Q J Med 2008; 101:291–298 doi:10.1093/qjmed/hcn002 Advance Access published on 5 February 2008
Implementation of a stroke thrombolysis service within a tertiary neurosciences centre in the United Kingdom MICHAEL T. MCCORMICK1, IAN REEVES2, TRACEY BAIRD3, IAN BONE3 and KEITH W. MUIR1 From the 1Division of Clinical Neurosciences, University of Glasgow, 2Department of Medicine for the Elderly and 3Department of Neurology and, Institute of Neurological Sciences, Southern General Hospital, Glasgow, G51 4TF, UK Received 16 August 2007 and in revised form 28 December 2007
Background: Intravenous alteplase is licensed for treatment of ischaemic stroke within 3 h of onset. Up to one-third of patients in the UK present to hospital within this time window but few are treated. Aims: To examine the effect of a stroke thrombolysis protocol on service provision for an acute stroke service in the UK, jointly run by Neurology and Medicine for the Elderly providing a comprehensive stroke service to a local population of 370 000. Design: Prospective observational study. Methods: Data collected prospectively for all thrombolysis referrals over a 12-month period beginning July 2004.
Results: One hundred and eighty-eight patients were referred for potential thrombolysis, 129 transferred, 102 had an ischaemic stroke and 49 received intravenous thrombolysis. Referral rates from primary care and accident and emergency increased after guideline dissemination. Forty-three percent of the 49 patients treated with intravenous rt-PA achieved independence (modified Rankin Scale score 0–2) at 3months. Conclusions: A high proportion of ischaemic stroke patients can be treated with alteplase within 3 h of onset with organized hospital services and dissemination of a simple referral protocol to local primary and secondary care services.
Introduction Intravenous alteplase (recombinant tissue– Plasminogen Activator, rt-PA) treatment within 3 h of onset improves the chances of neurological recovery and functional independence after ischaemic stroke, with a number needed to treat of only eight for one additional person to make a full or nearly full recovery in the National Institute of Neurological Disorders and Stroke (NINDS) trials,1 and with similar proportions of patients having favourable outcomes in post-licensing registries when guidelines have been adhered to.2 The odds for favourable outcome decline as
onset-to-treatment time lengthens.3 The results from the NINDS alteplase trials led to its licensing in the US in 1996.1 Several re-analyses of the NINDS trial data set have subsequently confirmed the benefit,4,5 and alteplase is recommended by British, American and European stroke treatment guidelines.6–8 In April 2003, alteplase was licensed in the UK and other European countries, conditional on a further randomized controlled trial to establish efficacy between 3 and 4.5 h, and the establishment of the SITS-MOST (Safe Implementation of Thrombolysis in Stroke—Monitoring Study) register for all patients
Address correspondence to Dr Michael McCormick, Division of Clinical Neurosciences, University of Glasgow, Institute of Neurological Sciences, Southern General Hospital, Glasgow, G51 4TF, UK. email:
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Summary
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Methods Setting The South Glasgow stroke service incorporates a 4-bedded monitored acute stroke unit within an acute neurology ward, linked to acute stroke care and rehabilitation beds in a dedicated stroke ward. The stroke service provides a local acute stroke service to an urban population of 370 000 in South Glasgow. The Institute of Neurological Sciences additionally accepts regional neurosciences referrals from other hospitals in the west of Scotland (population 2.8 million), including stroke patients on a referral basis. The Institute is one of two referral centres for thrombolysis in the city of Glasgow. Twenty-four hour, 7-day access to neuroimaging is available. Patients with suspected acute ischaemic stroke are discussed with the on-call stroke clinician and transferred if deemed appropriate. (All patients referred with potential strokes from the local health area are transferred, whilst patients’ referred from out-with the local health area are transferred acutely only if deemed potentially eligible for thrombolysis.) Local ambulance personnel had not received
training in the application of specific stroke screening measures at the time of the study. Patients are referred from primary care, hospital wards or accident and emergency departments. The study was performed using a prospective log of all thrombolysis referrals for a 12-month period beginning July 2004. The on-call stroke clinician recorded details of all referrals on a standardized form, including symptom onset time, patient triage, contraindications to thrombolysis and time of acute stroke unit admission if transferred. As per licence, all patients were prospectively registered with the SITS-MOST. Thrombolysis referral guidelines were introduced for the Greater Glasgow Health Board (GGHB) area in October 2004, advising primary care and emergency department physicians to refer all patients with suspected acute ischaemic stroke within 2 h of onset to one of the two designated thrombolysis centres in the city. Guidelines were developed as part of the stroke strategy for the GGHB area, coordinated through a subcommittee of the local managed clinical network and reinforced with meetings in the two respective thrombolysis centres. The subcommittee contained medical