National Institute for Health and Clinical Excellence (NICE)
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Stroke prevention surgery 'not performed in time'

More than half of stroke patients in the NHS are not getting early access to potentially life-saving stroke-prevention surgery, according to a report from the Royal College of Physicians and the Vascular Society.

The report published this week highlights the degree of variation, across the UK, in the time between patients first experiencing symptoms of stroke and then receiving preventative treatment.

Carotid endarterectomy is surgery carried out by specialist surgeons to prevent stroke by removing a blockage in the arteries of the neck. NICE guidance recommends that provided the person's symptoms have stabilised, this surgery should be performed within two weeks of a stroke or minor stroke - known as a transient ischaemic attack (TIA).

However, the report reveals that the majority of patients (60%) with symptoms of TIA or stroke are not receiving carotid endarterectomy surgery within the two-week timescale recommended by NICE.

Furthermore, the time between patients experiencing symptoms and receiving treatment varies widely across the UK. Some patients requiring surgery undergo treatment within two days, while others wait nearly two months before receiving it.

Reasons for patients not receiving treatment within the recommended timescale include delays in referral to specialist stroke centres or TIA clinics (41%), and delays in patients visiting their GP or contacting emergency services (25%).

The report calls for the continued promotion of public awareness of stroke and TIA, such as the NHS F.A.S.T. campaign, and urges a reorganisation of services. This is order to minimise any delays resulting from a shortage of operating time, or availability of surgeons.

Summarising the third round of the National Carotid Interventions Audit, the audit questions in the report were based on NICE guidance and the Department of Health's ten-year National Stroke Strategy. This sets a 2017-target of providing patients with treatment 48 hours after showing symptoms. Currently treatment for only 2% of NHS patients is met within this target.

NICE guidelines on stroke, published in 2008, say that 110,000 people have a first or recurrent stroke each year in England. A further 20,000 people have a TIA. More than 900,000 people in England currently live with the effects of stroke. And half of this figure are dependent on other people for help with everyday activities.

David Mitchell, Vascular Society Chair and Consultant Vascular Surgeon, said: “Despite the good work by many clinicians, this study shows that we have a long way to go if we are to meet current NICE guidance of getting 100% of patients who need surgery into the operating theatre within 14 days of symptoms.”

He added: “We know that fast referral to TIA clinics where specialist staff can identify those at high risk of stroke, begin treatment and rapidly refer to the nearest vascular surgery unit for surgery, is absolutely vital in preventing needless strokes and deaths.”

Mr Mitchell also urged clinical teams “to recognise TIA as an emergency requiring a rapid response to deliver high-quality care in a timely manner”.

Dr Geoff Cloud, Consultant Stroke Physician at St Georges Healthcare NHS Trust, added: “The public need to be aware of stroke symptoms as described in the F.A.S.T. campaign and not ignore them if they are only short lived. They also need to know what action to take.

“TIA symptoms require prompt hospital-based investigation in a specialist service to make an accurate diagnosis and start treatment in order to prevent a further TIA or stroke. Such preventative treatment may include carotid surgery.”

NICE published a quality standard on stroke in July 2010. The standard is a list of quality statements that describe a high-quality stroke service.

Both the stroke quality standard and tools for implementation of the guidelines on stroke are available from our website.

All of NICE's guidance, implementation tools and the quality standard on stroke have been brought together in the NICE Pathway on stroke, making it easy to see at a glance everything NICE has recommended on this topic.

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