Stroke care

Background

Stroke is a leading cause of death and disability in the UK. People with stroke need urgent access to high-quality acute care followed by preventative care, rehabilitation, psychological support and long-term social support. The National Institute for Health and Care Excellence (NICE) defines a number of quality standards for stroke care. These aim to define what high-quality care for stroke patients should consist of, and drive measurable improvements in quality. The Sentinel Stroke National Audit Programme (SSNAP) collects data on a number of these quality standards.

People presenting with acute stroke should be diagnosed, scanned and have urgent treatment when it is needed in A&E, and then be admitted directly to a specialist stroke unit as soon as possible. Early admission to a stroke unit ensures that patients have the best chance of receiving the correct assessments and treatments to prevent complications, and enables them to be looked after by a specialist multidisciplinary team. 

The NICE quality standard states that adults presenting at A&E with suspected stroke should be admitted to a stroke unit within four hours of arrival. Data from SSNAP shows that the percentage of patients admitted to a stroke unit within four hours declined from 58% in 2018/19 to 55% in 2020/21.  Quarterly data shows that in April-June 2020, 63% of patients were admitted within 4 hours, however this fell to 50% in January-March 2021 (data not shown). The SSNAP suggests multifactorial reasons for this; in the first wave of the Covid-19 pandemic (April-June 2020) there was increased bed availability as well as a reduction in stroke admissions. In comparison, the second wave of the pandemic (January-March 2021) saw an increase in emergency admissions of Covid-19 and non-stroke patients, leading to problems with bed availability on stroke units.

Brain scans are used to diagnose the type of stroke and rule out other causes of the patient's symptoms. NICE guidelines recommend that brain imaging should be performed immediately for people with acute stroke, and there is an associated target that this should happen within one hour for at least 50% of stroke patients. Between 2013/14 and 2020/21, the percentage of patients who had a brain scan within one hour of arrival at hospital increased from 42% to 55%. Over the same period, the proportion of patients who had a brain scan within 12 hours increased from 85% to 96% (data not shown).

One of the main drivers for faster brain scanning in recent years has been the availability of thrombolysis for acute stroke, which is a time critical treatment. Thrombolysis is a treatment administered to stroke patients which can break down and disperse a clot that is preventing blood from reaching the brain. The percentage of patients who are thrombolysed within one hour of arriving at hospital increased from 53% in 2013/14 to a high of 64% in 2017/18, but has since decreased to 60% in 2020/21, far below the target of 95%. Further, in 2020/21, rates of thrombolysis for all stoke patients fell to below 11% (data not shown), the lowest on record and below the target of 20%. 

Swallow screenings should be carried out to ensure the patient can swallow without assistance; spotting this can ensure correct care is in place for patients at an earlier stage and prevent severe complications like pneumonia, a leading cause of preventable deaths. The SSNAP recommends that all patients who have had an acute stroke should have an initial swallow screen within four hours of arrival at hospital. The percentage of patients that were given a swallow screen within four hours increased from 64% in 2013/14 to a high of 76% in 2018/19 but declined slightly to 75% in 2020/21.

It is also important for stroke patients to receive all of the necessary assessments in a timely manner. A key indicator of timely screening for stroke patients as well as a measure of multidisciplinary team working, is the proportion of patients who:

• are seen by a stroke nurse and one therapist within 24 hours;
• are seen by all other relevant therapists within 72 hours; and
• have their rehabilitation goals agreed within five days.

Between 2013/14 and 2020/21, the proportion of patients receiving a timely multidisciplinary review increased from 44% to 66%. 

Higher intensity stroke rehabilitation therapies can improve the quality of life for people who have had a stroke. The NICE quality statement says that patients having stroke rehabilitation in hospital or in the community should be offered at least 45 minutes of each relevant therapy for a minimum of five days a week.

Here we look at compliance against the targets for occupational therapy, physiotherapy and speech and language therapy (SALT). Overall, compliance against the SALT target is significantly lower than the physiotherapy and occupational therapy targets. In 2020/21, compliance against the SALT target was 60% compared with 92% for physiotherapy and 96% for occupational therapy. The percentage of people receiving the recommended intensity of therapies has improved over the last eight years. Both physiotherapy and occupational therapy have exceeded the 80% performance threshold, but there are still many patients who do not receive the amount of rehabilitation therapy that they need, especially speech and language therapy. 

People who have had a stroke should be offered early supported discharge if the multidisciplinary stroke team assesses that it is suitable for them. Early supported discharge is a system in which rehabilitation is provided to stroke patients at home instead of in hospital, at the same intensity as inpatient care. Here we assess the quality of supported discharge for stroke patients.

Patients who are suffering from a loss of bladder and bowel control should have a continence plan drawn up within at least three weeks of arriving at hospital. The percentage of applicable patients who met the continence plan target increased from 75% in 2013/14 to 95% in 2020/21.

The percentage of applicable patients who receive mood and cognition screening before leaving hospital has also increased over time, from 78% in 2013/14 to 94% in 2020/21. This is encouraging since some of the main concerns of people with stroke relate to its psychological consequences – for example, mood disturbance and memory problems. People who are screened are much more likely to receive the support they need if therapists are aware of their problems.

The percentage of patients receiving a joint health and social care plan on discharge has similarly increased over time, from 70% in 2013/14 to 95% in 2020/21. However, the target is for all applicable patients to receive a joint care plan, so there is still some way to go.

Many people with stroke are at risk of malnutrition because of swallowing and feeding difficulties, or nutritional problems prior to stroke. Research has shown that malnutrition reduces the chance of survival after stroke and can cause additional complications such as pneumonia, so timely recognition and intervention for those at risk is important. Between 2013/14 and 2019/20, the percentage of applicable patients who were screened for nutrition and seen by a dietitian by discharge increased from 66% to 83%, but has since fallen to 80% in 2020/21.