• Barry Moynihan, Daniel Davis, Anthony Pereira, Geoffrey Cloud, and Hugh S Markus.
• Department of Neurology, Atkinson Morley Neuroscience Centre, St George's Hospital London. barry.moynihan@stgeorges.nhs.uk
• J R Soc Med. 2010 Sep 1;103(9):363-9.

ObjectivesAudits in the United Kingdom and other countries show that only a small proportion of eligible stroke patients receive thrombolysis. Providing 24-hour thrombolysis cover presents major challenges in both infrastructure and staffing. One model for improving access is to provide out-of-hours cover in a regional centre but this may present problems including greater delays to hospital admissions.DesignEvaluation of the introduction of a 'hub-and-spoke' model of thrombolysis to increase access to thrombolysis for patients in south west London. One-year data are presented.SettingA network in south-west London comprised of a hub hospital and three district 'spoke' hospitals.ParticipantsAll suspected stroke admissions to a regional stroke centre. Main outcome measures Thrombolysis rates for acute stroke.ResultsIncreased out-of-hours thrombolysis rates were achieved with only a small increase in stroke admissions (approximately 10%) in the hub hospital. Thrombolysis rates increased from 1.2 per 100 stroke admissions for the local daytime service to 6 per 100 admissions for the regional service. Most patients thrombolysed were not local to the hub hospital. Only 1 in 4 patients considered for thrombolysis was thrombolysed, in line with previous data. Ten percent of all thrombolysis calls were not stroke but represented stroke mimics. Median length of stay was 6 days (target was 3 days). Fifty percent of the thrombolysed patients from spoke hospitals were discharged directly home.ConclusionsIn an urban area, a hub-and-spoke thrombolysis model increased access to thrombolysis without resulting in a marked increase in overall stroke admission numbers for the hub hospital. Proactive plans to repatriate patients back to district hospitals are required, and repatriation protocols have to prioritize regional patients over other targets in spoke hospitals to facilitate capacity in the hub hospital.

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