22 July 2010
Despite previous warnings, patients with symptoms of stroke or transient ischemic attack (TIA or ‘mini stroke’) are missing out on life saving operations because they fail to recognise the symptoms, and when they do, they are routinely treated as low priority cases in the NHS, says a UK surgical audit published today (22nd July). The UK Audit of Vascular Surgical Services and Carotid Endarterectomy, which also flags up significant variations in the quality of vascular care provision in the UK, has prompted surgeons to call for an urgent review of vascular services. Ensuring that these high risk patients are fast-tracked into hospital - in the same way as potential heart attack patients - would avoid hundreds of needless deaths every year.
Irrefutable evidence exists that shows patients who show classic symptoms of TIA – facial or arm weakness, speech problems and blurred vision - are at risk of having a severe stroke if they do not receive surgery of the neck arteries (carotid endarterectomy or CEA) as soon as possible, ideally within 48 hours but no longer than 14 days. However, a lack of public awareness of the symptoms of TIA combined with poor professional understanding of treatment and referral options, mean that instead of being treated as emergency cases at the first sign of symptoms, thousands of patients are waiting weeks or sometimes months for an operation that may be of no benefit by the time they receive it. In practical terms, if patients undergo surgery within two weeks, experts predict that around 200 strokes could be prevented for every 1,000 operations.
The National Institute for Health and Clinical Excellence (NICE) sets a timeframe of two weeks from symptoms to surgery, while the Government’s National Stroke Strategy (NSS) is 48 hours. The audit shows that only 3% of patients made the NSS guideline and approximately a third of patients made the NICE guideline of 14 days. Currently, the average wait from symptom to surgery is 28 days and referral to surgery is 19 days. Most delays in meeting the two week timeframe relate to presentation and referral, with 18% of patients failing to present to a GP or hospital and 40% not being referred on from primary care. However, 18% of patients missed the deadline due to the limited availability of staff or operating time and 9% due to a lack of imaging equipment, prompting surgeons to call for an immediate review of the organisation of vascular services.
The findings come from the second round of the Audit of Vascular Surgical Services and Carotid Endarterectomy, commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Physicians and the Vascular Society. Surgeons say that although improvements have been made since the first CEA audit in 2009, there is still a long way to go.
The report, which also looks at the wider issue of vascular surgical services, also highlights significant regional variations in quality of vascular care provision for CEA and four other conditions, including Abdominal Aortic Aneurysm surgery (AAA) and leg amputation. Vascular surgeons say that to ensure patients are receiving the highest quality care, centralisation of some services will be necessary. Low volume centres hospitals will also need to create vascular networks, merging with other centres in order to ensure that the full range of vascular services, specialist staff, clinics and facilities are available 24 hours a day, 7 day a week.
Each year in the UK, around 120,000 people have a stroke and 20-30% die within a month. Stroke is the largest single cause of significant adult disability, with nearly a million people living with the devastating after-effects. Stroke costs the economy £7 billion yearly and £2.8bn in direct hospital care. Of the estimated 10,000 patients per year who might benefit from carotid endarterectomy only 4,500 operations are performed annually in the UK. Stroke is a preventable and treatable disease and with better recognition of people at highest risk, early surgical intervention can significantly reduce the incidence and severity of stroke.
Professor Ross Naylor, consultant vascular surgeon at Leicester Royal Infirmary and member of the UK Audit Steering Group, said:
“Given the very high initial risk of stroke after a patient presents with their first symptom, achieving the NSS guideline of 48 hours from symptom to surgery must be our ultimate goal and multi-disciplinary team working is key to achieving this. Evidence shows that the best quality of care comes from those centres which are geared up to offer rapid access to TIA clinics which offer immediate access to imaging of the brain and its blood vessels. These centres can then quickly identify high risk for stroke patients, start their medical therapy and arrange for their immediate transfer to the nearest Vascular Surgery unit for urgent surgery. Healthcare purchasers and providers must stop tolerating delays in the system and address the problems. Strokes and TIAs are emergencies and must be treated as such.”
Vascular Society Audit chairman and Consultant vascular surgeon, Mr David Mitchell said:
"This study shows that services are currently not organised well enough to deliver the standards of care set out in NICE guidelines, or the NSS targets. A comprehensive service fit for purpose for urgent carotid surgery is unlikely to occur without centralisation of in-patient vascular services which would be achieved most effectively by the creation of formal networks of specialists working together 24 hours a day, 7 days a week”.
The second round audit of CEA is the largest continuous audit of CEA in the UK. Round two includes almost 7,000 cases carried out between January 1st 2008 and 30th September 2009. This represents 70% of cases reported in Hospital Episode Statistics for the same period (up from 56% in round one) The Vascular Society is urging surgeons to submit data for round three which will report in early 2011.
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Notes to Editors
1. The Royal College of Surgeons of England is committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care. Registered charity number: 212808. For more information please visit www.rcseng.ac.uk
2. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Its purpose is to engage clinicians across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. NCAPOP comprises 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions, including diabetes.
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