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Service provision

Access to imaging

At the time of implementing the stroke strategy, many clinical imaging departments were using systems that allowed rapid access to CT under NICE Guidelines for Head Injury. This meant that this access to CT scanning for patients 24 hours a day, seven days a week could be utilised for Stroke Imaging.  Following this, many developments have taken place to further improve stroke services, such as the Accelerating Stroke Improvement (ASI) programme which was launched in 2010 by the Department of Health. The ASI further built upon the quality markers outlined in the national stroke strategy and the NICE quality markers developing nine key measures. Those related to imaging were:

●  50% of patients to have received brain imaging within one hour of arrival

●  100% of patients to have received brain imaging within 24 hours of arrival

●  % of high risk TIA patients investigated and treated within 24 hours of first contact with a health professional.

Various methods of collecting data in order to audit stroke services were utilised; one such data collection was performed by The Stroke Improvement National Audit Programme (SINAP) and data collected relating  to imaging  in  stroke circumstances during  2011 and 2012 can be viewed in its final report. 7

There is now just one portal for collecting data related to stroke services and this is the Sentinel Stroke National Audit Programme SSNAP hosted by the Royal College of Physicians: further details and reports on recently collected data can be viewed at

https://www.rcplondon.ac.uk/projects/sentinel-stroke-national-audit-programme

In its annual report, 8 the median arrival-to-scan time was reported as 88 minutes for patients admitted between April 2013 and March 2014.

The report highlights that there are differences in the numbers of patients getting a brain scan within 12 hours depending on what time of day and what day of the week they arrive. There is a very clear contrast with patients arriving after 5 pm who are less likely to receive a scan within 12 hours.  There is also a difference in service between five day and seven day services in terms of access to vascular imaging for high risk patients. The report can be viewed online at:

https://www.strokeaudit.org/Documents/Results/National/2014/2014-AcuteOrgPublicReport.aspx

There are many examples of how imaging departments  developed in order to meet the key measures  outlined in the ASI programme 9  including : improving the patient pathway to the CT scanner, increasing the number of staff ,  utilising radiographer reporting ,  and extending the service.

Image interpretation and further imaging requirements

Interpretation of the images needs to be both rapid and accurate. This may be achieved using a variety of options involving neuroradiologists, appropriately skilled stroke physicians or the use of tele-radiology. A better solution may be suitably trained, competent and authorised advanced practitioner radiographers to provide both imaging and reporting. It should be noted that postgraduate courses in interpretation of head CT images have existed for some years and CT head reporting by radiographers is considered normal practice in many imaging departments.

Those patients who are either unsuitable for thrombolysis therapy, or who do not show a positive response, will need other types of imaging such as chest radiography, either at the bedside  or in the department. They may also have associated pathology which has predisposed them to cerebral infarction, such as peripheral vascular disease, or a history of mobility problems that requires radiological investigation. The Royal College of Speech and Language Therapy has demonstrated the value of early assessment of dysphagia (difficulty in swallowing) which has the potential to cause long term problems. 10  Video fluoroscopy can be useful in the assessment and appraisal of damage; this is undertaken by speech and language therapists in conjunction with radiographers.

Stroke survivors who suffer deficit following a stroke may also suffer ongoing medical problems. These may include pneumonia, urinary tract infections, and thrombo-embolic events and they may also have sustained other injuries at the time of the stroke. In both cases they will be frequent visitors to the radiology department and will require sensitive support, particularly if they have cognitive impairment, in order to explain the imaging procedure to them and enable them to co-operate.

Workforce

The workforce required to deliver effective imaging in TIA and stroke patients includes staff with skill in image acquisition and interpretation, together with more specialised neuroradiological expertise when required. Clerical, nursing and portering staff within the imaging department also need to be considered.

The Society and College of Radiographers would expect all newly qualified radiographers to be competent to undertake emergency unenhanced CT imaging of the brain, following appropriate induction, and preceptorship in departments. However, additional skills will be required to undertake more advanced techniques such as CT and MR angiography and perfusion imaging. There will need to be consideration of how appropriately trained MR radiographers deliver the TIA and stroke service both in and out of hours.

The workforce carrying out carotid ultrasound investigations comes from a wide variety of backgrounds. As duplex ultrasound is operator dependent, ensuring the correct competences are held by this group is essential, and regular departmental audit should be undertaken.

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