Joining up prevention: case studies from the Stroke Improvement Programme projects


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Joining up prevention: case studies from the Stroke Improvement Programme projects

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Joining up prevention: case studies from the Stroke Improvement Programme projects

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKEStroke Improvement ProgrammeJoining up prevention:case studies from the Stroke ImprovementProgramme projects
  2. 2. Contents Introduction 3 Buckinghamshire Hospitals NHS Trust 4 Epsom General Hospital 6 Lancashire Teaching Hospitals NHS Foundation Trust 7 Milton Keynes Hospital NHS Foundation Trust 10 North Bristol NHS Trust 12 North West London Cardiac and Stroke Network 16 Royal Devon and Exeter NHS Foundation Trust 18 Surrey and Sussex Healthcare NHS Trust 21 United Lincolnshire Hospitals NHS Trust 23 Stroke resources 25 Further information 27
  3. 3. Joining up prevention: case studies from the Stroke Improvement Programme projects | 3IntroductionThe Stroke Improvement Programme 18 atrial fibrillation projects were TOP TIPSworked with 10 sites from March established in October 2007 and2009 to test implementing quality completed in April 2009. Working • Clearly define a pathway formarkers 5 and 6 of the National across 15 networks, with PCTs, high and low risk patients,Stroke Strategy and to contribute to general practices, practice based agreed across primary andnational learning. consortia and acute trusts, they secondary care piloted a range of approaches to • Streamline the referral route with single point of contact for highThese markers set some challenging improve detection and optimal and low riskgoals for health communities to treatment of patients with AF in • Employ a comprehensiveachieve and required many previously primary care to reduce the risk of communication strategyunanswered questions to be solved, stroke. The Stroke Improvement • Establish a sustainable data andnot least what will be the real Programme publications that provide audit systemdemand for the service. a summary and overview of the • Tailor the weekend service to outcomes from this first phase are local needs and demandSites commenced work in March listed in the Stroke resources section. • Think differently about how and2009; during the following 12 where TIA clinics are providedmonths they met together on six The suggestions, experiences andoccasions to share ideas and learning. examples provided in this document are intended to generate ideas, toAll sites were at very different stages show what is possible when teams Contacts for each of the projects arein the development of their TIA work constructively together and to included. Full details of the serviceservices and had different aims to guide planning for improvement improvement can be found at:work towards. Much of the work this activities. Nine of the 10 sites are has concentrated on the front included in this publication.end of the TIA pathway and work inthe coming year will concentrate on The Stroke Improvement Programmeaccess to carotid endarterectomy, continuously publishes materials tofollow up and implementing seven help those striving to improve strokeday services, as well as ongoing work and TIA services. All materials areon access to imaging. Work in the available on the Stroke Improvementcoming year will also be linked closely Programme web site at:with the NHS Improvement work on fibrillation (AF).
  4. 4. 4 | Joining up prevention: case studies from the Stroke Improvement Programme projects Buckinghamshire Hospitals TIA Service Buckinghamshire Hospitals NHS Trust Aims Actions All of these changes were To deliver a TIA service to the people The team planned to see high-risk coordinated via the creation of a of Buckinghamshire in line with the patients on an ad-hoc basis at one of multidisciplinary TIA project group, recommendations of the National the day hospitals at 9am on the day which met monthly during the main Stroke Strategy. after the “first contact”. To start development phase, and quarterly with, one MRI slot was kept free on subsequently. Issues each site at 10.30am, on the Buckinghamshire Hospitals NHS Trust understanding that it would be used Outcomes is a split site trust with two main for an inpatient if no request were The pathway was implemented in sites, Stoke Mandeville Hospital and received for an outpatient by 10am. July 2009, and has worked very well Wycombe Hospital, with a combined for patients referred in as per population of about 500,000. A There was concern that there would protocol. Patients attending the clinic twice weekly MRI-based TIA clinic be a large number of, possibly at 9am, or shortly after almost had been running at Stoke inappropriate, referrals or that the always get brain MRI and carotid Mandeville since 2000, and at service would break down during MRA imaging the same morning, Wycombe since 2006. While there periods of leave. To tackle this, all and this part of the pathway has were many good aspects to this patients in the high risk service were proven very reliable. service, including routine MRI brain seen briefly by the medical on-call and carotid imaging since the team, partly to filter out Numbers were slightly lower than inception of the clinics, audits on inappropriate referrals and partly to expected and the radiographers both sites had shown that the mean check consultant stroke physician dropped the dedicated 10.30am slot wait to be seen was about two availability the following day. in favour of fitting patients in as weeks. necessary. The low numbers and very For low-risk patients the team made few inappropriate referrals meant One of the challenges locally was that two innovations: the need for review by the on-call each site has just one stroke • rationalisation of the referral medical teams was rapidly dropped, physician, and neurology input on process so that all referrals on both making use of middle grade staff each site restricted by each sites were faxed to stroke service with appropriate supervision during neurologist being off-site for secretaries periods of consultant leave. substantial parts of the working • patients not able to be seen on one week, so it was not practical to offer site within a week were seen on a daily traditional clinic on each site the other site, if space was every day of the week. available. The major advantage of this is around clinic cancellations for on call duties, annual and study leave
