitor the percentage of patients’ that are receiving appropriate CT imaging on arrival from ED, as delays in the diagnosis of a stroke that is suitable for thrombolysis can have an immediate and direct effect on a patients’ care pathway, morbidity and potential mortality.

Contributors – E.Piper, Lead Specialist Stroke Nurse. Dr W. Adams, Neuroradiologist