NHSCANCER                                     NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKEStroke Improvement ProgrammeImpleme...
Contents           Introduction                                       3           Milton Keynes Hospital NHS Foundation Tr...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   3IntroductionSin...
4   | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects    Sustainable...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   5    Figure 1: P...
6   |   Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects    Direct ac...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   7This new phone ...
8   |   Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects    Improving...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   9Data shows that...
10 |   Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects  Improving ac...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   11A&E now recogn...
12    |   Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects     Royal ...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |    13Fast access t...
14    |   Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects     The mo...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   15Acute stroke c...
16 |   Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects  Two experien...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   17EASY (early ad...
18       | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects     nurse...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |    19One call does...
20    | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects     Despite ...
Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects |   21Stroke Resourc...
22    | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects     Commissi...
Further informationStroke Improvement ProgrammeNational TeamNHS Improvement - StrokeImprovement Programme3rd Floor, St Joh...
NHSCANCER                                                                                        NHS ImprovementDIAGNOSTIC...
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Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

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Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

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Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKEStroke Improvement ProgrammeImplementing best practice in acute care:case studies from the Stroke ImprovementProgramme projects
  2. 2. Contents Introduction 3 Milton Keynes Hospital NHS Foundation Trust 4 Nottingham University Hospitals NHS Trust 6 Poole Hospitals NHS Foundation Trust 8 Queens Hospital NHS Foundation Trust 10 Royal United Hospital, Bath 12 Sandwell and West Birmingham Hospitals NHS Trust 13 Surrey and Sussex Healthcare NHS Trust 15 Worcestershire Acute Hospitals NHS Trust 17 Yeovil District Hospital NHS Foundation Trust 19 Resources 21 Further information 23
  3. 3. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 3IntroductionSince March 2009, ten projects TOP TIPSworked with the Stoke ImprovementProgramme to explore how to • Protect stroke unit bedsimprove the care they provide for • Actively cooperate with the resttheir patients. Their experience has of the hospitalled to the identification of the some • Develop a flexible, stroke skilledkey actions. workforce • Work with stroke survivors and carersThe suggestions, experiences and • Build an active partnership withexamples provided in this document A&Eare intended to generate ideas, to • Work with the ambulanceshow what is possible when teams servicework constructively together and to • Move to six days a weekguide planning for improvement working for therapy servicesactivities. Nine out of the 10 sitesare included in this publication.The Stroke Improvement Programmecontinuously publishes materials tohelp those striving to improve strokeand TIA services. All materials areavailable on the Stroke ImprovementProgramme web site at:www.improvement.nhs.uk/strokeContacts for each of the projects areincluded. Full details of the serviceimprovement can be found at:www.improvement.nhs.uk/stroke www.improvement.nhs.uk/stroke
  4. 4. 4 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Sustainable acute stroke and TIA management programme Milton Keynes Hospital NHS Foundation Trust Aims Actions wider patient journey, and increased The project in Milton Keynes aimed The need for ‘fast track’ bed was awareness of the importance of to achieve a patient-centred pathway agreed with acute stroke unit stroke as a specialism. for stroke, and worked across several clinicians, the bed management team areas of their stroke and TIA service. and divisional manager. Use of the A ‘productive board’ listing all The main aims for the acute stroke bed is monitored and reported patients, and key information on their portion of this work were to improve weekly, and it is kept solely for use by status and care, was installed to access and quality of care through: stroke patients to enable timely improve ward organisation. This • ensuring all patients with acute transfer from A&E and the clinical enabled staff to better plan patient stroke were admitted directly to an decision unit. care, enable safe discharge, and acute stroke unit equipped and improve communication amongst all staffed to be able to deliver high To ensure stroke patients identified in those involved in a patients care. quality care A&E or clinical decision unit do not • providing timely access to transfer to another ward, a bed Outcomes diagnostics both within and out management protocol was put in By the end of the project, all stroke of hours place and shared