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Lack of specialised stroke services

Brian Herron reports on the publication of the Irish Heart Foundation’s Stroke Manifesto, which contains 16 urgent proposals

The severe lack of specialised stroke services is putting Irish patients in ‘unnecessary and intolerable danger’.

That’s the message from Dr Brian Maurer, Medical Director of the Irish Heart Foundation, who spoke at the launch of the IHF’s new Stroke Manifesto. The Manifesto contains 16 proposals that the IHF is asking the HSE to implement without delay.

“Getting specialist treatment immediately after a stroke could be the difference between a lifetime of disability, or a complete recovery,” said Dr Maurer.

Services unavailable
Despite warnings from the IHF following their first National Stroke Audit on Irish hospitals last year, access to thrombolysis, experienced stroke physicians, TIA clinics and rehabilitation services remains unavailable across large parts of the country.

There are just 11 stroke units operating in Ireland, representing one sixth of the county’s acute hospitals. In comparison, 90 per cent of acute hospitals in the UK have stroke units.

It is not just patients that could benefit if more specialised stroke units are introduced to hospitals: People who are totally dependent on care are an enormous cost to the state,” explained Dr Maurer. “We know from the experience of other countries that a high concentration of stroke units has an effect in stopping instances of disability.”

According to figures provided by the IHF, the HSE spends roughly €422 million on stroke services per annum. Dr Maurer estimates that €100 million of this could be saved by preventing long-term disabilities and providing extended preventative treatment. These goals could mostly be achieved through ‘restructuring and reorganising our acute hospitals’.

“Capital investment will still be needed,” acknowledged Dr Maurer, “but it will pay in the end.”

Misdiagnosed
The massive cost of caring for stroke patients partly arises from TIAs going undiagnosed. Up to half of all TIAs are missed, and at least 15 per cent of strokes — translating to roughly 1,500 patients each year — are misdiagnosed. Patients who have suffered mini-strokes, if they have not been treated properly, often go on to have full strokes.

This results in far more extensive care being required by the patient. There is not enough work being done on preventative care or reducing the risk of reoccurrence of strokes, argue the IHF.

This situation isn’t the fault of the doctors who treat them, said Dr Joe Harbison, Geriatrician at St James’s Hospital and Secretary of the IHF Council on Stroke.

“Mild strokes can be easy to misdiagnose, or to miss completely. Misdiagnosis usually occurs if the stroke patient is young, if strokes are mild or if they affect the balance centre. They can be mistaken for some other neurological illness.”

Having dedicated services catering for stroke patients is key to ensuring that strokes are diagnosed correctly and that a patient’s health is managed correctly following an attack, the IHF say.

The stroke manifesto claims that TIA services can reduce the risk of repeat mini-strokes or full strokes by up to 80 per cent.

Part of the problem is the shortage of specialist physicians. “Those that have specialisation in the area of stroke care cannot dedicate all of their time to stroke patients,” said Dr Harbison.

Last year, IMT reported that Stroke Unit in St James’ hospital, which Dr Harbison helped to establish, was put in place by reorganising existing services without relying on major capital investments.

Speaking to IMT Dr Maurer said that ‘20 per cent of stroke patients qualify for treatment with thrombolysis, and there’s a three-hour window for administration. At the moment only 7 per cent of stroke patients receive the treatment. We need emergency services to be reconfigured to cope with strokes. We need to introduce telemedicine facilities in all emergency units, providing access to the specialist physicians that stroke patients need’.

“The long-term benefits are substantial — we can save lives, reduce disabilities and save money,” said Dr Maurer.

Atrial fibrillation
“GPs have a huge role to play. They can watch out for atrial fibrillation, check pulses and if appropriate proscribe warfarin. They can aid in the early identification of symptoms, and can help patients to tightly control their blood pressure; for instance by reducing SBP by 10 points, the risk of stroke can be significantly reduced.”
Some studies have placed this relative risk reduction at 31 per cent.

Services in acute hospitals are important, but they’re only part of the solution. The IHF identify a gap in public awareness of stroke. It claims that less than half of people would call 999 if they thought they were having a stroke.

“Because they don’t seek treatment, people are suffering unnecessary disability. The general public has to be taught to recognise symptoms and understand what’s happening,” said Dr Maurer.

The IHF plans to introduce an extensive, five-year public awareness campaign. The campaign will highlight the risk of stroke and introduce people to the FAST acronym, which is used to identify the warning signs of stroke: Facial Weakness, Arm weakness and Speech problem — Time to call 999.

Posted in Guests on 25 November 2009
Tags: stroke