there is variation in how effiCiently departments use equipment
DISCUSSION Changes in the way stroke and TIA services are being delivered are happening already. Targets have been set and there has already been a substantial improvement in access to timely imaging over the last few years.
For imaging departments there are huge implications. The impetus for TIAs imaging has led to an increase in workload and flexibility that requires a joined-up approach, particularly with vascular surgeons, to offer the complete service. Likewise, stroke physicians will need to ration their referrals for both MRI and carotid imaging because not all patients referred with TIA symptoms require imaging.
There are different strategies that imaging departments can introduce - and some already have - to help achieve these ambitious targets. Carotid arteries can be imaged with US, CT and MR angiography. Adapting to availability of these different modalities can facilitate a 24-hour turnaround. Training other staff, such as nurse practitioners, to provide carotid artery ultrasound screening has also been successfully trialled in Exeter10
. Including stroke and TIA
imaging as part of seven day working can facilitate the development of business cases and designing workflow. MRI brain imaging capacity can be created by providing ‘short scans’. There is no evidence of significant quality loss but patient throughput is increased.
In the urgent stroke setting, training more radiographers to perform CT heads is being encouraged by the Society and College of Radiographers and many centres have implemented this already. Reducing the time between arrival in the accident and emergency department and CT is vital. Paramedics given access for direct referral have reduced time to scan and the concern that there would be subsequent unnecessary examinations has not materialised. Cascade bleep systems, as used in the cardiac arrest scenario, can include the CT radiographer, who can have the scanner ready to receive the thrombolysis patient.
Stroke and TIA imaging should, however, not be seen in isolation and there are numerous other pressures on departments, including recent emphasis on cancer targets and seven day working, to name but two. However, there is a wide variation in how efficiently different departments use their equipment and reviewing all aspects of workflow and patient
throughput is vital10 . The claims that all departments are working to ‘full capacity’ is not
supported by analysis and the National Audit Office is currently linvestigating the utilisation of high cost equipment, including MRI, CT and Linacs. They will be reporting in the spring of 2011.
CONCLUSION The days of passive management in stroke and TIAs are over. Imaging departments cannot rest easy and must engage in the concept of ‘Time is Brain’ to do their part in improving the outcome of these conditions.
Dr Andy Beale is the national clinical lead for radiology and Dr Damian Jenkinson is the national clinical lead for stroke at NHS Improvement.
REFERENCES 1. Department of Health. National Stroke Strategy, London: DH, 2007.
2. Saver JL. Time is brain – quantified. Stroke. 2006; 37(1):263-6.
3. Wardlaw J M, Murray V, Berge E, Del Zoppo G J. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst. Rev. 2009; (4); CD000213.
4. Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischaemic stroke. N Engl J Med. 2008;359(13):1317-29.
5. Ogawa A, Mori E, Minematsu K, Taki W, Takahashi A, Nemoto S, et al. Randomized Trial of Intraarterial Infusion of Urokinase Within 6 Hours of Middle Cerebral Artery Stroke. The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan. Stroke. 2007; 38, 2633-2639.
6. Rothwell PM, Eliasziw M, Gutnikov SA et al. Endarterectomy for symptomatic carotid
stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004; 363 (9413): 915-924.
7. Department of Health. Implementing the National Stroke Strategy - an imaging guide. London: DH, 2008.
8. National Sentinel Stroke Audit, Organisational Audit. Royal College of Physicians and Intercollegiate Stroke Working Party. August 2010.
9. Smith W S, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind D S, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008; 39(4):1205-12.
10. Stroke Imaging Case Studies – Examples of how departments have changed their ways of working to support the delivery of timely imaging for stroke patients. Available from
www.improvment.nhs.uk/ diagnostics.
57 2011
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