around the trust to patients received brain imaging • ensuring seamless transfer of care ensure members of staff across all within 24 hours of arrival at hospital. from acute stroke rehabilitation to levels identify the urgency of The proportion of stroke patients the community based rehabilitation transferring a patient to the acute spending at least 90% of their time stroke unit. in hospital on a stroke unit increased Issues from 50% to 70% and continues to At the start of the project, there was Multiple workshops were held with improve (see figure 1). a high proportion of stroke outliers acute and community staff involved on other medical wards. The in stroke patient care to map the proportion of stroke patients pathway a patient has access to, spending at least 90% of their stay identify current constraints in hospital on a stroke unit was, on average, and the community, involve staff on 45%, and 20% of patients were not the ground in suggesting receiving brain imaging within 24 improvements, and develop transfer hours. of information across teams. This helped healthcare professionals put into perspective their role in the www.improvement.nhs.uk/stroke
  5. 5. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 5 Figure 1: Patients spending 90% of their time in an acute stroke unit in Milton Keynes 80 Blip due to 70 winter bed pressures April 2009 60 40% 50 Percentage March 2009 40 75% 30 20 10 0 Apr May Jun Jun Aug Sep Oct Nov Dec Jan Feb Mar 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010 MonthsCommunication around the hospitalhas been improved and there is muchgreater awareness and recognition ofstroke within the trust.ContactNicola EvansProject ManagerMilton Keynes Hospital NHSFoundation Trustnicola.evans@mkhospital.nhs.uk www.improvement.nhs.uk/stroke
  6. 6. 6 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Direct access into the stroke hyper acute unit (DASH) Nottingham University Hospitals NHS Trust Aims Actions The central aim of the Nottingham As many stakeholders as possible project was that individuals who had were involved to gain commitment, a stroke had rapid and equitable including the support and access to the stroke hyper-acute sponsorship of the chief executive, service. This would include admission along with clinical and medical directly to the stroke unit when directors. arriving at the hospital, as opposed to admission through A&E. Patients The existing pathway was ‘process should be admitted, assessed and, mapped’ to identify what worked where appropriate, treated with well and the gaps in service. thrombolysis within three hours of Communication and monitoring work onset of symptoms. was systematically undertaken. This included contacting the ambulance Issues service to ensure they had the At the start of the project there were pathway information and supported patients being admitted directly onto the project, and collecting the stroke unit, but lower in number information weekly on stroke than compared with those being admissions to A&E to enable transferred from the A&E situated on challenge of the ambulance service to a campus five miles across the city, explore why patients were not and from the emergency admissions admitted directly into the stroke unit. management to produce bulletins unit which was on the same site as Common themes that arose were containing the direct access policy, the stroke unit. that crews were unaware of and more importantly, the direct admission protocol, unsure of time phone number for the telephone on Patients began to arrive on the stroke for admission, and there was the stroke unit, known as ‘the bat unit from A&E without a call being confusion around thrombolysis. phone’. made to the stroke unit to advise them in advance. Telephone calls and To ensure that the ambulance crews To help distinguish the ‘bat phone’ triage of the calls were not reliably were fully informed of changes which from the several other phones on the recorded. would affect the patients pathway, unit, a new ring tone and flashing work was undertaken with East light was installed to alert the team Midlands Ambulance Service to the emergency response required. www.improvement.nhs.uk/stroke
  7. 7. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 7This new phone and number alerts Outcomes Contactstaff on the ward immediately when The project has successfully produced Heather McCormacka patient is going to be transferred, a direct access route into the hyper- Service Development Managergiving them the opportunity to triage, acute stroke unit. All suspected East Midlands Cardiacand then give advice to the crew on stroke patients are now referred and Stroke Networkwhere to take the patient. directly to the stroke unit via the ‘bat heather.mccormack@nhs.net phone’.Information was sent to all GPsasking them to contact the stroke The ‘bat phone’ changed theunit if they assessed a patient with pathway for the patient almoststroke symptoms. A further request immediately, with everyonewas sent with a reminder that the call concerned fully aware of what wasto East Midlands Ambulance Service happening, where the patient was toshould include the instructions for an be sent and what would happenemergency ambulance, and not a next. There was a reduction in delaysroutine admission. The vehicle to be in transfer, and a decrease in thesent must also be a four wheel number of patients being admittedvehicle with a two manned crew. via A&E. FAST-negative patients later confirmed as a stroke are then sent‘Walking the patient pathway’ was directly to the stroke unit from A&E.carried out by both clinical and non-clinical members of the team, and All ambulance crews now assesshighlighted a number of problems patients at site and report theirthat could be easily and rapidly findings to the triage nurse, whoaddressed, such as the A&E not records all relevant information onhaving the ‘bat phone’ number new documentation in readiness fordisplayed, even though the ‘bat the arrival of the patient. The unitphone’ number had been included on now has new signs identifying wherethe stroke emergency department they are located, which helps withpathway poster. directions for both ambulance crews and relatives. www.improvement.nhs.uk/stroke
