02 professor tony rudd london strategy.ppt


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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
  • 02 professor tony rudd london strategy.ppt

    1. 1. Transforming Stroke Care in London: The story so far Tony Rudd Clinical Director for Stroke in London
    2. 2. 2 2 In 2004 the Sentinel Stroke Audit showed that stroke services in London were poor… Physiotherapist assessment within 72 hours of admission % 646561 63 96 73 53 87 75 68 32 64 29 43 70 57 4943 87 68 94 75 91 26 90 82 75 100100 84 6970 57 7776 59 28 8683 38 77 90 52 7481 64 45 9191 75 100 70 34 65 89 100 93 70 95 79Emergency brain scan within 24 hours of stroke % 90% 90% Patients treated in a Stroke Unit % 0035 8 1518 20 30353845454550555859606466 72 82848585 9395 100100 90% Case for change
    3. 3. 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. 4. Story so far 4 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. 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. 6. 6 Following bidding and evaluation a preferred model was agreed and consulted on
    7. 7. London Stroke Care: How is it working? • 1st February 8 Hyperacute (HASU) stroke units opened taking all patients who might be suitable for thrombolysis • 19th 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. 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. 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. 10. 10 The number of stroke patients taken by London Ambulance Service to a HASU has been increasing as implementation progresses 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% O ct-09 N ov-09 D ec-09 Jan-10 Feb-10 M ar-10 A pr-10 M ay-10 Jun-10 Jul-10 A ug-10 -indicative Non-HASU HASU
    11. 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. 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. 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. 14. 14 Performance data shows that London is performing better than all other SHAs in England 40 45 50 55 60 65 70 75 80 85 90 Q1 Q2 Q3 Q4 Q1 2009/10 2010/11 %achievement London England Target 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 40 45 50 55 60 65 70 75 80 85 90 Q1 Q2 Q3 Q4 Q1 2009/10 2010/11 %achievement London England Target % of TIA patients’ treatment initiated within 24 hours 0% 2% 4% 6% 8% 10% 12% 14% 16% 12% 10% 3.5% Feb – Jul 2009 Feb – Jul 2010AIM
    15. 15. 15 Efficiency gains are also beginning to be seen 0 2 4 6 8 10 12 14 16 18 20 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2009/10 2010/11 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%. 0% 10% 20% 30% 40% 50% 60% Home Other Stroke Unit RIP (blank)
    16. 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. 17. 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. 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. 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. 20. Areas where issues remain • Stroke unit catchment areas • Interventional neuroradiology service • Stroke in children
    21. 21. Areas where issues remain • Community services in many areas still insufficient – Early supported discharge – Longer term rehabilitation – Vocational rehabilitation
    22. 22. Areas where issues remain • Collecting data to prove the model is worth it – SINAP – Additional London data items – Economic evaluation
    23. 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. 24. Next steps 24 • 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...............
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