Mike Farrar, former chief executive of the NHS Confederation, and advisor at Visonable, explains how technology can play a major role in the prevention and management of strokes and acquired brain injury.
Acquired Brain Injury (ABI) is a leading cause of death and disability affecting over 1.3 million people and costing £15 billion to the UK economy each year. Stroke, which is just one form of ABI, has seen significant improvement in mortality rates over the past 20 years, however the long-term outlook for those patients remains poor. Here are eight practical steps to help stroke and ABI patients.
1. Take stroke patients directly to specialist units
There is strong evidence that taking patients directly to hyperacute stroke units via ambulance will improve their outcome. A faster emergency response to stroke reduces mortality and disability and so we need to empower paramedics to make the decision as to whether to take a patient to a hyperacute stroke unit or to A&E. Technology can play a central role in supporting paramedics to do this effectively. For example, video conferencing telemedicine apps can be used effectively to link paramedics directly to specialist stroke consultants via tablets. These can then also be used to enable paramedics to access a patient's medical record enabling further evidence-based decision making. This is already happening in the East of England through the NHS East of England Stroke Telemedicine Partnership with demonstrable success.
2. Use technology to predict people at risk and avoid relapse
The risk of recurrent stroke is 26% within five years of a first stroke and 39% by 10 years and yet many of these could be prevented if we adopt simple prevention techniques.
Electronic health records (EHR) have the potential to provide additional information that could be used to predict stroke risk and trigger early intervention and yet this is often still not utilised to its potential.
Thinking beyond recurrent strokes, there are also opportunities for prevention initiatives in the community. The Innovation Agency in partnership with the Stroke Association recently launched its successful “Atrial Fibrillation Ambassadors” initiative in a bid to prevent strokes. Volunteers were recruited to use portable ECG devices to identify people who may have atrial fibrillation (AF). The initiative in the North West Coast region is predicted to identify over 1,000 new cases of atrial fibrillation during the initial two year campaign which could prevent up to 34 strokes and save more than £750,000 in associated health care costs.
3. Adopting multi-disciplined approach
In a lot of cases, stroke patients will have multiple conditions that all need managing. Technology can help to facilitate joined-up care and enable multi-disciplinary teams to work more effectively in the co-management of a patient. It’s now very straightforward to host MDT conference calls rather than each consultant treating the individual conditions in isolation. This is something that has proven to be a success at the North West London Cancer Network where, using Visionable’s technology, they were able to allow any clinician to join from anywhere while also allowing participants to simultaneously transmit large amounts of clinical information.
4. Continuous monitoring of those after stroke to predict further episodes
Technology can help with the identification of those at high risk and, in introducing regular monitoring through regular check-ups, help to prevent further episodes. A quarter of all strokes annually, or nearly half of recurrent strokes, could be prevented through simple blood pressure control. The technology exists for patients to continuously monitor their blood pressure from home and yet this is not routinely offered. Additionally, as technology evolves there is the potential for this to expand beyond the use of wearables into the territory of smart homes that can facilitate remote monitoring of things such as gait and balance.
5. Provision of wrap around support for individual patients
Individuals with high vulnerability and complex needs following stroke or brain injury will have wider support needs during rehabilitation. However, patients tend to get referred back to the GP. While there are often well established MTD approaches during the acute phase of recovery, this is often not the case following discharge; the GP will often assume sole responsibility for ongoing care management relying on a patient to report any deterioration. This doesn’t need to be the case - there are lots of opportunities for additional support from, for example, voluntary organisations providing support to families and carers, charity services and community care. The technology is available to link all of this support, to ensure that information and data is shared and where the patient can also see the support that is available to them. Which leads me on to point 6…
6. Patient-orientated support for people post brain injury
Rehabilitation is crucial - not only in helping to achieve the best possible quality of life for a patient post brain injury or stroke. While we are good at providing the physical care that a patient needs, we are less so at meeting their emotional and mental health needs. This is still very much fragmented, and it shouldn’t be. We should take learning from the Maggie Centres which provide holistic support for cancer patients with dedicated cancer support specialists, benefits advisors, nutritionists, therapists, and psychologists. This is something that we are pioneering through our partnership with the charity SameYou. Together we aim to rebalance the current inequality in recovery service provision and reprioritise neurorecovery care.
7. Patient-led care: putting patients in charge of their wellbeing
Many of a patient’s vital signs can now be collected remotely and recorded digitally. Patients are often happy to take responsibility for their own monitoring - and in fact they want to due to the fear of a recurrent stroke. Patients often have a better understanding of their own conditions in that they know when there are subtle changes. When they are educated in the use of monitoring technology and the data it is producing, they are often motivated to stick to the monitoring schedule. Data from Mount Sanai in the United States revealed that 80% of the patients that were taking part in its blood pressure monitoring programme presented issues which could then be managed.
8. Data-led performance management
Data can prove to be a powerful tool for driving improvements. Visible management techniques can be used to understand how people are performing against others. For example, using benchmarks where the clinicians have comparable data on how their stroke unit is performing compared to other units can create a sense of competition and encourage us, as clinicians, to be the best we can be. But, for this to work we must share best practice. It’s not good enough just to tell someone they are not as good as someone else. You must help them to improve.
