Going up a gear: Practical steps to improve stroke care

NHS
CANCER NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

Stroke Improvement Programme

Going up a gear:
practical steps to improve stroke care

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

Going up a gear: practical steps to improve stroke care | 3

Foreword

We are at an important milestone in But they also reminded us that there
the implementation of the National is much to do, particularly to support
Stroke Strategy. people to live long term with the
consequences of their stroke. That is
This publication, Going up a gear, is a why earlier this year we launched the
chance for all of us to learn from the Accelerating Stroke Improvement
projects which were launched in programme, to go further, faster in
March 2009. It is a testament to the improving stroke services with the
contribution the teams have made additional support and tools
locally and the product of a lot of available, to sustain improvement
hard work. You will no doubt into the future. Professor Roger Boyle CBE
recognise many of the issues they National Director for Heart Disease
and Stroke, Department of Health
faced, and we hope you will be able We can all agree that excellent stroke
to use their solutions as you are care is our main goal. Going up a
continuing to develop your own gear, has been designed to help you
services. in meeting that challenge.

All those involved in stroke services Professor Roger Boyle CBE
have been making great strides to National Clinical Director for Heart
improve care since the publication of Disease and Stroke
the Strategy in 2007. This Department of Health
contribution of many individuals and
teams across the country is starting to Dr Damian Jenkinson
show results for people who have a National Clinical Lead
stroke in England, as the National NHS Stroke Improvement Programme
Audit Office recognised in their Dr Damian Jenkinson
National Clinical Lead, NHS Stroke
report, Progress in improving stroke Improvement Programme
care, published earlier this year.

www.improvement.nhs.uk/stroke

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



Joining up prevention

Joining up prevention includes The first phase of 18 projects were The Stroke Improvement Programme
information on stroke prevention established in October 2007 and publications that provide a summary
through better identification and completed April 2009. Working and overview of the outcomes from
treatment 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 agenda
Both these approaches are essential improve detection and optimal The opportunity to provide cost
to realise the ambitions of the treatment of patients with AF in effective high quality care to prevent
National 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 key
and ‘TIA and minor stroke’ (quality TOP TIPS recommended interventions under
markers 5 and 6). Chapter eight of the national quality and productivity
the National Service Framework on • Detect AF though opportunistic agenda, details of which can be
Coronary Heart Disease also set out screening e.g. at annual flu accessed at NHS Evidence.3
clinics
the quality requirements for the
• Consider local enhanced service
prevention and treatment of patients Driving forward
schemes for detection, screening
with cardiac arrhythmias.2 A further stage of this work began in
and review of AF
• Develop new models for
October 2009 with nine health
Atrial fibrillation: detection anticoagulation services in communities, led by the Heart and
and treatment primary and community settings Stroke Improvement Programmes.
Atrial fibrillation (AF) is the most • Develop tools to support the Building on the evidenced based
common sustained dysrhythmia, review of patients with AF, to risk learning, resources and demonstrable
affecting at least 600,000 (1.2%) stratify for stroke and optimal outcomes from the first phase, they
people 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 for
strokes 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 palpation
AF. It is also an eminently • barriers to anti-coagulation in
preventable cause of stroke with a primary care
simple highly effective treatment; • ECG training and interpretation 2National Framework for Coronary Heart
with warfarin known to reduce risk • AF as a major risk factor for Disease; Arrhythmias and Sudden Cardiac
by 50-70%. stroke. Death, Department of Health, March 2009.
3See: www.library.nhs.uk/qualityandproductivity



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.



North West London Cardiac and North West London Cardiac and North Bristol NHS Trust, with the
Stroke 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 module
protocols and out of hours service for new referral forms to GPs, A&E for ABCD2 assessment for all GPs
TIA referral, having gained consensus departments and all interested and Great Western Ambulance
from clinical teams in each hospital. parties. It included comprehensive Service staff.
Separate forms were made for A&E information for services, clearly
departments and GPs in every format defining what information was Establish a sustainable data and
likely 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 to
forms included an aid to diagnosis to do this. understanding the pathway and
including ABCD2 score) and contact where improvement needs to be
details 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 an
Lancashire Teaching Hospitals • the network sent emails to all GPs ongoing basis to create a
NHS Foundation Trust established a across north west London, sustainable service
unified single point of access, with an explaining the new referral forms. • an understanding of the service at
initial 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 bottlenecks
TIA patients. This was used from included a link to dedicated web • regular audit of referrals with
October 2009 to improve GP access pages on the network website feedback to primary care A&E and
and minimised the time from the • dedicated web pages were created, ambulance services
patient presenting to the GP to clinic including downloadable versions of • ongoing review of demand and
review. all forms and information regarding capacity, which has been essential
aids to diagnosis and use of referral for these new services as projects
Employ a comprehensive forms noticed that demand changed as
communication strategy • printed copies of the forms were the referral system and the use of
An explicit communication strategy, sent to every practice manager, ABCD2 was refined and the
covering awareness, education and including pens inscribed with the pathway embedded
training, will provide benefits for web address of the dedicated TIA
those 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.



