Potential for quality improvement of acute stroke management in a district general hospital

Background: Stroke units and thrombolysis are evidence based treatments for stroke patients. Few studies have prospectively assessed the success of, and obstacles to implementation of such strategies in patients admitted to district general hospitals. Objective: To document delays in admissions of acute stroke patients to hospital, failures in accessing a stroke unit and the clinical impact of missed opportunities for intervention in acute stroke patients. Design, setting and methods: Prospective observational study in a district general hospital in Northern Ireland. Delays, demographic details, risk factors, stroke severity and classification were recorded prospectively in all stroke patients admitted to a district general hospital from 22 March 2004 until 21 March 2005. Using established numbers needed to treat to prevent disability or death, the clinical impact of the lost opportunities was determined. Results: Of 171 acute stroke patients 115 (67%) spent some or all of their hospital stay in a stroke unit. Less severe strokes, living alone and attending a general practitioner all independently delayed hospital admission. Nineteen (12.5%) ischaemic stroke patients would have been eligible for intravenous thrombolysis treatment. Admitting all patients to the stroke unit would have gained independence for two patients, allowed two more patients to live at home, and prevented one death. Failure to thrombolyse eligible acute ischaemic stroke patients resulted in six patients having more disability, two of whom may have lost their independence. Conclusions: Improved stroke unit access is required in this district general hospital. Reorganisation of acute stroke services should allow thrombolysis for acute ischaemic stroke in most district general hospitals.