NHSCANCER                                   NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKEStroke Improvement ProgrammeGoing up ...
Contents           Foreword                                   3           Introduction                               4    ...
Going up a gear: practical steps to improve stroke care |   3ForewordWe are at an important milestone in       But they al...
4   | Going up a gear: practical steps to improve stroke care    Introduction    The Stroke Improvement Programme         ...
Going up a gear: practical steps to improve stroke care |          5Joining up preventionJoining up prevention includes   ...
6   | Going up a gear: practical steps to improve stroke care    In pushing forward the challenge to           TOP TIPS   ...
Going up a gear: practical steps to improve stroke care |   7North West London Cardiac and             North West London C...
8   | Going up a gear: practical steps to improve stroke care    Tailor the weekend service to                The service ...
Going up a gear: practical steps to improve stroke care |    9   Figure 1: Before and after TIA referral pathways in Bourn...
10 | Going up a gear: practical steps to improve stroke care   Implementing best practice in acute care   Quality markers ...
Going up a gear: practical steps to improve stroke care |            11This has raised the stroke unit’sprofile within the...
12    | Going up a gear: practical steps to improve stroke care     Bed management was improved in               Actively ...
Going up a gear: practical steps to improve stroke care |   13Sandwell and West Birmingham             Milton Keynes Hospi...
14    | Going up a gear: practical steps to improve stroke care     Work with stroke survivors and               were high...
Going up a gear: practical steps to improve stroke care |   15In Queens Hospital NHS                               A&E. Wi...
16 | Going up a gear: practical steps to improve stroke care   When the project teams analysed the   data after the pilot ...
Going up a gear: practical steps to improve stroke care |   17Table 1: Care package of patients going home from the Medway...
18    | Going up a gear: practical steps to improve stroke care     Post hospital support and long term care     Since Mar...
Going up a gear: practical steps to improve stroke care |    19The project leads from each of the                 conditio...
20       | Going up a gear: practical steps to improve stroke care     reinforced information given during                ...
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
Going up a gear: Practical steps to improve stroke care
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Going up a gear: Practical steps to improve stroke care

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Going up a gear: Practical steps to improve stroke care
The Stroke Improvement Programme's publication draws together the key themes and learning from the 2009/10 projects and includes ‘top tips’ that have emerged from the projects to help others as they make improvements in stroke care

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Transcript of "Going up a gear: Practical steps to improve stroke care"

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKEStroke Improvement ProgrammeGoing up a gear:practical steps to improve stroke care
  2. 2. Contents Foreword 3 Introduction 4 Joining up prevention 5 Implementing best practice in acute care 10 Post hospital support and long term care 18 Sustainability 27 Measuring for improvement 30 Resources and contacts 34
  3. 3. Going up a gear: practical steps to improve stroke care | 3ForewordWe are at an important milestone in But they also reminded us that therethe implementation of the National is much to do, particularly to supportStroke Strategy. people to live long term with the consequences of their stroke. That isThis publication, Going up a gear, is a why earlier this year we launched thechance for all of us to learn from the Accelerating Stroke Improvementprojects which were launched in programme, to go further, faster inMarch 2009. It is a testament to the improving stroke services with thecontribution the teams have made additional support and toolslocally and the product of a lot of available, to sustain improvementhard work. You will no doubt into the future. Professor Roger Boyle CBErecognise many of the issues they National Director for Heart Disease and Stroke, Department of Healthfaced, and we hope you will be able We can all agree that excellent stroketo use their solutions as you are care is our main goal. Going up acontinuing to develop your own gear, has been designed to help youservices. in meeting that challenge.All those involved in stroke services Professor Roger Boyle CBEhave been making great strides to National Clinical Director for Heartimprove care since the publication of Disease and Strokethe Strategy in 2007. This Department of Healthcontribution of many individuals andteams across the country is starting to Dr Damian Jenkinsonshow results for people who have a National Clinical Leadstroke in England, as the National NHS Stroke Improvement ProgrammeAudit Office recognised in their Dr Damian Jenkinson National Clinical Lead, NHS Strokereport, Progress in improving stroke Improvement Programmecare, published earlier this year. www.improvement.nhs.uk/stroke
  4. 4. 4 | Going up a gear: practical steps to improve stroke care Introduction The Stroke Improvement Programme Accelerating Stroke Improvement How to use this document worked with 37 project sites in Accelerating Stroke Improvement is a The suggestions, experiences and 2009/10 on implementing the drive to rapidly improve stroke examples provided in this document National Stroke Strategy.1 The services in 2010/11. The systems and are intended to generate ideas, to projects aimed to help clinical teams structures are in place to provide show what is possible when teams improve their service and to generate leadership, guidance and support a work constructively together and to learning to benefit others. Projects programme of work to go further, guide planning for improvement were grouped into four areas, based faster in improving stroke services in activities. on sections of the strategy: this year. The three main areas of focus are: The Stroke Improvement Programme • Transient Ischaemic Attack (TIA) continuously publishes materials to services • Joining up prevention help those striving to improve stroke • Acute care • Implementing best practice in and TIA services. Resources and • Transfer of care acute care materials will be made available this • Rehabilitation • Improving post hospital and long year to support the Accelerating term care Stroke Improvement programme Key themes and learning have been work. New materials will be drawn from the projects and other The programme is about advertised in the Stroke sites around the country. ‘Top tips’ systematically taking stock of what Improvement e-bulletin and will be have emerged which will help others has been achieved so far in improving available on the Stroke Improvement as they also make improvements to stroke services and assessing what Programme website at: their stroke services. else needs to be addressed, including www.improvement.nhs.uk/stroke long term care. This means building More detail and contact information on existing plans, mapping out what is available in the accompanying can be achieved this year with the publications, Case studies from the additional support and tools available Stroke Improvement Programme and how this can be sustained and projects. extended into the future so that everyone gets the right treatment, in Additional learning has been drawn the right place, at the right time from the projects investigating the detection and treatment of atrial Learning from the projects has been fibrillation. organised to support this new focus. National Stroke Strategy, Department of Health, 2007. 1 www.improvement.nhs.uk/stroke