  5. 5. Joining up prevention: case studies from the Stroke Improvement Programme projects | 5Table 1: Proportion of high risk patients seen within 24 hours 2009 -10 Proportion of high risk patients seen within 24 hours Q1 33% Q2 56% - new services started July Q3 52% Q4 59%These figures include patients seen as inpatients, but this proportion has beendeclining steadily over the year. It is still the policy of the trust to admit patientsover weekends when there is no outpatient service, and patients still get MRIbrain and carotid MRA at weekends.Table 2: Proportion of high risk patients seen as inpatients 2009 -10 Proportion of high risk patients seen as inpatients Q2 37% - new services started July Q3 23% Q4 11%Performance on the vital sign has been less good, with some patients recordedas not having had blood tests or an ECG, or not having been started on allnecessary medication with the 24 hour time period. It is possible some of thisreflects the complexities of the data acquisition and transfer.Table 3: Proportion of low risk patients seen within seven days 2009 -10 Proportion of low risk patients seen within 24 hours Q1 38% Q2 70% - new services started July Q3 70% Q4 67%ContactDr Matthew BurnConsultant Stroke PhysicianBuckinghamshire Hospitals NHS
  6. 6. 6 | Joining up prevention: case studies from the Stroke Improvement Programme projects TIA service development Epsom General Hospital Aims Because of this lack of TIA service key departments, such as A&E. A To establish a comprehensive TIA and stroke specialists, there was referral proforma was drawn up and service for patients in the Epsom area no data to quantify the need for circulated to key clinicians in the of Surrey who attend the Epsom improvement, just a very wide gap hospital. A secretary who can book General Hospital site of Epsom and that all in the trust acknowledged. appointments at short notice was St Helier NHS Trust. made available to the stroke service. Actions Issues A project team was established that Outcomes Epsom General Hospital only drew together the key clinicians and The team have achieved: provided one neurovascular clinic run managers required to develop the TIA • one TIA clinic now runs every week, on alternate weeks by a geriatrician, service, i.e. stroke consultant, stroke on a Tuesday afternoon, for low far below the standard of service specialist nurse, radiologists, vascular risk TIA patients. Some ad hoc demanded by the quality standards scientists, service manager, assistant clinics are held on the ward when for TIA services being developed by medical director, GP, outpatient resources allow (high risk patients Surrey Heart and Stroke Network department manager, director of continue to be admitted) (based upon national guidance and operations for planned care, network • good liaison with the vascular clinical recommendations). data analyst and network service department, that means the entire improvement manager. TIA clinic can be covered Consideration for development of TIA • same day scanning is now being services took into account a A one-stop TIA clinic was immediately provided. challenging baseline with regards to established to run once per week in • approval by the trust board of a staffing, imaging, location and the outpatient department. business case to invest in stroke referral. and TIA services to enable Immediate difficulties encountered by provision of a Monday to Friday The stroke consultant to lead this the carotid duplex service were TIA service for high and low risk project was recruited at the addressed e.g. inappropriate referrals. patients beginning of 2009 on a part time Longer-term issues such as basis. Before that, the stroke service inadequate staffing for a daily service, Contact at Epsom General Hospital was led by were addressed through Janet Putterill a stroke specialist nurse and general departmental meetings. Consultant Stroke Physician, physicians. The role of the new Epsom General Hospital consultant therefore was to embed A TIA pathway was developed by the best practice into the care of patients project team and agreed with other presenting with stroke or TIA.
  7. 7. Joining up prevention: case studies from the Stroke Improvement Programme projects | 7TIA service improvement projectLancashire Teaching Hospitals NHS Foundation TrustAims Table 4: Working towards a high quality, accessible and effective TIA serviceTo achieve a high-quality, accessibleand effective TIA service through jointinput from the medicine, Where we are now Where we want to beneuroscience and radiology • Conventional model • Daily one-stop-shopdirectorates to ensure urgent • Four weekly clinics between • High risk patients seen withinassessment and treatment of patients Preston and Chorley 24 hourswith TIA, in line with quality markers • Mix of high/low risk • Lower risk patients seen within5 and 6 of the National Stroke • Various referral routes one weekStrategy. • Timing of intervention variable • Unified referral pathway • GP supervised secondary • Carotid intervention (high risk)Issues prevention seen within 48 hoursIn January 2009, Lancashire