What did we do?
We aimed to improve outcomes for patients by increasing the:
accuracy with which pre-hospital clinicians assess suspected strokes and care needs,
number of correct patient transfers (to the appropriate local hospital) based on the assessment
Currently, pre-hospital clinicians use the FAST (Face, Arm, Speech, Time) test to guide the identification of a patient having a stroke. In Greater Manchester (GM) and Eastern Cheshire, stroke services are centralised into three Hyper Acute Stroke Units (HASUs). Pre-hospital clinicians transfer a patient to a HASU if a stroke is suspected. The North West Ambulance Service (NWAS) in GM and Eastern Cheshire use the GM Stroke Pre-hospital pathway flow chart, which in addition to the FAST test, incorporates clinical exclusions that determine if a patient needs immediate treatment to stabilise a life-threatening situation; in which case patients need transferring to the nearest Emergency Department, before being transferred to a HASU for stroke treatment.
The Greater Manchester Stroke Operational Delivery Network (ODN) developed the Pre-Hospital Pathway Aid (PHPA) app which guides pre-hospital clinicians through the GM stroke pathway with the aim of improving compliance. The PHPA app has been piloted by the ODN and results show potential for the app in reducing pathway breaches. We are now using existing data to better understand why pathway breaches occur and how we could improve.
How did we do it?
Working with NWAS we linked historical ambulance data, with data from Salford Royal NHS Foundation Trust to identify:
Number of cases with a FAST-positive test not given a final diagnosis of stroke (referred sometimes as stroke mimics)
Number of cases with a FAST-negative test that were given a final diagnosis of stroke (referred as missed strokes)
How cases of stroke mimics or missed strokes arise
Using this information, changes were then implemented and tested iteratively and their impact on the stroke mimics and missed strokes rates monitored.
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”. The centralised pathway in GM means that patients with a suspected stroke can receive urgent specialist treatment around the clock. However, if non-stroke patients or unstable patients are transferred in error to a HASU, this can be harmful for the non-stroke or unstable patients and can also reduce the time that staff have at the HASU to provide specialist care to stroke patients. Getting the pre-hospital pathway right can improve care for all patients.
Who did we work with?