The 2018 National Stroke Register highlights urgent need for the reintroduction of the FAST stroke public awareness campaign

The average time from when someone suffers the first symptoms of a stroke to their arrival at hospital in Ireland has increased by 25 minutes over the past three years and some patients delayed seeking help for more than three hours after suffering a stroke, putting them at risk of worse stroke outcomes.

This was one of the findings of the 2018 National Stroke Register Annual Report which was published today (Monday, 7 October 2019) by the HSE and highlights the need for a reintroduction of the FAST stroke awareness campaign.

According to the Report, “the median time of symptom onset to hospital arrival has increased by 25 minutes since 2015 and in nine hospitals the median time to hospital was >3hrs, including four Model 4 hospitals. This would support the need for increased public awareness campaigns such as the FAST campaign.”

The 2018 Register also recorded a high level of ‘wake-up’ or unwitnessed stroke with time of onset recorded as ‘unknown’ in 48 per cent of cases.

A wake-up stroke is a stroke that happens in your sleep. The definition of a wake-up stroke is one where a patient wakes up with stroke symptoms that were not present prior to falling asleep. It is estimated that 20 per cent, or one in five of all strokes are wake-up strokes.

According to the Register, “Data recorded on time of onset suggests high levels of ‘wake-up’ or unwitnessed stroke with time of onset recorded as ‘unknown’ in 48% of cases. The date and time of stroke onset was only recorded in 49% of cases therefore caution is advised when reviewing onset to admission results.”

Last year, 4,817 cases were recorded on the stroke register, with approximately 75 per cent of strokes occurring in over 65s.

Data on thrombolysis (where clot busting medication is delivered) was available in 97 per cent of ischaemic stroke cases treated. This data revealed that thrombolysis was administered in 11.2 per cent of cases where there was a clot in the brain in this stroke population comparable to the UK which reports an 11.5 per cent thrombolysis rate.

The 2018 Register contained some good news in that once they arrive at hospital, stroke patients are being seen and treated quicker than ever before.

It found that overall 71 per cent of patients were seen by the stroke team within 3 hours of admission – an increase from 54 per cent in 2016 – and median door to imaging times (time from when a patient arrives at the hospital to when they receive their first scans) have reduced by 30 minutes to 1 hour 25mins, from 1 hour 55mins in 2017.

Median ‘door to needle’ times (time from when the stroke patient first arrives at the hospital to when they receive thrombolysis) have also reduced and are now under an hour for the first time ever at 58 minutes, reduced from 71 minutes in 2017.

The Register noted that the significant reduction in all three acute stroke processes (door to medical review, door to imaging and door to needle times) “are a direct result of the quality improvement projects undertaken by 20 hospitals through the RCPI Stroke QI Collaborative and all teams are to be congratulated.”

However, the Register also revealed that just 71 per cent of stroke patients were admitted to an acute stroke unit in 2018 which is below the national target of 90 per cent.

Overall the number of people dying from ischaemic stroke has reduced and according to the 2018 register, the in-hospital mortality rate was 11.6 per cent. This compares to the Irish Heart Foundation/HSE National Stroke Audit 2015 rate of 14 per cent.

When reported by stroke type, the register revealed that in 2018 the mortality rate for ischaemic stroke was 7.9 per cent (243/3066) and 32.7 per cent (175/536) for haemorrhagic stroke.

Commenting Mr Chris Macey, Head of Advocacy at the Irish Heart Foundation said, “It was already estimated that every year in the region of 5,000 stroke patients may not be getting to hospital in time to receive potentially lifesaving treatment and the Register’s finding that median time of symptoms onset to arrival in hospital has increased to almost three hours indicates that public knowledge of the need to act fast in the aftermath of stroke continues to deteriorate.

“It is crystal clear that a new FAST campaign will save lives and reduce long-term severe disability. In addition, the cost of such a campaign will be paid for many times over in the reduced need for nursing home care it generates. We hope the funding application submitted recently to the HSE by the Irish Heart Foundation will be successful.

“Aside from delayed presentations clot busting thrombolysis rates remain worryingly low in some hospitals, while at 71 per cent admission rates to acute stroke units remain far below the national target of 90 per cent. This highlights the shortages of stroke unit beds in addition to severe staffing shortfalls across all therapy disciplines that we know has been exacerbated by the latest recruitment embargo.

“On a positive note the latest statistics show a further significant reduction in deaths from ischaemic strokes. In addition, door to medical review and imaging times are down substantially, whilst door to thrombolysis has fallen below one hour for the first time due to quality improvement programmes implemented across much of the acute stroke care network and the extraordinary commitment of stroke teams around the country.”

The 2018 National Stroke Register presents an analysis of all National Stroke Register cases discharged from acute public hospitals in Ireland between January 1st and December 31st, 2018. Analysis is based on the aggregate data of 18 hospitals and measured against previous annual reports. A total of 24 out of 27 hospitals with access to the Stroke Register are currently participating in reporting data, and some hospitals are not yet entering data on all acute stroke patients.

The 2018 report will be the last to be developed by the National Stroke Programme as the National Stroke Register is currently in the process of transitioning to the National Office of Clinical Audit (NOCA).

For more information on stroke please see here