Teaching • TIA nurse supervision ofHospitals NHS Trust were nearing secondary preventiondelivery of a daily emergency ‘one-stop shop’ TIA service for high riskpatients, led jointly by a strokephysician and a stroke neurologist.Further substantial work was required Figure 1: Patient pathway - original referral -to achieve the service envisaged (see procedure performed March 2008 - Jan 2009table 4). Numbers of date pairs used to calculate average delaysA conventional TIA service was in 44 U/SScanplace at commencement of the to CTDelproject. There had been a recent 286 OrigRef 687 U/SRef 44 CTDel 25 CTScan 10 MDT1 to U/SRef to U/SScan to CTScan to MDT1 to Clin Revmove to a rapid access TIA clinic with 4 Clin Reva view to TIA patients being assessed Average to Proc Perf Delay, 10 13 2 2 8 9 6more quickly. Little hard data was Daysavailable for the baseline position but Range 0-185 0-49 0-89 0-35 Rangean imaging directorate audit, 0-261 days 0-20 3-11 dayssummarised in figure 1, suggests an 0 10 20 30 40 50 60average 50 day interval betweenoriginal patient referral and carotid OrigRef - U/SRef U/SRef - U/SScan U/SScan - CTDel CTDel - CTScanintervention. CTScan - MDT1 MDT1 - Clin Rev Clin Rev - Proc Perf
  8. 8. 8 | Joining up prevention: case studies from the Stroke Improvement Programme projects Actions • created a unified single point of Outcomes The development of the service has access, with initial telephone call to By establishing ongoing monitoring been at a time of substantial efforts the acute stroke unit for high and and audit, the team are able to to improve stroke services and to lower risk TIA patients, triage, and understand their service. Figures 2 to promote awareness and education by subsequent electronic patient 7 show the outcome of an audit of the acute trust and in partnership booking and confirmation of 58 patients between May and with other organisations including appointment time October 2009. The original pathway the Central Lancashire PCT and the • set up monitoring and audit of the had an emphasis on referral from Stroke Network in Lancashire and service on an ongoing basis A&E. Following the audit showing a Cumbria. The Stroke 90:10 project is • established a potential role for a longer referral time from GPs, the also under way in the North West. specialist TIA nurse to supervise single point of access was introduced The team: continued adherence to secondary in October 2009. • convened a multidisciplinary group prevention, as a strategy to comprising clinicians and the maintaining long-term stroke risk relevant general managers, in order reduction to develop a daily emergency clinic • developed a business case to for high risk TIA patients sustain and develop the service • launched a daily emergency TIA further clinic in May 2009, with two (three • hosted educational events if necessary) daily slots and promoting developments in stroke immediate access to carotid and TIA imaging if appropriate, Monday to Friday Figure 2: Referral source by interval from first Figure 3: Referral source of all contact to clinic appointment patients 7% 20 Number of patients 10% 15 42% 10 5 41% 0 <24 hrs 24-48 hrs 2-7 days 1-2 weeks 2-4 weeks >4 weeks Interval from first contact to clinic appointment A&E MAU GP Other A&E MAU GP Other Figure 4: Interval from first contact to clinic Figure 5: Diagnosis amongst appointment by final diagnosis patients seen within 24 hours 1 20 Number of patients 15 6 10 5 7 0 <24 hrs 24-48 hrs 2-7 days 1-2 weeks 2-4 weeks >4 weeks Interval from first contact to clinic appointment by final diagnosis High risk TIA Low risk TIA Non TIA High risk TIA Low risk TIA Non TIA
  9. 9. Joining up prevention: case studies from the Stroke Improvement Programme projects | 9 Figure 6: Interval from first contact Figure 7: Interval from first contact to carotid imaging amongst all high to carotid imaging amongst high risk TIA patients risk TIA patients assessed in clinic with 24 hours 8% 13% 17% 20% 33% 21% 21% 67% <24 hours 24-48 hours 2-7 days 1-2 weeks 2-4 weeks >4 weeks <24 hours 24-48 hoursTable 5: Clinic performance Patients seen in clinic within 24 hours of ‘first contact’ vital sign definition Assessed within 24 hrs of symptom onset 64% (9) 24 – 48 hrs 29% (4) 2-7 days 7% (1)This demonstrated: ‘The opportunity to exchange ideas with other teams in• the shortest interval between first contact and clinic assessment other parts of the UK was one of the most valuable occurred in patients referred aspects of the project. In particular, perhaps our directly from A&E, whereas longer intervals were seen when patients preparedness to adapt quickly based on ideas shared at initially presented to their GP• a high non-TIA rate exists amongst the peer support days (for instance, single point of patients seen within 24 hours, referral) helped to influence our own service which has implications for planning carotid and brain imaging capacity development whilst it was ‘a work in progress’.• a rapid improvement in key Lancashire Teaching Hospitals NHS Foundation Trust measures can be achieved with such a model – % high risk patients seen within 24 hours and % high 23 patients attending the emergency Contact risk patients having carotid imaging clinic between May and July 2009 Dr Hedley Emsley within 24 hours (already 100% completed a questionnaire Consultant Neurologist within 48 hours) encompassing a range of issues Lancashire Teaching Hospitals relating to their experience of the NHS Foundation TrustSustaining improvements will depend clinic. Patients were also asked to hedley.emsley@lthtr.nhs.ukon continued effective interaction provide an overall rating of thebetween all the relevant specialties. service, from poor (one) to excellent (five). Nineteen (83%) gave a rating of five, the remaining four (17%) giving a rating of four.
