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Stroke Services at HWPHNHS Foundation Trust

“Getting It Right”

Dr Derek HiltonConsultant Stroke Physician

Annual Members Meeting18th September 2013

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What is a stroke?

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TIA / “Mini-strokes”

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• Rule of ⅓• 6% NHS expenditure

– £2.8 bn– Does not include social

care

• Average LOS 28 days• ¼ all stroke – working

age

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A Comprehensive Stroke Service

ComprehensiveStroke Service

Prevention:TIA Clinics

Hyperacute &Acute StrokeManagement

Rehabilitation

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• TIA: “Medical Emergency”• High Risk patients

– Seen within 24 hours– Surgery within 7 days

• Low Risk patients– Seen within 7 days– Surgery within 14 days from onset

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• “Thrombolysis” within 3 hours– Extended to 4.5 hours

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• Rehabilitation at home works– For a specific cohort of patients

• Creation of Community ESD Teams• Well-defined service specification

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A Comprehensive Stroke Service

ComprehensiveStroke Service

Prevention:TIA Clinics

Hyperacute &Acute StrokeManagement

Rehabilitation

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Low Risk ‘One Stop’TIA Clinic

• Heatherwood Hospital

• Mon, Weds, Fri Clinics

• Summer 2012

• Morning: Doppler, ECHO, Bloods

• Afternoon: Consultant review

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Hyperacute Services &High Risk TIA Clinics

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Acute Stroke Unit

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Acute Stroke Unit

• Later-presentation stroke patients

• Receive Bucks repatriated patients < 72 hours

• 17-bedded Unit

• Stabilisation

• Therapy Assessment for rehab potential

• Significant proportion of patients go home or to NH from ASU

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Rehabilitation – Ward 8 HW

• 12 rehab beds

• 6 weeks therapy

ESD Early Supported Discharge

• Community-based therapy• 6 weeks

– Home Sooner– Better outcomes

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Performance – Bed capacity

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Performance – Bed capacity

90% Stay

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Month (2012-13)

Pe

rce

nta

ge

Percentage of patients w ho spent 90% stay on a StrokeUnit

Target

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Length Of Stay

Total Admissions

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5

10

15

20

25

30

35

40

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

Months (2012-13)

Nu

mb

er

of

Da

ys

Total admissions

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Performance – Diagnostics

CT Scans within 24 hours

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Months (2012-13)

Pe

rce

nta

ge

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Performance – Therapies & Nursing

Occupational Therapy Assessment

within 72hr

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Month (2012-13)

Per

cent

age

Physiotherapist Assessment

within 24hr

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Month (2012-13)

Pe

rce

nta

ge

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Performance – Therapies & Nursing

Dysphagia Screen within 4hr

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Month (2012-13)

Pe

rce

nta

ge

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Performance – Therapies & Nursing

Dysphagia Screening within 24hr

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Month (2012-13)

Pe

rce

nta

ge

Speech and Language Communication

Assessment within 72hr

0%

20%

40%

60%

80%

100%

120%

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Months (2011 - 2012)

Pe

rce

nta

ge

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Problem Mitigating actions/plans

Diagnosis Receiving late referrals from A&E & wards [process] Levels of skill to diagnose in A&E & wards [education] Default position should be to query stroke [education] Knowledge of stroke pathway [education]

Sharing data with A&E Stroke lead consultant identified on A&E Training for A&E nursing and medical staff on Stroke pathway and

diagnosis – Slot on A&E induction & sporadic teaching sessions Consultant and ANP walkabout – junior doctors 24/7 Stroke coordinator Targeting individual doctors

Diagnostics Doppler's - Patients wait (from 2 days to 2 weeks) whilst on

ASU due to capacity on sonographer’s list. CTs – generally done on time. Breaches occur due to late

referrals/late diagnosis

Gold standard is for patients to receive Doppler's and CT scans whilst on a Stroke ward within 24 hours of request.

Division B are aware of the need for extra capacity for Doppler's.

Capacity Bed modelling suggests we have enough beds to support

the number of patients admitted. ASU admit a range of between 0-5 patients per day.

However, using the 80/20 rule, ASU must be able to accept 4 patients per day.

In times of capacity pressures in the Trust, medical patients are admitted to ASU.

Not consistently repatriating patients within 72 hours from HASU at Wycombe – risk of financial penalties if consistently fail.

2 ring-fenced beds on the assessment unit once modular ward opens Increase awareness Trust wide Development of ESD service for Berkshire East will ensure some patients

go home much earlier (target of 41%) – will help flow through ASU and decrease LOS. Due to start Autumn 2013. Better rehab outcomes for patients. ESD service will support ASU in maintaining 4 discharges daily.

Increased communication between stroke coordinators in ASU and HASU. HASU will give us 24hrs warning of a patient becoming medically fit and in return we will endeavour to repatriate that patient to ASU within 24 hours.

Why missing inpatient targets?

Staffing Stroke coordinator post was vacant from May to Sept – vital

role in executing the stroke pathway SaLT post vacant – difficult to get a SaLT therapist to do

communication assessment within allotted timeframe

Stroke coordinators in post since September Stroke coordinators on weekdays are therapists and therefore cannot be

pulled. New locum SaLT therapist starts this month who will focus on

communication assessments.

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Infection Control Target NOV OCT SEPT AUG JULY JUNE MAY APRIL Trend

Hand Hygiene (%)   100.0 100.0 100.0 100% 100% 100% 100% 100% ►

VIP (%)   100.0 100.0 100.0 100% 100% 100% 100% 100% ►

Environment (%)   100.0 100.0 100.0 100% 100% 100% 100% 100% ►

MRSA protocol (%)   100.0 100.0 100.0 100% 100% 100% 100% 100% ►

Patient Experience Target NOV OCT SEPT AUG JULY JUNE MAY APRIL Trend

Compliments   15 20 23 23 18 15 12 10 ▲

Name bands   100% 100% 100% 100% 100% 100% 100% 100% ►

Consistently performing in infection control and patient experience

Good news…….

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0

5

10

15

20

25

Extremely Likely

Likely

Unlikely

Extremely Unlikely

Neither

ASU “Friends & Family” Questionnaire

Jan – August 2013

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CQC Report:

In contrast, on the acute stroke unit, patients and their relatives felt very well informed about their treatment plans and told us they were involved in making decisions about their care. One patient told us, "we have been given great family support."

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The Future…..

Thank you