Thrombectomy Service Survey
Stroke is the third leading cause of death in Europe and the leading cause of disability in the UK.
Mechanical thrombectomy is becoming a standard of care for the treatment of acute ischaemic stroke. Leading medical bodies such as NICE, AHA/ASA and ESO recommend its use and are encouraging the setup of organisational systems to facilitate the implementation of this service which now has strong evidence from high quality RCTs for its safety and efficacy in improving functional outcomes at 90 days follow-up (1-4).
The problem:
With the anticipated rise in the numbers of thrombectomy cases and its implications on anaesthetic service provision we feel that there is room for improvement on the already existing organisational setups for providing this service in the NHS.
The Aim of this survey:
We aim to gather information on current practices and organisational setups within the NHS to provide a platform for sharing ideas and best practices to help improve the service provision of this rapidly growing service.
We would like you to complete this survey as linkman on behalf of your DEPARTMENT. If you have a lead for neuroanaesthesia in
radiology it may be more appropriate that you get them to
complete this survey – but please ensure that they do – if you pass
it on.
Thank you for your assistance
Dr Mazen Elwishi Locum Consultant Neuroanaesthetist
Dr Judith Dinsmore Consultant Neuroanaesthetist
St George’s Hospital
London
10.1161/STR.0000000000000074. Epub 2015 Jun 29. 2015
American Heart Association/American Stroke Association Focused
Update of the 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.
10.1177/1747493015609778.
Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN.
Standards for providing safe acute ischaemic stroke thrombectomy services (September 2015) White, P.M. et al.
On behalf of which adult neuroscience centre are you responding?
Answer No Responses Percent
| ABERDEEN | 1 | 3.70% |
| BARTS and THE LONDON | 1 | 3.70% |
| BELFAST | 1 | 3.70% |
| BIRMINGHAM | 1 | 3.70% |
| BRISTOL | 1 | 3.70% |
| CAMBRIDGE | 1 | 3.70% |
| CARDIFF | 1 | 3.70% |
| CHARING CROSS | 1 | 3.70% |
| DUNDEE | 1 | 3.70% |
| EDINBURGH | 1 | 3.70% |
| GLASGOW | 1 | 3.70% |
| KING’S COLLEGE | 1 | 3.70% |
| LEEDS | 1 | 3.70% |
| LIVERPOOL | 1 | 3.70% |
| MANCHESTER (SALFORD) | 1 | 3.70% |
| MIDDLESBROUGH | 1 | 3.70% |
| NATIONAL | 1 | 3.70% |
| NEWCASTLE-UPON-TYNE | 1 | 3.70% |
| OXFORD | 1 | 3.70% |
| PLYMOUTH | 1 | 3.70% |
| PRESTON | 1 | 3.70% |
| PRINCESS ROYAL /
BRIGHTON |
1 | 3.70% |
| QUEENS, ROMFORD | 1 | 3.70% |
| SHEFFIELD | 1 | 3.70% |
| SOUTHAMPTON | 1 | 3.70% |
| ST GEORGE’S | 1 | 3.70% |
| STOKE-ON-TRENT | 1 | 3.70% |
27 response(s)
Do you have interventional neuroradiology available at you neuroscience centre?
Answer No Responses Percent
| Yes | 25 | 92.59% |
| No | 2 | 7.41% |
27 response(s)
Does your institution provide dedicated sessional / timetabled / job planned anaesthesia cover for interventional neuroradiology in your hospital?
Answer No Responses Percent
Yes 100.00%
25 response(s)
Who provides this timetabled / job planned cover?
Answer No Responses Percent
| neuroanaesthetists exclusively | 14 | 56.00% |
| neuro / general anaesthetist
mix |
9 | 36.00% |
| Other Answers | 2 | 8.00% |
Other Answers:
plus locums who are comfortable in neuro radiology
we aim to provide a neuroanaesthetist for all timetabled neuro ir sessions but due to staffing shortages we have to use locum general anaesthetists on occasion.
