Tracking every stroke Pushing the limits

You can’t improve what you don’t measure. It is a simple concept, but it’s a grand objective. A team, led by the Florey, aims to track the quality of hospital care and outcome of every stroke patient in Australia with the intention of improving patient care.

Given how inextricably a person’s survival and recovery from stroke is linked to the acute health care they receive, stroke experts – including those at the Florey – recognised early that hospitals must take regular stock of their performance.

For the past eight years, the Australian Stroke Clinical Registry (AuSCR) has enabled the collection and publication of patient outcomes from acute stroke and “mini strokes”, or transient ischemic attacks.

The register, which is managed by the Florey as one of four partners in the national project, has the aim of assessing stroke treatment and rehabilitation to ensure patients have the best possible chance of recovery, no matter where they are treated.

Head of Public Health at the Florey, Associate Professor Dominique Cadilhac says that while previous audits showed there was significant variability in best practice care across Australia, clinicians have struggled to access data to gauge whether they are meeting standards. Dominique believes the registry’s success lies in the way it gathers clinically relevant processes of care and outcomes, not routinely gathered by other data collections.

The AuSCR records various aspects of patient care including whether they received clotbusting medication, their mobility, if they were discharged on blood pressure lowering medication, and given a discharge care plan.

Patients also undertake a survey three months after discharge, to rate their degree of disability, quality of life, readmission to hospital and recurrent strokes.

Importantly, hospitals can regularly download their own data to measure their performance over time. The results also act as a checklist

“We’ve found that if hospitals contribute to the registry over a number of years, there’s a shift in their practice. They are improving.” to see if they’re meeting national benchmarks, and how they’re rating against the best performing hospitals.

“If there’s a problem they can identify it and act on it.

“We’ve found that if hospitals contribute to the registry over a number of years, there’s a shift in their practice. They are improving.”

Practical changes have been made. For example, after analysing their data, some hospitals have increased speech pathology for patients to address swallowing difficulties.

Other hospitals were able to increase access to their specialist stroke units and improve communication between patients and staff.

After starting as a pilot program in 2009 with six hospitals contributing, 45 services are now involved. The registry’s grand aim is to include data from all 50,000 strokes that occur across Australia each year.

“Stroke is a complex condition and there is now greater recognition that access to recommended care is essential to achieve better outcomes.

“For the first time, the registry gives clinicians important information for understanding the influence of the care they provide and patient outcomes after they have left hospital.”

Stroke statistics for Australia and the world

#1 cause of death and disability worldwide

STROKES EACH YEAR in Australia: 1000 a week or 1:6

There are few situations more heartbreaking than learning there is a proven, readily available treatment for stroke, but it’s a life-line out of reach because doctors don’t know the time the stroke occurred. A Florey-led study hopes to change international guidelines.

Florey researchers are trying to improve the chance of recovery for the thousands of Australians who suffer a stroke each year and can’t say when it happened, often because they were asleep. A ground-breaking international trial aims to extend the time that clot-busting medication can be administered after ischemic stroke.

The earlier you can reopen the blood vessel and get blood flowing again to the affected part of the brain, the more likely that tissue can be saved.

The protein tissue plasminogen activator (tPA) has been the most potent therapy for doing just that since it was first trialed in Melbourne in 1999.

Stroke survivors with physical or mental impairment

“To give them the drug and to see them hop up off the bed, to walk out of hospital – it’s quite emotional.”

An international trial is being led by the Florey to test whether tPA is still safe and effective up to nine hours after stroke onset.

Notes

EVERY TEN MINUTES someone in Australia will suffer a stroke

ISCHAEMIC VS. HAEMORRHAGIC STROKE

10% DEVELOP DEMENTIA AFTER STROKE

30% after subsequent strokes

% OF STROKES IN PEOPLE UNDER 65 

REDUCED RISK OF DEATH AFTER 180 DAYS IF TREATED IN A STROKE UNIT: 59%

A patient’s chance of getting up and walking out of hospital increases by 30 per cent if they are treated with tPA, but on average only 11 per cent of patients currently receive the drug.

Florey Director Professor Geoffrey Donnan says the other 89 per cent of patients do not make it to hospital in time to receive the intravenous infusion within the designated 4.5 hours that the drug is proven to work.

In major metropolitan hospitals across Australia, 20 per cent of eligible patients receive tPA. But because of the time pressures involved in busy emergency departments, many units struggle to treat even five per cent of eligible patients.

“To give them the drug and to see them hop up off the bed, to walk out of hospital - it’s quite emotional when you realise what you can do for them.”

But consensus is growing among the global stroke community. tPA may be useful beyond 4.5 hours. Advanced brain imaging is revealing that many patients have salvageable brain tissue well beyond this small window.

“We know there is viable brain tissue in some people for as long as 48 hours after the stroke onset. How the stroke plays out depends on how much circulation they’re getting from other arteries, how old they are, and other factors.”

If successful, the biggest beneficiaries of this new research will be the “wake up stroke” population; the 20-30 per cent of ischemic stroke patients who have the event at some stage overnight but don’t know when.

This could see between 2000 and 4000 extra Australians access tPA treatment each year, and between 500,000 and two million people worldwide.

“Even though we keep emphasising that patients must come to hospital as early as possible, if for some reason they’re unable to - and if the results of this trial are positive - then we’ll be able to treat them up to nine hours after the stroke.”

The international trial involving 23 centres in Australia, 12 in Taiwan and one in New Zealand has recruited 189 patients. Patients initially receive advanced brain scans to determine if there is still salvageable brain tissue before they are randomly allocated the tPA treatment up to nine hours, or given the standard treatment of aspirin.

Patients have follow-up brain scans 24 hours after the treatment, and again three months later to determine their level of disability.

They hope to reach 200 patients within the next three months. At this point they will analyse the interim results of the randomised, blinded study to determine if they need to expand or abandon the trial.

“For all of these trials, the eyes of the world are upon us,” he says.

TWO THIRDS of survivors will be disabled close to

440,000 Australians are living with the impact of stroke

By 2032 it will be 700,000

ECONOMIC COST TO AUSTRALIA EACH YEAR > $5 BILLION $3 billion in lost productivity $1 billion in lost wages

Risk factors

Australians most at risk of a stroke include:

6.1 MILLION people living with high cholesterol

4.1 MILLION with high blood pressure

434,000 with atrial fibrillation

PHIL BEART