  8. 8. 8 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Improving acute stroke care in Poole Poole Hospitals NHS Foundation Trust Aims Actions A ‘Patient Group Directive’ was The team from the Integrated Stroke After raising stroke higher on the established for aspirin to assist Unit at Poole Hospital aimed to trust agenda through widespread delivery to appropriate patients improve direct admissions to the unit, communication and process mapping within 24 hours of admission. and increase the percentage of (including bed managers and high Extending the developments to stroke patients spending more than 90% of dependency unit staff). A new patient patients who were not suitable for their hospital stay there. As part of pathway was agreed, focusing thrombolysis, they created an this they wanted to consolidate the specifically on the part of the ‘assessment trolley’ on the acute hyper-acute service experience for all pathway from arrival at hospital to stroke unit to speed their assessment stroke admissions and improve their completion of the multi-disciplinary and admission process. Local thrombolysis service. team assessment. This would agreements with a neighbouring minimise unnecessary delays for trust enabled 24 hour thrombolysis to Issues patients being admitted and ensure commence in November 2009, A lot of work had been done across a safe but speedy pathway for supported by a range of publicity and the stroke network to improve the thrombolysis patients both in and visits from the team to local GPs. urgent response by ambulance teams out of hours. to stroke in the area and develop Outcomes provision of 24 hour thrombolysis, The team put in place an ambulance Stroke patients are now more likely to but the number of patients pre-alert system to ensure A&E, the be thrombolysed, to be admitted thrombolysed at Poole remained low. stroke team and other key staff were directly to acute stroke unit, to have The team had tried a number of aware of any potential thrombolysis timely swallow screening and brain initiatives over the years to improve patient en route to the hospital to scanning and to be commenced on the quality of service, but were not speed up the response time on antiplatelet therapy within 24 hours. achieving the standards around arrival. They established training in assessment and treatment of stroke thrombolysis and telemedicine for all for every patient, and only 37% of relevant staff, from ambulance crews stroke patients were admitted to the through to radiology. Additional unit within four hours. nursing staff for the acute stroke unit to support thrombolysed patients were secured, protocols agreed for the senior nurse practitioner to request CT scans, and all registered nurses and medical staff undertook training in safe swallow screening. www.improvement.nhs.uk/stroke
  9. 9. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 9Data shows that thrombolysis rateshave improved from 1.4% at thestart of the project to 5.6% by March2010, and mean door-to-needle timehad reduced steadily from 120minutes in January to 96 minutes byMarch 2010. The percentage ofpatients receiving aspirin within 24hours of admission has risen by 40%and brain scanning within 24 hoursby 16%. The percentage of patientsadmitted to the acute stroke unitwithin four hours of arrival has risenfrom 50% to 76%.ContactDr Suzanne RagabStroke ConsultantPoole Hospitals NHS Foundation Trustsuzanne.ragab@poole.nhs.uk www.improvement.nhs.uk/stroke
  10. 10. 10 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Improving access to the acute stroke unit Queens Hospital NHS Foundation Trust Aims Actions A stroke unit admission protocol The team from Queens Hospital The TIA service was completely was written and agreed and a aimed to increase the numbers of redesigned to include a five day a competency based in-house training patients that access the acute stroke week drop in clinic, with a single programme put in place on the acute unit) through direct admission point of referral and dedicated stroke unit. Developments on the protocols from A&E. They also carotid ultrasound slots. All referrals stroke unit were linked in with wanted to enhance the stroke and carotid requests were screened hospital emergency pathway redesign pathway from A&E to the acute by a stroke coordinator, and a direct to make sure acute stroke was stroke unit and include TIA referral pathway for those patients included in daily operations meetings admissions, provide 24 hour needing vascular surgery was and bed allocation was used admission to support stroke established. appropriately. thrombolysis and to develop the acute stroke unit staff to support A&E The thrombolysis service was Outcomes in managing stroke patients and extended to 9am to 8pm weekdays TIA patients are now managed on an facilitating transfer. using on call registrars to manage outpatient basis, avoiding admission, calls and provision of an in-house and most are now seen within 24 Issues radiographer until 8pm. An out of hours. Initially, most stroke patients were hours pathway was developed to admitted to the emergency support staff. Developments included The acute stroke unit now runs much admissions unit