Reducing death and disability from stroke by raising awareness and improving emergency and hyperacute care
Submitting InstitutionUniversity of Central Lancashire
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
After the onset of stroke symptoms, much disability and death can be
prevented by ensuring immediate access to effective specialist assessment
and treatment. Our work on improving pathways of care in acute stroke has
included research on raising public awareness of stroke, so that people
seek emergency medical advice promptly, and research and development on
emergency medical services' skills and practice. The findings of this
research have led to impacts on clinical care and health services practice
via inclusion in national and international clinical guidelines and
training, improvements in the recognition of stroke, and reduced
pre-hospital delays and time to emergency department diagnosis. Such
improvements are known to reduce death and disability from stroke.
Public awareness - patients at higher risk of stroke (2006-2011)
We undertook a qualitative study of people's experiences of transient
ischaemic attack (Gibson and Watkins, 2011) and an integrative review
using PRISMA methodology of public knowledge of stroke symptoms, risk
factors and action to take when stroke is suspected (Jones et al., 2010).
These identified that public knowledge of stroke recognition and
prevention was poor, and that there was a mismatch between the public's
stated intentions to contact the EMS at the onset of stroke symptoms and
the actions of people at symptom onset. This led to a mixed-methods study
on patients' experiences of and decisions about seeking help after stroke
and TIA. Information from this study was synthesised with the review
results and used to inform a focus group that discussed the best way to
inform a stroke information leaflet. This leaflet was tested in patients
attending a TIA clinic. This work contributed to the development of
training materials in the ESCORTT programme (see below).
RESPONSE programme (2006-2009)
In parallel to our work on public awareness of stroke, we performed a
series of systematic reviews on the acute physiological effects of stroke
in order to identify whether there was evidence to support changes in
paramedic practice (Jones et al., 2007). These reviews underpinned the
development of on-line training for paramedics (Jones et al., 2011) and
were used to write an addendum on pre-hospital management for the National
Clinical Guideline for Stroke (2nd edition), in partnership with the Royal
College of Physicians Clinical Effectiveness Unit, British Paramedic
Association, College of Emergency Medicine, and The Stroke Association.
Emergency Stroke Calls, Obtaining Rapid Telephone Triage (ESCORTT)
This research programme built on our earlier work on public awareness and
emergency services response to stroke symptoms. The overall aim of the
programme was to facilitate recognition of stroke by frontline health
services staff. It consisted of 8 phases including exploration of
interaction between the public and the emergency medical services (EMS)
during emergency calls for stroke (Jones et al, 2011a; Jones et al.,
2011b), development of stroke-specific training for Emergency Medical
Dispatchers, and evaluation of the effectiveness of the training package
via an interrupted time series analysis (Watkins et al., 2013). The work
was conducted in partnership with several NHS organisations: North West
Ambulance Service, NHS Direct, and three NHS Foundation Trusts.
References to the research
1. Gibson JME, Watkins CL. People's experiences of the impact of
transient ischaemic attack and its consequences: qualitative study. Journal
of Advanced Nursing. 2011;doi:10.1111/j.1365-2648. 2011.05849
2. Jones SP, Leathley MJ, Mcadam JJ, Watkins CL. Physiological monitoring
in acute stroke: a literature review. Journal of Advanced Nursing.
3. Jones SP, Leathley MJ, Jenkinson M, Watkins C. Stroke knowledge and
awareness: an integrative review of the evidence. Age Ageing.
4. Jones SP, Dickinson HA, Ford GA, Gibson JME, Leathley MJ, McAdam JJ,
Quinn T, Watkins CL on behalf of the ESCORTT group. Callers' experiences
of making emergency calls at the onset of acute stroke: a qualitative
study. Emergency Medical Journal. 2011a;doi:10.1136/emj.2010.108563.
5. Jones SP, Carter B, Ford GA, Gibson JME, Leathley MJ, McAdam JJ,
O'Donnell M, Punekar S, Quinn T, Watkins CL on behalf of the ESCORTT
group. The identification of acute stroke: An analysis of emergency calls.
International Journal of Stroke. 2011b;doi: 10.1111/j.1747-
6. Watkins CL, Leathley MJ, Jones SP, Ford GA, Quinn T, Sutton CJ, On
behalf of the Emergency Stroke Calls: Obtaining Rapid Telephone Triage
(ESCORTT) Group. Training Emergency Services' Dispatchers to recognise
stroke: An interrupted time-series analysis. BMC Health Services Research.
Funding that has supported the research
Rapid Emergency Stroke Pathways: Organised Systems and Education
(RESPONSE). Cumbria and Lancashire Workforce Development Confederation.
Applicants: Watkins C, Jones S, Leathley M. Awarded £145,030. 2003.
Awarded: October 2003; Start: 01/11/2003; End: 30/04/2008
Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT). NIHR.
Applicants: Watkins C, Ford G, Cooke M, Durham S, Fairhurst R, Quinn T,
Rose M, Mitchell D, Leathley M, Morris S, Jones S, Mackway-Jones K.
Awarded £1,064,124. 2007. Awarded: August 2007; Start: 01/09/2007; End:
Senior Investigator Award. NIHR. Applicant: Watkins CL. Awarded total
£60,000. 2009-2013. Awarded: 27 Feb 2009; Start: 01/04/2009; End:
Details of the impact
Public awareness - patients at higher risk of stroke
The integrative review was cited in: the 4th edition of the
National Clinical Guideline for Stroke (Intercollegiate Stroke Working
Party, 2012); the Australian National Guidelines for Stroke Management
(National Stroke Foundation, 2010); and the New Zealand Clinical
Guidelines for Stroke Management (Stroke Foundation of New Zealand, 2010).