representatives from public health, primary care, general medicine, neurology, accident and emergency, nursing staff and allied health professionals. A date was agreed for implementation of the new guidelines across the health board. The thrombolysis referral pathways were specific to Greater Glasgow and were not disseminated to hospitals or primary care physicians outside the health board area. Meetings were held on the two hospital sites providing thrombolysis on consecutive nights and were attended by interested primary care physicians (including out of hours service providers), emergency room personnel and members of the stroke team. Guidelines advised that patients presenting with suspected acute ischaemic stroke within 2 h at the time of initial assessment should be referred to one of two thrombolysis centres in the GGHB (patients from the north of the city to the western infirmary and patients in the south to the southern general). Thrombolysis was first administered in 1996 and was initially given on an ad hoc type basis; provisional licensing of alteplase in the UK in 2003 saw a marked increase in numbers referred and treated and coincided with an increase in the stroke consultant on call rota to 1 : 4 (three neurologists and one geriatrician). Prior to February 2005, patients with suspected stroke were admitted to one off two separate stroke services in the South Glasgow area; however, February 2005 saw the two services amalgamate with all stroke admissions now being admitted through a single service on the
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treated openly with alteplase to provide effectiveness data under real world conditions. Analysis of the SITS-MOST data has subsequently demonstrated that intravenous alteplase is safe and effective when used within 3 h of stroke onset in routine clinical practice in both new and previously established thrombolysis centres.9 Initial concerns that few patients would be eligible due to the short-time window were contradicted by a prospective study in the UK identifying over onethird of patients as being present in hospital within 3 h of onset.10 Improved hospital organization may therefore deliver treatment to a significant proportion of patients, and centres in North America and Europe have achieved treatment rates as high as 20%.11,12 Perceived barriers to wider thrombolysis in the UK are access to immediate radiology and clinical support for a service that has, hitherto, been constructed around a rehabilitation model.13 The recent National Audit Office report; ‘reducing brain damage: faster access to stroke care’, commented that fewer than 1% of stroke patients in England receive thrombolysis annually.14 We describe the implementation of a thrombolysis protocol, including workload and number of patients eligible for treatment. We sought to establish the impact of guideline dissemination on the development of a thrombolysis service within the UK.
Stroke thrombolysis service within a tertiary neurosciences centre in UK
Statistics The impact of the introduction of guidelines was assessed using the chi-squared test. Non-parametric comparisons were made by the Kruskall–Wallis test (values expressed as medians with interquartile range). The concepts of numbers needed to be referred ‘NNR’ and numbers needed to be seen ‘NNS’ were applied. ‘NNR’ was the number of patients who had to be referred in order to administer intravenous thrombolysis to one patient. ‘NNS’ was the actual number of patients needed to be transferred and physically examined to treat one patient (Values being expressed to the nearest whole number). The 95% confidence intervals (CI) for symptomatic haemorrhage were calculated using an adjusted Wald method. Statistical calculations were performed using SPSS version 13.5.
Results Over the study period, 188 patients were referred for potential thrombolysis (15.7/month). Referral rates
increased from 9/month in the first quarter to 24/month in the final quarter. Following telephone discussion 129 patients (69%) were deemed eligible for urgent ambulance transfer. The 129 patients admitted accounted for 29% (129/440) of all admissions to the stroke unit for the same period. One hundred and seventeen patients (91%) transferred acutely had a final diagnosis of stroke. One hundred and two patients (79%) had an acute ischaemic stroke (AIS), 15 patients (12%) an intracerebral haemorrhage (ICH) and 12 patients (9%) were diagnosed as having a conditionmimicking stroke. Of the 102 patients presenting with acute ischaemic stroke, 79 patients (77%) presented within 3 h, of which 46 patients (45%) received intravenous thrombolysis, with one additional patient receiving intra-arterial alteplase. Three patients presenting after 3 h received intravenous alteplase (one basilar occlusion and two with middle cerebral artery occlusion). One patient presenting between 3 and 4.5 h was recruited to a thrombolysis trial and was not included in further analysis. Overall 50 patients (11.4%) out of a total 440 admitted to the stroke unit received thrombolytic drug treatment. For the 312 patients with acute ischaemic stroke, 50 (16%) were treated. By excluding all 59 patients admitted to the stroke unit as tertiary referrals (including the 34 potential thrombolysis patients), there were a total of 383 local admissions, 31 (8.1%) receiving thrombolysis. For the 272 local population patients with confirmed acute ischaemic stroke, 31 (11.4%) received intravenous alteplase. Of the 49 patients who received intravenous thrombolysis, eight patients (16.3%) were aged >80 years.
