Using technology and data to improve the diagnosis and treatment of strokes

Manchester icon Greater Manchester
data saves lives
Researchers will look at the ways that existing data can be re-used to benefit patients.

Project Overview

The signs of a stroke can begin suddenly.  Often, it’s a paramedic that is the first person to assess a patient suffering from stroke and depending on how severe their symptoms are they may be taken to a specialist stroke unit or to their local hospital.

There is a lot of support available for people that have had a stroke.  This support can come from GPs, doctors working in specialist units, from local hospitals and out in the community.  Each of these services record information in their databases but there isn’t any way for doctors, health professionals and researchers to get an overview of how patients flow through and in-between services.

Researchers working on this project will analyse data from different stroke services to develop a comprehensive overview of how stroke patients pass between primary, secondary and community care in Manchester and Salford. Not only will they better understand the patient journey, they will also be able to spot gaps in the care that is offered and suggest improvements to support stroke patients and ensure services are efficient and well-coordinated.

This project will look at four specific aspects of the existing stroke care pathway.

  1. Improving the recognition of stroke by paramedics to maximise the proportion of acute stroke patients taken directly to a specialist stroke centre for timely expert care and minimising the number of non-stroke patients entering the stroke pathway.

  2. Providing timely and focused referral to neurosurgery for patients in Greater Manchester with stroke caused by brain haemorrhage.

  3. Ensuring that all patients get all the right treatments that they need to reduce the risk of another stroke when they are discharged from hospital.

  4. Making sure those patients who are ready to be discharged to the community do not have unnecessary and expensive delays in hospital beds.

 

You can read more about each of these aspects below.

 


Workstream 1:  Stroke Mimics

GM Connected Health City: A learning health system for stroke in Greater Manchester

 

Workstream 1:  Stroke Mimics

 

Leads: Dr Kyriaki Paroutoglou and Chris Ashton

 

What are we trying to do?

Reduce the number of stroke mimics (also known as false-positives) entering and progressing through the stroke pathway.

 

Why is it important?

To deliver high-quality care, it is of paramount importance that the right patients go to the right place at the right time to receive the right care from the right specialists. The 2016 Royal College of Physicians National Clinical Guideline for Stroke states that “Community medical services and ambulance services…should be trained to recognise people with symptoms indicating an acute stroke as an emergency requiring transfer to a hyperacute stroke centre”. In Greater Manchester (GM), specialist stroke units or HASUs (Hyper Acute Stroke Units) are located in three hospitals across the region, providing clot-busting treatments and teams of specialist staff. This centralised pathway means that patients with a suspected stroke should be taken by ambulance to a HASU, rather than their local hospital, for treatment.

 

Currently, paramedics determine whether patients have a suspected stroke and therefore whether or not they need to be transported to a HASU. They do this assessment using the Face-Arm-Speech-Time (FAST) test.  However, in a recent GM study, around half of the patients being taken to a HASU were found to be stroke mimics. Mimics have a direct impact on workload and use of resources in the HASUs, diverting them away from acute stroke patients. This also increases risks for non-stroke patients, as essential treatment for other conditions may be delayed. As many areas of England are now moving towards a centralised pathway for acute stroke, this is likely to be a problem replicated nationwide.

 

How will we do it?

We will link historical ambulance data from NWAS (North West Ambulance Service) with data from Salford Royal, Central Manchester and South Manchester Hospitals, to identify both false-positive (stroke mimics) and false-negative (missed strokes) rates, and to explore how such situations may arise.  Using this information as a foundation, changes will then be implemented and tested iteratively and their impact on the false-positive and false-negative rates monitored. Such changes may, for example, include enhanced paramedic learning through feedback, paramedic access to urgent telephone advice or development of a decision support system.

 

What data sources will we need?

  • NWAS data
  • EPR data from Salford Royal, Central Manchester and South Manchester Hospitals

 

Who are the collaborating organisations?

  • Salford Royal NHS Foundation Trust
  • Central Manchester University Hospitals Foundation Trust
  • University Hospital of South Manchester
  • Greater Manchester Stroke Operational Delivery Network (ODN)
  • University of Manchester/Manchester Academic Health Sciences Centre
  • North West Ambulance Service (NWAS) NHS Trust


Workstream 2:  Secondary Prevention

Workstream 2:  Secondary Prevention

 

Lead: Professor Pippa Tyrrell

 

What are we trying to do?

The aim of this workstream is to improve the quality of secondary prevention for stroke and TIA patients following discharge from the acute setting.

 

Why is it important?

People who have had a stroke or TIA are at increased risk of further events. Approximately 18% of people who have had a stroke/TIA have another within the first three months, and for around two-thirds of these patients, this happens within the first 30 days. Guidelines for stroke management from the Royal College of Physicians state that, for each patient, “People with stroke or TIA should receive a comprehensive and personalised strategy for vascular prevention including medication and lifestyle factors, which should be implemented as soon as possible and should continue long-term.” Such secondary prevention may include, but is not limited to, appropriate blood pressure control, modification of lifestyle factors, use of antithrombotic treatment and lipid-lowering therapies, and surgical intervention for symptomatic carotid stenosis.

