Ireland’s improving stroke care services

But its not good enough. You will need to force improvements by having them focus on measuring results rather than processes. They seem to think delivering tPA is the answer to stroke recovery. Its not, something better needs to be found that stops the neuronal cascade of death.
So contact them and give them the ideas on these 177 hyperacute therapies.
http://www.imt.ie/features-opinion/2013/06/irelands-improving-stroke-care-services.html
The 2010 Cost of Stroke Care in Ireland study estimated that approximately €5 million could be saved annually through the provision of stroke unit care to 95 per cent of admitted patients.
Up to 10,000 people in Ireland suffer a stroke every year and 2,000 people die from stroke annually, and up until the past couple of years, Ireland’s services for these patients were inadequate and piecemeal.
However, it has been widely acknowledged that one of the HSE’s most successful clinical care programmes to date is the National Stroke Programme, which since its launch in 2010 has led to a dramatic improvement in the level of specialised stroke care for patients and has seen Ireland go from being one of the worst countries in the world for successful thrombolysis to one of the best in the space of three years.
The over-arching key aims of the Programme are to: ensure national, rapid access to best-quality stroke services; prevent stroke, disability, and the death of one patient per day (370 per year); and spend existing funds better and reduce costs.
This is being achieved through a number of major service changes and upgrades to allow national 24/7 access to safe stroke thrombolysis, while stroke units have now been developed in all hospitals accepting stroke patients. These units include rapid transient ischaemic attack (TIA) assessment and early supported discharge programmes.
Significant progress has been made on the necessary changes to allow this, though there has been some criticism that not all the stroke units are adequately staffed or have their facilities ring-fenced and a number of posts still have to be filled.
While full national 24/7 thrombolysis cover is still a work in progress, it is now available in all Model 3 and Model 4 hospitals, either directly or via bypass protocols. The percentage of stroke patients who receive thrombolysis has increased from a baseline of 2.4 per cent to 9.5 per cent, and this was achieved ahead of the HSE’s delivery target. The Programme has also created a detailed bundle of evidence-based best practice care guidelines and protocols for the units and involved healthcare staff and ambulance services.
Telemedicine
One of the key parts of ensuring 24/7 thrombolysis access to patients across the country has been the development of the telemedicine stroke project — Telemedicine Rapid Access for Stroke and Neurological Assessment (TRASNA).
A TRASNA network is planned to link the smaller sites to the bigger centres and enables the provision of thrombolysis to all eligible stroke patients nationally under the supervision of a stroke physician. This development means Ireland will be the first country internationally to have a single integrated telemedicine service for stroke, and while it was due to be fully in place by the end of last year, its rollout has been delayed.
Director of Stroke Services in Tallaght Hospital Dr Ronan Collins helped spearhead the first telemedicine stroke pilot project in Ireland. In  2008 the project was awarded €250,000 of HSE Innovation Funding to finance the purchase of Remote Presence Solution (RP7) robots, which allowed doctors from a remote location to conduct video consultations and communicate with patients and staff and supervise thrombolysis for suitable patients.
The ‘robo-docs’ were originally trialled in Tallaght and, after well-publicised success, then extended to the Dublin Mid-Leinster network to incorporate Naas and Mullingar initially, with patients from as far as Tullamore and Portlaoise being able to avail of this service.
“Of those presenting with stroke out-of-hours in the Mid-Leinster network, about one-in-3.5 would be thrombolysed, which is a very high rate in comparison to one-in-five in most centres.
“One of the reasons for this is, firstly, what I’ve found in out-of-hours is that patients are more likely to present with a genuine stroke, and, secondly, they tend to present faster when coming in out-of-hours, as many daytime presenters would have gone to bed the night before not realising they would have had a stroke [and therefore are too late for thrombolysis],” Dr Collins told IMT.
“It marks a great step forward. This telemedicine technology is not only significant for stroke, but allows physicians to make accurate diagnoses in a range of other specialities. The great thing about the particular system we have set up is the flexibility it allows in diagnosing patients,” he commented.
While the initiative has been a great step forward for patients and was pushed for strongly by stroke consultants, it has meant adding to their heavy workload. Dr Collins’s network spent the first two years on a one-in-four rota, which was essentially a one-in-two rota during the summertime, to man the service to cover Tallaght and Naas. The telemedicine pilot project treated more than 230 patients up until the end of last October.
“We took this on without any ask that we take it on, and we have delivered on it and provided the information from it, which allowed proof of concept for the development of the national tender. There was a huge amount of extra work and personal sacrifice for those involved in the project and we didn’t ask for extra pay. Sometimes I think that Minister [for Health Dr James] Reilly forgets that all the new initiatives in health don’t come about because the Department of Health has dreamt them up, they come because we go to conferences and find out about them and think ‘yes, that’s a good idea, we should trial that and see if it would work’,” he told IMT.
The stroke telemedicine service finally went to national tender in 2011 and was to be put in place by the end of 2012. However, like so many HSE projects, it has not been without frustrating delays. IMT understands there have been difficulties linking-up the different radiology systems in the participating hospitals to the chosen telemedicine system, but it is hoped it will be fully in place in the coming months and the old system is still in operation in the pilot network.
Dr Collins said while the replacement technology sought under the national tender meant a number of challenges, as did the outdated ICT systems in Irish hospitals, he felt the HSE’s data concerns were a little excessive.
“I think the encryption they [HSE] were looking for was twice what the CIA and FBI look for. It would be the top encryption that you can get but that doesn’t mean it would be practical,” he commented.
Stroke Register
Another key aspect of the stroke programme is the National Stroke Register, which is being run off the HSE’s HIPE data system.
The primary aim of the National Stroke Register is the collection of key data items to provide information on the quality of care for individual patients with stroke and TIA admitted to Irish hospitals, in order to identify areas where improvements in quality of care should be prioritised. As of the end of January, the Register was operational in 25 acute hospitals, with the goal of including the remaining acute stroke hospitals by the end of this year. Data-wise, at the end of 2012 there were data entered for approximately 2,600 stroke and TIA patients.
To date, there has been wide variation in coverage across stroke subtypes, compared to HIPE principal diagnosis and wide variations across hospitals using the Register, with some incomplete data capture, so it is very much still a work in progress. The Steering Group has agreed several key changes to the Register for 2013, including that it is no longer mandatory to enter data on patients with subarachnoid haemorrhage and TIA into the Register.
“To finally have a fully operational National Stroke Register will be great, as we will for the first time be able to nationally produce figures on outcomes, access to care and quality of care. There will of course be comparisons on the units but I think what is important is assuring people on the standards of stroke care in general across the system that it is good and that it is comparable nationally, and that they should be reassured that stroke is moving in the right direction,” Dr Collins commented, adding that he is now confident that Ireland is finally giving stroke patients the care they deserve.
“In fact, I would say that the stroke care here in Tallaght and most of the other units is better than the stroke care in England… The stroke programme is going really well and you have great initiatives. The leads are to be congratulated — they’ve done a lot of good work, though there is still a lot left to do,” he concluded.