Referrals The median age of thrombolysis referrals was 69 years (interquartile range 60.79). This was the same median age as for the admitted stroke unit population. There were 63 tertiary referrals from ten different hospitals all within 24 miles of our unit accounting for 34% of all thrombolysis referrals. The local accident and emergency unit (comprising two departments, one on site and another 6.5 miles away) referred 61 patients (32%), primary care 46 patients (24%) and 18 (10%) were hospital in-patients. The introduction of thrombolysis guidelines to the GGHB saw direct GP referrals increase from 0.7/month to 4.9/month, with local A & E referrals increasing from 1.3/month to 6.3/month. Overall referral numbers differed significantly
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southern general site. Service expansion saw the stroke team increase to six consultants (three neurologists and three geriatricians for a 1 : 6 on call rota) complemented by a stroke specialist registrar and senior house officer. The referral sources for the purposes of the study were defined as (A) local accident and emergency (A & E), (B) Primary Care, (C) In-patients and (D) Tertiary referrals. For thrombolysed patients, door to needle time was defined as the time from stroke unit admission to alteplase administration. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS) score. In those patients for whom the NIHSS was not documented, a score was imputed retrospectively from the medical records at admission; blind to knowledge of outcome.15 Reasons for treatment ineligibility and final clinical diagnosis were documented. Brain imaging was repeated at 24–36 h in all patients receiving thrombolysis and symptomatic haemorrhage rate was defined as per SITS-MOST criteria (a parenchymal haemorrhage type 2 plus a neurological deterioration of four points or more on the NIHSS from baseline).9 Functional outcome at 3 months was obtained for patients receiving thrombolysis by face-to-face interview or telephone interview with the patient or carer. Medical and nursing staff trained in using the modified Rankin scale undertook assessments. The results presented relate to patients managed solely by the South Glasgow Stroke Service.
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Number of Patients Referred/Month (95%CI)
9
( X2 = 18.38; p < 0.001)
Table 1 Reasons documented for 57 of 59 patients not transferred acutely for treatment
8 7 6 5 4
Reasons cited for not transferring patients
(n = 57)
Timing Uncertain time of onset Referred outside time window Unlikely to arrive within 3 h Stuttering onset
22 (39%) 11 6 3 2
Stroke severity Mild episode Rapidly improving Deterioration prior to transfer
18 (32%) 12 3 3
Service availability No thrombolysis service available No bed available
7 (12%) 5 2
Relative contraindication to treatment Persistently hypertensivea Poor pre-morbid state Malignancy Recent surgery in the past two weeks History of subarachnoid haemorrhage INR 3.4 Haemorrhagic cystitis
17 (30%) 3 3 2 6 1 1 1
Non-stroke referrals Diagnosis more typical of seizure Known brain neoplasm Non-stroke diagnosis likely
7 (12%) 5 1 1
3 2 1 0
Pre-guidelines
Post-guidelines
In-patient
Other A&E
Local A&E
General practice
Figure 1. Source and number of patients referred for thrombolysis per month pre- (3 months) and post(9 months) guideline implementation with 95%CI. Guidelines saw a significant change in referral patterns (2 = 18.38; P50.001). Monthly referral rates for each source expressed to second decimal point.
Thrombolysis Despite the majority of primary care referrals being transferred, only 15% were treated. The numbers needed to see to thrombolyse one patient was five for GP referrals, compared to two for in-patients, ‘Local A & E’ and other hospitals (Table 2). For those patients presenting within 3 h, the most frequent reason for not receiving treatment was clinical improvement and/or a mild deficit. The median NIHSS of patients not treated on the basis of a mild deficit was 4 (2,4) (Table 3). Twelve percent of patients transferred were found to have had an ICH. Only 9% of transferred patients
a Blood pressure persistently elevated above inclusion criteria (SBP>185 mmHg and/or DBP>110 mmHg).
were non-stroke presentations, the commonest mimic being seizure.