25 response(s)
Please select the days of the week and sessions that your institution has timetabled / job planned anaesthesia sessional cover for interventional neuroradiology
am pm evening
| Monday
|
18
|
20
|
2 |
| Tuesday
|
17
|
18
|
2 |
| Wednesday
|
19
|
17
|
2 |
| Thursday
|
15
|
17
|
2 |
| Friday
|
21
|
19
|
2 |
| Saturday
|
4
|
3
|
0 |
| Sunday | 2 | 1 | 0 |
42 response(s)
Does your centre provide an out of hours emergency / on-call interventional neuroradiology service at evenings and / or at weekends?
Answer No Responses Percent
16.00%
Yes but only at weekends 2 8.00%
| Occasionally dependent on
neuroradiology rota |
11 | 44.00% |
| Add hoc only on direct approach to neuroradiologist – no formal on call service | 4 | 16.00% |
| Other Answers | 4 | 16.00% |
Other Answers: accommodate ad hoc requests as well
ad hoc out of hours, neuroradiology on call service daytime sunday but no dedicated anaesthetic service, provisioned from current on call team. daytime cover at weekends
unless both of interventionosts are away
25 response(s)
Who usually provides the anaesthesia cover for out of hours interventional neuroradiology at your institution?
Answer No Responses Percent
| Consultant neuroanaesthetists | 10 | 40.00% |
| Consultant general
anaesthetist |
1 | 4.00% |
| Consultant neuro or general
anaesthetists mix |
7 | 28.00% |
| Neuroanaesthesia fellow / SpR | 1 | 4.00% |
| General Anaesthesia SpR | 1 | 4.00% |
| Other Answers | 1 | 4.00% |
| No Answer | 4 | 16.00% |
Other Answers:
no formal cover, but if an intervention is needed as an emergency the consultant neuroanesthetist and the neuroanaesthesia trainee on call would cover the case
21 response(s) , 4 No Answer(s)
On average, how frequently do you currently provide anaesthesia/sedation for thrombectomy cases in your institution?
Answer No Responses Percent
| None in last 12 months | 1 | 4.00% |
| Less than 2 cases a month | 12 | 48.00% |
| Approx 2-3 cases a month | 1 | 4.00% |
| Approx 1 case a week | 5 | 20.00% |
| More than 1 case a week | 2 | 8.00% |
| No Answer | 4 | 16.00% |
21 response(s) , 4 No Answer(s)
Do you currently have an anaesthetic protocol / guideline for mechanical thrombectomies in your centre?
Answer No Responses Percent
| Yes | 11 | 44.00% |
| No | 8 | 32.00% |
| Other Answers | 2 | 8.00% |
| No Answer | 4 | 16.00% |
Other Answers:
but we intend to produce some over the next 12 months. in process of being formalised
21 response(s) , 4 No Answer(s)
Please tick the box if your protocol / guideline includes recommendations on the following
Answer No Responses Percent
| Seniority of cover | 12 | 70.59% |
| Technique (eg LA, sedation or
GA etc) |
10 | 58.82% |
| Airway management (eg IPPV
vs SV etc) |
10 | 58.82% |
| Anaesthetic drugs | 6 | 35.29% |
| Monitoring to be used ( eg
NIBP vs art line, ECG etc) |
10 | 58.82% |
| BP parameters (eg range and
intervention triggers) |
10 | 58.82% |
| Post procedure destination | 11 | 64.71% |
| Other Answers | 3 | 17.65% |
Other Answers: none
protocol for sah patients
technique is variable dependent upon the patient, awake with non invasive monitoring if cooperative, i&v ga with invasive monitoring if not, drugs as individual selection, post thrombectomy destination dependent upon clinical need, acute stroke ward, hdu or itu.
17 respondent(s), showing percentage as a maximum of 100% per
answer (multiple checkbox selection)
Which is the usual / preferred starting anaesthetic technique offered in your centre for mechanical thrombectomies?
Answer No Responses Percent
| General Anaesthetic | 4 | 16.00% | ||||
| Conscious sedation / LA | 7 | 28.00% | ||||
| Variable | 9 | 36.00% | ||||
| Other Answers | 3 | 12.00% | ||||
|
Other Answers: |
2 | 8.00% | ||||
| depends on the nhiss score and the gcs none
prefer la without sedation initially
|
||||||
| 23 response(s) , 2 No Answer(s) What or whom drives this preference?
|
||||||
| Answer No Responses | Percent | |||||
| Radiologist preference | 3 | 12.00% | ||||
| Anaesthetist preference /
choice / availability |
2 | 8.00% | ||||
| Each case individually discussed between radiologist and anaesthetist | 17 | 68.00% | ||||
| No Answer | 3 | 12.00% | ||||
22 response(s) , 3 No Answer(s)
Where do (or would) patients usually / routinely go post thrombectomy procedures in your institution?
