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  • In complete opposite to major trauma, most cases of stroke occur in the suburbs – where older people tend to live. The next two most important factors in stroke are i) ethnicity (there is a 60% greater incidence of stroke within the black African and black Caribbean populations than the white population and ii) social deprivation. However the actual numbers of people from BME communities having a stroke are not as high as would be expected as there are fewer older black and minority ethnic people in London.
  • The bid process was open to all acute trusts in London Evaluation was undertaken by an independent team of experts A comparative analysis of all configuration options was undertaken against clinically developed criteria including: Sustainable and optimal quality of provider services Comprehensive coverage of London’s population Strategic coherence Pan-London consultation then ran on The shape of things to come outlining plans to improve stroke and trauma services in London and subsequently commissioners agreed to implement the preferred option 11, 000 responses 73% of respondents supported the plans Including only high scoring units would not have allowed commissioners to ensure that all Londoners had access to a high quality service therefore the decision was taken to support lower scoring units to improve their standards

Transcript

  • 1. Transforming Stroke Care in London: The story so far Tony Rudd Clinical Director for Stroke in London
  • 2. In 2004 the Sentinel Stroke Audit showed that stroke services in London were poor… Physiotherapist assessment within 72 hours of admission % Emergency brain scan within 24 hours of stroke % 90% 90% Patients treated in a Stroke Unit % 90% Case for change
  • 3. More strokes occurred in outer London but most providers were in inner London GAPS GAPS GAPS OVERLAPS The more intense the red the greater number of providers available to provide service to the area.
  • 4. Story so far The development of the strategy was subject to wide engagement with the model of care agreed by clinicians and user groups
    • HASUs
    • Provide immediate response
    • Specialist assessment on arrival
    • CT and thrombolysis (if appropriate)
    • within 30 minutes
    • High dependency care and
    • stabilisation
    • Length of stay less than 72 hours
    • Stroke Units
    • High quality inpatient rehabilitation
    • in local hospital
    • Multi-therapy rehabilitation
    • On-going medical supervision
    • On-site TIA assessment services
    • Length of stay variable
    30 min LAS journey* After 72 hours Discharge from acute phase Community Rehabilitation Services * This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU New acute model of care
  • 5. Prophets of doom predictions
    • It would not be possible to implement major system reorganisation in London for a condition as complex as stroke
    • Staffing requirements would not be achievable
    • Patients would not accept being taken to a hospital that is not local to them
    • It would not be possible to transport people within 30 minutes to a HASU
    • Repatriation would fail and HASUs would quickly become full
    • Trusts would fight to retain services
    • Even if acute services work it would fail because it would be impossible to change community services
    • The new model would be unsustainable
  • 6. Following bidding and evaluation a preferred model was agreed and consulted on
  • 7. London Stroke Care: How is it working?
    • 1 st February 8 Hyperacute (HASU) stroke units opened taking all patients who might be suitable for thrombolysis
    • 19 th July all stroke patients taken to one of the HASUs
    • Over 400 additional nurses and 87 additional therapists recruited to work in stroke care in London by July 2010
  • 8. Beds – Open vs Planned HASU Beds NWL NCL NEL SEL SWL Open 36 18 24 22 16 Planned 36 18 24 33 20 SU Beds Open 130 93 114 57 90 Planned 156 93 114 140 92
  • 9. London Stroke Care: How is it working?
    • Between February and July the proportion of patients admitted directly to a HASU increased from 33% to 69% . Since July over 90%
    • The average journey time from home to a HASU is 14 minutes. The HASU with the longest average transfer time was Kings at 17 minutes. The average time from LAS taking the call to arrival at a HASU is 55 minutes
  • 10. The number of stroke patients taken by London Ambulance Service to a HASU has been increasing as implementation progresses
  • 11. London Stroke Care: How is it working?
    • 587 patients thrombolysed in the 5 months between Feb 2010 and June 2010 compared to 174 in the same 5 months in 2009
    • The thrombolysis rate for patients brought by LAS to hospital in London is 14%. If use the incidence data of 11,000 strokes per year in London then the thrombolysis rate is 12%. These rates are higher than any reported for a large city in the world
  • 12. London Stroke Care: How is it working?