  10. 10. 10 | Joining up prevention: case studies from the Stroke Improvement Programme projects Sustainable acute stroke and TIA management programme Milton Keynes Hospital NHS Foundation Trust Aims attending to identify waiting times to Seamless GP and A&E referral for being seen in clinic, whether the patients suspected of having had a patient is low or high risk, whether TIA, with access to treatment, investigations are required and including timely access to diagnostics whether they are confirmed TIA. both within and out of hours. Implementation of five day a Issues week TIA clinics. Recognising the There was no assessment of patients lack of coverage across the week, by referrer to determine high or low clinic slots were changed to occur five risk TIA. TIA clinics were held once a days a week using the same three week. Waiting times were up to three consultants, with the addition of a weeks for a patient to be seen by a general medicine consultant stroke specialist and up to two weeks providing TIA clinic slots in his clinic. for carotid imaging following TIA clinic. Same day carotid imaging. The waiting time for a carotid doppler Actions scan was a bottleneck in patients Standard TIA pro-forma and receiving urgent outpatient referral process. The team created assessment and treatment for TIA. A a standard referral pro-forma for all same day referral process means TIA referrals sent to TIA clinic, used by is now considered urgent and A&E, GP surgeries, CDU, patients receive a scan the same day ophthalmology etc. This ensures as their outpatient appointment. patients are risk assessed using national clinical ABCD2 assessment to Outcomes identify whether they are high or low • same day carotid imaging in place – risk TIA. removed waiting time • reduction in patient waiting times Data reporting mechanism in to be seen by specialist, average place. The team created a data waiting time reduced by three days collection form for consultants to complete in clinic for all patients
  11. 11. Joining up prevention: case studies from the Stroke Improvement Programme projects | 11 Figure 8: Milton Keynes TIA pathway analysis Data from Q3 2009 - 2010 Best we did was 8 days - Target was 24 hours First contact Referral to clinic TIA clinic Referral for cartoid imaging Cartoid imaging All cases within 1 day Took at least five days in all cases All cases same day Two cases within one day Data from March to April 2010 Best we did was 3 days - (Result after first month) First contact Referral to clinic TIA clinic Referral for cartoid imaging Cartoid imaging All cases within 1 day Took at least three days in all cases All cases same day Same day was bestContact ‘Research other organisations to understand lessonsNicola EvansProject Manager learnt - don’t reinvent the wheel, the chances ofMilton Keynes Hospital NHSFoundation Trust someone having implemented the same change as is highly likely’.
  12. 12. 12 | Joining up prevention: case studies from the Stroke Improvement Programme projects Providing a seven day, one stop, TIA service at North Bristol NHS Trust North Bristol NHS Trust Aims Issues Imaging needed to be available: The team at North Bristol NHS Trust, In March 2009, one stop TIA clinics • negotiated one stop services with supported by the Avon, were held three times a week, with a radiology to provide head CTs and Gloucestershire, Wiltshire and variable waiting time. There was one carotid doppler scans Somerset Cardiac and Stroke stroke physician and one registrar. • training of ultrasonographers to Network, had a clear vision for the carry out doppler to increase service they wished to provide and Actions staffing in response to demand aimed to: The weekday service was developed • diffusion weighted imaging (DWI) • provide a seven day, one stop TIA and strengthened and the pathway available for weekday services service with full diagnostic imaging was redesigned for the weekend instead of CT if required that patients can access within 24 service, with the development of • MRI imaging for weekend TIA hours of onset of symptoms, to close links with A&E. services including DWI and MR include same day brain and carotid angiography imaging and next day cardiac The team developed a standard TIA diagnostics network-wide referral form for all The University of West England • have a single point of referral GPs and appointed a TIA coordinator developed a online training module • ensure universal use of ABCD2 as single point of referral. for ABCD2 assessment for all GPs and score and stratification of patients Great Western Ambulance Service with a score above and below 4, The following staffing changes were staff. with patients ≥ 4 assessed and made: treated within 24 hours and • increased number of stroke Pre-packs of medication for patients patients < 4 assessed and treated consultant sessions to take away from TIA outpatient in less than seven days • a stroke co-ordinator assessment attendances were made available. • ensure prompt referral and of patients as part of the weekday Patient information packs were treatment for all patients requiring service developed for all TIA patients. vascular surgery • nurse staffing on the acute stroke • ensure patients are discharged unit changed to accommodate from outpatient clinic with a copy weekend service of the discharge summary • an on call physician rota for weekend service • a weekly neuro-vascular meeting to ensure prompt referral and treatment and to review all critical carotid imaging
  13. 13. Joining up prevention: case studies from the Stroke Improvement Programme projects | 13OutcomesThe following outcomes have been Figure 9: Clinics running three times a weeeknoted:• five day service is embedded and running well, a seven day one stop service commenced in April 2010• there is a good relationship with clinical support and vascular services• the appointment of a TIA co-ordinator ensures timely and efficient booking of patients according to ABCD2 prioritisation• there is a commitment within stroke team to develop services• the mean waiting time for patients seen in clinic went from 7.78 days to 1.76 days as the frequency of clinics was increased• there is an indication of reduction in admissions for high risk patients during weekdays as frequency of clinics has increasedReduction in admissions will beexplored further. There is thepotential to reduce weekendadmissions but this needs furtherwork as the trust provides the out ofhours service for the whole of Bristol.