Answer No Responses Percent
| Recovery then monitored /
level 1 bed on stroke unit |
9 | 36.00% |
| Recovery then Neuro
ICU/HDU |
6 | 24.00% |
| Straight to Neuro ICU/HDU
from radiology suite |
1 | 4.00% |
| Other Answers | 6 | 24.00% |
| No Answer | 3 | 12.00% |
Other Answers: depends – l2 in hdu or repatriated to stroke ward in referring hospital. depends on itu capacity & clinical indications for most appropriate destination
ideally to stroke ward and if escalated care required to general hdu individual patient clinical need dictates destination after recovery be it acute stroke ward, hdu or itu.
its on a case by case basis – most go to neurology wards, but we’d like to change this if a foral service comes into being recovery then high care neurosurgical ward unless ga and unstable
22 response(s) , 3 No Answer(s)
Does your institution have a pre-hospital activated alert system for receiving and fast tracking stroke patients?
Answer No Responses Percent
Yes 17 68.00%
| No | 5 | 20.00% |
| No Answer | 3 | 12.00% |
22 response(s) , 3 No Answer(s)
Who does that system alert / call / activate?
Answer No Responses Percent
| ED / A&E | 11 | 55.00% |
| on call Stroke team | 19 | 95.00% |
| on call neuroradiology
consultant or fellow |
7 | 35.00% |
| on call neuroanaesthetic
consultant |
2 | 10.00% |
| on call anaesthetic Registrar | 2 | 10.00% |
| on calll general anaesthetic
consultant |
1 | 5.00% |
| ODP | 2 | 10.00% |
| ICU SpR / Fellow | 1 | 5.00% |
| ICU consultant | 1 | 5.00% |
| Other Answers | 3 | 15.00% |
Other Answers:
once a decision has been made to proceed to stroke thrombectomy the anaesthetic consultant co-ordinator, neuroanaesthetic registrar on-call and odp co-ordinator are all bleeped starred consutlant holding the thrombectomy bleep
stroke specialist nurse
20 respondent(s), showing percentage as a maximum of 100% per
answer (multiple checkbox selection)
Do you feel that providing a 24/7 thrombectomy service is feasible at your institution with your current staffing numbers?
Answer No Responses Percent
| Yes | 4 | 14.81% |
| No | 21 | 77.78% |
| Other Answers | 2 | 7.41% |
Other Answers: feasible from anaesthetic and critical care side but not from neuroradiology with current referral numbers yes – 1-2 per week would be manageable.
27 response(s)
Prior to this survey had you (or your neuroanaesthesia radiology lead) read the joint statement between BASP, BSNR and NACCS on ‘Standards for providing safe acute ischaemic stroke theombectomy services (September 2015)’
Answer No Responses Percent
| Yes | 19 | 70.37% |
| No | 8 | 29.63% |
27 response(s)
Thank you for taking the time to complete this survey. If there are any other comments you would like to share with us please enter them in the box below.
Our neuroradiology service is set up for SAH/ AVM patients and we have been doing basilar thrombectomy for years. MCA stroke work is yet to be commissioned and the block is mainly identifying and thrombolysing patients in under 5 hours, from onset time. Our other issue is IR radiology and nursing staff cover. Providing emergency GA cover is less of a problem with a separate neuroanaesthetic rota and duty floor anaesthetic role.
To provide a 24/7 thrombectomy service we would need to recruit at all levels within the team, Neurogadiologist, Neuroradiographer, Neuroradiology nursing, Anaesthesia, Anaesthesia assistance, recovery staff. We have no additional capacity in ITU/HDU for further workload and any increase in acute patient traffic would adversely affect scheduled patients and workstreams that require ITU/HDU capacity.
We only have 2 neuroradiologists at present so can’tr run a full rota