for at least 24 hours daily provision of an admission bed more smoothly. Patients are identified and transferred to the stroke unit on the stroke unit to support by bed management earlier and are later. No protection of stroke unit thrombolysis. allocated to the stroke unit quicker. beds meant the six beds in the stroke Communication between clinicians unit were often used for care of the An agreement was put in place with and capacity management is much elderly and medical admissions. the imaging department to routinely improved. The proportion of patients scan all stroke patients over spending 90% of their stay on the All high risk TIA patients were weekends and bank holidays. This stroke unit has increased from 71% admitted and managed as inpatients, included provision for tele-radiology to 89%. Now 96% of stroke and the thrombolysis service only ran so radiologists could read scans at patients are scanned within 24 hours, 9am to 5pm on weekdays. home. compared to 70% at the start of the project. www.improvement.nhs.uk/stroke
  11. 11. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 11A&E now recognise the importanceof the stroke pathway and thebenefits of thrombolysis. Morepatients are being assessed forsuitability and the stroke service hasjoined the IST-3 research trial.1Two members of the stroke teamreceived the trusts serviceimprovement award this year.ContactPeter TariStroke Co-ordinatorQueens Hospital NHSFoundation Trustpeter.tari@burtonh-tr.wmids.nhs.uk1The 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
  12. 12. 12 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Royal United Hospital, Bath, Stroke 2010 Royal United Hospital, Bath Aims Actions Outcomes The team from the acute stroke unit Systematic modelling showed that As there is now, for the first time, an at Royal United Hospital, Bath aimed bed numbers were inadequate for entire ward clearly signposted ‘Acute to improve access to the unit and demand on the unit. In addition, Stroke Unit’, the service’s profile develop the services provided there. existing beds were integrated on a within the trust has been raised, The existing stroke services would be 28 bed ward shared with neurology, morale for staff much improved and expanded to include a hyper-acute which resulted in a lack of clear a clear mandate given to gear the unit and to provide thrombolysis 24 identify for the acute stroke unit. ward around providing the best hours a day. These improvements Calculations showed that 26 acute stroke care. would be evident through measures stroke unit beds were needed to on speed of access to the unit, time ensure all stroke patients could be Patients are now admitted directly spent on the unit and scanning directly admitted from A&E, even at from A&E to the acute stroke unit, promptness. times of peak stroke admissions. bypassing the medical admissions unit and other wards. By the third Issues Board level sign up to improving stroke week of direct admissions, length of The biggest problem was getting all services was obtained to make this a stay had reduced from 18 to 5.5 stroke patients in the trust onto the priority within the trust. Stroke and days. Staff throughout the hospital, acute stroke unit. Despite proactively neurology services were separated into from infection control to bed tracking stroke patients within the two ward areas to give each specialty management, commented on the hospital and managing beds closely, its own clear identity. This left a 28 bed dramatic change in the unit. in the 2008 National Sentinel Audit, ward, including one six bed area that only 36% of patients spent 90% of was converted into a hyper-acute Twenty eight patients have already their stay on a stroke unit. In stroke unit and reduced to four beds. been thrombolysed in the last year addition, only 2% were admitted to compared to 12 the year before. a stroke unit within four hours of Support for bed availability was The service has been significantly admission to hospital. provided by agreeing equity of the improved with no extra money, and acute stroke unit with the coronary the reduced length of stay has Patient focus groups, run with the care unit within the trust in terms of resulted in cost savings to the trust. help of The Stroke Association, bed and site management. Every day highlighted how bad acute stroke at the site meeting, the availability of Contact patients’ experiences were when on a stroke bed is checked in the same Dr Louise Shaw the medical assessment unit for way as a cardiac bed. As soon as a Consultant Stroke Physician several days. stroke patient is admitted to acute Royal United Hospital, Bath stroke unit, bed management louise.Shaw@ruh-bath.swest.nhs.uk prioritise clearing another bed. www.improvement.nhs.uk/stroke
  13. 13. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 13Fast access to stroke care pathwaySandwell and West Birmingham Hospitals NHS TrustAims Actions An audit clerk has been recruited andThe core aim of the team in Sandwell Two initial consultation exercises were the information department havewas to develop a direct admission held with all staff and also patients developed a monitoring system thatpathway and protocol for all stroke and carers. This lead to a plan of highlights patients that do not spendpatients. This would improve care areas to be reviewed and developed 90% of their time on a stroke unit.and result in patients being and had management support and This allows the pathway to betransferred directly to an acute stroke engagement. An initial review of the continuously checked and data to beunit from A&E within four hours, pathway confirmed that there were validated easily. There is a weeklyspending at least 90% of their