  14. 14. 14 | Joining up prevention: case studies from the Stroke Improvement Programme projects Figure 10: Clinics increased from three to five a week in November
  15. 15. Joining up prevention: case studies from the Stroke Improvement Programme projects | 15 Figure 12 shows high levels ofFigure 11: Six day a week clinics tested from December 2009 patient satisfaction: • the majority of patients felt that they were fully informed of the various parts of their outpatient attendance (diagnosis, tests, results etc) • all patients received information and the majority found this to be helpful • two patients (out of a total of 10 respondents) commented that they had not received information regarding not driving prior to their attendance Contact Dr Neil Baldwin Consultant Stroke Physician North Bristol NHS Trust neil.baldwin@nbt.nhs.ukFigure 12: Patient satisfaction 100 90 80 % positive responses 70 60 50 40 30 20 10 0 Explanation Purpose Adequate Understanding Were given for of tests time with of final leaflets attending understood staff diagnosis helpful clinic Understanding Test results Ease of Information Adequate which tests explained finding scanning leaflets information to receive departments received given
  16. 16. 16 | Joining up prevention: case studies from the Stroke Improvement Programme projects Improving the TIA pathway for high and low risk patients across north west London North West London Cardiac and Stroke Network Aims supplied with referral forms. These • who to? The aim of the project was the GPs also needed to be encouraged to • how do we do this? prompt assessment and treatment of complete these forms accurately and • what products do we need to high and low risk TIA patients and increase their knowledge and acquire or produce? the communication of relevant understanding of TIA. There were no • what resources do we need? information to key stakeholders procedures in place to collect data. • roles and responsibilities across north west London. This is a • timescales multi-site project coordinated by the The project commenced in November • how do we need to consider North West London Cardiac and 2009 following the publication of the additional stakeholders? Stroke Network, involving the Stroke Strategy for London.1 • how do we measure success? following organisations: • North West London Cardiac and Actions New referral forms were launched on Stroke Network The team created new referral forms 7 December 2009: • Imperial College Healthcare outlining the approved protocols and • emails were sent to all GPs across NHS Trust out of hours service for TIA referral: north west London explaining the • TIA clinics and A&E departments at • gained consensus from clinical new referral forms the following hospital sites: teams in each hospital • the clinical contracts lead for each Northwick Park, West Middlesex, • produced separate forms for GPs PCT assisted by forwarding emails Charing Cross, St. Mary’s, and A&E departments to GPs to save the lengthy process Hillingdon, Chelsea and • forms included an aid to diagnosis of creating a database Westminster (including ABCD2 score) and • GPs mailshot included a link to • GP surgeries across north west contact details for TIA clinics, both dedicated webpages on the London weekdays and out of hours network website • produced forms in every format • dedicated webpages included Issues likely to be used by GPs (EMIS, downloadable versions of all forms GPs were demonstrating an Vision, Word) and information regarding aids to inconsistent approach to TIA diagnosis and use of referral forms diagnosis and referral. Awareness of Alongside this, the project created a • stroke consultants at each trust TIA and stroke also needed to be communications plan to launch the trained their local A&E departments improved. There are over 600 GPs new forms to GPs, A&E departments on use of forms across eight PCTs within the north and all interested parties which west London region who needed to included: be informed of pathways and • what information do we need to communicate? 1Stroke Strategy for London, Healthcare for London, November 2008.
  17. 17. Joining up prevention: case studies from the Stroke Improvement Programme projects | 17Ongoing engagement of GP practices Outcomescontinued: The team have achieved:• additional emailshot to GPs • a well defined TIA service has been encouraging them to access the created within north west London, website to download the forms and with provision of TIA services in six for information on how to fill them hospitals, with clear protocols and out correctly one referral form• hard copy mailshot with forms sent • a clear pathway for both high and to every practice manager, low risk patients with suspected enclosing pens with the website TIA address of the dedicated TIA • an out of hours, 24 hour TIA webpage to further publicise the service for high risk referrals based site at the hyper-acute centres• stroke consultants write to every • dedicated webpages have GP who has referred a TIA patient provided a new reference point to using the old form and sends a offer everything that a GP needs to copy of the new form know about the new forms and pathwaysAdditional GP and A&E aids to • A&E departments and Londonencourage timely assessment of Ambulance Service use the newpatients: pathways• urgent TIA assessment referral card created for A&E departments to Baseline data is in the process of give to patients to encourage them being collected and collated and data to attend TIA clinics and reduce regarding referral patterns and vital levels of DNAs signs and subsequent improvement• appointment card reproduced on of service should be available soon. the dedicated webpages in a downloadable form for GPs to give Early indications show the following: to patients with suspected TIA • use of new referral forms in A&E who present at the surgery departments is now in excess of 80%The team created a data template for • use of new referral forms by GP isuse within TIA clinics to collect variable but is increasing month bybaseline data, assess the use of month and has reached 60% inreferral forms and measure referring one unitpatterns and vital signs: • hits on the network website• data was accepted in hard or soft increased by 20% after the launch copy .• assistance was offered by the Contact network to facilitate collection Marcia Reid Interim Senior Project ManagerData was collected for the: North West London Cardiac and• use of new referral forms by GPs Stroke Network and A&E departments (measured in TIA clinics)• number of TIA referrals (total and % of mimics)• vital signs for high and low risk patients• GP awareness (through survey monkey, evaluation forms and one to one interviews)