Time to presentation Patients referred from different sources differed significantly in stroke severity (NIHSS), age and time to admission following referral (Table 4). There was no significant difference in onset to referral or door to needle time among groups. Patients referred from accident and emergency or in-patient wards on the southern general hospital site were transferred to the acute stroke unit by internal ambulance, whilst patients from other sites were transferred by emergency (999) ambulance.
Outcome Functional outcome at 3 months using the modified Rankin score was available for all 49 patients treated with intravenous alteplase. By defining independence as a score of 0–2, 43% of patients were independent at 3 months. When compared to the
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in the two time periods (2 = 18.39; P50.001) (Figure 1). Eighty-three percent of GP referrals were transferred, compared to 82% of local A & E referrals, 55% of other hospital referrals and 39% of in-patients. Time of referral was recorded for 154 patients (82%); 138 referrals (90%) were made between 07:00 a.m. and midnight, with only 10% of referrals between midnight and 7.00 a.m. By applying the times of stroke onset and admission, referral time periods for a further 22 patients were estimated resulting in the same proportional breakdown. Only two patients received thrombolysis between the hours of midnight and 7.00 a.m. Reasons cited for not being transferred were documented for 57/59 (97%) patients. Mild stroke severity was the commonest single explanation, present in 21% of non-transferred patients (Table 1).
Stroke thrombolysis service within a tertiary neurosciences centre in UK Table 2
295
Numbers needed referred ‘NNR’ and numbers needed seen ‘NNS’ to treat one patient Local A & E
Tertiary referral
In-patients
Primary care
Overall
Referred (NNR) [95%CI] 61 (3) [2.2–4.7] 63 (3) [2.3–5.2] 18 (5) [2.1–15.6] 46 (7) [3.5–15.8] 188 (4) [3.0–4.9] Transferred (NNS) [95%CI] 52 (2) [1.9–4.0] 35 (2) [1.4–2.7] 6 (2) [1.0–4.5] 36 (5) [2.8–12.2] 129 (3) [2.1–3.3] Treated 20 19 4 7 50 Values expressed both overall and for individual sources. ‘NNR’ and ‘NNS’ rounded to the nearest whole number with 95% CI expressed to the nearest decimal point.
treatment group in the NINDS study, outcomes are similar despite higher median stroke severity at baseline (Figure 2). Three-month functional outcome for the recently published SITS-MOST study are also shown.9 There were two symptomatic haemorrhages, both fatal (4.1%, 95%CI 0.35%, 14.49%).
We were able to treat a high proportion of acute stroke patients with intravenous alteplase within 3 h, with safety and efficacy outcomes consistent with those seen in randomized controlled trials. Referral rates increased significantly after dissemination of simple guidelines to primary care and local emergency departments. This prospective registry also emphasizes the different referral routes taken by patients dependent on symptom severity. Our findings suggest that patients who contact primary care differ fundamentally from those who contact hospital services directly, with primary care referrals having less severe strokes and thus providing a possible explanation for cited delays in hospital presentation.10 In order to treat the greatest proportion of eligible patients, it appears that optimal organization of in-hospital treatment pathways, and ambulance transfer prioritization, are likely to be most effective. The current short-time window for treatment means that provision of thrombolysis is a challenge to service organization at several levels. However, our experience mirrors that in stroke centres in other countries, and indicates that a high proportion of patients can be treated. Strategies for increasing treatment availability may vary depending upon local circumstances. Cited barriers include public recognition of stroke symptoms, delays in contacting emergency services, triaging patients in the community and on arrival to emergency rooms. Additional reasons suggested to explain poor service implementation include limited access to rapid neuroimaging, experienced service providers and
Reasons cited for patients transferred not being treated (n = 78) Acute ischaemic stroke Arrived outside time window (on arrival at ASU) Clinical improvement Mild deficit Uncertain time of onset Severe deficit (established CT changes) Significant comorbidity On warfarin (increased INR>1.3) Severe hypertension (refractory to treatment) Recent surgery
51 patients 19 15 13 7 4 4 1 3 2
Intracerebral haemorrhage
15 patients
Non-stroke Migraine Benign paroxysmal positional vertigo Seizure Functional Alcohol related Gastrointestinal haemorrhage Urinary sepsis
12 patients 2 1 4 2 1 1 1
