Angie Mezzetti reports on a facility that sets a new standard for the successful treatment of people with strokes.
Stroke is the third-highest cause of death in Ireland after cancer and coronary disease, yet it receives less media attention and has never had a national task force to measure its extent or devise a strategy for stroke treatment countrywide.
This may be because it is seen simply as a consequence of age. Stroke, however, is the major cause of long-term physical disability in Ireland and can leave patients and their families devastated. It is also one of the most expensive illnesses for the health service to treat - with an average acute episode running at €7,680 per patient, according to a 2002 study. In the UK, it is estimated to account for 6 per cent of all healthcare spending.
In 2002, a specialised Stroke Unit was opened in the Mater Hospital, Dublin, with its own gym and rehab support services. Units like this have been shown internationally to reduce death and disability of patients by almost 20 per cent.
Moreover, significantly more stroke patients could avail of the state-of-the-art unit in the Mater if second-phase rehab care was made available nearby in Dublin's northside. "All treatments needed in the immediate acute phase are physically located in the same area and this increases the expertise of all service providers and increases the care of the patient, with the end result that they do better," according to Dr Tim Lynch, consultant neurologist at the Stroke Unit - and its outgoing director.
"Occupational therapists assist with strategies for daily living such as dressing and self-care," explains Dr Peter Kelly, director of the service, who specialised in stroke in Harvard Medical School. "Language is commonly affected and trying to find the correct words can cause anxiety and frustration to stroke patients. This can exacerbate their condition and lead to depression. This is where the speech and language therapists make life easier."
Physiotherapists are on site to help with recovery of mobility.There are five consultants - two neurologists and three geriatricians. Other team members are specialist nurses and medical staff, dieticians, physiotherapists and social workers.
"Clinical nutritionists underpin everything we do," Dr Kelly says, "as intake by mouth is often difficult post-stroke. Patients need help with swallowing to make sure food doesn't go down the wrong way. The priority for us all is to limit brain damage and to prevent an early second stroke."
Before the six-bed unit opened, stroke patients could be admitted under any admitting physician and would have ended up in a ward not necessarily geared for the management of stroke. "Only about 50 to 60 per cent of the stroke patients admitted to the Mater currently get into the unit," says Dr Lynch. However, they also have a mobile unit.
"The main problem is the outflow," he says, "patients end up here too long because there is frequently nowhere to send them on for second-stage rehab care."
Dr Kelly, one of only two specialist stroke neurologists in the Republic, says it is an inefficient use of hospital beds and resources to be providing post-acute rehabilitation care in an acute hospital unit.
St Mary's in the Phoenix Park is the Mater's main referral rehab hospital, and there are plans to develop more beds there. But that will still not meet demand on Dublin's northside. Dr Lynch suggests that if St Brendan's and St Bricin's hospitals in Dublin could be used for this phase - especially for those under 65 - more stroke patients could be seen in the dedicated unit and casualty would be more efficient. "The average stay should be five to seven days but it's frequently longer than that."
Developments internationally with new clot-busting drugs embracing a technique called thrombolysis are exciting and have been shown to reduce the likelihood of severe neurological disability by a third in certain cases. Thrombolysis means giving clot-busting medication to dissolve the clot that has caused the stroke. It can be done intravenously or by using a catheter to jam it directly into the clot.
In the minority of cases where it is suitable, if it's delivered by a trained consultant within a three-to-six hour window of the stroke, the recovery can be dramatic. "This is a treatment that is available to patients with acute stroke in many centres of excellence in the US, Europe and Australia and increasingly in the UK. Although licensed here, there have been difficulties in implementing thrombolysis in a programmatic way - because of a lack of medical personnel specially trained in delivering it on a 24/7 basis, and insufficient back-up infrastructure, i.e. stroke units," says Dr Kelly.
Cutting edge developments such as these are some way off and the priority, according to Dr Lynch, is to roll out more stroke units. He believes ideally there should be one in every acute hospital taking casualty admissions. More consultants in neurology are needed too. "At present, there are 14 neurologists in the country and only two west of the Shannon, whereas Denmark has 180 for a similar population."
Limerick was a major pilot area for the Hanly report, he notes, "but there is no neurologist there so the neurology needs were not identified to any huge extent".
Although the Mater's unit has benefited from National Development Programme funding, improvements with patients are making the consultants ambitious to spread success countrywide. It involves even more specialised care but, critically, leads to better and more cost-effective treatment for stroke patients.