often long delays in admission to the review of the patient’s pathway and ahospital stay on a stroke unit, and stroke unit. monthly stroke action groupreceiving timely swallow assessment (including representation from alland brain scanning. A process of meetings and departments) which provides support discussions were held over a period for development of the wider strokeIssues of time with the acute on-call teams, service.At the start of the project, the stroke A&E, the stroke unit and radiologypathway meant patients went teams. The agreed path was to Outcomesthrough the emergency assessment admit patients directly from A&E, A staff and patient and carerunit before going to the stroke unit. following a medical review there with engagement process, called ‘listeningThere could be a delay of a day or the co-operation of the on call teams, in action’, was successful in raisingmore before the patients were and patients should receive their CT awareness of stroke and engaging alladmitted to the stroke unit; those head scans before transfer to the key stakeholders.who had minor strokes could be stroke unit, all within 24 hours.discharged home without reaching Stroke has become recognised as anthe stroke unit at all. However, everyday pressures meant emergency and it is acknowledged that the new pathway required widely that ‘time is brain’. Scans areAlthough there was a clear pathway continuously reinforcing, monitoring done faster and suspected strokeestablished, the thrombolysis service and reviewing. There was agreement patients are transferred directly fromwas from 9am to 5pm weekdays from management, bed management A&E to the stroke unit. There hasonly. and the stroke unit that there would been a significant increase in patients always be a bed available on the being scanned in a timely manner, stroke unit. Any delays in A&E were and there is always a bed available on escalated up to the on call manager. the stroke unit. www.improvement.nhs.uk/stroke
  14. 14. 14 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects The most significant change is the recognition of stroke and team development across a wide range of departments from the ambulance service, A&E, bed management, radiology, the acute stroke unit and general management. There is now a 24 hour thrombolysis service including a comprehensive pathway and a structured education programme for both doctors and nurses. Contact Jackie Wilkinson Stroke Co-ordinator Sandwell and West Birmingham Hospitals NHS Trust jackie.wilkinson@swbh.nhs.uk www.improvement.nhs.uk/stroke
  15. 15. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 15Acute stroke care: ‘building teams,building stroke services’Surrey and Sussex Healthcare NHS TrustAims Having had a long period of time Many initial difficulties within theThe project aimed to develop an with different clinical leadership and service stemmed from the lack of aeffective stroke team, which would styles, morale on the ward was low. unified vision of its future amongstdrive their stroke service forward and the team. The project was used to setto develop comprehensive Actions objectives with timeframes in whichinterdisciplinary working. This would Two key actions have facilitated to map the changes, and establishsupport wider aspirations around improved bed management and flow: working groups to achieve them.improving the acute stroke service, 1. the introduction of a fast-trackincluding establishing an acute bed for patients who can be Senior team members organisedpathway for direct access to specialist moved off the acute stroke unit, training for junior members as well asstroke services, introducing a and a daily bed status form to ensuring core competencies werethrombolysis service, improved access highlight delays to discharge is met, and specific training on goalto brain imaging and patients presented at the daily 9am bed planning was given to therapy andspending more of their stay on the meeting nursing staff. As a result, workingstroke unit. 2. a 24 hour stroke outreach team practices have gradually developed, now identifies and tracks stroke delivering a more cohesive approach.Issues patients within the hospital, with a This includes interprofessionalThe acute stroke unit comprised 21 supernumery bleep holder during support for the daily ward rounds tobeds, but lacked a formal bed policy the day, a senior acute stroke unit enable status updates, effectiveor stroke pathway. The service had nurse at night and other outreach discharge planning and a predictedbeen led by successive locum nurses who proactively seek stroke date of discharge for each patient.consultants for two years, and patients from the wardsselection of patients for the acute A new whiteboard has become thestroke unit was made by on call Through engagement with radiology, centre of the teams’ activities,medical staff, resulting in an ad hoc a dedicated bleep is held by a duty allowing rapid knowledge of theapproach. CT was accessed via the radiographer for 24 hours and acute current status of each patient,‘next day early bird slot’ system. The stroke patients are automatically including their predicted dischargetrust did not have a thrombolysis added to the urgent protocol for next date and destination. This allows theservice for eligible patients and so CT scan slot. weekly interdisciplinary teamFAST positive patients were diverted meetings to focus on patient centred,to other trusts. Only 7% of patients specific goals and trialling differentwere directly admitted from the A&E outcome tools.and 56% of stroke patients did notspend any time on acute stroke unit. www.improvement.nhs.uk/stroke
