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Trust develops a service for mechanical extraction of brain blood clots, treating over 350 stroke patients and reducing mortality rates

ORGANISATION:
University Hospitals of North Midlands Trust
CATEGORY:
HSJ Value Awards 2018/ Acute service redesignHSJ Value Awards 2018/ Improving the value of surgical servicesHSJ Value Awards 2018/ Specialist services
AWARD:
Winner- Improving the value of surgical services Winner- Specialist Services Shortlisted- Acute Service Redesign

Challenge

    • Previous conventional treatment of intra-venous thrombolysis was effective in only 15-20% of large vessel occlusive stroke patients
    • Patients with severe strokes have a prolonged stay of 90 days in a stroke unit which costs £31500/per patient
    • Improve safety and clinical outcome of stroke patients

Action

    • Developed a 24/7 Mechanical Thrombectomy service for mechanical extraction of brain blood clots
    • A slender tube is inserted into an artery in a patient’s groin and pushed up towards the brain to suck the clot
    • Stroke Team/Neurologists assessed hyperacute stroke patients
    • Referred patients to an Interventional Neuroradiologist, if a main brain blood vessel occlusion is noted in CT Head/angiogram imaging

Result

    • Resulted in treating more than 350 patients
    • Reduced mortality rate from 40% to 17%
    • Reduced hospital stay of patients from 90 days to 12 days
    • Improved clinical outcomes and saved £2.4 million annually
    • Resulted in 90% of patients being discharged home (previously over 40% would go to a nursing home because of significant impairment)

 * Please describe the challenges or problems your solution set out to solve.

 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 has now been adopted by the Department of Health (April 2017) to be rolled out to the rest of the NHS.

 * Please describe the actions you took to achieve your result.

 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 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 organizational 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. Average hospital stay of patients in our series of select patients is now 12 days when compared to 90 days previously.

 A NICE analysis published in March 2016 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.

 * Please list the most significant 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.

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.

 * Describe how your project has spread to other teams, departments or organisations

 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 organization. We have established a website http://www.stroke-instoke.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. 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.

Key individuals

Sanjeev Nayak