Stroke is the world’s second-leading cause of death1 and the third-leading cause of death and disability, as well as being the third most common-cause of death in Australia. 2 Stroke is among Australia’s most costly health conditions, for society, for the health system and most importantly, the individual, their carers and their family.3
Three key acute stroke interventions can substantially mitigate these deleterious outcomes:
- stroke unit care4
- thrombolysis5
- endovascular therapy (EVT) 6
The interventions are suboptimally utilised in Australia, 7,8 however the impact of optimised stroke intervention would be substantial.
- For every 17 patients treated on a stroke unit, one death or dependent outcome is prevented. 4
- For every ten patients treated with thrombolysis under three hours, one disabled outcome is prevented. 5
- For every five patients treated with thrombectomy, one dependent outcome is prevented. 6
Further, thrombolysis and EVT are highly time-critical; earlier treatment magnifies improved outcomes. In routine clinical practice, for every 15 minutes faster treatment with thrombolysis9 and thrombectomy, 10 the odds of death are lower (4% and 6%, respectively) and odds of discharge home higher (3% and 9%).
Globally there have been many quality improvement initiatives to improve access to these high-priority time-critical interventions. For example, in 2010 the American Heart Association (AHA) established the Target Stroke program, which was associated with large and consistent improvements in timely access to stroke thrombolysis and EVT. 11 Consequently, stroke mortality and disability in participating hospitals substantially decreased. 12
Australia has the infrastructure to deliver word-class acute stroke care. Most large-volume hospitals have dedicated stroke units and offer reperfusion therapies, supplemented by telestroke networks providing thrombolysis in regional areas. Despite this, national data demonstrates that performance on key acute stroke interventions has stagnated for several years. 7,8 Stroke unit access for stroke patients has remained around 75%, median door to thrombolytic times remain around 75 minutes, and door to arterial puncture times for EVT remain around 115 minutes. Importantly, Australia lags significantly behind international peers on stroke unit access and reperfusion timeliness. In Australia only 27% of thrombolysis occurs within 60 minutes; corresponding figures for the USA are 75%,13 and for England 61%.14
There are examples from a small number of local hospitals demonstrating that high performance is achievable. However, there remains much variation in care. Australia has the infrastructure to deliver world-class acute stroke care and is well positioned to utilise a stroke learning health system15 to drive improved national performance. Such a system incorporates rapid performance monitoring, evidence-based implementation strategies, educational resources and specific quality improvement tools, and award and recognition for stroke teams. Therefore in 2023, to act in synergy with the ‘Championing Care’ theme of that year’s Trans-Tasman combined Smart Strokes and Australian and New Zealand Stroke Organisation (ANZSO) conference, conference leaders* proposed holding a pre-conference workshop focused on national quality improvement, noting the need for a collaborative, co-ordinated effort.
These Stroke 2023 conference leaders – A/Prof. Ben Clissold (the ANZSO conference co-chair and Victoria Stroke Network Chair), Prof. Geoffrey Cloud (the Scientific co-chair and AuSCR Clinical Quality Improvement Committee Chair), Prof. Dominique Cadilhac (the Scientific co-chair and AuSCR Data Custodian) and Prof. Timothy Kleinig (the ANZSO President and South Australia Stroke Community of Practice Chair) – invited the Angels Initiative** Australia Lead, Kim Malkin, to support and collaborate on this workshop.
After several iterative discussions, commencing in March 2023, initially focused around ‘breaking the 60-minute thrombolysis barrier’, this group in April 2023 proposed expanding the scope to the current ‘30/60/90 National Stroke Targets” (the Targets), adding stroke unit care and endovascular thrombectomy metrics, and setting a 2030 deadline (below).
The 30/60/90 National Stroke Targets (Australia 2023)
By 2030
- National median endovascular clot retrieval door to puncture time <30mins for transfers
- National median thrombolysis door to needle time <60mins
- National median door in door out time for endovascular clot retrieval <60mins#
- National median endovascular clot retrieval door to puncture time <90mins for primary presenters
- Certified stroke unit care provided to >90% of patients with primary stroke diagnosis
#Where same-crew ambulance door-in and -out transfer is possible. Regional services retrieving via road should aim for a 75 minute DIDO time (hospitals requiring aero-retrieval service are not included in this target).
The Targets were formally presented to national stroke leaders on August 22nd 2023 at a Stroke 2023 pre-conference workshop (the Workshop), chaired by Prof. Helen Dewey, with substantial input from the Stroke 2023 keynote speaker, Prof. Matt Reeves, a key leader of the AHA ‘Target Stroke’ initiative. Workshop invitees included representatives of major Australian stroke-interested organisations (state government-based stroke clinical networks, national stroke organisations, prehospital and emergency bodies, stroke nursing, stroke allied health and stroke educational groups) the majority of whom were able to attend. Attendees unanimously agreed that the Targets were necessary, appropriate, and achievable.
