Stroke care is improving in England but not in Wales, audit shows

A growing number of people in England who have had a stroke are being cared for in specialised stroke units, but no similar improvement has occurred in Wales, says the report of a national audit published this week. The report also warns that waiting times for a brain scan and for starting treatment remain longer than guidelines recommend.

The 2006 national sentinel audit for stroke is the latest in a two yearly review of stroke care being funded by the Healthcare Commission, the independent body that assesses quality of care in the NHS. The audit was carried out by the Royal College of Physicians on behalf of the Intercollegiate Stroke Group and included all eligible hospitals in England and Wales.

The results showed that the proportion of patients receiving care in a specialist stroke unit had risen. In 2006 nearly two-thirds (62%) of patients were admitted to a stroke unit at some point in their stay in hospital stay, whereas the percentage in 2004 was 46%. Fifty four per cent spent more than half of their hospital stay in a stroke unit (40% in 2004).

The audit found that the results of key indicators among patients who were managed in stroke units were considerably better than those of patients looked after in other settings. Patients in stroke units were much more likely to have had a swallowing screening test (overall assessment including consciousness, truncal control, ability to communicate, and a test to swallow water), to have started aspirin treatment within 48 hours, to have been assessed by therapists within the recommended time frames, and to have had rehabilitation goals documented and a home visit after discharge.

The report considered that the increase in the number of people being cared for in stroke units was a significant improvement, noting that 91% of all the hospitals now have a stroke unit, an increase from 79% in 2004. The most dramatic rise in the number of stroke units was in England, where they increased from 82% of hospitals in 2004 to 97% in 2006. In Wales only nine hospitals (45%) had stroke units, the same as in 2004.

The report recommends that all trusts that manage stroke patients should increase the proportion who spend most of their hospital stay in a stroke unit to more than 80% by the time of the next audit, in 2008. With respect to the particular problem in Wales, the report recommends that Welsh trust need to identify ways to raise the quality of stroke care across the whole patient pathway, particularly through the development of stroke units.

Tony Rudd, programme director for stroke with the Royal College of Physicians' clinical effectiveness and evaluation unit, London, said: “There have been some major improvements in the quality of stroke care over the last two years, with some fantastic examples of first class services in some centres. But there are still too many patients who receive substandard care, which is likely to result in higher death rates or greater disability than necessary.”

He added: “The failure of the majority of hospitals in Wales to offer stroke unit care is scandalous and needs urgent action.” He considered that likely reasons were that Wales had only recently introduced a national service framework for older people, which includes stroke care, while England had introduced this in 2001. Geography was also a problem, with Wales having small hospitals covering large rural areas. “But this is not a good enough reason for patients to suffer higher mortality and disability. Patients should have greater access to specialist stroke units, even if they may have to travel a distance to reach them.”

Further results from the audit showed that only 42% of patients had had a brain scan within 24 hours of the onset of symptoms (as recommended by the national clinical guidelines for stroke), which is worse than the 59% achieved in the 2004 audit. The authors considered that this was “unacceptably low,” although the latest audit included a much greater proportion of patients as being eligible for this standard, which may have affected the result.

Only 9% of patients were scanned within three hours of a stroke. If not scanned on the day of admission, they normally had to wait until the next working day. This was a particular problem if patients were admitted at the weekend, as very few scans were performed outside the hours of 8 am to 6 pm on these days.

The speed of access to imaging needs to be radically improved, the audit advises. It recommends that by 2008 all patients should have brain imaging within a maximum of 24 hours of admission with symptoms of a stroke.

Dr Rudd said, “There are good clinical reasons why patients should be scanned within 24 hours. It is important to differentiate between an infarct and a haemorrhage, as treatment differs. A number of patients will benefit from being scanned even more quickly, to determine if use of thrombolytics would be appropriate.” He considered that the national stroke strategy, currently being developed by the Department of Health, would introduce measures to improve access to scanning.