  5. 5. Going up a gear: practical steps to improve stroke care | 5Joining up preventionJoining up prevention includes The first phase of 18 projects were The Stroke Improvement Programmeinformation on stroke prevention established in October 2007 and publications that provide a summarythrough better identification and completed April 2009. Working and overview of the outcomes fromtreatment of both atrial fibrillation across 15 networks, with PCTs, this first phase are listed in the(AF) and transient ischaemic attack general practices, Practice Based Resources section.(TIA). Consortia and acute trusts, they piloted a range of approaches to Quality and productivity agendaBoth these approaches are essential improve detection and optimal The opportunity to provide costto realise the ambitions of the treatment of patients with AF in effective high quality care to preventNational Stroke Strategy under primary care, to reduce risk of stroke. avoidable mortality and morbidity has‘Managing Risk’ (quality marker 2) been recognised as one of six keyand ‘TIA and minor stroke’ (quality TOP TIPS recommended interventions undermarkers 5 and 6). Chapter eight of the national quality and productivitythe National Service Framework on • Detect AF though opportunistic agenda, details of which can beCoronary Heart Disease also set out screening e.g. at annual flu accessed at NHS Evidence.3 clinicsthe quality requirements for the • Consider local enhanced serviceprevention and treatment of patients Driving forward schemes for detection, screeningwith cardiac arrhythmias.2 A further stage of this work began in and review of AF • Develop new models for October 2009 with nine healthAtrial fibrillation: detection anticoagulation services in communities, led by the Heart andand treatment primary and community settings Stroke Improvement Programmes.Atrial fibrillation (AF) is the most • Develop tools to support the Building on the evidenced basedcommon sustained dysrhythmia, review of patients with AF, to risk learning, resources and demonstrableaffecting at least 600,000 (1.2%) stratify for stroke and optimal outcomes from the first phase, theypeople in England alone. It is also a therapy aim to embed the identification,major cause of stroke with 16,000 • Develop guidelines for primary to diagnosis and optimal therapy forstrokes annually in patients with AF, secondary care referral patients with AF to significantly • Educate both professionals and reduce risk of stroke.of which approximately 12,500 are patients on:thought to be directly attributable to • pulse palpationAF. It is also an eminently • barriers to anti-coagulation inpreventable cause of stroke with a primary caresimple highly effective treatment; • ECG training and interpretation 2National Framework for Coronary Heartwith warfarin known to reduce risk • AF as a major risk factor for Disease; Arrhythmias and Sudden Cardiacby 50-70%. stroke. Death, Department of Health, March 2009. 3See: www.library.nhs.uk/qualityandproductivity www.improvement.nhs.uk/stroke
  6. 6. 6 | Going up a gear: practical steps to improve stroke care In pushing forward the challenge to TOP TIPS Streamline the referral route with join up prevention, some teams are single point of contact for high working across the whole primary • Clearly define a pathway for and low risk and secondary care pathway to TOP TIPS low risk patients, high and It is crucial to streamline the referral understand the issues and improve agreed across primary and process to ensure patients quickly get the management and outcomes for secondary care on the correct pathway. A single stroke and TIA patients with AF. • Streamline the referral route with contact point for all TIA patients single point of contact for high simplifies the referral process and is and low risk The learning, evidence and outcomes more efficient for co-ordinating the • Employ a comprehensive from this phase of work will be service, enabling efficient use of communication strategy published later this year. • Establish a sustainable data and appointments and facilitating the 24 audit system hour requirement for high risk Timely and effective • Tailor the weekend service to patients. Data collection can also treatment of TIA local needs and demand begin at one entry point. The Stroke Improvement Programme • Think differently about how and worked with 10 sites from March where TIA clinics are provided It requires standardised referral 2009 to test implementation of proformas that are appropriate to the quality markers 5 and 6 of the referrer, highlight the pathway, give National Stroke Strategy and to an aid to diagnosis (such as the Clearly define a pathway for high ABCD2 score) and include information contribute to national learning. and low risk patients, agreed to be given to patients. across primary and secondary care Key themes and learning have been A clear pathway is essential to ensure drawn from the projects and other Some providers are operating or patients are referred and treated on aiming for one queue for high and sites around the country. Much of the right pathway from initial referral. the work this year has concentrated low risk patients. Early results indicate The pathway will differ according to that once demand and capacity are in on the ‘front end’ of the TIA local catchment populations and pathway, ensuring prompt access to balance, and a seven day service in geography, staffing and access to place, this is possible. This makes life effective diagnosis and treatment. imaging. Different models are The following points aim to identify easier for everyone, especially emerging across the country. referrers, and protects lower risk the changes that will make the biggest difference to services. patients that turn out to be high risk. NHS Doncaster: after reviewing, mapping and redesigning their Surrey and Sussex Healthcare More detail is available in the pathway, the team in Doncaster were accompanying publication, Joining up NHS Trust created a single bleep able to introduce a new service that holder to take all calls. GPs found it prevention: case studies from the provides: Stroke Improvement Programme very helpful, confirming that this • rapid access next day clinic, from access is exactly what they want. projects. referral to being seen in clinic, for Consultants were reassured that it did all patients not translate into an unmanageable • same day carotid doppler, ECG and number of calls. echocardiogram and brain imaging • same day diagnosis North Bristol NHS Trust appointed • immediate preventive treatment a TIA co-ordinator as a single point of • same day clinic vascular surgery referral to ensure timely and efficient review and listing for theatre booking of patients according to • rapid communication of results to ABCD2 prioritisation. the patient and the GP This has removed between 21 and 41 days from the original pathway of care. www.improvement.nhs.uk/stroke
  7. 7. Going up a gear: practical steps to improve stroke care | 7North West London Cardiac and North West London Cardiac and North Bristol NHS Trust, with theStroke Network created new Stroke Network created a University of the West of England,referral forms outlining the approved communications plan to launch the developed an online training moduleprotocols and out of hours service for new referral forms to GPs, A&E for ABCD2 assessment for all GPsTIA referral, having gained consensus departments and all interested and Great Western Ambulancefrom clinical teams in each hospital. parties. It included comprehensive Service staff.Separate forms were made for A&E information for services, clearlydepartments and GPs in every format defining what information was Establish a sustainable data andlikely to be used by GP databases needed by whom, and giving audit system(e.g. EMIS, Vision, Word etc. Both practical advice and examples of how Accurate data collection is vital toforms included an aid to diagnosis to do this. understanding the pathway andincluding ABCD2 score) and contact where improvement needs to bedetails for TIA clinics for both To ensure the new referral forms concentrated. It enables:weekdays and out of hours. reached everyone and increase the • an understanding of the current likelihood of their adoption: position and monitoring, on anLancashire Teaching Hospitals • the network sent emails to all GPs ongoing basis to create aNHS Foundation Trust established a across north west London, sustainable serviceunified single point of access, with an explaining the new referral forms. • an understanding of the service atinitial telephone call to the acute The clinical contracts lead for each all points along the pathway,stroke unit, for high and lower risk PCT forwarded emails to GPs and identifying bottlenecksTIA patients. This was used from included a link to dedicated web • regular audit of referrals withOctober 2009 to improve GP access pages on the network website feedback to primary care A&E andand minimised the time from the • dedicated web pages were created, ambulance servicespatient presenting to the GP to clinic including downloadable versions of • ongoing review of demand andreview. all forms and information regarding capacity, which has been essential aids to diagnosis and use of referral for these new services as projectsEmploy a comprehensive forms noticed that demand changed ascommunication strategy • printed copies of the forms were the referral system and the use ofAn explicit communication strategy, sent to every practice manager, ABCD2 was refined and thecovering awareness, education and including pens inscribed with the pathway embeddedtraining, will provide benefits for web address of the dedicated TIAthose experiencing TIA through: webpage to further publicise the Surrey and Sussex Healthcare NHS• supporting implementation on the site Trust created an electronic audit tool pathway and ensuring patients • stroke consultants at each trust to standardise note-keeping, letters enter the right pathway of care as trained their A&E departments on to GPs and gather audit data that soon as possible use of forms was reliable and easy to analyse.• raising awareness in primary care, They have since achieved a figure of the ambulance service, A&E and Data collection is under way but early 66% of high risk patients with TIA any other referral points in the TIA indications show that the use of new seen and treated in 24 hours. pathway referral forms in A&E departments is• emphasising and reinforcing the now in excess of 80% and the use of North West London Cardiac and importance of early referral new referral forms by GPs, although Stroke Network created a data• enabling education in the ABCD2 variable, is increasing month by template for use within TIA clinics to score ensuring appropriate referrals month and has reached 60% in one collect baseline data, assess the use and effective triage unit. Hits on the network’s website of referral forms, measure referring• highlighting the need for clear increased by 20%. patterns and report on the vital sign. patient information and supporting Data was accepted in whatever its provision format was convenient, and assistance offered by the network to facilitate collection. www.improvement.nhs.uk/stroke
  8. 8. 8 | Going up a gear: practical steps to improve stroke care Tailor the weekend service to The service has moved from full In Surrey and Sussex Healthcare local needs and demand assessment of three to four patients NHS Trust the Acute Medical Unit Work to date indicates that it is likely per week to up to seven per day, and deliver the TIA service, operating each that only large centres will be able to are now assessing 66% of high risk day Monday to Friday for all patients sustain an independent weekend TIA patients within the 24 hour referred the previous day with TIA service. Accurate demand for the window. (including low and high risk patients). weekend service will only be Using the acute medical unit has apparent once the pathway is North West London Cardiac and ensured that the acute medical teams established and all referrers are using Stroke Network developed an out have an excellent operational it. Many services are reporting lower of hours, 24 hour TIA service for high knowledge of TIA and stroke and numbers than expected at weekends, risk referrals. The Monday to Friday therefore manage the patients in a and it is not yet clear whether this is a TIA service is based in six hospitals in much more effective way. true reflection or because referrers north west London; the weekend are unaware of the service available. service is based at the two hyper- Cornwall and the Isles of Scilly Further work will be undertaken on acute units, making efficient use of PCT operated with a daily mobile this over the coming year to try to the staff and facilities available. multidisciplinary team (which establish the optimal population base included a stroke doctor, a vascular for a viable weekend service. Rather than replicate a traditional technician with portable doppler, the face-to-face outpatient clinic service stroke co-ordinator, and a clinic Different approaches to weekend at weekends Royal Devon and nurse) running a clinic across five services are developing, typically Exeter NHS Foundation Trust sites. They moved from a 90 day based on cooperation between decided to investigate using stroke wait to an average 24 hour wait for services within the same network. nurse practitioners to perform carotid medium to high risk patients, and a These include: ultrasound screening, to address the 48 hour wait for low risk patients. • hyper-acute stroke centres issue of appropriate urgent imaging They have seen 35 patients weekly, providing a weekend service based and screening during weekend and from five to ten per week previously, on the agreements in place for bank holiday periods. The stroke and reduced the wait for carotid thrombolysis cover nurse practitioners cover the hospital endarterectomy to seven days. • rotating service provision at seven days a week, 7.30am to 8pm, weekends within multi-site trusts providing a potentially cost effective The Royal Bournemouth and • partnering with neighbouring trusts solution to providing a weekend Christchurch Hospital NHS where one trust operates at service. Foundation Trust, with South weekends or the lead trust rotates Western Ambulance Service, have Think differently about how and set up a referral pathway allowing The University Hospitals of where TIA clinics are provided open-access for GPs, emergency Leicester NHS Trust has established Services are acknowledging that ‘one department staff and paramedics. An a seven day service, agreed with the size doesn’t fit all’ necessarily, and are education leaflet was developed for PCT with a locally negotiated tariff, developing more imaginative models paramedics, so that they could using this structure: than standard out-patient clinics. undertake the triage and refer • consultant-led clinic These include: suspected TIA patients to the clinic. • Saturday and Sunday: one Band 6 • basing TIA clinics in the acute nurse, one clinical aide or clinic stroke unit clerk • using medical assessment units or • specialist registrars help when equivalent facilities open 24 hours available a day • morning attendance • providing a mobile service in rural • carotid ultrasound screening from areas where travelling is difficult or 10am to 12.30pm lengthy for patients • MRI available 11am to 2.30pm (five • developing paramedic assessment slots), CT at weekends (five slots) and triage • consultant review from1pm onwards www.improvement.nhs.uk/stroke
  9. 9. Going up a gear: practical steps to improve stroke care | 9 Figure 1: Before and after TIA referral pathways in Bournemouth EVENT EVENT 3-15 DAYS POST EVENT WITHIN 1-2 HOURS Patient seeks a Patient calls 999 GP appointment Patient is seen and assessed Patient is seen and assessed as presumptive TIA/minor stroke as presumptive TIA/minor stroke Ambulance clinician, nurse GP refers to outpatient clinic or out-of-hours GP referrs direct to TIA clinic SAME/NEXT WORKING DAY HIGH RISK 7-20 DAYS POST EVENT ADMISSION Clinic receives referral and books Clinic receives referral and contacts patient directly to make same/ appointment for the patient next working day appointment Tests are done Tests are doneImaging The NHS Improvement DiagnosticsMeeting the imaging requirements of team have been working with sitesthe National Stroke Strategy is a involved in projects to review thesignificant challenge for many issues in imaging for TIA. Furtherorganisations. Key suggestions from information on the review by thethe projects include: Diagnostics Team is available on• review scanning capacity regularly the Stroke Improvement as it will change as the service is Programme web site at: publicised and referrals refined www.improvement.nhs.uk/stroke• consider carotid imaging with MRA at weekends if an MR scanner is already in operation• consider nurse training in carotid ultrasound screening www.improvement.nhs.uk/stroke
  10. 10. 10 | Going up a gear: practical steps to improve stroke care Implementing best practice in acute care Quality markers 7, 8 and 9 in the TOP TIPS various tactics and agreements, will National Stroke Strategy define the ensure that stroke patients are more key components of effective acute • Protect stroke unit beds likely to get the necessary care. One stroke care. It is clear what needs to • Actively cooperate with the rest approach is to apply the model be done for those experiencing stroke of the hospital developed by cardiac services, where to guarantee best outcomes, and • Develop a flexible, stroke skilled heart attack treatment is accepted as how the health care system needs to workforce a clinical priority and consequently • Work with stroke survivors and organise itself to provide the best cardiac beds are protected. carers service for patients. • Build an active partnership with Royal United Hospital, Bath initially A&E Ten projects worked with the Stoke • Work with the ambulance undertook bed modelling work which Improvement Programme to explore service showed a lack of beds, shared on an how to improve the care they provide • Move to six days a week integrated ward with neurology. The for their patients. Together with working for therapy services stroke and neurology services were learning from three rehabilitation separated into two ward areas to give projects, their experience has led to each specialty its own clear identity. the identification of the some key Protect stroke unit beds Left with a 28 bed ward, the team actions. Key to achieving effective and converted one bed area (from six prompt treatment of stroke is beds to four) into a hyper-acute More detail is available in the ensuring that patients are cared for in stroke unit, ensuring the 26 accompanying publication, a properly staffed and skilled stroke dedicated stroke beds needed. Implementing best practice in acute unit. When this happens, stroke care: case studies from the Stroke patients receive optimal care, The team got agreement for the Improvement Programme projects. resulting in improved outcomes and a acute stroke unit to have the same shorter length of stay in hospital. bed and site management principles as the cardiac unit. Every day at the Bed availability can be a barrier to site meeting, the availability of an this, often due to the use of stroke acute stroke unit bed is checked in unit beds for people who have not the same way as for a cardiac bed, had a stroke. Bed management and as soon as a stroke patient is policies that ensure stroke patients admitted to the unit, bed can be admitted straight onto the management prioritise clearing unit are essential. Successfully another bed. protecting stroke beds, through www.improvement.nhs.uk/stroke
  11. 11. Going up a gear: practical steps to improve stroke care | 11This has raised the stroke unit’sprofile within the trust, boosted Figure 2: Patients spending 90% of their time inmorale for staff working on the unit, an acute stroke unit in Milton Keynesand given a clear mandate to geareverything about the ward around 80providing the best stroke care. By the 70 Blip due to winter bed pressuresthird week of direct admissions, the April 2009 60 40%length of stay had reduced from 18to 5.5 days. 50 Percentage March 2009 40 75%Queens Hospital NHS Foundation 30Trust linked in with the hospitalemergency pathway redesign to 20make sure the acute stroke unit was 10included in daily operations meetings 0and bed allocation ensured stroke Apr May Jun Jun Aug Sep Oct Nov Dec Jan Feb Marunits beds were for people who have 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010had a stroke. A stroke unit admission Monthsprotocol was written and agreed.Patients are identified by bedmanagement earlier and are allocated This was also communicated through This led to an increase in directto the stroke unit quicker. screensavers and posters around the admissions to the stroke unit - up toCommunication between clinicians hospital to ensure stroke patients are 63% from 54% at the start of theand capacity management is much referred to the stroke unit. project, and a dramatic increase inimproved. The percentage of patients patients reaching the stroke unitspending 90% of their stay in a The Trust met the SHA goal of 70% within four hours of arrival, up tostroke unit is now 89% as of April of stroke patients spending 90% of 76% from 54%. Patients who are2010 (up from 71%). their time in hospital on a specialist managed via the assessment trolley stroke unit. have higher quality of care – they areMilton Keynes Hospital NHS assessed quicker, scanned quickerFoundation Trust agreed the need Poole Hospitals NHS Foundation and treatment is started earlier thanfor a fast track bed with the acute Trust have developed an ‘assessment those not admitted via this route.stroke unit clinicians, the bed trolley’ on the acute stroke unit tomanagement team and the divisional speed up assessment processes by Similarly, the team in Sandwell andmanager to enable timely transfer the stroke team for suspected stroke West Birmingham Hospitals NHSfrom A&E and the clinical decision patients not likely to benefit from Trust negotiated an agreement withunit (CDU). The use of the bed is thrombolysis, and assist admission managers, including bed managers,monitored and reported weekly. High directly to the stroke unit for optimal that there would always be a bedbed pressures in the Trust remove the care. available on the stroke unit. Anyeffectiveness of the bed. delays in A&E were escalated up to the on call manager. To overcomeA bed management protocol for data collection problems in trackingstroke patients was implemented to this, an audit clerk was employed toensure stroke patients identified in collect times of admission to A&E andA&E or CDU do not transfer to the stroke unit and this data isanother ward. The protocol was reviewed weekly with seniorshared around the trust to ensure management.members of staff across all levelsidentify the urgency of transferring apatient to the acute stroke unit. www.improvement.nhs.uk/stroke
  12. 12. 12 | Going up a gear: practical steps to improve stroke care Bed management was improved in Actively cooperate with the rest The Nottingham University Surrey and Sussex Healthcare NHS of the hospital Hospital NHS Trust project was Trust through a fast-track bed policy, To enable the stroke unit to function called DASH – Direct Access to Stroke now in operation 24 hours a day, effectively, it must cooperate with Hyper-acute Unit. As the project which uses a system of identifying other services in the hospital. would involve other hospital patients that can be moved from the Problems have arisen in the past due departments, it was felt important to acute stroke unit to a ‘fast track’ bed. to a lack of understanding of the engage as many stakeholders as Additionally, a daily bed status form importance of the clinical functions of possible in order to gain commitment was developed to identify delays the stroke unit and the necessary to progress. This ensured the project to discharge, patients awaiting urgency of scanning and transfer of had the support and sponsorship of repatriation in and transfer out of patients to the stroke unit. As a the trust chief executive, along with the acute stroke unit for ongoing consequence, stroke patients are not clinical and medical directors. rehabilitation or care home treated appropriately and promptly, placement. The form is presented at services such as scanning not Poole Hospitals NHS Foundation the daily bed meeting, and copies of performed quickly enough, and Trust improved their links with other the forms are kept for audit purposes patient experience and outcomes services through process mapping the and have been used to monitor the suffer. acute stroke patient pathway with number of stroke outliers. Through clinicians from all teams involved with this and other measures, direct To combat this, many acute stroke the patient, including ambulance admissions to the acute stroke unit unit teams have recognised the teams, A&E, radiography, radiology, have gone from 7% at the start of benefit of actively building stroke unit, bed management, and the project to 60%, and 67% of relationships with other parts of the the high dependency unit. This led to patients are spending the majority of hospital, e.g. A&E, radiology and a new patient pathway being agreed their time on the stroke unit medical admissions units, to promote by all teams, covering from hospital compared to a baseline of 33%. the effective pathway for stroke arrival to completion of patients. Better cooperation leads to multidisciplinary assessments. This Through promoting stroke services to more coordinated transfer of care for helped teams minimise unnecessary have equal status with urgent each patient, and avoids mistakes delays for patients being admitted specialist services such as cardiology, and delays due to misunderstanding with stroke and ensured a safe but the team in Worcestershire Acute and poor communication. It provides speedy pathway for thrombolysis Hospitals NHS Trust raised the subtle education for other clinical and patients (in and out of hours). profile of stroke management and managerial staff, and can have the care within the organisation. This led additional benefit of improving the Process mapping helped the staff to agreement to ring-fence beds on ability to care for stroke patients well involved along the patient pathway acute stroke units countywide, and in non-specialist services when better understand the patient journey three additional acute stroke beds attending for other clinical reasons – and the impact of their performance opened on the site in August 2009. a frequent complaint from people on overall patient outcomes and As a consequence, access to the who have had a stroke and carers. patient and carer experiences. It also stroke unit and the proportion of helped build relationships between time spent on the unit has been Royal United Hospital, Bath different departments and increasing month by month. developed strong links with A&E, organisations which have been radiology and the older people’s unit invaluable in making changes to expand thrombolysis to provide 24 happen. hour cover. Patients are now admitted directly from A&E to the acute stroke unit, bypassing the medical assessment unit and other wards. www.improvement.nhs.uk/stroke
  13. 13. Going up a gear: practical steps to improve stroke care | 13Sandwell and West Birmingham Milton Keynes Hospital NHS consequence, all stroke patients haveHospitals NHS Trust has a monthly Foundation Trust developed an benefited from greater stroke-specificstroke action group with integrated multidisciplinary team care knowledge by the staff caring forrepresentation from all departments. record, a collaborative record of each them. All qualified nursing staff alsoThere is a weekly review of the profession’s contribution to a have received individual teachingpatient’s pathway and an ongoing patient’s care throughout their stay from the stroke lead for themonitoring system that highlights the on the acute stroke unit. It sets out department which has also impactedpatients that do not spend 90% of guidelines for good practice based on on clinical care.their time on a stroke unit, which the National Stroke Strategy or NICEallows the pathway to be monitored guidelines and is used to set goals for The Aintree University Hospitalsand data to be validated easily. the patients to aid care planning of NHS Foundation Trust team the patient during the weekly undertook a mapping exercise,Develop a flexible, stroke multidisciplinary meetings. involving representatives from all keyskilled workforce staff impacting on the unit and,A key principle of the National Stroke The team from Poole Hospitals NHS combined with the views of patientsStrategy is to ensure that there is an Foundation Trust undertook several and carers, identified issues forappropriately stroke skilled workforce training and staff development improvement. This process in itselfto meet the needs of patients. Stroke initiatives to improve care, including: has meant the team have developedservices generally function in • agreeing a protocol for the senior a mutual understanding and respect,multidisciplinary teams and this is an nurse practitioner to request a brain good foundations for developing realimportant factor in tackling problems scan (CT), speeding up scan multidisciplinary team working.and bottlenecks than can arise requests so that now 78% of Communication within the team hasthrough shortages of staff in key eligible patients receive a brain scan improved, the occupational therapistsareas. within 24 hours of arrival at attend the daily nursing handover hospital compared to 65% at the and occupational therapy andProviding stroke team staff with start of the project physiotherapy staff actively use andnecessary skills and competencies, • training acute stroke unit staff update the nursing electroniceven if outside of traditional roles nurses and stroke medical staff to handover. The team is working on(e.g. speech and language therapy gain competency in swallow screen how nurses can support thestaff training non-speech and after stroke, resulting in 89% of therapists work through teaching andlanguage therapy colleagues in patients now receiving a swallow education within the multidisciplinaryswallowing screening) can provide a assessment within 24 hours of team.much needed additional flexibility to admission compared to 50% at thethe team. start of the project Six day working in York Hospitals • establishing a Patient Group NHS Foundation Trust and NHSWhen done well, this approach can Directive for aspirin to assist Medway has led to a different workimprove staff satisfaction through delivery to appropriate patients environment. During the pilot,development of roles. The Stroke within 24 hours of admission. feedback indicated that therapists areSpecific Educational Framework is Consequently, the percentage of more accessible to relatives and carersdesigned to help this process by patients receiving aspirin within as they tend to be more able to visitproviding a clear and structured 24 hours of admission has gone at weekends and consequently, abledescription of patient need and from 23% to 63% to attend therapy sessions. Nursingassociated clinical skills.4 staff are often more available at In Yeovil District Hospital NHS weekends to observe or support the Foundation Trust, recent changes to therapy sessions, providing a useful the thrombolysis service, extended to education opportunity, assisted with 8am to 11pm Monday to Friday, has transfer of information across the resulted in all medical registrars being multidisciplinary team and supported trained in the NIHSS and acute carry over of therapeutic treatments. management of stroke. As a directStroke-specific education framework,4Department of Health, April 2009. www.improvement.nhs.uk/stroke
  14. 14. 14 | Going up a gear: practical steps to improve stroke care Work with stroke survivors and were highlighted, which could be ward, as most expressed a wish for carers easily and rapidly addressed. For more therapy. Carers also felt it Clinical teams working with those for example, in A&E, staff had only the would give them more opportunity to whom their service is provided, to general ward phone number meet with therapy staff. This is in properly understand patient needs displayed, not the emergency contrast to views of patients using and how best to meet them, is a number, despite it being included on the community service, who by then fundamental principle of effective the A&E stroke pathway poster. felt weekend therapy would be improvement work. intrusive to family time. Aintree University Hospitals NHS Through systematic and effective Foundation Trust undertook a series Build an active partnership gathering and analysis of patient of questionnaires and consultations with A&E views and experiences, teams can: with staff, patients and carers, An effective and cooperative • ensure that they are providing the including a patient observation study. relationship with A&E services is key aspects of care that patients This enabled the team to have a very central to acute stroke care, and and carers require different perspective on ‘life in fundamental to two main areas of • develop insight into the patient and rehabilitation.’ Feedback from essential clinical care - prompt arrival carer perspective to guide patients showed that there were on a stroke unit and spending the development and planning periods of boredom, particularly in majority of time under its care. • improve outcomes through giving the afternoons, and that most patients and carers a sense of patients did not even know that a Acute stroke services that have involvement and partnership in day room existed. From a staff developed and formalised working management of the service and of perspective, much of the day is practices with A&E colleagues have their own care planned around getting patients up seen their patients benefit from • enhance staff satisfaction and dressed, accessing medical tests, earlier diagnosis and prompt • create more responsive and patient or being ready for therapy, treatment, and enhanced the ability centred services medication and mealtimes, with little of A&E services to manage stroke time for considering much else. patients. The cognitive and communication impairments that can result from Staff are now more confident around This has included: stroke make the gathering of patient the process of patient and carer • discussing, mapping and viewpoints more complex than in engagement. The team have agreed redesigning the pathway of care some other areas, but can be on a plan to improve the access to, between A&E and the acute stroke addressed. and use of, the day room and are unit considering the reintroduction of • procedures for ‘alert calls’ to the Royal United Hospital, Bath communal eating on the wards, to stroke unit when a suspected undertook patient focus groups with reduce isolation and boredom and to stroke patient is due to arrive the help of The Stroke Association, provide therapeutic opportunities. • developing the skills of nominated and the main theme to emerge was Plans are also in progress for the individuals within the A&E team as poor patient experiences on the development of information for a stroke liaison post medical assessment unit, on patients and carers, a stroke staff • clear protocols to avoid stroke occasions when this took several days newsletter and focus groups to look patients being admitted to medical for them to be transferred to the at the other issues flagged up from admission units or clinical decision stroke unit. This both informed and the project work around discharge services strengthened the case for direct planning and the admission process admission to the acute stroke unit. to the unit. Royal United Hospital, Bath has continued to develop strong links to In Nottingham University Hospital When the NHS Medway project A&E, to support the delivery of NHS Trust, both clinical and non team were planning the move to a thrombolysis, but also so that clinical members of the stroke team weekend rehabilitation service, they patients are now admitted directly engaged in ‘walking the patient received the overwhelming message from A&E to the acute stroke unit. pathway’. A number of problems of support from patients on the acute www.improvement.nhs.uk/stroke
  15. 15. Going up a gear: practical steps to improve stroke care | 15In Queens Hospital NHS A&E. With a respected member of A new ring tone and flashing lightFoundation Trust, the project has the existing nursing team to act as an was installed to alert the stroke unitraised the profile of the stroke service advocate for stroke, address the team to the emergency responsewithin the hospital. Where once most training needs and support the required. This new phone andstroke patients were admitted to the development of protocols to embed number would alert staff on the wardemergency admissions unit for at the change in practice, there has immediately that a patient was goingleast 24 hours and transferred to the been a dramatic improvement in the to be transferred, giving them thestroke unit later, staff now recognise perception of the stroke patient opportunity to triage, and then givethe importance of the stroke pathway within the department and the advice to the crew on where to takeand the benefits of thrombolysis. processes required for quick triaging the patient. This action changed theMore patients are being assessed for after arrival in A&E. pathway for the patient almostsuitability for thrombolysis and the immediately, with everyonestroke service has joined the IST-3 Work with the ambulance service concerned fully aware of where theresearch trial.5 Ambulance services are the first line patient was to be sent and what of effective stroke care. It is crucial would happen next. There was aIn Sandwell and West Birmingham where a network approach to the reduction in delays in transfer, and aHospitals NHS Trust stroke unit staff delivery of thrombolysis is in place so decrease in the number of patientsworked with the A&E general that patients travel to the right being admitted via A&E.manager and the stroke co-ordinator hospital, quickly. They have excellentto reinforce new pathways with the knowledge of the issues in moving Poole Hospitals NHS Foundationstaff in A&E and the on call team. patients round the local patch. Closer Trust set up an ambulance pre-alertThere was confusion, so a pathway working can help tackle problems, system to ensure A&E, the strokewas developed on an A4 sheet for all such as ensuring the right type of team and other key staff were awaresuspected stroke patients to be vehicle, i.e. one which is able to of potential thrombolysis patients endirectly transferred to the stroke unit. safely transport the patient, is sent to route, assisting speed of response onThis was circulated to all A&E suspected stroke cases. arrival.doctors, nurses and the radiologydepartment and laminated and In Nottingham University Hospital Move to six day a week workingdisplayed in all departments. This NHS Trust a communication was for therapy servicespathway clarified who was sent to all GPs informing them to Two project sites in Medway and Yorkresponsible and what to do when a contact the stroke unit directly if they tested the provision of a six daysuspected stroke came to A&E. assessed a patient with stroke therapy service and evaluated itsScanning times were reduced to four symptoms, and asked that the call to effect on patient experience, accesshours. the East Midlands Ambulance Service to services and flow. should include the instructions for anIn Yeovil District Hospital NHS emergency ambulance, a four wheel Often services experience aFoundation Trust a key limitation in vehicle with a two manned crew, and bottleneck every Monday whenenabling patients to be accurately not a routine admission. therapy staff have a backlog ofassessed and admitted to the stroke assessments accrued over theunit was poor early assessment within To ensure that ambulance crews were weekend. For new patients it meansA&E. This was solved through fully informed of changes which some may have waited for 48 hourseducation of medical and nursing would affect the stroke pathway, to be assessed and commencestaff and ensuring an accurate work was undertaken with the treatment, for others skills gainedpathway. Redeployment of resources managers of the ambulance service during the previous week may notwithin the stroke team also enabled to produce bulletins containing the have been practiced over thethe appointment of a Band 6 stroke direct access policy, but more weekend, and for staff, theirand neuro lead junior sister within importantly, the direct phone number treatment time is reduced, as priority for the telephone on the stroke unit, has to be given to new assessments. known by all as ‘the Bat Phone’.5The Third International Stroke Trial (IST-3) of thrombolysis for acute ischaemic stroke: aninternational multi-centre, randomised, controlled trial to investigate the safety and efficacy oftreatment with intravenous recombinant tissue plasminogen activator (rt-PA) within six hours ofonset of acute ischaemic stroke. For further information, see www.controlled-trials.com www.improvement.nhs.uk/stroke
  16. 16. 16 | Going up a gear: practical steps to improve stroke care When the project teams analysed the data after the pilot services and Figure 3: Impact on length of stay in NHS Medway compared it with the routine services, they were able to determine various Length of Stay, SRU, 5 Day Therapy Undertaken using less than 25 points factors, including how provision of a 100 Saturday service impacted on the 92 90 number of new patients to assess on 80 a Monday, admission to referral time, and access to therapy time for patients. 60 Value 56 Target 56 46 47 NHS Medway evaluated the effect 40 of a six day service on the number of patients who needed to be seen on a 31 Mean 33.5 28 Monday. They found that moving 20 19 towards providing rehabilitation on a 15 4b 12 12 Saturday had a limited effect on 8 11 LCL 2 0 reducing the bottleneck of new Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient patients, as in practice this captured 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Interval only those new patients admitted on Friday afternoon or evening. If the Length of Stay, SRU, 6 Day Therapy sixth day of therapy had been Undertaken using less than 25 points Sunday, patients on Saturday could 80 also be assessed, therefore having UCL 73.48 65 greater impact on the work Monday 60 57 morning. Target 56 Value The project team did however reduce 40 34 admission to assessment time from 27 42 hours to 35 hours by moving to Mean 22.06 20 15 six days a week. There was little 19 18 20 21 4b 15 difference between the time to 12 10 9 3 5 LCL 0 assessment for physiotherapy with 0 Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient the addition of a Saturday service as 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 they already met the recognised 72 Interval hour standard. However, in Value Mean UCL LCL Target occupational therapy where they were not delivering the desired standard of assessment within four days, a one day reduction in access there was a 100% increase in the facilitating an unanticipated but safe time was achieved. There was also an number of Friday discharges during weekend discharge, preventing improvement in the time between six day working compared with five inappropriate transfers off the ward, admission and first contact by a days. identifying an appropriate stroke speech and language therapist. patient located elsewhere in the During the six day working period, hospital. This also had a beneficial The team found that six day therapy bed occupancy rose from 69% to effect on the trust’s vital sign data. does not significantly impact on 79%. The effect of the additional weekend discharges without other therapy staff on the ward at There was a positive effect with the changes. However, the data showed weekends may impact on decision acute unit length of stay, reducing that the six day service did bring making by the ward staff and bed from 8.2 to 5.1 days. On the forward the date of discharge to an managers. For example, guiding bed rehabilitation unit, the impact was earlier point within the working managers’ decisions around selection significant, reducing from 33.5 to 22, week. On the rehabilitation unit, of patients to move off the ward, a reduction of 8.5 days. www.improvement.nhs.uk/stroke
  17. 17. Going up a gear: practical steps to improve stroke care | 17Table 1: Care package of patients going home from the Medway rehabilitation unit Audit Period Number of Number of patients Total number Average number Percentage of patients needing care of carers of carers per patients needing discharged home package needed patient care package Five day therapy 7 6 20 3.6 85 Six day therapy 8 3 5 1.3 37.5In York Hospitals NHS Foundation Many of the project teams across allTrust the project team found that of the workstreams refer to the50% of their patients accessed impact of noro-virus or other hospitalphysiotherapy within 48 hours during acquired infections on their work.the five day service but when they This not only complicated theirprovided a six day service this rose to improvement work, but lent64%, averaging ½ day reduction in additional importance to their effortsreferral to treatment time for to effectively manage beds for strokephysiotherapy. patients.The project team examined the effectof a six day service on access totherapy time. Their baseline dataindicated that on average patientswere seen four times a week forphysiotherapy and occupationaltherapy. Only 63% of patients forwhom it was appropriate received 45minutes or more of either therapy.When a six day service was providedtheir patients were then able toreceive physiotherapy five days aweek, and 90% of them could access45 minutes of occupational therapy.The baseline length of stay for allstroke patients averaged 47 days,when a six day service was availablethis reduced to 21 days. TheMedway team also found thatalthough the numbers of patientsreturning home did not change, thereis likely to be a link to the reductionin the number of patients requiringcare packages. www.improvement.nhs.uk/stroke
  18. 18. 18 | Going up a gear: practical steps to improve stroke care Post hospital support and long term care Since March 2009, the Stroke Getting transfer of care right has an Manage the health and social Improvement Programme has been impact on the whole stroke pathway. care interface running projects looking at the key The project teams have demonstrated All national project teams whether areas of transfer of care and that improvements to transfer of care led by health or social care expressed rehabilitation. This chapter focuses on processes enable more patients to concerns about how to enable the learning to date in those areas. access the stroke ward more rapidly meaningful joint working across and for longer by creating capacity organisations. The teams established More detail is available in the and improving flow through the the key differences in ways of accompanying publication, Post ward, as well as reducing waiting working and developed methods to hospital support and long term care: times for community rehabilitation improve joint working and case studies from the Stroke and improving patient and carer communication: Improvement Programme projects. satisfaction. Understanding national drivers Transfer of care for health and social care The National Stroke Strategy set a TOP TIPS Social care priorities are focused on clear standard that individuals should long term conditions, personalised • Manage the health and social have a discharge plan, covering all care, partnership working and carer care interface their needs, both health and social support. Key drivers for stroke • Involve patients in improving care. Nine sites across England transfer of care services in health are the National analysed their systems for transfer of • Provide emotional support for Stroke Strategy and NICE and RCP care for people with stroke and stroke survivors and carers clinical guidance. Analysis of national focused their improvements on • Ensure access to appropriate drivers helped to establish common processes influencing this stage of services, including rehabilitation, themes and objectives to align both the pathway. social care and community with national and organisational opportunities agendas. Nottinghamshire County Council and Nottinghamshire Community Health established a team which included a social care commissioner from Nottinghamshire County Council, a community stroke team leader from Nottinghamshire NHS community health team and The Stroke Association. www.improvement.nhs.uk/stroke
