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Stroke deaths down, but services still need improvement

The death rate from stroke in Ireland has been cut by more than a quarter and the rate of direct discharge to nursing homes has almost halved in the last seven years, a national audit of acute stroke services carried out by the Irish Heart Foundation  (IHF) and HSE has revealed.

 The audit, published earlier this year, showed that in-hospital mortality has been reduced from 19 per cent to 14 per cent, whilst eight per cent of patients are now being discharged to nursing homes, compared to 15 per cent in 2008 when the previous national audit was conducted.

Around 7,000 people are hospitalised due to stroke in Ireland each year. The annual death toll of just below 2,000 makes stroke Ireland’s third biggest killer disease after cancer and heart disease.

The improvement in outcomes has been driven by the HSE’s National Stroke Programme, which has led a reorganisation of acute stroke services in Ireland, increasing the number of hospitals with stroke units from one to 21 and raising the rate of potentially lifesaving thrombolysis treatment tenfold to 11 per cent – one of the highest national rates in the world – in the wake of the IHF’s FAST campaign.

Despite the Programme’s success in developing services, many stroke deaths remain preventable, while a high proportion of stroke survivors continue to suffer undue disability in terms of both severity and length of time due to inadequate rehabilitation services, according to the IHF.

For example, despite their crucial importance in improving outcomes, only 29 per cent of patients are admitted directly to a stroke unit and almost half do not receive treatment in a unit at any point during their hospital stay. Nearly a quarter of hospitals providing acute stroke care do not meet minimum requirements and three of these had none of the required infrastructure in place for a stroke unit.

In addition, there are staffing deficits of 50 per cent for physiotherapists, 61 per cent for occupational therapists and 31 per cent for speech and language therapists, while only 44 per cent of hospitals had any access to medical social workers and 19 per cent had access to a neuropsychologist.

“The audit shows encouraging improvement in many areas of stroke care that has been achieved in the midst of the worst economic crisis in the history of the State, a rapidly contracting health service and just a small amount of dedicated financial resource,” said HSE National Stroke Programme co-lead Prof Joe Harbison, who led the audit along with Dr Paul McElwaine and project manager Ms Joan McCormack of the IHF.

Prof Harbison continued: “But the progress made cannot take away from persistent substantial deficits in services. The study shows that only about half of patients are admitted to a stroke unit at any time during their hospital stay. Treatment in a stroke unit is the most basic standard in the care of stroke patients and substantially improves the chances of independent recovery after a stroke.”

Prof Harbison said there is also a large deficit in the availability of rehabilitation services to stroke patients with few receiving the level of any therapy recommended in national and international guidelines. And while half of stroke survivors suffer anxiety, depression, or severe psychological distress, access to services was limited to just two hospitals nationally.

He concluded that there had been little additional investment in stroke care since the National Stroke Programme was established: “To maintain the improvements and to progress care of our fellow citizens suffering stroke to a level commensurate with a modern Western country, further investment in stroke services is undoubtedly necessary.”

IHF Head of Advocacy Mr Chris Macey said the results reveal huge progress from a low base in the development of acute stroke services. But given that only around half of patients were receiving the benefit of the service improvements, it was reasonable to assume that many patient deaths from stroke in Ireland were entirely preventable.

In addition, while more people than ever are surviving stroke, in-hospital rehabilitation service levels are grossly inadequate and community rehabilitation provision is even worse, he said.

This was exemplified by audit results showing just one hospital in Ireland has access to a specialist community stroke rehabilitation team and only three have a hospital/community stroke liaison worker.

“More people are returning home after stroke than ever before due to reductions in death and discharge to nursing homes. But after they pass back through the hospital gates most are effectively being abandoned. We need extra investment to ensure that nobody who has a stroke in Ireland dies because services fail to meet minimum standards. And we need to develop rehabilitation services to ensure that the recovery of patients is not squandered after so much skill and commitment is deployed to save their lives,” Mr Macey said.

Prof Harbison added that early supported discharge teams are currently operating from just four hospitals nationwide, despite strong evidence of their effectiveness in reducing length of hospital stay. This now stands at 22.4 days according to the audit, which although a week less than in 2008 is still around a week longer than in the UK.

He also called for greater investment in the new clot retrieval therapy, thrombectomy, which Irish doctors have helped to pioneer and which trials show could reduce death and severe permanent disability from stroke by 50 per cent.

National Stroke Awareness Week took place from 4-8 April. The IHF hosted the 4th Annual National Stroke Survivor Conference on 7 April, in Croke Park Conference Centre, Dublin, with a conference on stroke for health professionals taking place on 8 April.

Stroke Audit 2015 headline figures

The 2015 National Stroke Audit is the second audit of stroke services, following the Irish National Audit of Stroke Care 2008.

  • 27 hospitals in Ireland treat stroke patients during the acute phase of their care.
  • 21 hospitals have a stroke unit, up from one stroke unit in the whole country in the 2008 audit.
  • The 2015 audit found 150 stroke beds nationally. However, 61 per cent of inpatients with a stroke at the time of the audit were being managed on a ward other than a stroke unit.
  • 29 per cent of patients are admitted directly to a stroke unit, while almost half do not receive treatment in a stroke unit at any point during their stay.
  • The estimated national thrombolysis rate of 11 per cent is comparable to international rates, with the 2014 UK rate being approximately 12 per cent of all strokes.
  • Only 36 per cent of patients have a swallow screening in the first 24 hours, compared to over 80 per cent in the UK.
  • 23 hospitals (85 per cent) have a consultant physician with specialist knowledge of stroke; up from one-third of hospitals in the 2008 audit, while 23 hospitals have a clinical nurse specialist (CNS) in stroke.
  • There are large gaps in staffing of multidisciplinary stroke teams across the country. There is a staffing deficit of: 69 per cent for clinical nutrition; 61 per cent for occupational therapy; 50 per cent for physiotherapy; and 31 per cent for speech and language therapy.
  • The length of time stroke patients spend in hospital has reduced from almost 30 days in the 2008 audit to just over 22 days in 2015.
  • Only eight per cent of patients were newly admitted to nursing homes in 2015, compared to 15 per cent in 2008.
  • There are only three early supported discharge teams in Ireland, serving suitable patients in four hospitals. 

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