Opinion: Stroke physician calls for greater urgency for remote patients

Why are transfers of acute stroke patients who require urgent intervention, such as clot retrieval, not routine for rural and remote Australians, asks Dr Anna Holwell of Alice Springs Hospital.

Dr Anna Howell at work

I work at Alice Springs Hospital, in a remote part of Central Australia. The catchment for the health service is over 1.5million km2 extending into western Queensland, the APY lands in north-east South Australia and the Western desert regions in eastern Western Australia, including some of the most remote communities in the world. The population of this area is around 55,000, with 40 per cent being First Nations people. The incidence of stroke in this population is significantly higher than national rates, and stroke occurs in younger patients, with poorer outcomes.

The nearest tertiary health centres to our hospital are 1500km to the north (Darwin) or south (Adelaide). Due to the size of our hospital, we do not have cardiac angiography or interventional radiology (including neurointerventional services). As in many rural and remote places across Australia, it is a well-established practice for us to transfer acute cardiac patients presenting to our hospital centres to Adelaide for angiography services. This process is so ingrained in our management of non-ST-segment myocardial infarction (NSTEMI) that the initiation of the transfer process is a routine part of initial assessment. In complicated presentations, such as failed thrombolysis in STEMIs, often urgent transfers are necessary. With limited retrieval resources and assets available, such urgent transfers can have significant implications for the overall health service – however the benefit to the individual patient is so great that these transfers happen.

Why are transfers of acute stroke patients to receive urgent intervention such as clot retrieval not similarly routine for rural and remote Australians?

Without getting too deep into statistics, acute neurointerventional radiology in the setting of a large vessel occlusion stroke is arguably more time critical, with more beneficial outcomes than rescue percutaneous coronary intervention (PCI) for failed thrombolysis in STEMI. The number needed to treat being in the realm of 5 – 10 for acute stroke intervention, as opposed to closer to 40 in complex STEMI cases.

Acute ischaemic stroke management has had many treatment advances in recent years – thrombolysis and endovascular clot retrieval becoming routine practice within the last 10 years. For various reasons these treatments have taken longer to filter into smaller and more remote hospitals – lack of onsite neurological and neurosurgical services being a big part of this. The first acute stroke patient was thrombolysed at Alice Springs Hospital in 2019, and shortly after we formally joined the SA Rural Telestroke service – giving us 24/7 access to stroke neurologists. We transferred the first patient for endovascular clot retrieval to Royal Adelaide Hospital in 2020.

Although formalised policies and agreements are in place, and the tide is turning, reperfusion therapies in acute stroke management are still not considered routine.

Despite our best intentions, it can be difficult to change the way we have always done things, there is always scepticism of new processes, and of extra work in an already overburdened system.

In comparison to cardiac transfers, to organise urgent transfer of a stroke patient requires extra work – having more conversations, answering the whys, advocating for our patients to have access to these new but proven treatments.

While it can be tempting to put all this in the too hard basket, these are challenges we must face and overcome to provide our patients with the best care. If rural and remote patients continue to struggle to access to life saving treatment, what does that do to the “gap” – the gap between urban and remote health outcomes, Indigenous and non-Indigenous health outcomes.

Too frequently, I am attending discharge planning meetings for young patients – patients in their 30s – who are unable to return to their home communities due to poor stroke outcomes. These people are destined to live far from their families and Country – their cultural and spiritual homes.

To quote a colleague who has worked in remote communities for decades – “the worst outcome of a STEMI is death, the worst outcome of a stroke is surviving and being left non-verbal and bed bound in a nursing home”.

I strongly believe that addressing the social determinants of health is the key to reducing a large proportion of these health ‘gaps’ (stroke after all, it is by and large a preventable disease). However, whilst we advocate for better housing, food supply, and health services for these populations, we also need to address the acute health crises in remote Australia.

It is time to shift the paradigm. We need to look at the evidence and be prepared to advocate for our patients – we need to push for rural and remote patients to have access to proven acute stroke interventions. New technologies bringing acute stroke interventions to the patient within the Australian Stroke Alliance’s Golden Hour program – no matter what postcode they live in – need to be embraced. While challenges may seem insurmountable, overcoming them starts with accepting that advances in medicine now present us with alternate ways to doing things. This will involve ongoing education, advocacy and innovation.

Read more about the Australian Stroke Alliance’s quest to improve communication and fast stroke transfers here.