the impact of geographical location and choice of presenting hospital.13,16 Despite a perceived deficit in patient knowledge of stroke symptoms, 37% of 739 patients presenting to 22 different hospitals in the UK and Ireland arrived within 3 h of onset in a multicentre observational study.10 The value of public education campaigns targeted to stroke symptom awareness is uncertain, but our findings suggest that this might expedite less severe strokes being brought to medical attention. The likelihood of a subsequent increase in the presentation of stroke mimics is a recognizable concern for resource implications. Screening procedures have been implemented elsewhere for both ambulance and accident and
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Discussion
Table 3 Reasons documented for patients transferred and not treated
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Table 4 Median age and stroke severity (NIHSS) for each referral source
Age (year) (n = 181) Onset to referral (mins) (n = 150) Referral to admission (mins) (n = 104) NIHSS (n = 113) Door to needle time (mins) (n = 49) Onset to treatment (mins) (n = 49)
In-patients
Local A & E
Tertiary Referral
Primary Care
P-value
82 60 60 16 40 153
71 90 35 9 33 160
66 105 60 13 25 170
70 85 55 5 40 175
50.001 0.184 0.002 0.002 0.079 0.650
(77,87) (30,123) (44,98) (8,24) (31, 49) (125,180)
(59,80) (65,125) (30,55) (4,15) (20,60) (150,180)
(55,72) (70,120) (45,70) (9,21) (20,35) (150,185)
(62,81) (50,120) (37,75) (3,11) (35, 75) (160,180)
Median Onset to treatment time expressed for patients receiving IV alteplase only. (onset to referral, referral to admission and door to needle times (mins) shown for respective patient numbers when sufficient data available). All values expressed in medians with (Q1,Q3) in brackets. Values compared across groups using Kruskal–Wallis test.
27
NINDS Placebo group (n = 312)
52
21
43
40
17
South glasgow treated patients (n = 49)
43
41
16
55
SITS-MOST (n = 6136) 0%
20%
34 40% 0-2
60% 3-5
80%
11 100%
6
Figure 2. Outcome at 90 days for the 49 patients treated with intravenous rtPa (measured using the modified Rankin scale). Outcomes compared to treatment and placebo groups for the NINDS study and the SITS-MOST population. (Modified Rankin scale: 0–2 Independent; 3–5 dependent; 6 dead.)
emergency personnel to improve patient recognition and referral.17–19 Pre-hospital paramedic use of the FAST (Face Arm Speech Test) stroke identification instrument, which assesses facial weakness, arm weakness and speech impairment enabled 68% of patients with confirmed stroke or TIA to arrive directly in hospital within 3 h of stroke onset.20 The proportion of non-stroke admissions was similar for paramedics, primary care and emergency room physicians. To improve the triage and disposal of stroke patients attending emergency departments, a similar screening tool (ROSIER: recognition of stroke in the emergency room) has been developed.19 With the recognition of stroke as a medical emergency and quicker hospital presentation eligible patients may still face in-hospital barriers to treatment in many centres with limitations on immediate brain imaging and availability of suitably experienced medical staff. Local guidelines saw a 7-fold increase in primary care referrals, 83% being deemed eligible for transfer. Median time from stroke onset to stroke unit admission for GP referrals was 140 min (105 min, 165 min). Stroke severity was significantly
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NINDS treatment group (n = 312)
less for referrals from primary care, consistent with the severely affected stroke patients utilizing emergency services for transfer to hospital. The smaller proportion of patients treated from primary care may reflect clinical uncertainty about the risk-benefit ratio in less severe stroke. This may be unjustified, since stroke severity was not defined as an entry criterion for the NINDS trial, and post hoc analysis of the trial using multiple different definitions of mild stroke, found no difference in the odds of favourable outcome compared with the trial results as a whole.5 In an analysis of patients admitted to Calgary within 3 h of stroke onset, the commonest reason for treatment exclusion was mild stroke (13.1%) or clinical improvement (18.2%). However, of those patients not treated on these grounds, 32% remained dependent at hospital discharge or died during hospital admission.21 Avoidance of treatment in mild stroke may reflect understandable reluctance in the face of a perceived risk of treatment. Unfortunately, we were unable to provide details of outcomes on patients not transferred after referral. Emergency department triage may be an important determinant of service provision. For approximately every two patients transferred, one was treated. Despite large distances, delay beyond 3 h was a reason for non-treatment in only 19% of patients transferred with acute ischaemic stroke. Three patients referred within 3 h were not transferred, as it was felt unlikely they would arrive within the desired time window. Numbers of patients not referred by other hospitals cannot be defined by this study. Despite no significant difference in onset to referral or door to needle time, the median door to needle time was much shorter for local (33 min) and tertiary (25 min) referrals compared to in-patient and primary care referrals (40 min each). An explanation is that referrals from local A & E departments and tertiary referrals have venous cannulation and blood sent