  18. 18. 18 | Joining up prevention: case studies from the Stroke Improvement Programme projects Improving access to TIA assessment Royal Devon and Exeter NHS Foundation Trust and Peninsula Heart and Stroke Network Aims defined by the ABCD2 score) The role of the stroke nurse To develop an equitable and remained at two days. The main practitioners includes: responsive TIA assessment service, reason was that referrals received on • assessment of all new acute stroke with improved out of hours access, Friday, Saturday or Sunday, could not admissions in A&E and the through the use of risk stratification, be assessed until the next working medical triage unit, using ROSIER. based upon carotid ultrasound day. If positive, the stroke nurse screening undertaken by stroke nurse practitioners are able to request CT practitioners. Actions imaging and arrange admission to Rather than replicate a ‘traditional’ the acute stroke unit within four The project was initiated to improve face-to-face outpatient clinic service hours of hospital arrival the responsiveness of the TIA service at weekends, the project team are • initial point of referral for TIA for patients presenting at weekends investigating an innovative model of patients assessed in A&E. Referrals and bank holidays, achieve the vital providing specialist assessment and are risk stratified and allocated to signs target of TIA cases with a addressing the issue of appropriate the next available daily stroke clinic higher risk of stroke who are treated urgent imaging and screening (i.e. slot. On weekdays, a TIA clinic slot within 24 hours, and assist in carotid ultrasound) during weekend is often available later the same day working towards the 48 hour and bank holiday periods. • thrombolysis assessment and liaison window for urgent carotid surgery. with the on-call stroke team and Carotid ultrasound scan results for a provision of 1:1 care in the period Issues 12 month period have been collated following thrombolysis The daily TIA/stroke clinic at the Royal to establish a ‘baseline’ percentage of • dysphagia screening Devon and Exeter NHS Foundation ‘normal’ and ‘abnormal’ scans. Trust serves a population of 350,000 The stroke nurse practitioners are and receives approximately 1,000 The results shown in table 6 provided currently being trained to perform new referrals per year (60% of these a broad indication of the percentage carotid ultrasound screening to referrals are diagnosed as either TIA of ‘abnormal’ screening results which enable improved access to TIA or minor stroke). will be identified by the stroke nurse assessment during weekends and practitioners. bank holidays. Since the clinic was established in 2006, access times from referral to Three stroke nurse practitioners at assessment have improved the Royal Devon and Exeter work dramatically. However, the median seven days a week, from 7.30am to referral to assessment time, for both 8pm. high risk and lower risk patients (as
  19. 19. Joining up prevention: case studies from the Stroke Improvement Programme projects | 19Table 6: Data from the Royal Devon and Exeter TIA clinic - 14 May 2008 to 13 May 2009 Degree of Stenosis within the Common Carotid Artery (CCA), Internal Carotid Percentage of patients affected Artery (ICA), Carotid Bulb and Carotid Bifurcation No Visible Disease 32% Minimal (Detectable but < 30%) 31% Mild (30 – 49%) 28% Moderate (50 – 69%) 5% Severe (70 – 99%) 4% Occluded (100%) <1%Training is provided ‘in house’ by the Outcomeschief clinical technologist. Two Between 1 April 2009 and 31 Marchstages of training were initially 2010, 36 TIA patients were admittedidentified: during weekends and bank holidays.1. ability to locate and identify the The carotid ultrasound results for common carotid artery and the these patients were examined to carotid branches provide an indication of whether the2. ability to record velocities and patients would have been admitted if assess velocity shifts using a the carotid screening service had spectral doppler, and produce been in place. B-mode colour images It is envisaged that the cut-off forThe training includes a period of ‘dual admission will be >50% stenosis.scanning’. A clinical technologist Using this figure, analysis of thevalidates the results. 36 weekend and bank holiday admissions in 2009/10, (see table 7)All patients presenting during shows:weekend and bank holiday periodswill have a carotid ultrasound Table 7: Analysis of the 36 weekend and bank holiday admissions in 2009/10screening investigation. Thosepatients considered as ‘normal’ willbe discharged home with an < 50% or no detectable disease - Potential ‘avoided’ admission 16appointment to attend the clinic the < 50% but difficult scan 2next working day. Patients whosescreening results suggest an >50% 4abnormal result (as defined by an No Scan requested during admission 16agreed protocol, which includes keymeasurements, defined ‘normal’results and tolerance levels) will beadmitted. Prior to this project, allpatients presenting during weekendsand bank holiday periods with TIAwould be admitted.
  20. 20. 20 | Joining up prevention: case studies from the Stroke Improvement Programme projects This provides a prospective indication Training will continue, to enable the of the impact of the new service, and stroke nurse practitioners to become indicates that 44% of TIA admissions proficient in carotid ultrasound during the weekends and bank screening. It is anticipated that the holidays of 2009/10 could potentially stroke nurse practitioners training have been avoided if the stroke nurse and sign-off of competencies will be practitioners service was in place. It completed by September 2010. It is will also be necessary to establish the intention of the project team to whether any other factors, such as co produce a project report, including morbidities, determined the costs, training information and requirement for admission. competencies, to support future commissioning decisions with regard It is anticipated that this model will to development of TIA assessment be a cost effective solution for services. increasing access to, and enhancement of, TIA assessment at Contact weekends and bank holidays. Carol Massey Service Improvement Manager The stroke nurse practitioners and Peninsula Heart and Stroke Network clinical measurements department have approached the project enthusiastically. A collaborative and open approach has enabled specialties and disciplines to work together and understand roles within the project.
  21. 21. Joining up prevention: case studies from the Stroke Improvement Programme projects | 21Acute medicine TIA serviceSurrey and Sussex Healthcare NHS TrustAims A pathway was created to ensure To improve awareness across theTo create a sustainable, effective one- that fasting blood tests, CT brain health economy the team:stop TIA service to meet the vital sign scans and doppler of the carotids • produced standardised forms forrequirement for high risk and low risk were all performed as early as GPs and other referral areasTIA. possible, as needed, usually the same • taught GPs and other clinicians morning ahead of the consultant • worked with the Surrey Heart andIssues review, results discussion and Stroke Network on training daysAt baseline in, 2008 Surrey and treatment prescription from the clinic • rolled out a newly empoweredSussex NHS Trust offered a TIA service in the afternoon. This was broadly stroke team across the trustbased on two clinics per week that based on the EXPRESS2 study. • created a single bleep holder towas unable to offer assessment, take all callsinvestigation and treatment within 24 In the early days this relied on onehours. Since the retirement of the consultant and the challenge became The team also worked closely withsubstantive consultant physician in how to make the service sustainable. radiology to access CT and doppler2008 the stroke service had been led In order to do this the trust: slots on a needs related basis andby successive locum consultant • appointed a trust doctor created an electronic audit tool toclinicians throughout 2009. Clinicians • appointed two stroke consultants standardise note-keeping, letters towere clear that a system-wide change with job plans including TIA review GPs and gather audit data that wasof practice was needed. • embedded the service within the reliable and easy to analyse. ever-open acute medical unitActions environmentA TIA service was created based on • included more junior staff fromthe acute medical unit, operating the stroke and acute medical uniteach day, Monday to Friday, for all servicespatients referred the previous day • created pathways and proformas towith TIA (including low and high risk standardise care deliverypatients). 2Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JNE, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJV, Bosch S, Carasco-Alexander F, Silver LE, Gutnikov SA, Mehta Z, on behalf of the Early use of Existing Preventive Strategies for Stroke (EXPRESS) Study. Major reduction in risk of early recurrent stroke by urgent treatment of TIA and minor stroke: EXPRESS Study. Lancet 2007; 370: 1432-42
  22. 22. 22 | Joining up prevention: case studies from the Stroke Improvement Programme projects Outcomes Creating a patient-centred service, Figure 13: TIA bed days per month accessible at the point of need, was very well received by patients and 180 clinicians alike. GPs are very happy 160 with the bleep holder for stroke; they 140 told the team that this sort of access 120 is exactly what they want. The profile of TIA and stroke has been raised Days 100 dramatically internally and externally. 80 60 The team are waiting for validation of 40 an outcome audit of strokes at 90 20 days. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 There is no waiting list at all for TIA Month April 2007 to May 2010 patients and there is consistently good performance against the vital sign. The percentage of high risk patients with TIA seen and treated in TIA patients are no longer admitted 24 hours is 66% currently (baseline to the trust other than in exceptional data is not available, but anecdotally circumstances. Data in table 8 shows assumed to be 0%). a reduction of 88% in required bed days for TIA. Assuming £255 a night, this represents a potential saving to the trust of over £100,000 per year. Table 8: Total Q4 TIA bed days 2007/08 124 2009/10 15 Contact Dr Ben Mearns Consultant Physician, Surrey and Sussex Healthcare NHS Trust
  23. 23. Joining up prevention: case studies from the Stroke Improvement Programme projects | 23Improving TIA services in LincolnshireUnited Lincolnshire Hospitals NHS TrustAims Table 9: Stroke physician capacity and frequency of TIA clinicsThe objectives for this project wereto: Site WTE Stroke Physicians Number of TIA Clinics• develop sustainable TIA services that are available five days per Lincoln County 1.00 2 per week week, with plans to progress the Pilgrim 0.8 5 per week service to cover weekends during 2010/11 Grantham and District 0.2 2 per month• implement a rapid access TIA pathway for high risk patients• develop the workforce to ensure Patients were referred to the hospital Actions all TIA patients receive care from via traditional referral letters and The project team ran a service staff with the appropriate level of were appointed to the next available scoping day with all those involved expertise clinic slot. The information included to review current service provision, in the referral letter varied greatly and identify gaps, and explore optionsIssues the inclusion of the ABCD2 score was for service redesign. The preferredUnited Lincolnshire Hospitals NHS minimal. It was therefore difficult to model for service delivery agreedTrust has three acute hospital sites, grade referrals based on a was an extension of currentLincoln County Hospital, Grantham standardised risk stratification system. outpatient based service, withand District Hospital and Pilgrim High and low risk patients were increased capacity and frequency toHospital Boston. At commencement referred to any site. meet demand and access to sameof this project, the configuration of day diagnostics.TIA service provision varied across the At the commencement of the projectsites (see table 9). there was no baseline data or a A TIA referral form was designed mechanism for data collection. The and piloted which could be used by timeframes for access to diagnostics all healthcare professionals to refer varied across the sites. into the TIA clinics. The purpose of the form was to: • collect set information about each patient to allow for accurate grading of referrals, so the team could appoint patients into clinic slots based on high or low risk ABCD2 scores