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



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 done

Imaging The NHS Improvement Diagnostics
Meeting the imaging requirements of team have been working with sites
the National Stroke Strategy is a involved in projects to review the
significant challenge for many issues in imaging for TIA. Further
organisations. Key suggestions from information on the review by the
the 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



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



This has raised the stroke unit’s
profile within the trust, boosted Figure 2: Patients spending 90% of their time in
morale for staff working on the unit, an acute stroke unit in Milton Keynes
and given a clear mandate to gear
everything about the ward around 80
providing the best stroke care. By the 70
Blip due to
winter bed pressures
third week of direct admissions, the April 2009
60 40%
length of stay had reduced from 18
to 5.5 days. 50
Percentage

March 2009
40 75%
Queens Hospital NHS Foundation
30
Trust linked in with the hospital
emergency pathway redesign to 20
make sure the acute stroke unit was 10
included in daily operations meetings
0
and bed allocation ensured stroke Apr May Jun Jun Aug Sep Oct Nov Dec Jan Feb Mar
units beds were for people who have 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010

had a stroke. A stroke unit admission Months

protocol was written and agreed.

Patients are identified by bed
management earlier and are allocated This was also communicated through This led to an increase in direct
to the stroke unit quicker. screensavers and posters around the admissions to the stroke unit - up to
Communication between clinicians hospital to ensure stroke patients are 63% from 54% at the start of the
and capacity management is much referred to the stroke unit. project, and a dramatic increase in
improved. The percentage of patients patients reaching the stroke unit
spending 90% of their stay in a The Trust met the SHA goal of 70% within four hours of arrival, up to
stroke unit is now 89% as of April of stroke patients spending 90% of 76% from 54%. Patients who are
2010 (up from 71%). their time in hospital on a specialist managed via the assessment trolley
stroke unit. have higher quality of care – they are
Milton Keynes Hospital NHS assessed quicker, scanned quicker
Foundation Trust agreed the need Poole Hospitals NHS Foundation and treatment is started earlier than
for 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 to
management team and the divisional speed up assessment processes by Similarly, the team in Sandwell and
manager to enable timely transfer the stroke team for suspected stroke West Birmingham Hospitals NHS
from A&E and the clinical decision patients not likely to benefit from Trust negotiated an agreement with
unit (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 bed
bed pressures in the Trust remove the care. available on the stroke unit. Any
effectiveness of the bed. delays in A&E were escalated up to
the on call manager. To overcome
A bed management protocol for data collection problems in tracking
stroke patients was implemented to this, an audit clerk was employed to
ensure stroke patients identified in collect times of admission to A&E and
A&E or CDU do not transfer to the stroke unit and this data is
another ward. The protocol was reviewed weekly with senior
shared around the trust to ensure management.
members of staff across all levels
identify the urgency of transferring a
patient to the acute stroke unit.



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.



Sandwell and West Birmingham Milton Keynes Hospital NHS consequence, all stroke patients have
Hospitals NHS Trust has a monthly Foundation Trust developed an benefited from greater stroke-specific
stroke action group with integrated multidisciplinary team care knowledge by the staff caring for
representation from all departments. record, a collaborative record of each them. All qualified nursing staff also
There is a weekly review of the profession’s contribution to a have received individual teaching
patient’s pathway and an ongoing patient’s care throughout their stay from the stroke lead for the
monitoring system that highlights the on the acute stroke unit. It sets out department which has also impacted
patients 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 NICE
allows the pathway to be monitored guidelines and is used to set goals for The Aintree University Hospitals
and 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 key
skilled 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 patients
Strategy is to ensure that there is an Foundation Trust undertook several and carers, identified issues for
appropriately stroke skilled workforce training and staff development improvement. This process in itself
to meet the needs of patients. Stroke initiatives to improve care, including: has meant the team have developed
services 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 real
important 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 has
through shortages of staff in key eligible patients receive a brain scan improved, the occupational therapists
areas. within 24 hours of arrival at attend the daily nursing handover
hospital compared to 65% at the and occupational therapy and
Providing stroke team staff with start of the project physiotherapy staff actively use and
necessary skills and competencies, • training acute stroke unit staff update the nursing electronic
even 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 the
staff training non-speech and after stroke, resulting in 89% of therapists work through teaching and
language therapy colleagues in patients now receiving a swallow education within the multidisciplinary
swallowing screening) can provide a assessment within 24 hours of team.
much needed additional flexibility to admission compared to 50% at the
the team. start of the project Six day working in York Hospitals
• establishing a Patient Group NHS Foundation Trust and NHS
When done well, this approach can Directive for aspirin to assist Medway has led to a different work
improve 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 are
Specific Educational Framework is Consequently, the percentage of more accessible to relatives and carers
designed to help this process by patients receiving aspirin within as they tend to be more able to visit
providing a clear and structured 24 hours of admission has gone at weekends and consequently, able
description of patient need and from 23% to 63% to attend therapy sessions. Nursing
associated 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 direct

