Hospital Services for Patients with Acute Stroke in Ireland:
The Volunteer Stroke Scheme Survey of Consultant Opinion

By:Dr. Morgan Crowe
& Dr. Mark Delargy

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INTRODUCTION

Stroke is a major cause of mortality in Ireland. Despite the proven value of coordinated stroke care in improving outcome, we have little information about services for patients admitted to hospital with stroke in this country. In the United Kingdom a survey of consultant opinion identified a number of deficiencies leading to recommendations about improvements in stroke care.

The aim of this Volunteer Stroke Scheme (VSS) survey was to document the provision of hospital services for patients admitted with acute stroke with a view to formulating recommendations about improved stroke care in this country.

METHODS

The names and hospital addresses of consultant physicians working in acute general Health Board and Voluntary Hospitals were obtained from the medical Directory.

A questionnaire adapted from the Stroke Association survey of consultant opinion in the UK was sent to all consultants under whose care patients with acute stroke were likely to be admitted. This included consultant physicians in cardiology, endocrinology, gastroenterology, general medicine, geriatric medicine, infectious diseases, nephrology, neurology, respiratory medicine, oncology, haematology and rheumatology. Each consultant received a questionnaire, a personal letter from two of us on VSS headed note paper and a stamped addressed envelope. Non responders were followed through via postal and telephone communication.

For the purpose of the questionnaire, stroke was defined as a sudden onset of focal, and at times, global neurological deficit with symptoms lasting greater than twenty four hours, with a presumed vascular cause but excluding subarachoid haemorrhage. Acute stroke was defined as onset of symptoms within the previous seven days.

RESULTS

162 consultants were identified to whom the questionnaire was sent in November 1998. Over the three months 140 questionnaires (86%) were returned. Of these one consultant had retired whilst 4 indicated that stroke patients were not admitted under their care and were not required to complete the remainder of the forms.

Of the remaining 135 questionnaires available for analysis, the main speciality stated by consultants were;

general medicine 39 (28.9%), gastroenterology 23 (17%), geriatric medicine 22 (16.3%), endocrinology 12 (8.9%),

respiratory medicine 10 (7.4%), rheumatology 9 (6.7%), cardiology 8 (5.9%), nephrology 6 (4.5%),

oncology 2 (1.5%), infectious diseases 2 (1.5%), neurology 2 (1.5%).

Consultants worked in 38 hospitals (EHB 9, NEHB 5, WHB 5, SHB 6, NWHB 2, SEHB 4, NWHB 4, NHB 3) representing a total of 10,067 acute hospital beds.

  • 127 (94%) consultants usually admitted their patients to general medical or occasionally general surgical wards; 4 to geriatric assessment units; 2 to neurological units; 1 to ICU; and 1 to a specialised area of a general medical ward.
  • 25 (18.5%) consultants worked in hospitals where there was a physician or neurologist with special responsibility for stroke.
  • 31 (23%) consultants worked in hospitals where there was a multi-disciplinary team which had special responsibility for stroke.

In 5 hospitals (St. Vincent's, Tallaght, Roscommon, Tralee, Waterford) there was a designated consultant physician with special responsibility for stroke patients mainly associated with a stroke team.

In 2 other hospitals (Cork University Hospital, Beaumont) a similar service for patients less than 65 years of age was provided by the neurology department.

For older patients (Table 1), access existed to a consultant led rehabilitation unit in 8 out of 9 hospitals in the Eastern Health Board.

In only 3 of those hospitals was the rehabilitation unit on the general hospital campus whilst in the remaining 5 cases , the rehabilitation unit was not located on the general hospital campus.

Similar results are shown for each health board area (Table 1). It is noted that only a minority of hospitals in the SHB, SEHB, MHB AND WHB have access to a consultant led rehabilitation unit whilst there is no such unit in the NEHB.

Table 1. Access for stroke patients in Acute Hospitals in each Health Board area to Consultant led Rehabilitation Unit (CLRU) for patients >65 yrs and <65 yrs within their health board area.
N0. of acute Hospitals
CLRU for pts>65yrs
CLRU for pts>65yrs
On Site
Off Site
On Site
Off Site
EHB
9
3
5
1
8
NEHB
5
0
0
0
0
WHB
5
0
2
0
1
SHB
6
1
1
2
0
NWHB
2
0
1
0
1
SEHB
4
0
1
0
1
MWHB
4
0
3
0
0
MHB
3
0
1
0
1

All hospitals in the EHB have access to the National Rehabilitation Hospital (NRH). However, only 15/55 (27%) of consultants in the EHB stated that they had access to a consultant led rehabilitation unit for younger patients perhaps reflecting the limited number of beds and long waiting lists for admission to the NRH.

In the other health board areas consultants in 0/5 hospitals in NEHB; 1/5 in WHB; 2/6 in SHB; 1/2 in NWHB; 1/4 in SEHB; 0/4 in MWHB; 1.3 in MHB has access to a consultant led rehabilitation unit within their own health board areas.