    • Vital signs performance data
      • London is performing better than all other SHAs in England
        • % of patients spending more than 90% of their hospital stay on a stroke unit
          • 48.3% in Q1 08/09
          • 83.7% in Q1 10/11 (England performance 68.1%)
        • % of patients with high risk TIA treated within 24 hours
          • 48.6% in Q1 08/09
          • 84.9% in Q1 10/11 (England performance 56.2%)
  • 13. London Stroke Care: How is it working?
    • Average length of stay in a HASU is 3 days. Average length of stay overall has fallen e.g. 24 to 17 days at UCLH
    • % of patients discharged home directly from HASU about 40% (predicted 20%)
  • 14. Performance data shows that London is performing better than all other SHAs in England Thrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world % of patients spending 90% of their time on a dedicated stroke unit % of TIA patients’ treatment initiated within 24 hours 12% 10% 3.5% Feb – Jul 2009 Feb – Jul 2010 AIM
  • 15. Efficiency gains are also beginning to be seen Average length of stay HASU destination on discharge
    • The average length of stay has fallen from
    • approximately 15 days in 2009/10 to
    • approximately 11.5 days in 20010/11 YTD
    • This represents a potential saving of
    • approximately [DN - insert figure]
    • Approximately 35% of patients are discharged
    • home from a HASU. The estimate at the
    • beginning of the project was 20%.
  • 16. London Stroke Care: How is it working?
    • No significant problems with repatriation to SUs. Good exchange of patient information.
    • Significantly improved quality of care in SUs
    • Evidence of constructive collaboration between hospitals
      • SU Consultants joining HASU rotas and participating in post-take rounds and educational meetings
    • Very positive anecdotal patient feedback
  • 17. Case study
    • A 73 year old male from Harrow was one of the first patients to be taken to the Northwick Park Hospital HASU after suffering a stroke at home.
    • He describes the experience as “miraculous”.
    • He collapsed at home at 2.30am feeling sick and dizzy with weakness in his legs. His wife called an ambulance and paramedics took him to Northwick Park Hospital A&E. He was immediately given a CT scan and subsequently thrombolysis.
    • The patient recalls “It was very serious…My care at the hospital was superb. My speech was slurred before I had the injection but afterwards I was word perfect .It was incredible. After being given the treatment I came round straight away and the next day I woke up and was almost back to normal, had breakfast and went home. I am now completely back to normal and go to the gym twice a week.”
    • The patient was not unfamiliar with stroke. He had one three years previously following a triple heart bypass and was in hospital following complications for three and a half months. So the experience this time – in and out of hospital in less than two days – was a revelation for him.
  • 18. Medical Workforce Initiatives
    • 1 month intensive training for consultants on HASU rota
    • 6 month fast track training post CCST
    • E learning programme in development
    • Simulation centre courses being developed
      • Senior doctors and nurses
      • Band 5 nurses
  • 19. Areas where issues remain
    • Acute stroke patients presenting at non HASU A&E departments
      • Too many
      • Some difficulties transferring to HASU
      • Concerns by some SUs that inappropriate to transfer to HASU and not in patients interest to move
    • Out of London patients being brought by ambulance to non HASU A&E departments
  • 20. Areas where issues remain
    • Stroke unit catchment areas
    • Interventional neuroradiology service
    • Stroke in children
  • 21. Areas where issues remain
    • Community services in many areas still insufficient
      • Early supported discharge
      • Longer term rehabilitation
      • Vocational rehabilitation
  • 22. Areas where issues remain
    • Collecting data to prove the model is worth it
      • SINAP
      • Additional London data items
      • Economic evaluation
  • 23. What does the future hold?
      • Unlikely enhanced tariff will continue
    • GP Commissioning: How will this work for the London stroke model?
    • Andrew Lansley not convinced that the London model is the right one
    • Outcomes framework
      • Public data being displayed by London Health Observatory
      • Need to collect real outcome data
  • 24. Next steps
    • Assessment of stroke outcomes data from all London units
    • Appraisal of new financial arrangements to ensure best efficiency and value for money
    • Improve availability on stroke outcomes data to patients and the public
    • More focus on life after stroke and long term care
      • Longer term commissioning strategy...............