Trust introduces a service for mechanical extraction of brain blood clots, treating over 350 stroke patients and reducing their hospital stay

Challenges

 Improvement in outcomes for patients presenting with severe stroke due to large vessel occlusion had changed little over recent years and in order to improve outcomes, major cultural change and radical treatment were needed. At the University Hospital of North Midlands (UHNM), we pioneered the first 24/7 Mechanical Thrombectomy service in the UK for mechanical extraction of the brain blood clots which causes severe disabling strokes or death. The previous conventional treatment of intra-venous thrombolysis was effective in only 15-20% of large vessel occlusive stroke patients. We resigned our stroke pathway by introducing a pioneering mechanical clot extracting interventional technique and produced the largest patient series treated with this technique in the UK with a mortality rate of 17% (top 6 in UK) compared to 40% previously.This new treatment, which offers fresh hope that doctors will be able to reverse the effects of a stroke in some of the most serious cases, has now been adopted by the Department of Health (April 2017) to be rolled out to the rest of the NHS.

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 The treatment – which has been hailed as one of the greatest breakthroughs in recent times – involves inserting a slender tube into an artery in a patient’s groin and pushing it up towards the brain. The blood clot can then be sucked down the tube or removed using a tiny wire. The starting point for this project was to present the case for change to Clinical Governance and gain trust board approval which was obtained in January 2010.

A working group was convened and motivated team leads with a common aim to improve patient safety and clinical outcomes identified. A range of professionals from various directorates were involved in implementing this project with major input from the Interventional Neuroradiology, Stroke Team, Anaesthetics, A & E and ITU. Interventional Radiology nursing and radiographer staffs were also required in providing in and out- of- hours service for this project. Inclusion criteria and patient pathway for this project were defined and agreed at an early stage. The target from onset of symptoms to completion of thrombectomy is 6 – 8 hours. The hyperacute stroke patients are triaged in the A&E and are assessed by the Stroke Team/Neurologists. Patients meeting set clinical criteria are then sent to have specialised imaging of their brain blood vessels (CT Head and angiogram). If a main brain blood vessel occlusion is noted by a radiologist; the patients are then referred to an Interventional Neuroradiologist for mechanical extraction of the brain vessel blood clot. Communication has been key throughout this project and would not have worked without full co-operation between the relevant parties.

The early clinical success created an organisational culture change in treating severe stroke patients and the results of good clinical outcomes were presented to the local clinical commissioning groups and funding was agreed by specialised commissioning and the service was offered on a 24/7 basis. The basic bed day in a Stroke Unit costs £170/day and with added treatment costs it amounts to £350/day. Patients with severe strokes (MRS 4 or 5) have a prolonged stay of 90 days in a Stroke unit which costs £31500/per patient. The community cost for a disabled stroke patient ranges between £28,600/year to £130000/year (patients with MRS 5 with tracheostomy).

Average hospital stay of patients in our series of select patients is now 12 days when compared to 90 days previously. A National Institute for Health and Care Excellence (NICE) analysis published in March 2016 (evidence attached) based on data provided from our service, showed offering the procedure could cost individual commissioning groups up to £500,000 a year but trusts could achieve savings of £2.4 million a year as a result of reduced time in hospital and savings from on-going social care costs.

Results

 UHNM has treated the largest number of patients with this new pioneering method within the UK, having treated more than 350 patients to date and the first UK centre to provide this service on a 24/7 basis since 2010. A peer review study and audit on Mechanical Thrombectomy (MT) on our data published by NICE showed good clinical outcomes with 50% of patients alive and independent with no significant disability (mRS<2). It also showed mortality rates of 17% (top 6 in UK) compared with 40% previously for such subset of patients. The median hospitals stay for patients undergoing MT is 14 days, less than a sixth of the previous figure of 90 days. More than 90% of patients are discharged home, compared to previous situation when over 40% would go to a nursing home because of significant impairment. This also led to an annual saving of £2.4 million for our organization.

Spread

 At UHNM we were the first in the UK to implement this treatment pathway on a 24/7 basis in 2010.

•We contributed to the NICE QIPP data and our cost saving model published by NICE is now being used by numerous other NHS organizations as a vital part of their business planning process for the development of such service at their organisation.

•We have established a website http://www.stroke-in-stoke.info/ containing key information about the service for the benefit of patients and other health care professionals, not only in the UK but around the world.

•We run a “centre of excellence” programme facilitating visits from other NHS Trusts to help them understand the infrastructure and business planning required to develop similar service.

•We run numerous educational courses including the annual “stroke alert course” which has led to increase in our patient referral population from 666,000 (local Stoke-on-Trent) to a wider 2.5 million population of North Midlands, Staffordshire, Shropshire and Wolverhampton.

•We are also a part of “thrombectomy 2020” world-wide campaign which is an attempt to introduce this new treatment to less informed part of the developing world. Our contribution of data through NICE and medical literature has been vital for the NHS England to recommend this state-of-the-art procedure to be rolled out to specialist centres nationwide in April 2017.