The review also identified that people from minority ethnic groups were
less likely to have knowledge of stroke risk factors and symptoms, yet
often had a higher risk of stroke. To address this lack of knowledge in
the local South East Asian community in north west England, we conducted a
collaborative project. This involved training people from those
communities in interview techniques in order to enable interviews in the
participants' first language. A DVD was then developed with local service
users from South Asian communities. This was a short `soap opera' style
film in Hindi with English subtitles about someone having a stroke, and
included information on risk factors, action to take when stroke is
suspected, acute care, rehabilitation and secondary prevention. Making and
refining the DVD involved the co-operation of 20 local community groups.
Subsequent evaluation indicated a significant increase in knowledge of
stroke in the short and medium term, and an associated positive increase
in health behaviours.
Further testing in different populations is underway. This work has been
cited as an example of good practice in Patient and Public Engagement by
NHS Improvement. The DVD has been widely disseminated including free
distribution of 7000 copies with Asian Image newspaper.
Our systematic review (Jones et al., 2007) identified that routine oxygen
supplementation via facemask was not based on evidence, yet this was
common practice. This led to consultation with the Joint Royal Colleges
Ambulance Liaison Committee and subsequent amendment to their guideline
for pre-hospital care in suspected stroke. Other systematic reviews
undertaken to underpin the RESPONSE course were incorporated in
pre-hospital guidelines which were initially an addendum to, now
incorporated in, the National Clinical Guideline for Stroke. The work of
setting up the pre-hospital guideline group was initiated by Watkins and
Jones and the team further collaborated with the Royal College of
Paramedics in updating the pre-hospital guidelines for the 4th
edition of National Clinical Guideline for Stroke.
The RESPONSE online training has been undertaken by over 3000 health care
staff worldwide, including Australia, Jamaica and Canada. An evaluation of
the course conducted with UK participants found that participants were
either very satisfied or satisfied with it and reported an increased
knowledge in the management of acute stroke. They especially welcomed its
usability, interactive nature, and flexibility (Jones et al., 2011c). The
RESPONSE programme has been further developed to provide training for
staff working in A&E, care homes, and primary care.
Emergency Stroke Calls: Obtaining Rapid Telephone Triage (ESCORTT)
The impact of the stroke-specific training package which was based on
earlier phases of this programme (Jones et al., 2011a; Jones et al 2011b)
on the recognition of stroke by Emergency Medical Dispatchers has been
evaluated over 8 months with 488 patients, using an interrupted time
series analysis (Watkins et al., 2013). The percentages of those with
final diagnosis of stroke who were correctly dispatched by EMS were 63.0%
in the pre-implementation phase, rising to 87.5% during implementation,
and remaining higher than baseline at 79.7% post-implementation. The
training package also improved aspects of pre-hospital delay, amounting to
a mean overall reduction of more than 10 minutes from time of call to
emergency department diagnosis. It has been estimated that a typical
patient loses 1.9 million neurons each minute in which stroke is untreated
(Saver, 2006) and the benefits of rapid diagnosis of stroke on improving
both mortality and morbidity are well-recognised.
Our work in this field contributed to a successful application for NIHR
Research for Patient Benefit project funding on the development and
evaluation of training in a telemedicine system for acute stroke in
A&E: Acute Stroke Telemedicine: Utility, Training and Evaluation
(ASTUTE). In the ASTUTE programme we are exploring how standardisation of
procedures and training can facilitate the effective use of telemedicine
in stroke in order to benefit patient care. The research programme was
developed in collaboration with the introduction in 2011 of a Telestroke
service throughout Cumbria and Lancashire across nine NHS Trusts. A
Standardised Telemedicine Toolkit has been developed
(http://www.astute-telestroke.org.uk) to support individuals or
organisations that want to set up a telemedicine system.
Sources to corroborate the impact
Public awareness - patients at higher risk of stroke
Citation in: Intercollegiate Stroke Working Party. National Clinical
Guideline for Stroke 4th edition 2012. London; Royal College of
Physicians. Section 3.17 Improving public awareness of stroke.
http://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition.pdf .Section 3.17 p35.
Citation in: National Stroke Foundation. Clinical Guidelines for Stroke
Management 2010. Melbourne, Australia, National Stroke Foundation. Section 4 Acute stroke management.
Citation in: Stroke Foundation of New Zealand and New Zealand Guidelines
Group. Clinical Guidelines for Stroke Management 2010. Wellington: Stroke
Foundation of New Zealand. Section 2.1 Stroke recognition and
Reference supporting these sections Jones SP, Leathley MJ,
Jenkinson M, Watkins C. Stroke knowledge and awareness: an integrative
review of the evidence. Age Ageing. 2010;39:11-22.
South Asian DVD project:
National Pre-hospital Guidelines Group. The recognition and emergency
management of suspected stroke and TIA: Guidelines Supplement. 2007.
RESPONSE on-line training (2005) was cited in the National Stroke
Strategy (2007) as a marker of success for Quality Marker 18.
Citation in: Canadian Stroke Strategy. Canadian Best Practice
Recommendations for Stroke Care, Update 2010. Section 4.0 Acute stroke
Reference supporting this section Jones SP, Leathley MJ, McAdam
JJ, et al. Physiological monitoring in acute stroke: a literature review.
J Adv Nurs 2007;60:577-94.
The RESPONSE initiative was a finalist in NHS Northwest Innovation Awards
Emergency Stroke Calls, Obtaining Rapid Telephone Triage (ESCORTT)
The Standardised Telemedicine Toolkit is available at: