Delay in stroke units costing lives

When it comes to caring for stroke sufferers, where the Republic fails by comparison to other countries is in the provision of dedicated stroke units, writes Dr Muiris Houston, Medical Correspondent.

Up to 500 lives are being unnecessarily lost each year in the Republic from stroke. Unlike Northern Ireland, few patients in the Republic are admitted to dedicated stroke units which have been shown to reduce death and disability from the disease by 20 per cent.

With a sharp increase in our elderly population forecast, how much longer can we afford to wait before the State invests in the minimum level of care required by stroke patients?

A stroke is caused by an interruption of the blood supply to part of the brain. The term "stroke" comes from the fact that it usually occurs without warning, hence "striking" the patient out of the blue.

The medical name for stroke is "cerebrovascular accident". The interruption in blood supply is caused either by a blockage of an artery supplying blood to the brain (cerebral thrombosis) or a bleed into the brain from a burst blood vessel (cerebral haemorrhage).

As its name suggests, cerebral thrombosis is caused by the formation of a clot (thrombosis), usually in an artery that is already narrowed and thickened. It is the commonest cause of stroke.

The exact symptoms of stroke depend on what part of the brain loses its blood supply. In about 80 per cent of patients, hemipia, or half-paralysis, results. This may be either partial or complete, depending on the severity of the stroke. There may be loss of power in the arm, the leg and the side of the face.

Loss of sensation on one side of the body is also common; as well as losing feeling in the skin the patient may lose the "sense" of where an arm or a leg is positioned. Loss of vision - affecting half the field of vision, may also occur.

There may be communication difficulties in which the person either cannot express themselves or cannot understand what is being said to them. Swallowing difficulties can follow a stroke - with liquids being more difficult to swallow than solid food. And there may be difficulty controlling bladder function for some people, while others may experience emotional changes so that they laugh or cry inappropriately.

Some 9,500 people were admitted to hospital in the Republic with an acute stroke in 2001; 2,500 of these died. There are approximately 30,000 people in the State with residual disability from stroke - one fifth are unable to walk and up to half of stroke survivors require assistance with ordinary activities of daily living.

The annual incidence of stroke in the Republic is 375 cases per 100,000 of the population aged 45 or older. In the US, the equivalent figure is 352, while in Denmark it is 386, so that our incidence is average in comparison to other developed countries.

The international incidence of stroke has remained steady, although death from the disease has been falling for some decades. However, the projected increase in the older population in the State is likely to lead to an increased prevalence of stroke in the future.

Where the Republic fails by comparison to other states is the provision of dedicated stroke units within our acute hospital system.

In Northern Ireland, 70 per cent of stroke victims receive stroke unit care, whereas it is estimated that less than 5 per cent of stroke patients receive optimal care here. A study of stroke care in a general hospital in the State showed that 45 per cent of patients were not receiving the multidisciplinary services they required.

"There is no complete and comprehensive stroke unit service catering to all those admitted with stroke in any hospital in the Republic," according to Prof Des O'Neill, consultant geriatrician at Tallaght Hospital and Chairman of the Irish Heart Foundation Council on Stroke. "This is a huge missed opportunity to reduce death and disability from stroke by 25 per cent."In a stroke unit, the acute and rehabilitation care of the patient with stroke is under the direct care of a specialist with training and expertise in stroke management. The actual care is provided by a dedicated interdisciplinary team.

Unlike some other medical conditions, where medication or surgery form the main plank of treatment, successful stroke management is based on the intervention of a team of specialist doctors, occupational therapists, speech and language therapists, specialist nurses, social workers, nutritionists and physiotherapists.

The aim of acute care is to control and prevent complications, as well as to reverse the neurological effects of the stroke itself. Ongoing rehabilitation will address speech and swallowing difficulties, regain mobility, balance and awareness and ensure that the patient regains the ability to function independently in terms of washing, dressing, cooking and other everyday activities.

Stroke patients who receive specialist stroke unit care are more likely to be alive and living at home a year after a stroke than those managed in general medical wards. A stroke unit has some effect on the length of hospitalisation, reducing the average stay of a stroke patient by three days compared with a general ward.

A major international review of the effectiveness of stroke units - the Stroke Unit Trialists Collaboration - has shown that the specialist units reduce the chances of a patient dying by 18 per cent, of dying or requiring institutional care by 25 per cent, and of dying or remaining physically dependent by 30 per cent.

In a key audit of the acute stroke service in Tallaght, published in the Irish Medical Journal in May 2000, Dr Patricia McCormack and her co-authors documented some impressive outcomes over a three-year period.

The number of deaths from stroke dropped from 19 per cent to 9 per cent of patients treated in the unit; there was a corresponding rise in those discharged home, from 55 per cent to 68 per cent.

"This study confirms the value to patients of organised stroke care in terms of reduction in death rate and morbidity without increasing length of stay or disability," the authors stated, adding that "every acute hospital [in the State] should have organised stroke care".

The National Health Service framework in Britain has specified that all general hospitals introduce a stroke unit model of care from 2004. However, a recent audit by the Royal College of Physicians suggests there is an inadequate number of beds within the units, limiting the capacity to admit all stroke patients into appropriate care.

In the Republic, despite the overwhelming evidence for the effectivenes, we still await our first fully functioning stroke unit.

"Those who have started initiatives or expressed an interest include Tallaght Hospital, the Mater and St Vincent's Hospitals, Dublin as well as Waterford, Sligo and Limerick regional hospitals. But all are caught for funding and resources," Prof O'Neill says.

And while the present economic climate may not be conducive to health care development, O'Neill has a stark reminder for Micheál Martin: "For every year that the Minister for Health delays the implementation of stroke units, we are losing 300 to 500 lives".