  16. 16. 16 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Two experienced stroke consultant and become clearer, encapsulating physicians have been in post since status and goals, and a simple January 2010, bringing new summary sheet for better leadership and direction to the communication with patients and service, with new ideas for relatives. Average length of stay has development and productivity. The steadily reduced from 20.4 to 13.7 new stroke pathway commenced in days. January 2010, and an 8am to 10pm thrombolysis service was launched A recent staff feedback exercise with four consultant physicians showed positive attitudes and working the rota, supported by off- examples of considerably improved site CT viewing. mutual professional regard and understanding. A key learning point Outcomes has been that the team is more Significant improvements have been powerful as a whole than the sum of made to access to the acute stroke its parts, and that forward services and compliance with vital progression need not rely on any one signs targets is better. Direct individual. With mutual respect and admissions peaked at 60% in an understanding of each others roles February 2010, with 67% of patients a team can work effectively without a achieving 90% stays on the acute single leader. When a team is stroke unit, and 86% of patients motivated and empowered, it has spending some of their hospital stay direct effects on patient care and on the acute stroke unit. By March outcome measurements. 2010, 66% of patients had CT scans within three hours. Contact Dr Natalie Powell The team feels that much Specialist Registrar in Stroke improvement is due to the Surrey and Sussex Healthcare development of the outreach service, NHS Trust crucially incorporating a dedicated East Surrey Hospital bleep holder, presence in A&E and natalie.powell@sash.nhs.uk proactive approach. This has been further enhanced by staff enthusiasm, positive PR for the stroke service and improved relations with radiology. The bed status sheet has been invaluable in highlighting where problems are encountered on a daily basis and has given the team permission to actively manage their own beds. Documentation of the interdisciplinary team has improved www.improvement.nhs.uk/stroke
  17. 17. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 17EASY (early admission to strokeunit your brain heals quicker)Worcestershire Acute Hospitals NHS TrustAimsThe team aimed to improve patient Figure 2: Worcestershire Acute Hospitals NHS Trust process mapaccess to the acute stroke unit, andensure those transferred to otherwards are identified and moved toacute stroke unit promptly. This wascoupled with specific aims to speedup physiotherapy assessment,improve discharge processes anddevelop staff education and training.IssuesInitially, only 20% of patients weredirectly transferred to the acutestroke unit from A&E and/or themedical admissions unit. There weredaily issues with patients with strokeon other wards and stroke beds filledwith non-stroke patients.Process mapping showed thepathway for stroke patients wascomplicated and confused (see figure2). There was no formal programme A key step in the project was to A capacity mapping exercise wasof education for staff, rehabilitation promote the stroke service status as undertaken to look at the number ofwas bed-based and only one an urgent specialist service, similar to acute stroke beds and the numberconsultant physician was undertaking cardiology. This raised the profile of needed. An agreement was made tothrombolysis. improving the quality of stroke ring-fence beds on the acute stroke management and care within the units countywide, and threeActions trust by prioritising stroke patients, additional acute stroke beds openedThe service improvement lead for the and ensured stroke was considered at in August 2009. Two newtrust ran a pathway exercise with a bed meetings three times a day. appointments of stroke specialistgroup from the trust and the PCT toplot the current pathway and designa better one. www.improvement.nhs.uk/stroke
  18. 18. 18 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects nurses enabled an overview of where Outcomes appointment of a family and carer all patients are, and helped to work Access to the stroke unit and the support worker from The Stroke closely with the bed manager to proportion of time spent on the unit Association offers inpatient and post- transfer patients appropriately. has been increasing month by month, discharge follow up. The stroke with an increase in direct admissions rehabilitation ward has been The team set up a formal programme from A&E or the medical admission upgraded in line with privacy and of education and training for staff unit. Physiotherapy assessment has dignity guidelines and further clinic working in stroke units, including improved, and the Commissioning for slots opened for high-risk TIA patients thrombolysis training days, and Quality and Innovation (CQUIN) for to avoid admission. undertook a workforce mapping the service achieved.2 exercise. There was increased A successful ‘stroke school’ has been awareness of how fundamental it is There are now daily multidisciplinary established, and further sessions are to manage the ‘back door’, i.e. team meetings on the acute stroke being delivered, giving staff greater improving rehabilitation and speeding unit and all stroke patients are insight into their work and the work up discharge. Although delays still discussed at all bed meetings three of other members of the team. A occur with social services discharging times a day. The acute stroke unit on cardiovascular disease degree module patients, close liaison with the the Worcester site has been at Worcester University has also been community stroke team has enabled reconfigured to have its own staff set up. improved patients flows. (who are not rotated), and the Contact Elaine Stratford Stroke Specialist Nurse Figure 3: Percentage of stroke patients spending at least 90% of their time on a stroke ward Worcestershire Acute Hospitals NHS Trust 50 elaine.stratford@worcsacute.nhs.uk 45 40 35 Percentages 30 25 20 15 10 5 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2008/09 2008/09 2008/09 2008/09 2009/10 2009/10 2009/10 2009/10 Further information on CQUIN can be found on the 2 Department of Health website at: www.dh.gov.uk www.improvement.nhs.uk/stroke
