Centralising acute stroke services, with specialist care and state-of-the-art equipment, is saving lives, as Liz Bestic discovers
Stroke nurse specialist Alison Loosemore is passionate about her job on the Acute Stroke Unit at St George’s Hospital, South London. “It’s the total embodiment of what nursing should be about – compassion, care, understanding, focus and hard work,” she says.
“A stroke is everyone’s fear and is dramatic and potentially completely life-changing. You have to work closely with the patient, offering strategies that support their personal dignity and expectations.”
Underpinning that humanity is advanced diagnostic equipment, stroke consultants with banks of knowledge and a flow system that would be the envy of any consumer business.
Stroke treatment is about combining empathy, expertise and efficiency in a seamless delivery.
St George’s in Tooting is one of eight London hospitals that, under London’s stroke service reorganisation in 2010, now operate a Hyper Acute Stroke Unit (HASU). Patients get rapid access to CT scans, thrombolytics (clot-busting drugs) and continuous specialist care during the first 72 hours following a stroke.
A recent study by UCLPartners has shown that centralising acute stroke services in London has saved more than 400 lives since 2010.
“Before then, stroke services were provided in 30 acute hospitals across the region and stroke care in London was pretty patchy,” says Geoff Cloud, consultant stroke physician at St George’s. “We know that ‘time is brain’ which means the sooner someone who has a stroke is treated with clot-busting drugs, the better their chances of survival and being able to lead a normal life.
“A typical patient loses 1.9 million neurons for each minute their stroke is left untreated. Our aspiration at St George’s is for so-called ‘door to needle’ time to be within 30 minutes. Nationally, the typical time it takes to get to hospital is an hour. We currently average around 45 minutes.”
The stroke service provides a 24-hour, seven-day-a-week service for thrombolysis to unblock arteries, which have caused the stroke. Care is provided in a 20-bed HASU and a 16-bed stroke unit for less acute cases.
Stroke treatment is about combining empathy, expertise and efficiency in a seamless delivery
Patients are stabilised within three days and then start their rehabilitation at the NHS trust’s specialist stroke unit.
St George’s is unique in providing comprehensive rehabilitation at the Wolfson Neurorehabilitation Unit, a tertiary neuroscience centre with latest equipment and a wealth of neurological expertise.
“We have specialist diagnostic services, state-of-the-art brain imaging and specialist neurointerventional surgery all under one roof. It is about as good as it gets,” says Dr Cloud.
The hospital has consistently been rated the best in the Royal College of Physicians’ stroke audit, and a study recently praised staff for the way they communicate with patients and carers.
“You see patients who have lost control over their faculties in a very short space of time and you need to be able to console them in a way which sets them off on their journey. Their stroke can completely change their long-term expectations,” says Ms Loosemore.
“And then there are the Lazarus moments when you see someone who thought their whole life was over, and is given thrombolysis and starts to get the feeling back in their arm and leg. It’s tremendously rewarding.”
The gold-standard treatment for stroke doesn’t stop at stabilisation. A team of experts swings into action to integrate patients back into the community.
“The way we measure stroke services is as much about how people adjust at home to life after stroke as hyperacute care in the first phase of their stroke,” Dr Cloud adds.
“People spend far more time living with the effects of stroke in their own homes than in hospital. There has historically been a mismatch between how much has been invested in hospital care compared to rehabilitation at home, but that is rapidly changing.”
At St George’s, the early supported discharge team (ESDT) ensures that acute treatment dovetails with rehab. For many years there has been an assumption that if a stroke survivor has not improved in four to six weeks there will be no further improvement.
“This is patently untrue particularly for aphasia [speech difficulties] where intensive speech and language therapy can really improve the condition,” says Dr Cloud.
The ESDT consists of speech and language therapists, occupational therapists and psychologists who can all help make the transition to living back at home smoother.
“Research shows that people do better back in familiar surroundings. It’s not just about being able to discharge people back home, but about giving them a role in the family and the community,” says stroke nurse specialist Helen Mann.
“Rehabilitation in the home also makes it much more functional. It’s all very well learning to go up and down steps in the hospital, but that may not translate to the stairs in your own home.”
The ESDT can also help patients return to work by negotiating with employers about adaptations in the workplace, phased return or considering a different employment role.
Fatigue is often a serious side-effect of a stroke. “Even those who have had a comparatively mild stroke may say they are better, but they forget they are not doing normal things in hospital. When they get home, they are shocked at how shattered they feel. I always advise people not to return to work for at least two weeks,” says Ms Mann.
St George’s is also a centre of excellence in stroke research and is currently looking at the science around the different stages of the stroke journey. “One major piece of research examines methods for the interventional treatment of acute ischemic stroke, such as removing clots through endovascular techniques,” says Dr Cloud.
Other clinical trials are looking at preventative treatment for stroke, including drugs to reduce atherosclerosis (furring up of the arteries), which is a major risk factor for stroke, and a trial on implanting pumps so that drugs can be infused into the spinal cord to improve walking.
As Ms Loosemore says: “Stroke medicine is an exciting field now – and seeing someone recover from a stroke and get back home gives a real sense of achievement to everyone involved.”