CT SCANNING

  • 97 (73%) consultants reported that they had on site CT scanning in their main hospital.
  • 36 (27%) consultants worked in hospitals with no on site CT scanning. These included 18 hospitals (EHB 3; NEHB 3; WHB 2; SHB 3; SEHB 3; MWHB 3; MHB 1) representing 2,517 acute hospital beds (25% of national total).
  • 65 (49.6%) consultants considered their access to be unrestricted whilst 66 (50.4%) felt that they had partial or very restricted access.
  • 73 (55.6%) consultants obtained CT scan on the same day or next day following admission of the stroke patient.

The majority of consultants had access to non invasive cartoid imaging (duplex, cartoid, ultrasound). However 7 (5.3%) consultants (NEHB 4; WHB 1; NWHB 1; SEHB 1) stated that they did not have access to this service.

POLICY, STANDARDS and AUDIT

  • Only 12 (9%) of consultants were aware of a formal audit of stroke care in their hospital within the past year whilst only 26 (19.5%) were aware of a policy for implementation of minimum standards of care for stroke patients.
  • 10 (7.5%) consultants provided written information for patients or their carers about stroke.
  • 130 (98%) consultants stated that they would want a CT scan if they had a stroke.

DISCUSSION

The response rate of 86% to the questionnaire in this survey indicates that any bias due to non response is likely to be low. The majority of consultants stated that patients with acute stroke were admitted under their care. Furthermore replies were received from physicians working in all 38 acute general hospitals in the 8 health board areas indicating the representative nature of the survey.

Our results indicate that patients with stroke are admitted under and looked after by a large and diverse group of hospital specialists. Most patients are admitted to general medical or surgical wards. The low audit rate for stroke, low implementation of a policy for minimum standards of care and the low provision of written information for patients and their carers suggests a lack of organised consultant led care. This is consistent with only 25 (18.5%) consultants stating that they worked in a hospital where it was possible to identify a physician or neurologist with special responsibility for stroke.

It is now generally accepted that organised care in a stroke unit or mixed assessment rehabilitation unit compared to non organised care on a general medical ward reduces death and need for subsequent institutional care for acute stroke patients. Regrettably, access to a consultant led rehabilitation unit (CLRU) for older patients is particularly deficient in certain hospitals in the MHB, SEHB, WHB, and non existent in the NEHB. Even in areas such as the EHB with identifiable consultant led rehabilitation units, these are mostly not on the general hospital campus and the bed numbers are relatively small compared to the needs of the population.

For younger patients the situation is worse with only 27% of consultants in the Eastern Health Board hospitals stating that they had no access to a consultant led rehabilitation unit for younger patients. Similarly consultants working in the majority of hospitals in other health board areas stated that they had no access to a CLRU within their own health board for younger patients. Whilst stroke is predominantly a disease of the older age group, 20% of those in a recent Survey in South East Dublin/East Wicklow were less than 65 years old. The deficit in rehabilitation for younger patients has been highlighted in the recent report of the advisory committee on rehabilitation.

Whilst the majority of consultants and hospitals had access to prompt on site CT brain scanning, 36 (27%) consultants worked in 18 hospitals representing 2,517 acute hospital beds (25% of national total) without on site CT brain scanning. This often necessitates the transfer of a significant number of older and at times medically unstable patients to other hospitals for brain imaging. Furthermore 65 out of 131 consultants felt that their access was partially or very restricted. The importance of early CT brain scanning is becoming increasingly recognised as the place of Aspirin, Heparin, and Thrombolytic therapy is being slowly defined. Clearly the physicians recognise the potential benefits since the vast majority (98%) would want a CT brain scan themselves if they had a stroke. Furthermore 18 (17%) predominantly in hospitals without CT scanning felt that 24 hour access to CT scanning would most improve their hospital care with stroke patients.

The relatively small number of consultants (5.3%) without access to non invasive cartoid imaging compared to 20% in the UK may represent the increasing recognition of the importance of identifying patients with severe symptomatic cartoid artery disease who may benefit from cartoid endarterectomy.

This survey describes for the first time patterns of care and services for patients admitted to hospital with acute stroke in this country. Our results suggest that despite the general consensus about the value of co-ordinated stroke care, there are still major deficiencies in hospital stroke services.

We suggest that each health board should review its own services and where appropriate, reorganise hospital services to include a consultant with a special responsibility for co-ordinating and developing appropriately staffed and funded stroke services for patients of all age groups within each hospital.

Such stroke services would include easy and prompt access to investigations including CT brain scanning and non invasive cartoid artery imaging with co-ordinated stroke care in a consultant led stroke unit, assessment rehabilitation unit or by a multidisciplinary stroke team.

Furthermore, such a service should involve regular audit and include implementation of a policy of minimum standards of care for stroke patients, which, based on evidence to date may be the most effective way of improving stroke outcome.

This article appeared in the Volunteer Stroke Scheme News Letter - May 2000.