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Transforming Acute Stroke Care Locally and Globally

Project Added:
18 January 2016
Last updated:
1 February 2016

Transforming Acute Stroke Care Locally and Globally

Summary

John Hunter Hospital implemented advanced computed tomography (CT) imaging, which allows patient profiling, prognostic accuracy and personalised acute stroke care. 

This project was the recipient of the Translational Research category in the 2015 NSW Health Innovation Awards. Watch a video of this project (opens new window).

Aim

To improve clinical outcomes in patients who present with acute stroke and reduce the incidence of harmful or futile stroke interventions.

Benefits

  • Provides clinical evidence for the appropriate selection of patients to receive stroke therapy, resulting in better clinical outcomes.
  • Improves medical imaging techniques in radiology departments in hospitals with a modern generation CT scanner.
  • Minimises futile stroke interventions and reduces the risk of serious adverse outcomes, such as symptomatic intracerebral haemorrhage.
  • Provides cost-effective stroke care.
  • Improves access to advanced medical imaging and expert neurological assessment for patients in rural and regional areas, or countries where distance causes inequitable access to healthcare.
  • Improves the effectiveness of clot-busting treatments for acute stroke.
  • Enhances collaboration between pre-hospital and acute care partners, to deliver rapid access to treatment for those experiencing stroke.

Background

Acute stroke is Australia’s leading cause of long-term disability and the second leading cause of death. It is a complex and varied condition, commonly caused by a blood clot blocking oxygen from the brain and leaving it to die or infarct over a period of minutes or hours. Historically, the tools for frontline assessment of prognosis, response to treatment and risk of adverse outcomes were rudimentary.

Although the technology for advanced brain CT imaging was commercially available prior to this project, it had not been used to address the two key challenges in acute stroke care: the ability to identify oxygen deficient but viable brain tissue; and the delivery of clot-dissolving drug therapies to clear the blocked artery. Prior to the project, one in four acute stroke patients had poor outcomes as a result of stroke therapies that were either harmful or futile.

Implementation

  • The acute stroke translational research program took place within a clinical multidisciplinary service, comprising neurologists, stroke nurses, radiographers, radiologists, ambulance officers and emergency physicians.
  • The team developed advanced CT imaging techniques that identified viable brain tissue and reduced the need for costly and potentially risky acute stroke interventions.
  • Using telehealth technology, HNELHD made this advanced CT imaging available to rural health facilities.
  • A new clot agent (tenecteplase) was tested in comparison to a standard treatment (alteplase), to see if there was an improvement in patient outcomes.
  • In partnership with Apollo Medical Imaging, a validated and reliable automated brain perfusion imaging package was developed and implemented in routine clinical practice.
  • As part of the project, HNELHD established the only interventional neurology service in Australia.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

  • Project start: 2006

Implementation sites

  • John Hunter Hospital, HNELHD 

Partnerships 

  • Toshiba
  • Apollo Medical Imaging
  • Agency for Clinical Innovation (ACI)
  • The Australian Commission on Safety and Quality in Health Care (ACSQHC)
  • National Health and Medical Research Council

Results

  • 100% of potential thrombolysis candidates in rural health facilities were provided with access to advanced CT imaging and expert online acute neurological assessment, using the ‘telethrombolysis’ model of care. This process improved diagnostic certainty and allowed for safer and more effective management of acute stroke patients.
  • There was a significant improvement in the delivery of clot-busting therapies, from less than 1% prior to the project, to 5% of patients who presented with ischaemic stroke following implementation of the project.
  • The use of advanced CT imaging to select patients for therapy doubled the proportion of patients with favourable outcomes and reduced the risk of poor outcomes by 80%.
  • In an acute stroke population where 100 patients per annum are treated with alteplase, it was determined that the use of tenecteplase would see an additional 10 patients leave the hospital with full independence and an additional 10 patients avoid death and institutional care. It was therefore shown that the new clot-busting therapy was superior to the standard treatment.
  • The project has been translated into local, national and international protocols and training programs. It is now being adopted internationally in a large-scale, randomised trial of tenecteplase.
  • Phase three of the trial is now underway across Australasia, Europe and North America, in a $4 million project funded by the National Health and Medical Research Council.

Awards

  • 2015 NSW Health Innovation Awards recipient – Translational Research.
  • 2015 HNELHD Quality Awards Winner – Translational Research.

Further reading

  • Bivard A, Levi C, Krishnamurthy V et al. Perfusion computed tomography to assist decision making for stroke thrombolysis. Brain 2015; 138: 1919-1931.
  • Parsons M, Spratt N, Bivard A et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. New England Journal of Medicine 2012; 366: 1099-1107.

Contact 

Professor Christopher Levi
Director of Clinical Research & Translation
Hunter New England Local Health District
Phone: 02 4985 5593
christopher.levi@hnehealth.nsw.gov.au 

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