  19. 19. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 19One call does all: smoothing the transfer fromthe emergency room to the acute stroke unitYeovil District Hospital NHS Foundation TrustAims The issue of outlying stroke patients All the newly developedThe team wanted to improve the was highlighted to senior staff by documentation, protocols, andprocess for all acute stroke patients creating a daily list. This meant that training information for stroke wasbeing admitted and make the service the process of transfer onto the transferred onto the trust intranet,less dependent on individual staff. It stroke unit became less dependant for use as the key resource and forwas envisaged that this would on the knowledge of any one the stroke team collectively to keep itincrease the likelihood of success of professional and reduced the number up to date.expanding the thrombolysis service of duplicate phone calls.into evenings and the weekend. Outcomes To tackle challenges around transfer Stroke patients are being triagedIssues out of the unit, work with community more quickly in A&E. Initially, dataThere was agreement within the teams reduced the paperwork trail collection showed no significantteam on perceived key issues, but an and streamlined the process where improvement in either initialabsence of readily available data to possible. As there were three PCTs, diagnosis or direct admissions, butsupport this. Firstly, challenges each with different referral processes, this may been due to the recentaround early assessment for stroke this was a complex task. To resolve extension of the thrombolysis servicepatients in A&E, and secondly, this, at each multidisciplinary team to 8am to 11pm Monday to Friday,insufficient capacity on the stroke meeting, the stroke unit team would which had meant additional trainingunit because of difficulties with timely code each patient red (medically of medical and nursing staff. Astransfer to the community. unfit) amber (ready for transfer within with other teams, local factors, such 72 hours) or green (fit for transfer), as ward closures and peaks inActions and then share this with the admissions, may have skewed theThe team held monthly meetings appropriate PCT link team. The picture for direct admissions,with time divided between the two community team now anticipate although there is now a confidencekey issues to help them remain clear patients that will be ready for that a change in thinking has beenand progress with both aspects. discharge in the next few weeks, and embedded, and that all staff areMoney released by a reduction of take the necessary actions locally. working collectively to ensure accessclinical hours of the consultant nurse to the stroke unit from A&E.was transferred into two posts forstroke within A&E, therebysmoothing the process of trainingand developing protocols in strokeamongst A&E staff. www.improvement.nhs.uk/stroke
  20. 20. 20 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Despite problems created by ward closures for infection control creating Figure 4: 90% stay on a stroke unit ‘bumps in the road’, progress 100 continues towards the aspiration for 90 ‘90% stay on a stroke unit’. 80 70 The length of stay for Somerset Percentages 60 patients in the last three months has 50 reduced from 18 days to 13 days; 40 whilst the only change in practice has 30 been the smooth, consistent, transfer 20 of information from the acute trust to 10 the PCT on a weekly basis. 0 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 The team feel that the appointment % of total stroke admissions spending 90% of time on stroke unit PCT target of a stroke link within A&E has resulted in a greater than expected improvement in knowledge and stroke care, which is evidenced by increased attendance of A&E staff at stroke study days. Data collection will continue, as it has helped quantify ‘gut feelings’ and demonstrate improvements, however small. The service is now viewed less as a Monday to Friday service across all parts of the organisation, with more recognition being given to the importance of timely intervention, particularly in relation to brain scanning and direct admissions. Contact Caroline Lawson Consultant Nurse – Stroke Yeovil District Hospital NHS Foundation Trust caroline.lawson@ydh.nhs.uk www.improvement.nhs.uk/stroke