Stroke thrombolysis service within a tertiary neurosciences centre in UK
Limitations of the study include the relatively small number of patients; however, the study represents an accurate record of workload to a single centre in the UK. It documents problems encountered and avenues for service development in potential or established centres. Data were collected to document the true workload of thrombolysis over 1 year, including both local and tertiary referrals. Seasonal variation may contribute to the increase in local referrals, but referrals consistently increased beyond the winter months.28
Conclusion Provision of intravenous thrombolysis to a high proportion of ischaemic stroke patients is feasible in a predominantly urban population in the UK through introduction of referral guidelines to primary care and emergency departments. Over 90% of patients transferred for treatment had a final diagnosis of stroke. Patients who seek primary care physicians have less severe deficits than those who self-refer to hospital. If a local thrombolysis rate of 11% were replicated in centres throughout the UK, with an estimated 150 000 strokes per year, 16 500 patients would receive intravenous alteplase with 2640 additional patients achieving independence.
Acknowledgements We Dr Michael McCormick and Dr Keith Muir have the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence on a worldwide basis to Quarterly Journal of Medicine to permit this article (if accepted) to be published. MMCC and KWM conceived the study and designed the initial data collection form. TB, IR and IB contributed to further drafts of the data collection form. MMCC with KWM wrote the first and final draft of the paper. TB, IR and IB critically appraised the paper and contributed significantly to draft revisions. KWM is guarantor. All authors have seen and approved the final version. Ethical approval: The study design did not require a formal ethics submission following discussion with the local ethics committee. Dr McCormick was supported by the Stroke Association, UK (TSA03/ 06). The research was carried out independently.
References 1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581–8.
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prior to transfer and results available at the time of CT image interpretation to enable rapid thrombolysis decisions. Transfers from other hospitals would be routinely advised not to scan patient’s prior to transfer and thus negate any potential delays. While provision of stroke unit care has been a necessary priority because of its moderately large absolute benefit and wide eligibility,22 thrombolysis has a large additional population benefit when delivered to a high proportion of patients, and also ensures more rapid stroke unit admission. If 11% of all ischaemic stroke patients could be treated with alteplase in the UK as a whole, there would potentially be an additional 2640 disability-free survivors annually. Further, this would be expected to have a disproportionately greater benefit since most eligible patients have more severe strokes.23 It further emphasizes that stroke is a medical emergency, with the potential benefit of more rapid access to diagnostic services and organized stroke care even for patients not suitable for treatment. The ideal model for thrombolysis provision remains uncertain. Centralization around designated ‘Primary Stroke centres’ in the US and some European cities 24 may require significant reallocation of resources and have been criticized since transport of patients who are not treated may impede their entry into an organized stroke unit with detrimental effects. Telemedicine and teleradiology may overcome obstacles in geographically remote sites and may reduce inappropriate transfers.25 The implementation of a telemedical stroke service in Bavaria, Germany with the TEMPiS (Telemedic Pilot Project for Integrative Stroke Care) trial saw rapid access to stroke expertise and image interpretation for patients in community hospitals up to 60 km from the nearest stroke unit.26 Heightened public awareness of stroke as an acute treatable emergency in conjunction with widespread dissemination of thrombolysis guidelines will increase demands on stroke services. To meet such demands will be challenging, particularly in the context of changes in the UK Consultants Contract and impact of the European working time directives. Provision of stroke thrombolysis in district general hospitals outside the model of stroke centre care will need to consider out of hours staffing requirements and imaging availability. Only 30% of the total number of patients receiving thrombolysis in our unit were treated within the typical working hours of Monday–Friday 09:00–17:00.27 Numbers treated also underestimate the true workload with one patient being thrombolysed for every four referrals discussed and every three transfers.
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