Fundraising project for stroke patients 2009 – 2010

Dr Joe Harbison, Consultant Stroke Physician; "Stroke affects people of all ages - and it always seems a disaster. But the great majority can make an excellent recovery. We just need to be organised to react immediately when someone has a stroke and, most importantly, we need to begin their rehabilitation the day they come into hospital."

"We are organised to provide fast diagnosis and intervention for stroke patients. Next steps are to provide improved diagnostic equipment, provide special safe therapuetic seating and provide and equip a special gym dedicated to stroke rehabilitation - all of which is about preventing secondary occurence and trying to ensure that patients revert to living their lives as close to normal as possible."

Stroke is a huge health problem in Ireland but facilities for patients are underdeveloped and outcomes poor; it is the single most frequent cause of acquired physical disability in Ireland and the third most frequent cause of death. A dedicated team at St. James’s Hospital, led by Dr Joe Harbison, is focused on addressing the problem by developing organised specialist care. This team of clinicians now aims to fundraise €250,000 before the end of 2010 to provide a range of specialist facilities that will enable further improvements in the service for stroke patients and ensure outcomes consistent with best practice throughout the world.

Big problem with poor outcomes

Up to 10,000 people suffer stroke annually in Ireland. About one in five Irish people will suffer a stroke in their lifetime, and it is a disease that will strike almost every family in the country in some way.

Outcomes for stroke patients in Ireland are the worst in Western Europe. The risk of poor outcome from stroke, defined as risk of death or permanent disability, is 20% higher in Ireland than the European average and 52% higher than in Germany. The lack of rehabilitation and community facilities has left Ireland with the longest length of stay in hospital for stroke patients in Europe.

The stroke service at St. James’s Hospital

St. James’s is the largest hospital in Ireland, serving a local population of nearly 1/3 million people and one that is comparatively elderly and poor – groups that are disproportionately affected by stroke, suffer worse strokes and are left with more disability and are less likely to return home following treatment.

Clinical research has shown that the hours following stroke are critical to prevent permanent brain damage or paralysis. A dedicated team led by a specialist stroke consultant established a service for stroke patients in 2006 that has focused on early diagnosis and rapid intervention. St. James’s admits about 400 patients with stroke every year – more primary stroke admissions than to any other hospital in the state – and treats all cases as medical emergencies. In 2009 a six-bed acute stroke unit was established in the Acute Medical Admissions Unit – a rapid admissions ward beside the Emergency Department – where immediate non-invasive monitoring is available and skilled emergency staff are available to administer urgent treatment, including clot-dissolving thrombolysis, for patients.

The stroke specialists see all stroke patients within an hour of admission and, since 2006, the one-month mortality for stroke in St. James’s has been reduced from 18% to 11% and the average length of stay has been reduced by seven days.

This dedicated team has made advancements that have helped hundreds of patients. The aim of the service is to focus on the treatment of patients in the immediate hours and days following their stroke with the aim of identifying the cause of stroke, starting appropriate medical treatment and beginning early specialist rehabilitation.

The multidisciplinary team now provides the following services for stroke patients.

• Daily patient review and assessment service by a multidisciplinary team.
• Daily neurovascular and TIA  clinic.
• Daily secondary prevention clinic.
• Outpatient therapy services.
• Speech and language outreach and facilitated discharge service.
• Regular patient and relative information sessions.
• Telephone advice service for discharged patients.
• 24/7 intravenous thrombolysis service (the first in Ireland).
• Intra arterial thrombolysis protocol (the only one in Ireland).
• Pre-operative assessment service for patients with carotid disease.

All progress has so far been achieved by reorganisation, reallocation and borrowing staff and equipment from other departments – together with huge goodwill from all the staff and management of the hospital. This acknowledged, the stroke team has reached a point where further significant development will be impossible without provision of additional equipment and training resources.

