Reconfiguring stroke care

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The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).

This page summarises the report's findings on the reconfiguration of stroke care.

Proposals reviewed by NCAT

  • Concentrating acute stroke services and designating hospitals either as hyper-acute stroke units, able to offer CT scanning and thrombolysis 24/7, or as local stroke units.
  • Creating a stroke centre in an elective hospital to maximise local access.

Key drivers of stroke care reconfiguration

Quality was the primary driver of this type of reconfiguration.

Context and relevant policy

  • There are approximately 152,000 strokes in the United Kingdom every year and one in five strokes are fatal. The mortality rate has halved since 1993, partly due to better control of risk factors and partly due to better understanding and delivery of best practice in acute care.
  • The prevalence of stroke is expected to rise as a result of underlying risk factors in the population.
  • In 2007, the Department of Health set out a national strategy for stroke with expected standards of care. It proposed the development of hyper-acute centres in a ‘hub and spoke model’ supported by an increase in the range of clinicians available to provide specialist acute input.

The current evidence base

Stroke patients require specialist multidisciplinary care and rehabilitation. A centralised model of acute stroke care, in which hyper-acute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of stay. There is also growing evidence on the use of telemedicine to support the rapid assessment and treatment of stroke in areas without easy access to a hyper-acute stroke unit.

Relevant college guidance

From the National clinical guideline for stroke (Royal College of Physicians 2012b, p 19):

  • All community medical services and ambulance services (including call handlers) should be trained to treat patients with symptoms suggestive of an acute stroke as an emergency requiring urgent transfer to a centre with specialised hyper-acute stroke services.
  • All patients seen with an acute neurological syndrome suspected to be a stroke should be transferred directly to a specialised hyper-acute stroke unit that will assess for thrombolysis and other urgent interventions and deliver them if clinically indicated.
  • All hospitals receiving acute medical admissions that include patients with potential stroke should have arrangements to admit them directly to a specialist acute stroke unit (onsite or at a neighbouring hospital) to monitor and regulate basic physiological functions such as blood glucose, oxygenation, and blood pressure.
  • All hospitals admitting stroke patients should have a specialist stroke rehabilitation ward, or should have immediate access to one.
  • All ‘health economies’ (geographic areas or populations covered by an integrated group of health commissioners and providers) should have a specialist neurovascular (TIA) service able to assess and initiate management of patients within 24 hours of transient cerebrovascular symptoms.