The Targets have since been officially endorsed by every major Australian stroke-interested organisation, including those with representation at the Workshop and others unable to attend (below). The Targets have been embraced by the acute stroke community with significant momentum and progress made.
Endorsing organisations
Now that there is wide support and endorsement of the Targets, a priority is to finalise the governance structure. It is agreed that formal oversight of the targets should rest with the broadly representative Australian Stroke Coalition (ASC), which has, as a core aim, to promote universal access to quality stroke care, underpinned by comprehensive stroke data capture. The ASC oversees the overall governance of the project and provides strategic direction to ensure that it achieves its set goals, acts synergistically with other national stroke priorities, and operates in accordance with the ASC’s policies and procedures.
Reporting into the ASC, a National 30/60/90 Stroke Targets Taskforce (Taskforce) will drive the specific activities of the project, including the development and delivery of evidence-based strategies, educational resources and specific quality improvement tools, and award recognition, for hospitals and stroke care teams. Membership of the Taskforce will be open to organisations and individuals able to volunteer their skills to support the strategy and objectives of the 30/60/90 National Stroke Targets and will be selected by the ASC for their skills and expertise and will be governed by the Taskforce Terms of Reference.
*The full organising committee comprised Kelly Andersen, Anna Balabanski, Dominque Cadilhac, Ben Clissold, Geoffrey Cloud, Tanya Frost, Seana Gall, Tim Kleinig, Elizabeth Lynch, Alexis McMahon and Jessica Nolan.
** The Angels Initiative is a non-promotional healthcare project of Boehringer Ingelheim International to support the European Stroke Organization (ESO) and World Stroke Organization (WSO) in implementing their main goal, to improve stroke care around the world. 16 The Angels Initiative is fully endorsed by the ESO and WSO and are an essential part of their respective Quality Improvement Programs. The WSO Angels Awards are nationally endorsed and cross-validated by the Australian Stroke Coalition, recognising Australian hospitals for achieving global benchmarks in stroke care.
References
1. Collaborators GBDS. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Neurology 2021;20(10):795-820. DOI: 10.1016/S1474-4422(21)00252-0.
2. Australian Institute of Health and Welfare. Deaths in Australia. 11 Jul 2023 (https://www.aihw.gov.au/reports/life-expectancy-deaths/deaths-in-australia/contents/leading-causes-of-death).
3. Deloitte Access Economics. The economic impact of stroke in Australia, 2020. 2020. (https://www.deloitte.com/content/dam/assets-zone1/au/en/docs/services/economics/dae-economic-impact-stroke-report-061120.pdf).
4. Langhorne P, Ramachandra S, Stroke Unit Trialists C. Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database Syst Rev 2020;4(4):CD000197. DOI: 10.1002/14651858.CD000197.pub4.
5. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. The Lancet 2014;384(9958):1929-1935. DOI: 10.1016/s0140-6736(14)60584-5.
6. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. The Lancet 2016;387(10029):1723-1731. DOI: 10.1016/s0140-6736(16)00163-x.
7. Cadilhac DA DL, Morrison J, Paice K, Carter H, Campbell BCV, Cloud GC, Kilkenny MF, Faux S, Hill K, Donnan GA, Grimley R, Lannin NA, Stojanovski B, Cowans S, Middleton S, Dewey H; on behalf of the AuSCR Consortium,. The Australian Stroke Clinical Registry Annual Report 2022. 15. December 2023.
8. Foundation S. National Stroke Audit – Acute Services Report 2023. Melbourne, Australia. Melbourne, Australia.
9. Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 2013;309(23):2480-8. DOI: 10.1001/jama.2013.6959.
10. Jahan R, Saver JL, Schwamm LH, et al. Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice. JAMA 2019;322(3):252-263. DOI: 10.1001/jama.2019.8286.
11. Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017;2(2):94-105. DOI: 10.1136/svn-2017-000092.
12. Song S, Fonarow GC, Olson DM, et al. Association of Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries With Ischemic Stroke. Stroke 2016;47(5):1294-302. DOI: 10.1161/STROKEAHA.115.011874.
13. Xian Y, Xu H, Smith EE, et al. Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention. Stroke 2022;53(4):1328-1338. DOI: 10.1161/STROKEAHA.121.035853.
14. Sentinel Stroke National Audit Programme. SSNAP Summary for July – September 2023 admissions and discharges. 2023.
15. Cadilhac DA, Bravata DM, Bettger JP, et al. Stroke Learning Health Systems: A Topical Narrative Review With Case Examples. Stroke 2023;54(4):1148-1159. DOI: 10.1161/STROKEAHA.122.036216.
16. Caso V, Martins S, Mikulik R, et al. Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide. Int J Stroke 2023;18(8):898-907. DOI: 10.1177/17474930231180067.
