University College Hospital is one of only eight centres in London that has a Hyper-acute Stroke Unit or a HASU as they are known. HASUs bring experts and equipment under one roof to provide world-class treatment 24 hours a day, reducing death rates and long-term disability. The HASU at University College Hospital admits acute stroke patients from across North Central London. The HASU includes:
- Rapid assessment – our patients will arrive at the hospital’s Emergency Stroke Unit based at NHNN and be rapidly assessed by the specialist team at the earliest opportunity
- Early treatment - using clot-busting drugs (thrombolysis), if the scan shows they are needed and world class procedures such as Mechanical Thrombectomy.
- 24 hours a day, 7 days a week monitoring and physiological intervention in a high-dependency bed
- A multidisciplinary specialist team on call 24 hours a day, 7 days a week. This includes consultant neurologists, neurosurgeons, interventional radiologists, specialist nurses and therapists
Half of the patients who come to the HASU with a possible stroke have a different condition. Many of these will be other ‘neurological’ conditions (i.e. diseases affecting the brain, spinal cord or nerves) others will be general medical conditions that are best looked after by general physicians or specialists in elderly care.
The consultant will assess the patient on the HASU daily and order investigations to be completed either as an inpatient or after discharge as an outpatient to ensure that accurate diagnosis is made and appropriate treatment is given.
If a patient arrives within four hours of experiencing stroke-like symptoms, they will be assessed immediately by stroke experts to see whether they have had a stroke. If a stroke is thought likely they will be immediately taken to a CT scanner to ﬁnd out whether their stroke has been caused by a blocked artery (an ‘ischaemic stroke’) or a burst artery (a ‘haemorrhagic stroke’). If a blocked artery is the cause the ‘thrombolytic agent’ (clot- busting drug) is then infused into a vein (‘intravenously’). It circulates around the whole body and a small amount of it will reach the blood clot and usually dissolve it. In some cases the effects are immediate – the stroke symptoms disappear, but even if no beneﬁt is immediately obvious, we know that long terms outcomes are better if this treatment has been given.
Patients get more beneﬁt from stroke thrombolysis the earlier they are treated. We record the exact time that every patient arrives (this is called the ‘door’ time), and other essential steps along the way up to the point where the drug injection starts (the ‘needle’ time). Our door-to-needle times are amongst the lowest in the country and we review the pathway for every case to see how our door-to-needle times can be further reduced.
During their stay on the HASU our patients can expect to meet a variety of health professionals, all of whom bring a very specific set of skills in order to provide excellent quality care.
Our nurses are experts in looking after stroke patients. Many of their skills are those that you would expect from a nurse, overseeing the treatment of their patient, and keeping them comfortable and safe whilst they are on the ward. Our nurses are specifically trained to care for stroke patients and so the team includes a ‘thrombolysis nurse’ who leads the patient through the clot busting therapy part of the overall treatment plan.
Within their first 24 hours on the Unit any patient with a disability (whether from stroke or some other condition) will be assessed by a therapist. A physiotherapist will assess their physical functioning (how they are using their limbs, walking etc.). An occupational therapist will take a broader view of what activities they can manage to do (e.g. cooking, writing etc.) and what help they may need to do these tasks. A speech and language therapist will look at their language abilities and also the safety of their swallowing.
Patients treated at the HASU will soon notice that there is a consultant ward round every single day. The HASU Consultant is supported by a team of junior doctors. The doctor who first sees a stroke patient when they arrive in our hospital is usually a ‘Specialist Registrar’. These doctors are experts in the fields of stroke and/or neurology, so they can make a highly specialised assessment. If they think that a patient is suitable for clot-busting therapy they will always contact the consultant to discuss this.
On the HASU the primary focus of these assessments is to see whether a patient could go straight home from our ward. The therapists will work out whether they can be safe at home, if so what help they would need to keep them safe, and what ongoing therapy needs they may have to continue their recovery at home (e.g. a visiting community therapist).
Patients who are not well enough to go home may need to be transferred to an Acute Stroke Unit (see below) in which case the therapists will produce a detailed report of the patients abilities and disabilities which will be passed on to their new therapy team at the receiving Acute Stroke Unit.
After a day or two about a third of our patients are ready to go home, with the support that they need to carry on getting better if they still have any disability when they leave us. If a patient needs to stay in hospital, they will be transferred to an Acute Stroke Unit near their home. Many of these patients will go to one of the designated Acute Stroke Units in North Central London:
National Hospital in Queen Square (ASU),
the Royal Free Hospital,
the North Middlesex Hospital or the Barnet Hospital,
We ensure that there is a seamless transition of care between the HASU and the Acute Stroke Units at other hospitals.
As soon as the HASU team establishes that a patient will need hospital care for longer than a couple of days, the Repatriation Nurse alerts the Stroke Coordinator on the Acute Stroke Unit that the patient will need transfer to them, and thereafter updates them on a daily basis. This personal contact is extremely important to ensure that we work as a single team, across the whole of North Central London and beyond.
Every patient will be transferred with summaries from the medical, nursing and therapies teams, as well as copies of all of their hospital notes. When the patient arrives at their Acute Stroke Unit, the team there will know every detail of the patient’s care up to that point. The medical summary will concentrate on what the cause of the stroke seems to be, what tests have been done and what the results were, what other investigations need doing and what treatments have been started, what the patient’s nursing needs are, and what the patient can or cannot do.
Specialist rotating staff
The consultants who work on the Acute Stroke Units at the National Hospital (NHNN, part of our own Trust), Royal Free Hospital, North Middlesex Hospital and Barnet Hospital also work as consultants on the HASU at University College Hospital. We work together to maintain excellent relationships between these organisations.
Therapists also routinely rotate between the HASU and the local Acute Stroke Units (although mainly the Acute Brain Injury Unit as this falls within our own Trust). The nurses have also started to develop similar rotations.
In some cases more advanced treatment is required than cannot be provided on the UCLH site and a Critical Transfer Pathway is activated for these patients to allow this care to be provided at NHNN.
This Pathway allows rapid and safe transfer with medical and/or anaesthetic cover either to a high dependency bed at NHNN or directly to the catheter angiography suite to allow mechanical revascularization in selected patients with proximal cerebral artery occlusion.
For these patients subsequent treatment will be provided on the ABIU by the stroke team at NHNN and later on, where necessary, by the stroke team in the local acute stroke unit.
Remember the FAST campaign:
FAST requires an assessment of three specific symptoms of stroke.
- Facial weakness - can the person smile? Has their mouth or eye drooped?
- Arm weakness - can the person raise both arms?
- Speech problems - can the person speak clearly and understand what you say?
- Time to call 999