Stroke-specific education framework,
4

Department of Health, April 2009.



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



In Queens Hospital NHS A&E. With a respected member of A new ring tone and flashing light
Foundation Trust, the project has the existing nursing team to act as an was installed to alert the stroke unit
raised the profile of the stroke service advocate for stroke, address the team to the emergency response
within the hospital. Where once most training needs and support the required. This new phone and
stroke patients were admitted to the development of protocols to embed number would alert staff on the ward
emergency admissions unit for at the change in practice, there has immediately that a patient was going
least 24 hours and transferred to the been a dramatic improvement in the to be transferred, giving them the
stroke unit later, staff now recognise perception of the stroke patient opportunity to triage, and then give
the importance of the stroke pathway within the department and the advice to the crew on where to take
and the benefits of thrombolysis. processes required for quick triaging the patient. This action changed the
More patients are being assessed for after arrival in A&E. pathway for the patient almost
suitability for thrombolysis and the immediately, with everyone
stroke service has joined the IST-3 Work with the ambulance service concerned fully aware of where the
research 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 a
In Sandwell and West Birmingham where a network approach to the reduction in delays in transfer, and a
Hospitals NHS Trust stroke unit staff delivery of thrombolysis is in place so decrease in the number of patients
worked 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 excellent
to reinforce new pathways with the knowledge of the issues in moving Poole Hospitals NHS Foundation
staff in A&E and the on call team. patients round the local patch. Closer Trust set up an ambulance pre-alert
There was confusion, so a pathway working can help tackle problems, system to ensure A&E, the stroke
was developed on an A4 sheet for all such as ensuring the right type of team and other key staff were aware
suspected stroke patients to be vehicle, i.e. one which is able to of potential thrombolysis patients en
directly transferred to the stroke unit. safely transport the patient, is sent to route, assisting speed of response on
This was circulated to all A&E suspected stroke cases. arrival.
doctors, nurses and the radiology
department and laminated and In Nottingham University Hospital Move to six day a week working
displayed in all departments. This NHS Trust a communication was for therapy services
pathway clarified who was sent to all GPs informing them to Two project sites in Medway and York
responsible and what to do when a contact the stroke unit directly if they tested the provision of a six day
suspected stroke came to A&E. assessed a patient with stroke therapy service and evaluated its
Scanning times were reduced to four symptoms, and asked that the call to effect on patient experience, access
hours. the East Midlands Ambulance Service to services and flow.
should include the instructions for an
In Yeovil District Hospital NHS emergency ambulance, a four wheel Often services experience a
Foundation Trust a key limitation in vehicle with a two manned crew, and bottleneck every Monday when
enabling patients to be accurately not a routine admission. therapy staff have a backlog of
assessed and admitted to the stroke assessments accrued over the
unit was poor early assessment within To ensure that ambulance crews were weekend. For new patients it means
A&E. This was solved through fully informed of changes which some may have waited for 48 hours
education of medical and nursing would affect the stroke pathway, to be assessed and commence
staff and ensuring an accurate work was undertaken with the treatment, for others skills gained
pathway. Redeployment of resources managers of the ambulance service during the previous week may not
within the stroke team also enabled to produce bulletins containing the have been practiced over the
the appointment of a Band 6 stroke direct access policy, but more weekend, and for staff, their
and 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: an
international multi-centre, randomised, controlled trial to investigate the safety and efficacy of
treatment with intravenous recombinant tissue plasminogen activator (rt-PA) within six hours of
onset of acute ischaemic stroke. For further information, see www.controlled-trials.com



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.



