How the stroke team transformed the service at UCLH

When the pandemic struck last year, teams at University College London Hospitals NHS Foundation Trust (UCLH) and London Ambulance Service (LAS) worked together to find a way to triage and treat patients showing stroke symptoms without bringing them to hospital unnecessarily. 

The idea they piloted from 18th April 2020 hinged on using iPads in ambulances and remotely triaging patients at the scene with the input of stroke consultants via video conference. This has consistently proven that patients having a suspected stroke have been delivered to the appropriate place for the right care, first time, avoiding subsequent transfers. 

LAS paramedics video call the duty stroke consultant at The National Hospital for Neurology and Neurosurgery (NHNN), home to UCLH’s hyperacute stroke unit or HASU. Patients are then referred to either a HASU, a transient ischaemic attack (TIA) clinic or an emergency department (ED) depending on their needs.

Traditionally, all FAST (face, arm, speech test) positive patients were taken to HASU for further assessment and all TIA patients were taken to their local ED for assessment.

LAS and UCLH saw the pandemic as an opportunity to enhance the triage of patients presenting with stroke-type symptoms to ensure that they were conveyed to the best place for their presenting condition.

The video-assisted stroke triage pilot was run across North Central London (NCL), serving a population of about 1.27 million and included the participation of emergency departments and TIA clinics across NCL including Barnet, the Whittington, the Royal Free and North Middlesex.

It has led to faster ‘door to needle’ times for patients requiring intervention, reduced the number of stroke mimics presenting at the HASU and reduced the number of patients suffering from low risk TIAs attending busy EDs.

Additional benefits to patients include minimising potential exposure to COVID-19, being offered an enhanced neurological assessment from a specialist multidisciplinary team and getting faster treatment at their local ED if the likely diagnosis was not stroke. And if they were FAST negative because their symptoms were more subtle, but consultants felt they were still likely to be having a stroke, they were taken straight to HASU anyway.

Every patient’s outcome is being tracked and a scrutiny board meets regularly to review the cases and the safety of the pathway. An independent qualitative evaluation is being undertaken but data from the first 1400 evaluations has shown that the system is safe and reliable, reduced the number of non-stroke transfers to the HASU by more than 50%, achieved major reductions in the time to treatment for TIAs and reduced time to thrombectomy, known as clot retrieval, in eligible patients.

The pilot has been part of UCLH’s response to the pandemic. At the start of the first wave, the HASU was moved from University College Hospital (UCH) to NHNN. As well as freeing up capacity at UCH for treating patients with COVID-19, it has enabled all stroke care to be delivered in one place. Previously stroke patients were moved to NHNN from UCH after they had received initial treatment.

The UCLH and LAS video-assisted triage system is provided 24 hours a day and is now being rolled out across the NHS.

NHS chief executive Sir Simon Stevens told the Ambulance Leadership Forum on 18 May that 30,000 iPads will be issued to ambulance crews across England.

And at UCLH, the ED has now been equipped with iPads, thanks to funding by The National Brain Appeal, so that the stroke team at NHNN can also carry out video assessments to avoid any unnecessary patient transfers to the HASU.

Dr Rob Simister, consultant neurologist and clinical lead for the UCLH HASU said: “The exceptional circumstances of the pandemic and the pressures this placed on LAS and UCLH created the perfect environment to quickly collaborate on safe and effective solutions to ensure suspected stroke patients receive the right care in the right place, first time.

“Moving the hyperacute stroke service from University College Hospital to the NHNN was imperative to free up more space for patients who were critically ill with COVID-19. However, this was more than just moving a ward. It was a massive feat, achieved within three days and with stroke care maintained throughout. With no emergency department on site, the NHNN had to be geared up to be a 24/7 admitting unit, including additional advanced life support training for stroke nurses and a whole new pathway for LAS.” 

“We worked quickly and closely with our counterparts at LAS to create and test video assisted triage and get the new system up and running. It is good for patients and reduces unnecessary journeys for LAS. To say I am incredibly proud of what my colleagues in the stroke service and LAS have achieved in such a short space of time is an understatement.” 

Patrick Hunter, senior clinical lead paramedic at LAS in North Central London, said: “I am so proud of how LAS and UCLH adapted, innovated and collaborated under the extreme circumstances of the pandemic to work together to ensure patients with a suspected stroke get the right care at the right place, first time. The video assisted triage model has resulted in faster and more appropriate treatment whilst safely reducing ED attendance. Working closely with Dr Simister, Dr Salman Haider and the HASU team has provided mutual educational benefits and has been empowering for our staff when making complex clinical decisions.”