  21. 21. Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 21Stroke ResourcesStroke Improvement Programme website Trainer’s Resource Pack – An Introduction to ServiceThe Stroke Improvement Programme website offers Improvement, NHS Improvementinformation and resources on improving stroke and TIA The Trainers Resource Pack - An Introduction to Serviceservices, including: Improvement, is a collection of tried and tested training• information on topical issues affecting stroke and modules for service redesign tools and techniques, and TIA services change management skills.• presentations from events and meetings www.heart.nhs.uk/trainers_resource_pack.htm• examples of successful redesign and stroke improvement in stroke and TIA services Guidance on Risk Assessment and Stroke Prevention• information on measures for Atrial Fibrillation (GRASP-AF) Toolwww.improvement.nhs.uk/stroke This tool should be used as part of a systematic approach to the identification, diagnosis and optimal managementSustainability Checklist, NHS Cancer of patients with AF to reduce their risk of stroke.Improvement Programme Developed collaboratively and piloted by the WestA checklist containing key questions to ask about your Yorkshire Cardiovascular Network, the Leeds Arrhythmiaproject or service to ensure plans are in place to sustain team and PRIMIS+, as part of the AF in primary carethe improvement. projects, made available nationally through NHSwww.improvement.nhs.uk/cancer/documents/inpatients/ Improvement.Sustainability_Checklist.pdf www.improvement.nhs.uk/graspafThe Sustainability Toolkit, NHS Heart Atrial Fibrillation documents, NHS ImprovementImprovement Programme The following documents are available to download fromAlthough focused on improving cardiac pathways, The the Stroke Improvement websiteSustainability Toolkit provides useful information and www.improvement.nhs.uk/strokeexamples on how to sustain improvements. It alsocontains resources on capturing data, measurement Atrial fibrillation in primary care: making an impactand analysis. on stroke prevention, October 2009www.improvement.nhs.uk/heart/sustainability This document aims to capture the final summary of their individual approach, lessons learned, improvements to practice and quality outcomes, also sharing tools and resources developed to enable other health communities to drive this agenda forward. www.improvement.nhs.uk/stroke
  22. 22. 22 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects Commissioning for Stroke Prevention in Primary Sustainability Model, NHS Institute of Innovation Care - The Role of Atrial Fibrillation, June 2009 and Improvement Developed following a national consensus meeting of The Sustainability Model is a diagnostic tool that is used opinion leaders in the field, this document is to develop to predict the likelihood of sustainability for your a concerted strategy towards the management of AF in improvement project and provides practical advice on primary care, in particular anticoagulant management how you might increase the likelihood of sustainability for and its significance in relation to reduction in the risk of your improvement initiative. stroke. www.institute.nhs.uk/sustainability_model/general/ welcome_to_sustainability.html Atrial Fibrillation in Primary Care National Priority Project, April 2008 Improvement Leaders’ Guides, NHS Institute for A summary document produced in April 2008 including Innovation and Improvement descriptions, supporting information and key learning A series of service improvement guides, including a guide from the local projects that were part of the Atrial to sustainability and how it can be used in improvement Fibrillation in Primary Care national priority project. work. The NHS Institute for Innovation and Improvement website also contains worksheets for measuring Atrial Fibrillation in Primary Care Resources and improvement. Learning, April 2008 www.institute.nhs.uk/index.php?option=com_content&ta This online resource is a tool produced in April 2008 that sk=view&id=134&Itemid=351 captured the learning from the local project sites that worked on the Atrial Fibrillation in Primary Care national StrokEngine-Assess priority project. The resource provides documents, This website provides evidence to support stroke guidelines, presentations, proformas and algorithms rehabilitation assessment tools. developed and used by the local priority projects. www.medicine.mcgill.ca/strokengine-assess Stroke Improvement Programme e-bulletin Spreading good practice documents and Containing updates, news and information for anyone information, Sarah Fraser & Associates Ltd interested in developing stroke services, the Stroke Sarah Fraser is an independent consultant who works Improvement Programme e-bulletin is essential for with NHS organisations on how good practice spreads anyone working in stroke and TIA services. and how improvements can be made. The website contains a number of free resources on spreading good The Stroke Improvement Programme e-bulletin is practice and improvements. published every two weeks and the latest edition is www.sfassociates.biz/sitebody/MultiMedia/Documents.php available on the Stroke Improvement website www.improvement.nhs.uk/stroke. If you would like to subscribe to the Stroke Improvement e-bulletin, please email anne.coleman@improvement.nhs.uk. NHS Improvement System The NHS Improvement System is a free, comprehensive online resource supporting quality improvement in NHS services, offering a range of service improvement tools, case studies and resources. The Improvement System gives NHS staff the capability to record, track and report on projects, share improvement stories and documents, access Statistical Process Control (SPC) software, Demand and Capacity tools and a Patient Pathway Analyser, all within a secure environment. www.improvement.nhs.uk/improvementsystem Email: support@improvement.nhs.uk www.improvement.nhs.uk/stroke
  23. 23. Further informationStroke Improvement ProgrammeNational TeamNHS Improvement - StrokeImprovement Programme3rd Floor, St Johns House,East Street, Leicester LE1 6NBTel: 0116 222 5184Fax: 0116 222 5101www.improvement.nhs.uk/strokeEmail: info@improvement.nhs.uk
  24. 24. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKE NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk/stroke ©NHS Improvement 2010 | All Rights Reserved | June 2010 Delivering tomorrow’s improvement agenda for the NHS

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