Trends in New Zealand stroke thrombolysis treatment rates.

AIMS: To describe trends in treatment delays and short-term outcome over the first 18 months of the New Zealand stroke thrombolysis register. METHODS: The National Stroke Network introduced a central register of all ischaemic stroke patients treated with intravenous alteplase on January 1, 2015. The aim was to increase thrombolysis treatment rates and drive improvements in safety. RESULTS: From January 1, 2015 to June 30, 2016, alteplase was given to 623 patients [344 men, mean (range) age 70 (22-98) years] out of a total of 8,857 ischaemic and unspecified stroke patients, giving a thrombolysis rate of 7.0%. Between the first and second halves of the audit, there were more patients thrombolysed [350 of 4,456 (7.9%) versus 273 of 4,401 (6.8%); p=0.001] and more treated within 60 minutes of hospital arrival [137 of 325 (42%) versus 71 of 250 (28%), p=0.001]. Door-to-needle time reduced from 77 minutes to 64 minutes (p=0.002) and the onset-to-treatment reduced from 162 minutes to 140 minutes (p=0.070). Rates of symptomatic intracranial haemorrhage (4.3% patients) and survival at day seven (93%) were stable. CONCLUSIONS: There have been improvements in stroke thrombolysis rates and treatment delays in New Zealand hospitals since the institution of the National Stroke Network thrombolysis register. The Network will continue to adjust key performance indicators, and stroke thrombolysis targets for individual DHBs have been increased to 8% for 2017 and 10% for 2018.

Provision of stroke thrombolysis services in New Zealand: changes between 2011 and 2016.

AIMS: To obtain an overall picture of the organisation of stroke thrombolysis provision in New Zealand hospitals and compare changes between 2011 and 2016. METHODS: Surveys were distributed to all New Zealand district health boards (DHBs) in 2011 and 2016, and included questions about the infrastructure, staffing, training, guidelines and audit provided for stroke thrombolysis. RESULTS: Responses were received from all DHBs, with 86% offering stroke thrombolysis in 2011 and 100% in 2016. In 2016, thrombolysis rosters of large DHBs (those with a population >250,000 people) had a mean (range) of 14 (5-34) clinicians, approximately double that of medium-sized DHBs (population 125-250,000) who had eight (3-15) and small DHBs (population <125,000) with seven, (2-13) clinicians. While a similar distribution of senior medical officer clinical specialty was seen across medium and small DHBs in both years, large DHBs in 2016 had a higher number of neurologists (5, 1-12) and an increasing number of general physicians (8, 0-30) rostered to provide thrombolysis compared to 2011. Thrombolysis services at medium and small DHBs are chiefly managed by general physicians and geriatricians, while telestroke support was only available in three medium-sized DHBs. In 2016, all hospitals had developed thrombolysis guidelines and audited thrombolysed patients in the National Stroke Thrombolysis Register, which is an improvement compared with 2011 when only seven (39%) DHBs reported regular audit. Challenges in staffing and training remain greatest in smaller and geographically isolated DHBs. CONCLUSION: While there have been improvements in the provision of stroke thrombolysis throughout New Zealand, regional variations in service quality remains. The needs for better solutions to geographical barriers and formal training must be addressed as priorities.

Stroke thrombolysis in New Zealand: data from the first 6 months of the New Zealand Thrombolysis Register.

The New Zealand National Stroke Network introduced a National Stroke Thrombolysis Register on the first of January 2015 to assist with quality assurance and continuous service improvement. In the first 6 months, there were 179 [75 women, mean (SD) age 69.9 (14) years] treated with stroke thrombolysis out of a total of 2,796 ischaemic stroke patients, giving a national thrombolysis rate of 6.4%. The median [Inter-quartile range (IQR)] onset-to-treatment time was 154 (125-190) minutes, and the median (IQR) door-to-needle time was 74.5 (55.7-105.0) minutes. The rate of symptomatic intracranial haemorrhage following thrombolysis was 4.4%. These results are similar to other international centres, and indicate an approximate doubling of the proportion of stroke patients treated with stroke thrombolysis since a 2009 national audit. However, there is need for on-going efforts to improve treatment rates and process efficiency, particularly door-toneedle times.

New Zealand's neurologist workforce: a pragmatic analysis of demand, supply and future projections.

AIMS: To estimate current and future specialist neurologist demand and supply to assist with health sector planning. METHODS: Current demand for the neurology workforce in New Zealand was assessed using neuroepidemiological data. To assess current supply, all New Zealand neurology departments were surveyed to determine current workforce and estimate average neurologist productivity. Projections were made based on current neurologists anticipated retirement rates and addition of new neurologists based on current training positions. We explored several models to address the supply-demand gap. RESULTS: The current supply of neurologists in New Zealand is 36 full-time equivalents (FTE), insufficient to meet current demand of 74 FTE. Demand will grow over time and if status quo is maintained the gap will widen. CONCLUSIONS: Pressures on healthcare dollars are ever increasing and we cannot expect to address the identified service gap by immediately doubling the number of neurologists. Instead we propose a 12-year strategic approach with investments to enhance service productivity, strengthen collaborative efforts between specialists and general service providers, moderately increase the number of neurologists and neurology training positions, and develop highly skilled non-specialists including trained.