Table 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 37.5

In York Hospitals NHS Foundation Many of the project teams across all
Trust the project team found that of the workstreams refer to the
50% of their patients accessed impact of noro-virus or other hospital
physiotherapy within 48 hours during acquired infections on their work.
the five day service but when they This not only complicated their
provided a six day service this rose to improvement work, but lent
64%, averaging ½ day reduction in additional importance to their efforts
referral to treatment time for to effectively manage beds for stroke
physiotherapy. patients.

The project team examined the effect
of a six day service on access to
therapy time. Their baseline data
indicated that on average patients
were seen four times a week for
physiotherapy and occupational
therapy. Only 63% of patients for
whom it was appropriate received 45
minutes or more of either therapy.
When a six day service was provided
their patients were then able to
receive physiotherapy five days a
week, and 90% of them could access
45 minutes of occupational therapy.

The baseline length of stay for all
stroke patients averaged 47 days,
when a six day service was available
this reduced to 21 days. The
Medway team also found that
although the numbers of patients
returning home did not change, there
is likely to be a link to the reduction
in the number of patients requiring
care packages.



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.



The project leads from each of the condition or disease of the individual, Involve patients and carers in
organisations met regularly and so there may not be a stroke specific improving transfer of care
developed shared objectives which focus in social care for services or for The National Stroke Strategy makes it
agreed with their organisation’s data collection. Funding has been clear that stroke survivors should be
strategic objectives. The successful used with good effect, often for involved strategically in stroke service
implementation and effectiveness of stroke specific social care posts, many improvement, as well as in decisions
this improvement post has supported of which have demonstrated value about their own care. The challenge
the plan to commission two for money and will be continued after for services is to obtain real and
additional family and carer support the life of the social care grant. meaningful involvement of stroke
services in the county. survivors rather than token gestures.
Stoke on Trent City Council used The project teams were able to
Understanding 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 to
Standards in local authorities are the stroke rehabilitation ward and use these views to significantly
measured using national indicators facilitate earlier referral to social care change the service.
rather than the activity data and services. A single point of contact for
outcome measures used in health. patients and carers on discharge and Poole Hospital NHS Foundation
Investigation of the social care policies for discharge and for rapid Trust and NHS Bournemouth and
national indicators demonstrates links assessment were implemented. Both Poole, with Dorset Stroke Network
with the stroke strategy quality social care and the early supported used a patient and carer feedback
markers, e.g. National indicator 131 discharge teams adopted the new forum to establish the shortfalls in
is about delayed transfers of care, name of ‘Community Stroke the transfer of care pathway and
132 records timeliness of social care Discharge Team’ so that patients and suggest a vision for how they would
assessment and 133 is about carers were aware of the close like services to be, which was used by
timeliness of packages of care, all of working relationship to provide a staff from social care, health and the
which relate well to quality marker 12 seamless service. voluntary sector to develop an
of 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 the
national measures can also enable Christchurch Hospitals NHS team’ meeting early in the first week
alignment of objectives. Foundation Trust focused their of the hospital stay to discuss
attention on improvements which prognosis and plans for rehabilitation
Dudley PCT, key staff from Dudley could be made in transfer of care and discharge with the patient and
Social Services, Dudley Group processes in hospital. The team family.
of Hospitals and The Stroke supported closer working of health
Association improved and social care teams by co-location The Royal Bournemouth and
communication through regular short of the social workers, information Christchurch Hospitals NHS
meetings and task groups to tackle support officer and Stroke Foundation Trust team obtained
specific problems. The team made Association support staff in the patient and carer feedback using
an impact on delayed discharges, hospital, near to the stroke ward, questionnaires after hospital
reducing length of stay to 18.5 days rather than at the local authority. discharge. The feedback became
in 2008/9 and to 15.7 days in Measurable improvements made by integral to the project, informing the
2009/10, 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 patients
enabled a protected resource for process, reduced waiting times for and carers for enhanced
stroke specific posts and services in community therapy and improved communication and discharge
local authorities. The operational quality of handover information planning were implemented early in
focus in social care is on the needs of between hospital and community the hospital stay. Care review
the individual rather than the teams. documentation given to the patient

6For further information on similarities between National Indicators and Quality Markers,
see Stroke Improvement Programme website social care resources
www.improvement.nhs.uk/stroke/SocialCareforStroke/SocialCareforStrokeResources.aspx



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


Going up a gear: Practical steps to improve stroke care

Going up a gear: Practical steps to improve stroke care

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