Abstract
Re-evaluation of National Institutes of Health Stroke Scale (NIHSS) Score <5 at Sunderland Royal Hospital
Author: Dr Fruzsina Bako (FY2)
Supervisor: Dr Min Myint (Stroke Consultant)
Clinical Audit Registration: CA11032 Cycle 2
INTRODUCTION
Controlling BP minimises the rate of ICH and reperfusion to promote adequate cerebral perfusion (2). Antiplatelets reduce the risk of recurrent stroke and other vascular events (3). Cholesterol reduction reduces the risk of stroke by reducing harming lipids (4). Diet and exercise are independent stroke reducers and positively impacts both weight and blood pressure (5). Smoking cessation can greatly reduce your risk of stroke (7) (8) (9). If carotid endarterectomy takes place sooner the absolute risk reduction (ARR) is increased and the outcome for the patient is much better (1).
STANDARDS AND ETHICS
National Clinical Guideline for Stroke and it is under the section Acute Care Criteria for Carotid Doppler Ultrasound Scan (CDUS) include: Short lived symptoms (TIA), Minor non debilitating symptoms so that they can have further surgery (in this audit we have defined this as NIHSS score <5) and has to be anterior stroke.
Ethic approval was not needed as it is focused on improving the quality of care within routine clinical practice and do not involve interventions or data collection beyond standard acre. The audit was registered with the audit department and the audit registration number is Ca11032.
METHODS
A reevaluation of 49 patients with an (National Institutes of Health Stroke Scale) NIHSS score admitted to E58 in Sunderland Royal Hospital between 21st June 2024- 67th August 2024 were analysed.
Aims and Objectives
Aim:
- Complete cycle 2 of an audit investigating if ward E58 have improved their management of patients appropriate for CDUS
Objectives:
- Document how many patients had their carotid doppler ultrasound scans
- Log how many were seen within 24 hours
- Establish how many patients undergo vascular surgery
- Calculate how long patients were seen between CDUS report and surgery
- Demonstrate how many patients were treated correct with pharmacological therapy including
- Correct statin treatment
- Correct antiplatelet treatment
- Demonstrate how many patients had non pharmacological treatment explored
- Diet , Lifestyle & Smoking cessation
RESULTS
- 100% success rate in all strokes reviewed receiving the correct antiplatelet therapy.
- 25/30 (83.3%) patients were started on cholesterol lowering therapy. This is a three percent increase from last time.
- 4/30 patients (13.3%) were talked to about diet and exercise/lifestyle measures. This is a 2% increase from last time.
The doctors did well in this study and were better at commenting on blood pressure. 18/30 (60%) of patients which is a great improvement as there were only 3% of cases commented on previously.
Only one patient received vascular surgery and they did not have it within seven days. There were multiple factors leading to delay in surgery - they had their CDUS as an outpatient and there was a delay in the aorta CTa being ordered. Then the surgery was booked for 3 weeks after the aorta CTA was reported.
CONCLUSION
What we excel at:
- Prescribing antiplatelet medications and statins to stroke patients
Commenting on blood pressure and ensuring it is in range
Improvements:
Incorporate importance of ordering carotid dopplers within 24 hours of admission into ward induction so each doctor that rotates onto the ward knows to do this.
Take home message:
- There are some systemic issues that need to be addressed such as the ultrasound department only working Mon-Fri 9:00-17:00 so those admitted Friday afternoon- Early Sunday morning will never receive their US scan within 24 hours. Additianlly the stroke department does not have direct influrence on vascular lists so emergencies take
REFERENCES
1.Brott TG. Carotid surgery to prevent stroke. Lancet Neurol. 2004 Aug;3(8):452-3. doi: 10.1016/S1474-4422(04)00818-X. PMID: 15261602.
2.Bowry R, Navalkele DD, Gonzales NR. Blood pressure management in stroke: Five new things. Neurol Clin Pract. 2014 Oct;4(5):419-426. doi: 10.1212/CPJ.0000000000000085. PMID: 25317377; PMCID: PMC4196458.
3.Kamarova M, Baig S, Patel H, Monks K, Wasay M, Ali A, Redgrave J, Majid A, Bell SM. Antiplatelet Use in Ischemic Stroke. Ann Pharmacother. 2022 Oct;56(10):1159-1173. doi: 10.1177/10600280211073009. Epub 2022 Jan 29. PMID: 35094598; PMCID: PMC9393649.
4.Wang W, Zhang B. Statins for the prevention of stroke: a meta-analysis of randomized controlled trials. PLoS One. 2014 Mar 18;9(3):e92388. doi: 10.1371/journal.pone.0092388. PMID: 24643199; PMCID: PMC3958535.
5.Prior PL, Suskin N. Exercise for stroke prevention. Stroke Vasc Neurol. 2018 Jun 26;3(2):59-68. doi: 10.1136/svn-2018-000155. PMID: 30191075; PMCID: PMC6122300.
6.Spence JD. Diet for stroke prevention. Stroke Vasc Neurol. 2018 Jan 13;3(2):44-50. doi: 10.1136/svn-2017-000130. PMID: 30022800; PMCID: PMC6047334.
7.Papadakis, S. & McEwen, A. (2021) Very brief advice on smoking PLUS (VBA+). National Centre for Smoking Cessation and Training (NCSCT), Dorset, UK. September, 2021. https://www.ncsct.co.uk/publication_VBA+.php
8.Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database of Systematic Reviews. 2012
9.Holliday R, Hong B, McColl E, Livingstone-Banks J, Preshaw PM. Interventions for tobacco cessation delivered by dental professionals. Cochrane Database of Systematic Reviews. 2021