Waiting times for rehabilitation

Early intervention is essential for stroke patients. The earlier the diagnosis and the earlier the rehabilitation process begins the greater the chances of full recovery for patients.

Whilst the hospital’s stroke team does its utmost to provide the best care possible for all stroke patients in St. James’s, the hospital has few resources to provide the rehabilitative care needed. From the inpatient point of view, a donation of €20,000 fundraised by Trinity College’s medical students in 2008 helped provide electrical beds and a specialist chair to provide for the acute stroke unit – but the hospital has still no monitoring equipment necessary to meet guideline standards and the physical structure and equipping of the ward is not suited to dependent stroke patients.

Patients admitted to St James’s with stroke typically have to wait several weeks even to be provided with appropriate safe seating or even an appropriate wheelchair and, although the medical and therapy care of stroke patients is becoming increasingly complex, the hospital has little resources to provide continuing training and education of staff.

National guidelines and standards for the care of patients with stroke have recently been published by the Council for Stroke of the Irish Heart Foundation on behalf of the HSE, a process that was led by staff from St. James’s. These new guidelines recommend comprehensive, internationally comparable, standards of care which St. James’s cannot deliver with current equipment or resources. These include standards of monitoring and nursing of acute stroke patients, early sitting out and mobilisation, rehabilitation and effective swallow assessment. Although the hospital has an excellent relationship with the Department of Health and Children and with the HSE, it has been made clear that no additional resources for stroke will be provided.

Planned development

The stroke service at St. James’s has delivered substantial decreases in mortality and disability. It is the hospital’s objective to continue to deliver and add to these achievements.

The hospital now aims to raise the funds needed to provide the essential equipment to improve care for both inpatient and outpatient stroke patients, to provide a dedicated space within which early rehabilitative care may be provided and to train staff in techniques for rehabilitating and caring for stroke patients.
 
The equipment priority is a portable ultrasound system that enables dynamic imaging of blood flow through the major blood vessels in the brain. This item is an essential medical tool for immediate patient diagnosis and determination of the need or not for urgent operation.

A range of versatile and safe and supportive seating for stroke patients is also sought as a matter of priority. The longer patients remain in bed, in the absence of appropriate seating, the longer it is before they can begin rehabilitation and the greater their chances of permanent disability. A portable mini-endoscope is also sought as a matter of urgency to enable the speech therapists to observe vocal cord movement during speech and swallowing assessment and retraining – such equipment can be used immediately at patients’ bedsides eliminating the need to wait until they can be moved to the X-ray department for assessment – again reducing the risk of permanent disability.

Next in order of priority is the provision and equipping of a dedicated rehabilitation unit adjacent to the Acute Medical Admissions Unit so that patients can receive the timely and adequate intensity and duration of therapy appropriate to their physical condition. This will ensure early rehabilitation for patients and increase peoples’ chances of their return to living as normal before stroke.

Training for occupational therapy and physiotherapy staff is also prioritised – the newest therapies are increasingly complex and, to be able to provide the best possible care for patients, it is essential that staff competence is developed.

Other special priorities include additional electrically adjustable beds and a hoist for lifting patients for use on the medical ward for elderly stroke patients.

The stroke team

The stroke team at present comprises one full-time Consultant (partially funded by The Atlantic Philanthropies), a full-time Clinical Nurse Manager 2 (wholly funded by Mercers Institute), a full-time secretary, a shared Registrar (partially funded by The Atlantic Philanthropies), a shared Senior House Officer, a shared Intern, a half-time Senior Physiotherapist and a half-time Occupational Therapist. Speech and Language Therapy support is provided as outreach from rehab wards. Therapy and medical care for elderly patients is provided by the Medicine for the Elderly teams once patients are transferred.

Proposed investment in the Acute Stroke Service at St. James’s Hospital

Contact Us

St. James’s Hospital Foundation
St. James’s Hospital
James’s Street
Dublin 8

Telephone 01 428 4086
Email foundation@stjames.ie