 

It is during the transition from secondary to community and primary care, however, that deficiencies in secondary prevention management can arise, particularly for those patients who experience a TIA or minor stroke and are discharged from hospital quickly.

 

How will we do it?

We will bring together historical primary and secondary care data to create a large cohort of stroke and TIA patients and will use this to develop a model to predict those patients who are at highest risk of recurrent stroke/TIA.  This same data will also be used to examine current practice (including variation in practice) in primary care with regards to stroke secondary prevention, and explore the reasons why secondary prevention may currently be suboptimal.

 

We will then apply the developed model prospectively to identify patients most at risk of recurrent stroke and TIA, and informed by our increased understanding of current secondary prevention practices, test and implement changes in how secondary prevention is delivered, focusing on blood pressure control and anticoagulation.  As part of this we will also explore the potential for redefining the role of nursing staff in the stroke post-discharge service, to include a review of secondary prevention within 72 hours of hospital discharge for patients with a higher risk of early recurrent stroke.

 

The activities of this workstream will be aligned to, and supported by, work currently being undertaken by the Greater Manchester Stroke Operational Delivery Network to implement a common integrated stroke model of care across the area.

 

What data sources will we need?

  • Salford primary care data
  • EPR data from Salford Royal Hospital

 

Who are the collaborating organisations?

  • Salford Royal NHS Foundation Trust
  • NHS Salford CCG
  • Greater Manchester Stroke Operational Delivery Network (ODN)
  • University of Manchester/Manchester Academic Health Sciences Centre


Workstream 3:  Intracerebral haemorrhage

Workstream 3:  Intracerebral haemorrhage

 

Lead: Dr Adrian Parry-Jones

 

What are we trying to do?

The aim of this workstream is to reduce death and disability for patients presenting with intracerebral haemorrhage (ICH) in Greater Manchester.

 

Why is it important?

For patients that experience an acute intracerebral haemorrhage (a type of stroke caused by bleeding within the brain), a number of measures are considered critical in the acute phase.  These include rapid reversal of anticoagulation and the lowering of blood pressure, together with neurosurgical treatment which may be indicated for a small number of carefully selected people. Quality improvement work at Salford Royal NHS Foundation Trust using a ‘care bundle’ approach has led to the reliable delivery of these interventions and has been associated with a 9.2% reduction in 30-day case fatality (34.3% to 25.1%). However, a recent audit covering a 7-month period showed that only 25% of the 374 referred to the neurosurgical department initially presented to Salford Royal Hospital, with the remaining 75% of referrals coming from the other 11 Acute Trusts in Greater Manchester. To improve GM-wide ICH outcomes, we aim to implement our care bundle at all acute trusts and ensure equitable access to neurosurgery across Greater Manchester.

 

How will we do it?

We will establish a large cohort of historic ICH patients presenting at several acute trusts, which will provide detailed patient-level information including pre-morbid health, medication, investigations and outcomes.  Using these data, we will identify the factors that predict early deterioration and death within this patient population, as well as predictors of prolonged hospital stay in survivors.   From this, predictive models will be developed and will be used to refine the existing care pathway, ensuring that patients who are at risk of deterioration are identified early and, where appropriate, are referred in a timely manner for neurosurgical intervention at Salford Royal.   We will also investigate the possibility of linking these data to the existing neurosurgical referral database held at Salford, as well as the GM-wide radiology database, to enable us to understand prior referral patterns and decision-making processes.

 

The above will provide the foundation to develop and test multiple, iterative, changes in practice.  This will include implementation of the refined care pathway for patients with intracerebral haemorrhage, but may also include implementation of GM-wide ICH multidisciplinary team meetings, and development of a mobile application (app) to support front-line staff to deliver our acute care bundle. Throughout this period, data will continue to be collected and analysed prospectively from existing data sources and the app, to refine the changes being made and to analyse their impact. We will also establish an automated, prospective, GM-wide ICH registry using the regional radiology database to identify newly-diagnosed ICH patients from scan reports and to track outcomes including length of stay, place of discharge and survival.

 

What data sources will we need?

  • EPR data from Salford Royal and Fairfield
  • Neurosurgery referral database – Salford Royal
  • Live data from the ICH acute care app
  • CRIS regional radiology database

 

Who are the collaborating organisations?

  • Salford Royal NHS Foundation Trust
  • Pennine Acute Hospitals NHS Trust
  • Stockport NHS Foundation Trust
  • Greater Manchester Stroke Operational Delivery Network (ODN)
  • University of Manchester/Manchester Academic Health Sciences Centre
  • Sentinel Stroke National Audit Programme (SSNAP)