Challenge
How to organise stroke services in a way which ensures that thrombolysis is provided as quickly as possible to those stroke patients who could benefit from it.

Solution
Collaboration formed between SSNAP and the operational modellers at the South West Peninsula Collaboration for Leadership in Applied Health Research and Care (PenCLAHRC).

• Evaluated current state of play: Compared individual site performance with national norms to highlight variations in thrombolysis provision.
• Established important performance measures: 3 parameters identified which focused on what would clinically benefit people with stroke if rates were improved; increasing the proportion of patients with a known onset time; shortening the doorto-needle time; increasing the proportion of patients that are treated having been scanned with 30 minutes remaining in the licence period for alteplase (the clot busting drug used to administer thrombolysis).
• Highlighted potential gains from improving processes: The modelling team used SSNAP data from 7 acute stroke sites in the South West to model a potential three-fold increase in the number of stroke patients successfully thrombolysed and left with minimal disability compared to current practice.
• Used results to gain clinical buy in and build momentum.

This modelling work helped to foster a region wide acceptance of the improved patient outcomes that were possible by incrementally improving each metric, and acted as the stimulus to deliver a treatment rate that may not previously have been considered achievable.

Impact
Targeted quality improvement activity in several of these sites in response to the thrombolysis modelling work is already delivering improved treatment rates and door-to-needle times: for example, at Derriford Hospital, Plymouth, they have increased their thrombolysis rate by a third (from 8.0% to 11.7%) over the last two years, with a corresponding fall in door-toneedle times of 16 mins (from 69 minutes to 53 minutes). There is a growing acceptance now that relatively modest amendments to clinical practice and expectations can yield significant improvements in thrombolysis rates.

Next steps
We intend to apply this same modelling analysis and quality improvement methodology to the increasing numbers of patients receiving mechanical thrombectomy– modelling processes and outcomes in the comprehensive stroke centres delivering the treatment as well as the new quality measure of ‘door-in doorout’ time at referring primary stroke centres.

Reflection
Quality improvement driven by national comparative audit offers the prospect of accelerating the implementation of a paradigm shift in the treatment of acute ischaemic stroke, and reaching the point where nearly 1,500 people with severe stroke annually are spared major disability with its enormous personal, health and social care costs.

This case study is written by Dr Martin James, consultant stroke physician at Royal Devon and Exeter NHS Foundation Trust.


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