  19. 19. Going up a gear: practical steps to improve stroke care | 19The project leads from each of the condition or disease of the individual, Involve patients and carers inorganisations met regularly and so there may not be a stroke specific improving transfer of caredeveloped shared objectives which focus in social care for services or for The National Stroke Strategy makes itagreed with their organisation’s data collection. Funding has been clear that stroke survivors should bestrategic objectives. The successful used with good effect, often for involved strategically in stroke serviceimplementation and effectiveness of stroke specific social care posts, many improvement, as well as in decisionsthis improvement post has supported of which have demonstrated value about their own care. The challengethe plan to commission two for money and will be continued after for services is to obtain real andadditional family and carer support the life of the social care grant. meaningful involvement of strokeservices in the county. survivors rather than token gestures. Stoke on Trent City Council used The project teams were able toUnderstanding national their grant funding to enable a daily establish the patients’ and carers’measures of progress ward visit by social care workers to perspectives of stroke services and toStandards in local authorities are the stroke rehabilitation ward and use these views to significantlymeasured using national indicators facilitate earlier referral to social care change the service.rather than the activity data and services. A single point of contact foroutcome measures used in health. patients and carers on discharge and Poole Hospital NHS FoundationInvestigation of the social care policies for discharge and for rapid Trust and NHS Bournemouth andnational indicators demonstrates links assessment were implemented. Both Poole, with Dorset Stroke Networkwith the stroke strategy quality social care and the early supported used a patient and carer feedbackmarkers, e.g. National indicator 131 discharge teams adopted the new forum to establish the shortfalls inis about delayed transfers of care, name of ‘Community Stroke the transfer of care pathway and132 records timeliness of social care Discharge Team’ so that patients and suggest a vision for how they wouldassessment and 133 is about carers were aware of the close like services to be, which was used bytimeliness of packages of care, all of working relationship to provide a staff from social care, health and thewhich relate well to quality marker 12 seamless service. voluntary sector to develop anof the National Stroke Strategy.6 This aspirational pathway for the service.awareness of the potential for shared The Royal Bournemouth and The team established a ‘meet thenational measures can also enable Christchurch Hospitals NHS team’ meeting early in the first weekalignment of objectives. Foundation Trust focused their of the hospital stay to discuss attention on improvements which prognosis and plans for rehabilitationDudley PCT, key staff from Dudley could be made in transfer of care and discharge with the patient andSocial Services, Dudley Group processes in hospital. The team family.of Hospitals and The Stroke supported closer working of healthAssociation improved and social care teams by co-location The Royal Bournemouth andcommunication through regular short of the social workers, information Christchurch Hospitals NHSmeetings and task groups to tackle support officer and Stroke Foundation Trust team obtainedspecific problems. The team made Association support staff in the patient and carer feedback usingan impact on delayed discharges, hospital, near to the stroke ward, questionnaires after hospitalreducing length of stay to 18.5 days rather than at the local authority. discharge. The feedback becamein 2008/9 and to 15.7 days in Measurable improvements made by integral to the project, informing the2009/10, saving £750 per patient. this team include significantly team at many levels as to the improved patient satisfaction scores effectiveness of their improvements.Use of the stroke social care grant for involvement in the transfer of care Formalised care reviews with patientsenabled a protected resource for process, reduced waiting times for and carers for enhancedstroke specific posts and services in community therapy and improved communication and dischargelocal authorities. The operational quality of handover information planning were implemented early infocus in social care is on the needs of between hospital and community the hospital stay. Care reviewthe individual rather than the teams. documentation given to the patient6For further information on similarities between National Indicators and Quality Markers,see Stroke Improvement Programme website social care resourceswww.improvement.nhs.uk/stroke/SocialCareforStroke/SocialCareforStrokeResources.aspx www.improvement.nhs.uk/stroke
  20. 20. 20 | Going up a gear: practical steps to improve stroke care reinforced information given during The South West London Cardiac The joint commissioner-provider led the meeting. Patient satisfaction and Stroke Network project team from NHS Milton Keynes and about information given has implemented a self management Milton Keynes Council planned a improved. programme in Croydon. 72% of staff service redesign to establish a new participants changed their practice early supported discharge service. Provide emotional support for towards a more patient centred, goal There were no stroke specialist stroke survivors and carers orientated approach, which rehabilitation staff in the community The National Stroke Strategy, RCP promoted patients’ self efficacy. and poor follow up when they clinical guidance and Department of Improvements in patient self efficacy started. Implementation of the new Health guidance7 recommend the scores were shown in eight of the 12 service was less than straightforward, emotional needs of people who have patients and two others had scores but in its first month saw a dramatic had a stroke are met and carers are which remained high throughout. improvement in length of stay from supported to have their needs Improvements were also made in more than 23 days to less than 10 assessed. The challenge is in patients perceptions of the impact of days and an improvement in the identifying individuals in need of the stroke, measured using the Stroke stroke vital sign from an average of these services and in providing a Impact Scale. 50% to 70% of stroke patients skilled service to meet the need. spending 90% of their time on the Several of the project teams found In Dudley PCT, patients and families stroke unit. ways around these challenges to were given a contact number for the demonstrate positive outcomes for family support worker to use for any The team from Lincolnshire patient and carer satisfaction, carer questions and concerns, instead of Community Health Services set out strain and the economic benefits of seeking help from the GP or going to to establish a cost effective assisted good emotional support. A&E when they were anxious or discharge stroke service in a health worried. The team demonstrated the community, from no stroke specific Nottinghamshire County Council post saved the PCT around £94,500 community rehabilitation and very and Nottinghamshire Community in its first year on crisis admissions limited generic community Health’s improvement was focused and emergency room visits by rehabilitation. The team set up an on access to emotional support for patients recently discharged from assessment process, in-reaching to carers by funding and defining a role hospital. ward team meetings at referring for a family and carer support worker stroke units, and, in some areas, post on the stroke ward. Key learning Ensure access to appropriate attending daily handover sessions points were that: services, including rehabilitation, with stroke unit staff. Recruitment to • the timing of interventions and social care and community the new service was highly successful support for carers is critical. Carers opportunities and access to a seven day community are in crisis themselves at the acute Improving transfer of care is service was established across the stage of the pathway so support fundamentally about getting the county. Average Barthel scoring may be best received at the post process right and ensuring people improved, and waiting times for acute stage who have had a stroke access services community therapy reduced from • carers also wanted to talk after they need when they need them. three weeks to two to four days. usual office hours when they felt Several of the national project teams Patient satisfaction with the new they had more capacity after work obtained investment for major service is high. for visiting pathway redesign and were able to • specific carers support is valued implement improvements in the enormously and warrants particular transition from hospital and to attention by the stroke service accessing community therapy, social care support and beyond. Putting People First, Department of Health, 2007 7 www.improvement.nhs.uk/stroke

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