Stroke Services at HWPH
NHS Foundation Trust
“Getting It Right”
Dr Derek Hilton
Consultant Stroke Physician
Annual Members Meeting
18th September 2013
1
What is a stroke?
2
3
TIA / “Mini-strokes”
4
• Rule of ⅓
• 6% NHS expenditure
– £2.8 bn
– Does not include social
care
• Average LOS 28 days
• ¼ all stroke – working
age
5
A Comprehensive Stroke
Service
Comprehensive
Stroke Service
Prevention:
TIA Clinics
Hyperacute &
Acute Stroke
Management
Rehabilitation
6
• 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
7
• “Thrombolysis” within 3 hours
– Extended to 4.5 hours
8
9
• Rehabilitation at home works
– For a specific cohort of patients
• Creation of Community ESD Teams
• Well-defined service specification
10
11
A Comprehensive Stroke
Service
Comprehensive
Stroke Service
Prevention:
TIA Clinics
Hyperacute &
Acute Stroke
Management
Rehabilitation
12
Low Risk ‘One Stop’
TIA Clinic
•
•
•
•
•
Heatherwood Hospital
Mon, Weds, Fri Clinics
Summer 2012
Morning: Doppler, ECHO, Bloods
Afternoon: Consultant review
13
Hyperacute Services &
High Risk TIA Clinics
14
15
16
Acute Stroke Unit
17
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
18
Rehabilitation – Ward 8 HW
• 12 rehab beds
• 6 weeks therapy
ESD Early Supported Discharge
• Community-based therapy
• 6 weeks
– Home Sooner
– Better outcomes
19
20
Performance – Bed capacity
Direct Admissions within 4hr
100%
90%
80%
Percentage
70%
60%
Patient admitted directly to a Stroke Unit
within 4hours
50%
Target
40%
30%
20%
10%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Months (2012-13)
21
Performance – Bed capacity
90% Stay
100%
90%
80%
Percentage
70%
60%
Percentage of patients w ho spent 90% stay on a Stroke
Unit
50%
Target
40%
30%
20%
10%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Month (2012-13)
22
Length Of Stay
Total Admissions
40
35
Number of Days
30
25
Total admissions
20
15
10
5
0
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)
23
Performance – Diagnostics
CT Scans within 24 hours
100%
90%
80%
Percentage
70%
60%
50%
40%
30%
20%
10%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Months (2012-13)
24
Physiotherapist Assessment
Occupational Therapy Assessment
within 24hr
within 72hr
100%
100%
90%
90%
80%
80%
70%
70%
Percentage
Percentage
Performance – Therapies & Nursing
60%
50%
40%
60%
50%
40%
30%
30%
20%
20%
10%
10%
0%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Month (2012-13)
Mar
Apr
May
Jun
Jul
Aug
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Month (2012-13)
25
Jul
Aug
Performance – Therapies & Nursing
Dysphagia Screen within 4hr
100%
90%
80%
Percentage
70%
60%
50%
40%
30%
20%
10%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Month (2012-13)
26
Performance – Therapies & Nursing
Speech and Language Communication
Dysphagia Screening within 24hr
Assessment within 72hr
100%
90%
120%
80%
100%
60%
Percentage
Percentage
70%
50%
40%
30%
80%
60%
40%
20%
20%
10%
0%
0%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Month (2012-13)
Mar
Apr
May
Jun
Jul
Aug
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Months (2011 - 2012)
27
Aug
Why missing inpatient targets?
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]



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
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.
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












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
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.
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.
Stroke coordinators in post since September
Stroke coordinators on weekdays are therapists and therefore cannot be
pulled.
28
New locum SaLT therapist starts this month who will focus on
communication assessments.
Good news…….
Consistently performing in infection control and patient experience
Infection Control
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%
►
(%)
100.0
100.0
100.0
100%
100%
100%
100%
100%
►
MRSA protocol (%)
100.0
100.0
100.0
100%
100%
100%
100%
100%
►
NOV
OCT
SEPT
AUG
JULY
JUNE
MAY
APRIL
Trend
12
10
▲
Environment
Target
(%)
Patient Experience
Target
Compliments
15
20
23
23
18
15
Name bands
100%
100%
100%
100%
100%
100%
100%
100%
►
29
ASU “Friends & Family” Questionnaire
Jan – August 2013
25
20
Extremely Likely
Likely
15
Unlikely
Extremely Unlikely
10
Neither
5
t
Au
gu
s
Ju
ly
Ju
ne
ay
M
Ap
ril
ar
ch
M
Fe
b
Ja
n
0
30
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."
31
The Future…..
32
Thank you