Despite countless initiatives and high profile public awareness campaigns, more than half of NHS patients with symptoms of stroke or transient ischemic attack (TIA or mini stroke) are still failing to get fast access to life-saving, stroke prevention surgery. A lack of public and professional awareness about the need for quick treatment, combined with badly designed hospital services, is resulting in hundreds of preventable strokes. Surgeons say that unless awareness is increased to a level where these patients are routinely treated as emergencies, it will not be possible to meet Government stroke care standards.
Figures from the third report of the Carotid Endartectomy Audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Physicians and the Vascular Society and published today (June 21) show some improvement in the overall time in which patients are getting surgery of the neck arteries in order to prevent stroke (carotid endarterectomy or CEA). But the study also reveals considerable variation across the UK, with significant delays between patients experiencing symptoms, referral to stroke specialists and on to surgery. While some patients who need surgery are accessing it within 2 days, others are waiting almost 2 months. Surgeons say it is vital to discover why practise is variable across the UK. There is also concern that some hospitals are failing to provide any data, meaning care quality is impossible to determine.
The National Institute for Health and Clinical Excellence (NICE) sets a timeframe of two weeks from symptoms to surgery, while the Government's National Stroke Strategy (NSS) is 48 hours. Currently 40% of NHS patients are operated on within the NICE timeframe, up from 33% last year. The report describes the NSS timeframe as 'a major challenge' with only 2% of NHS patients currently meeting these standards.
Government TV advertising campaigns have also sought to raise public awareness that patients with the F.A.S.T. symptoms of stroke: (Facial or Arm weakness, blurred vision in one eye or Slurred speech = Time to call 999) should be considered as hospital emergencies, as patients who may benefit from emergency stroke prevention surgery should receive it within 14 days, as evidence shows that after this time the benefits diminish.
Surgeons say that most delays in meeting the two week timeframe relate to presentation and referral; of those patients who did not meet the 14 day timeframe, reasons cited were:
- 25% of patients failed to call 999, go to A&E or visit a GP
- 41% of patients experienced a delay in referral to specialist stroke centres or TIA clinics
- 13% of patients missed the deadline due to a lack of vital carotid imaging equipment
- 17% of patients because of limited availability of staff or operating theatre time.
Experts predict that if all patients were operated on within 14 days as many as 200 strokes would be prevented for every 1000 operations. Around 150,000 people have a stroke each year in the UK; around 17% die within a month and half of survivors are left dependent on others for everyday activities. It is the largest single cause of significant adult disability, costing around £8 billion per annum to the economy and £3 billion to the NHS. Stroke is a preventable and treatable disease and with better recognition of people at highest risk, early surgical intervention can significantly reduce the incidence and severity of stroke.
Vascular Society audit chairman and consultant vascular surgeon, Mr David Mitchell said:
Despite the good work by many clinicians, this study shows that we have a long way to go if we are to meet current NICE guidance of getting 100% of patients who need surgery into the operating theatre within 14 days of symptoms. Variation in the quality of care provision between Trusts highlights the need for those who are underperforming to follow the best practice of others who are proving that these standards can be achieved. We know that fast referral to TIA clinics where specialist staff can identify those at high risk of stroke, begin treatment and rapidly refer to the nearest vascular surgery unit for surgery, is absolutely vital in preventing needless strokes and deaths.
Dr Geoff Cloud, consultant stroke physician at St Georges Healthcare NHS Trust, said:
The public need to be aware of stroke symptoms as described in the FAST campaign and not ignore them if they are only short lived. They also need to know what action to take. TIA symptoms require prompt hospital based investigation in a specialist service to make an accurate diagnosis and start treatment in order to prevent a further TIA or stroke. Such preventative treatment may include carotid surgery.
The audit is the largest continuous audit of CEA in the UK. Round three includes almost 5,000 cases carried out between October 1st 2009 and 30th September 2010. This represents 79% of cases reported in Hospital Episode Statistics for the same period (up from 56% in round one and 70% in round two) The Vascular Society is urging surgeons to submit data for round four which will report in Summer 2012.