  24. 24. 24 | Joining up prevention: case studies from the Stroke Improvement Programme projects • educate referrers about the referral The business case was approved for process, the importance of the recruitment of a new stroke providing the information required physician at Lincoln County and on the form, advice on initiation of Pilgrim Hospital. This will enable treatment and prompts to provide additional clinics to be set up with essential information to patients enough capacity to ensure access to specialist assessment five days a week The referral pathway advised referrers for high risk patients. to fax all high risk referrals to either Lincoln County or Pilgrim Hospitals as Contact the frequency of clinics at Grantham Louise Pearson did not serve the requirements of Clinical Services Manager – high risk patients. Grantham Stroke and TIA continued to receive referrals for low United Lincolnshire Hospitals risk patients. Work took place with NHS Trust the A&E and emergency assessment unit teams to highlight the importance of urgent telephone referrals directly to the stroke physicians for patients presenting with symptoms of TIA and a dedicated fax line was established so referral went directly to the stroke physicians. Outcomes The biggest improvement made was to the streamline the referral process for TIA patients into the clinics by encouraging the use of the ABCD2 score at point of referral and ensuring that appointments for high risk patients could be prioritised. Implementation of the standardised referral form allowed collection of baseline data and the ability to continually monitor demand for TIA clinics. This will enable capacity to be tailored to the need for rapid access clinics for high risk patients.
  25. 25. Joining up prevention: case studies from the Stroke Improvement Programme projects | 25Stroke 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• 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) 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 Improvement.Sustainability_Checklist.pdf Sustainability Toolkit, NHS Heart Stroke Improvement Programme e-bulletinImprovement Programme Containing updates, news and information for anyoneAlthough focused on improving cardiac pathways, The interested in developing stroke services, the StrokeSustainability Toolkit provides useful information and Improvement Programme e-bulletin is essential forexamples on how to sustain improvements. It also anyone working in stroke and TIA services.contains resources on capturing data, measurementand analysis. The Stroke Improvement Programme e-bulletin published every two weeks and the latest edition is available on the Stroke Improvement website If you would like to subscribe to the Stroke Improvement e-bulletin, please email
  26. 26. 26 | Joining up prevention: case studies from the Stroke Improvement Programme projects Atrial Fibrillation documents, NHS Improvement Sustainability Model, NHS Institute of Innovation The following documents are available to download from and Improvement the Stroke Improvement website The Sustainability Model is a diagnostic tool that is used to predict the likelihood of sustainability for your improvement project and provides practical advice on Atrial fibrillation in primary care: making an impact how you might increase the likelihood of sustainability for on stroke prevention, October 2009 your improvement initiative. This document aims to capture the final summary of their individual approach, lessons learned, improvements to welcome_to_sustainability.html practice and quality outcomes, also sharing tools and resources developed to enable other health communities Improvement Leaders’ Guides, NHS Institute for to drive this agenda forward. Innovation and Improvement Commissioning for Stroke Prevention in Primary A series of service improvement guides, including a guide Care - The Role of Atrial Fibrillation, June 2009 to sustainability and how it can be used in improvement Developed following a national consensus meeting of work. The NHS Institute for Innovation and Improvement opinion leaders in the field, this document is to develop website also contains worksheets for measuring a concerted strategy towards the management of AF in improvement. primary care, in particular anticoagulant management and its significance in relation to reduction in the risk of task=view&id=134&Itemid=351 stroke. StrokEngine-Assess Atrial Fibrillation in Primary Care National Priority This website provides evidence to support stroke Project, April 2008 rehabilitation assessment tools. A summary document produced in April 2008 including descriptions, supporting information and key learning from the local projects that were part of the Atrial Spreading good practice documents and Fibrillation in Primary Care national priority project. information, Sarah Fraser & Associates Ltd Sarah Fraser is an independent consultant who works Atrial Fibrillation in Primary Care Resources and with NHS organisations on how good practice spreads Learning, April 2008 and how improvements can be made. The website This online resource is a tool produced in April 2008 that contains a number of free resources on spreading good captured the learning from the local project sites that practice and improvements. worked on the Atrial Fibrillation in Primary Care national priority project. The resource provides documents, guidelines, presentations, proformas and algorithms developed and used by the local priority projects. 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. Email:
  27. 27. Further informationStroke Improvement ProgrammeNational TeamNHS Improvement - StrokeImprovement Programme3rd Floor, St Johns House,East Street, Leicester LE1 6NBTel: 0116 222 5184Fax: 0116 222
  28. 28. 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 ©NHS Improvement 2010 | All Rights Reserved | June 2010 Delivering tomorrow’s improvement agenda for the NHS