A Learning Health System for stroke care in Greater Manchester - - PowerPoint PPT Presentation

A Learning Health System for stroke care in Greater Manchester

Adrian Parry-Jones MRCP PhD NIHR Clinician Scientist & Honorary Consultant Neurologist

Manchester Academic Health Sciences Centre Salford Royal NHS Foundation Trust, Salford, UK

Stroke: a common problem

In the UK:

• 152,000 strokes/year
• 1.2 million stroke survivors
• £9 billion in economic costs

(£4.38 billion health/social) Poor outcomes:

• 1 in 8 die by 30 days
• Survivors:
• ½ have a disability
• ⅓ dependent

Stroke: causes

Ischaemic stroke:

• 80-85% of strokes
• Occlusion of artery
• Clots from heart and neck

arteries Intracerebral haemorrhage:

• 10-15% of strokes
• Rupture of artery with

bleeding in to brain

Stroke: treatments

Ischaemic stroke (80-85%):

• Acute care: Stroke unit, reperfusion (thrombolysis/ clot retrieval),

prevention of complications (DVT, infections)

• Secondary prevention: antiplatelets, statins, blood pressure, AF –

anticoagulation, carotid surgery

Intracerebral haemorrhage (10-15%):

• Acute care: Stroke unit, reverse anticoagulation, blood pressure

control, neurosurgery

• Secondary prevention: blood pressure, review antithrombotics,

identify vascular malformations

Greater Manchester stroke pathway

Illustration courtesy of Greater Manchester Stroke Operational Delivery Network

Stroke Units in Greater Manchester

• Hyperacute Stroke

Units (HASUs): Salford, Bury, Stockport

• All other acute

hospitals are District Stroke Centres (DSCs)

Greater Manchester stroke pathway

Illustration courtesy of Greater Manchester Stroke Operational Delivery Network

1 2 3

Workstream 1: Stroke mimics

• GM Stroke ODN Audit Jan

2016:

• 480 of 969 patients

assessed were strokes (49.5%)

• 79% of patients arrived by

ambulance

• 70% of mimics arrived by

ambulance

Workstream 1: Stroke mimics

• Aims:
• 1. Describe patient flow and understand predictors for

stroke mimics using existing health data

• North West Ambulance Service (Stroke database, C3

dispatch system)

• DataWell (Salford, Central, South)
• 2. Test changes to improve system
• Individual feedback, telephone access to on-call stroke

teams, decision support systems

• Rapid assessment of impact via established data flows

(once NWAS EPR in place)

Workstream 2: ICH care bundle & pathway

• Common health problem

‒ Causes 10-15% of strokes ‒ More common in southeast Asian populations

• Poor patient outcomes

‒ Case fatality up to 40% at 1 month ‒ Causes 5.8% of all global deaths (vs. 6.0% for ischaemic stroke) ‒ Only 20% regain independence ‒ Little improvement in outcomes over last 30 years

GBD Study 2013 collaborators(2015) Lancet 386:743–800; van Asch et al.(2014) Lancet Neurol 9:167-176

Workstream 2: ICH care bundle & pathway

ABC Care bundle: A – anticoagulant reversal B – blood pressure control C – care pathway Salford QI project: 30-day case-fatality

• 34.3% before
• 25.1% after

Fall of 9.2%

N=216 before (May 2014 – May 2015) N=311 after (Jun 2015 – Jul 2016)

Workstream 2: ICH care bundle & pathway

Aim: Reduce death and severe disability after intracerebral haemorrhage in Greater Manchester by 10% by April 2018 Objectives:

• 1. Analysis of historic dataset to refine care pathway
• 2. Automated GM intracerebral haemorrhage registry
• 3. Development of app and dashboard to deliver bundle
• 4. Planed bundle launch April 2017

Funded by the Heath Foundation: Innovating for Improvement

Workstream 3: Secondary prevention

• Blood pressure:
• Causes 50% of ischaemic strokes
• Principal risk factor for intracerebral haemorrhage
• Guidelines suggest lowering to below 130 mmHg
• Atrial Fibrillation:
• Accounts for up to 15-20% of strokes
• Caries high risk of further stroke ~ 12% p.a.
• Anticoagulation prevents 65-70% of strokes

Workstream 3: Secondary prevention

Amarenco et al, N Eng J Med 2016, 374: 1533-42

Recurrent events:

• Happen early
• Some preventable

Possible problems?

• AF detection
• Anticoagulation
• Control of blood

pressure

Workstream 3: Secondary prevention

Aim: Reduce the rate of recurrent strokes by rapid delivery

• f secondary prevention

Objectives:

• 1. Describe AF and hypertension detection and

management using existing health data

• SIR & SSNAP
• DataWell (Salford & Central acute trusts and CCGs)
• 2. Test changes to improve system
• Enhanced role for ESD nurses, pharmacists
• Technology for patient self monitoring and detection
• Extended role for Stroke Association Co-ordinators

• University of Manchester: Adrian Parry-Jones, Goran Nenadic
• Salford Royal: Pippa Tyrrell, Hiren Patel, Kyri Paroutoglou, Amit

Kishore, Luca Cecchini

• NIHR CLAHRC Greater Manchester: Ruth Boaden, Katy Rothwell,

Lisa Dutton

• GM Stroke ODN: Sarah Rickard, Chris Ashton, Jane Molloy
• Stroke Association: Chris Larkin
• North West Ambulance Service
• Pennine Acute Hospital Trust: Khalil Kawafi
• Stockport NHS Foundation Trust: Appu Suman, Shivakumar

Krishnamoorthy

CHC: Stroke Project team & collaborators