Following the introduction of the Department of Health’s National Stroke Strategy in 2007 [1], national clinical guidelines [2] and NICE guide- lines [3] for the treatment of acute stroke have been introduced. Since August 2010, these guidelines have been implemented with the aim of admitting all patients with acute stroke to an acute stroke unit with assessment for thrombolysis where appropriate [1]. Thrombolysis for acute stroke is beneficial up to 4.5 hours after onset [4]. However, UK provision of thrombolysis for acute stroke shows wide variability [5].

Various models have been developed to provide a thrombolysis service [6,8]. Frequently, SpRs in neurology, acute medicine or emergency departments are the ‘front line’ medic assessing the patient [8]. Trainees in the UK now have to work within a 48 hour week as stipulated in the European Time Working Directive, creating extra demands when designing service provision for thrombolysis rotas. We wished to assess the involvement of Neurology SpR’s in thrombolysis provision in the UK and collect trainees opinions on the part that thrombolysis should play in general neurology training.

Methods: A survey of 10 questions was emailed to all trainee members of the ABN.

Results: 30 trainees responded to the questionnaire with representatives from all regions of the UK.

Total training in thrombolysis varied from four months on a stroke unit to five years on an on call rota. Only one centre has no exposure to thrombolysis during training. In 32 % of cases the rota consisted of non resident on call overnight with normal working hours the next day. Two centres have reduced 9-5 hours to compensate for the intensity of the on call period and in one centre trainees are only on call till 22:00, to meet EWTD. The move to Hyperacute Stroke Units has meant full shift rotas (with consecutive nights on call) being operated in London with plans for other major centres to adopt a full shift system. Most centres did not have the assistance of a specific stroke nurse out of hours.

The majority (86%) of trainees who responded felt thrombolysis was an important part of general neurology training; however several respondents felt the time spent on a rota should be limited so as not to affect general neurology training. The intensity of antisocial hours was strongly correlated with perception of a negative effect of thrombolysis on training and of stroke as a specialty.

| Sign up to the ACNR email newsletter here |

Discussion

The survey results represent a minority of trainee respondents. However, despite this small number, we have information from all UK centres. The involvement in acute stroke care in the UK by neurology trainees varies widely. Acute stroke provision is changing rapidly in the UK and we are often required to provide the necessary manpower to meet stroke targets The ABNT feel that thrombolysis training is an important part of neurology training. Acute stroke is part of the 2010 neurology curriculum for neurology trainees, but perhaps a minimum time of 6 or 12 months for involvement in acute stroke care should be stipulated. Care should be taken to ensure that this does not detract from general neurology training. This may mean that a maximum period of participation in an acute stroke on call rota should also be defined. 

SUMMARY

• The implementation of national acute stroke care guidelines has dramatically increased the need for ‘stroke specialists’ in the uk.

• These specialists are often geriatricians or neurologists

• Exposure to thrombolysis varies from none to 5 years in UK neurology training centres

• Clear guidelines are needed to ensure optimal exposure to acute stroke care for all neurology trainees whilst protecting general neurology experience both within and out of hours.

References

1. Department of Health. National Stroke Strategy. December 2008

2. Royal College of Physicians. National Clinical Guideline for Stroke. 3rd Edition, 2008.

3. Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). National Institute of Clinical Excellence; Clinical Guideline 68. July 2008.

4. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-29.

5. Lees KR, Ford GA, Muir KW, et al. Thrombolytic therapy for acute stroke in the United Kingdom: experience from the safe implementation of thrombolysis in stroke (SITS) register. QJM 2008;101:863-9.

6. Price CI, Clement F, Gray J, Donaldson C, Ford GA. Systematic review of stroke thrombolysis service configuration. Expert Rev Neurother 2009;9:211-33.

7. Muir KW, Baird T. Set up and run a thrombolysis service for acute stroke. Pract Neurol;10:145-51.

8. Moynihan B, Davis D, Pereira A, Cloud G, Markus HS. Delivering regional thrombolysis via a hub-and-spoke model. J R Soc Med;103:363-9.