The National Clinical Programme for Stroke, NCPS, has been in place since early 2010. The vision of the programme is to design standardised models of integrated care pathways for the delivery of clinical care to ensure sustained quality clinical operational management. Overall, the NCPS aims to improve quality, access and cost-effectiveness of stroke services in Ireland.
Some of the achievements of this programme in improving access to services to date include:
National 24/7 access to safe stroke thrombolysis
Emergency thrombolysis is provided to patients in all parts of the country, via improved hospital and ambulance protocols, health professional training and the appointment of new stroke physicians. The national stroke thrombolysis rate has increased from 1% in 2006 to a current rate of 12% (2016).
The NCPS has developed a number of initiatives including a telemedicine programme to allow delivery of expert thrombolysis therapy in smaller level three hospitals. It has been involved in the training of over 250 doctors nationally to deliver thrombolysis therapy and has participated in a training programme for Stroke in the Royal College of Physicians of Ireland.
Improved access to stroke unit care
Access to stroke unit care has been shown to improve stroke patient outcomes through reduced mortality rates, reduced dependency and shorter lengths of stay in hospital by patients. Since the commencement of the NCPS, nine new stroke units have been opened, bringing the total number of stroke units in acute hospitals to twenty-two. Two further stroke units are currently in development with a third at planning stages.
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Stroke Unit Available n22
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Stroke Unit in development/planning n3
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No Stroke Unit n2
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Mater Misericordiae University Hospital
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University Hospital Kerry
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Midland Regional Hospital Tullamore
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St Vincent’s University Hospital
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Connolly Hospital
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Our Lady’s Hospital Navan
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Midland Regional Hospital Mullingar
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Letterkenny University Hospital
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Wexford General Hospital
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St Luke’s Hospital Kilkenny
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St James’s Hospital
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Tallaght Hospital
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Naas General Hospital
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Midland Regional Hospital Portlaoise
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Beaumont Hospital
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Our Lady of Lourdes Hospital Drogheda
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Cavan General Hospital
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University Hospital Limerick
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University Hospital Waterford
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South Tipperary General Hospital Clonmel
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Cork University Hospital
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Mercy University Hospital
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Bantry General Hospital
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University Hospital Galway
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Portiuncula Hospital
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Mayo University Hospital
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Sligo University Hospital
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This is a major improvement from the first national stroke care audit report in 2006 which reported one stroke unit in the country. However, stroke units are typically too small and the recent national Audit showed that only half of stroke patients admitted spent any time in a stroke unit.
Admission to a stroke unit is a National Key Performance Indicator. In 2016, 65.6% of stroke patients were admitted to a stroke unit.
Early Discharge of Stroke Patients
It has been recognised internationally that Early Supported Discharge of stroke patients from hospital, improves outcomes, reduces need for long term care and increases acute hospital capacity by freeing up beds. It is estimated the 10-25% of patients could benefit from an ESD service.
The programme has helped establish three small but effective ESD teams in Dublin and Galway. In 2016, 137 patients were discharged to ESD services representing 15.6% of total stroke discharges. It is estimated that there was an average reduction in length of stay of 10.4 days per ESD patient.
Funding for increasing capacity in the three operational sites has been secured for 2017, with further funding secured to support the establishment of two further teams in University Hospital Limerick and Cork University Hospital. Recruitment of these ESD staff is ongoing. University Hospital Limerick is due to commence its ESD Service on 11 September 2017.
Emergency Endovascular Therapy – Thrombectomy
Thrombectomy is an emergency endovascular procedure that permits patients with severe strokes caused by clots occluding the major vessels of the brain and neck to have these clots removed using specialist devices. HIQA has completed a Health Technology Assessment which finds that this intervention is value for money. Full report of the HIQA HTA can be found at: https://www.hiqa.ie/reports-and-publications/health-technology-assessments/hta-mechanical-thrombectomy-stroke.
Provision of emergency endovascular thrombectomy remains highly specialised in Beaumont Hospital and Cork University Hospital and this model has been endorsed by the HSE, Acute Hospital Division with a view to a third centre when numbers increase as expected.
To date, the number of patients undergoing this procedure has risen annually, on average almost 50% increase each year: 2015=122 cases, 2016=172 cases, 2017 – end of August=154 cases. These patients have been referred from 20 different hospitals around the country.
I have noted the contents of the Stroke Manifesto published by the Irish Heart Foundation and it will be one of the factors that will contribute to the ongoing policy development in this area.
