Stroke Research making a
difference to practice
Early Supported Discharge versus
General Rehabilitation: A Debate
Dr Rebecca Fisher
University of Nottingham
A Debate – Oxford Style
• “This house proposes the motion for the
Implementation of evidence based Stroke Early
Supported Discharge services”
Overview
• Early Supported Discharge (ESD): an essential
part of the stroke care pathway
• Guidelines for the implementation of ESD services
• Stroke Rehabilitation Implementation research
Overview
• Early Supported Discharge
• Community Stroke Service
• Key differences
• Making research accessible
• Evidence based care
• Recommendations
Stroke Specialist Care
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Evidence supports stroke specialist care
Stroke Unit Trialist’s Collaboration, 2006
ESD: Langhorne 2005; Fisher et al 2011
Outpatient Service Trialists, 2003
• Stroke unit vs general medical ward
• Stroke specialist ESD
• Stroke specific intervention vs routine care
ESD – Key issues
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ESD Policy
CLAHRC ESD research
ESD Consensus – core components
Mapping/Evaluation – emerging issues
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Eligibility
Early intervention
Existence of other community services
Effectiveness
ESD Policy
• National Stroke Strategy, RCP guidelines,
Accelerated Stroke Improvement Programme
• Proportion of patients supported by a stroke
skilled Early Supported Discharge team (40% by
April 2011)
Hospital Acute Rehab
Home
Rehab
ESD
Rehab
Support
Support
CLAHRC ESD research
• Provision of the best evidence based care to patients
• Framework and tool-kit for Stroke Rehabilitation
Implementation research
• Are ESD services effective when implemented in practice?
ESD Consensus
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Cochrane systematic review – Langhorne 2005
Does ESD work? – Yes
How do you set up an ESD service in practice?
What are the key messages from the literature?
Accessible to commissioners
Guidelines for service providers
ESD Consensus
• Ten ESD trialists involved (P Langhorne, B Indredavik, C
Wolfe, M Power, H Rodgers, L Holmqvist, E Bautz-Holter,
N Mayo, C Anderson, O Morten Rønning)
• Core elements of an ESD service: list of statements
• Statements integrated into ESD service specification for
the East Midlands
• Fisher et al. 2011. A Consensus on Early Supported
Discharge. Stroke, 42:1392-1397
• Uncertainty remains – emerging findings from qualitative
research
Consensus statements: Team composition
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Team Composition
Stroke specialist, multidisciplinary
For 100 patients per year caseload:
OT (1.0), Physio (1.0), SALT (0.4)
Physician (0.1), nurse (0-1.2), social worker (0-0.5)
Consensus not reached: Rehab assistant
Interpretation: role of assistant depends on model
of rest of team and overall remit of team
Consensus statements: Model of team
• Model of team working
• An early supported discharge team should plan and
co-ordinate both discharge from hospital and
provide rehabilitation and support in the community.
• Key worker, co-ordinator
• An early supported discharge team should be
based in the hospital.
• Interpretation: ESD as an extension of
acute phase of stroke pathway
Consensus statements: Intervention
• Intervention
• Specific eligibility criteria
• Live safely at home, based on medical stability,
practicality and disability (barthel score 10/20 to 17/20)
• Transfer safely from bed to chair i.e. can transfer safely
with one with an able carer, or independently if living
alone.
• Hospital staff and ESD team staff should identify
patients for ESD
Eligibility
• ESD effective for mild/moderate stroke patients
• Most patients have a Barthel score 10-17
• Target 40%
Stroke severity on admission to hospital (years 2007-2009)
Percentage of population (n=2003)
60
50
40
30
20
10
0
Severe (0-9)
ESD eligible (10-17)
Admission Barthel Score
Mild (18-20)
• Decision made when?
(post-stroke)
• By whom?
• Cross boundary
working
Early & Intensive
• Early Supported Discharge - What is early?
• Early post stroke: referral within 7-14 days
• Earlier discharge: provision of rehab on hospital wards
required to reach eligibility (~30+ days)
• Reduction in length of stay (effectiveness)
• Importance of Physician: patients are medically stable
• High intensity of intervention (QM 10): 7 day working,
daily visits, role of rehab assistants
• Responsiveness and Intervention length (no waiting list)
Early & Intensive
Range of hospital stay of patients admitted to Nottinghamshire Community Health ESDT
All referring trusts included (Sept 2009 - Feb 2011 hospital admissions)
40%
Percentage of patients (n=219)
35%
30%
27%
25%
25%
20%
16%
14%
15%
10%
10%
8%
5%
0%
(0-3)
(4-7)
(8-14)
(15-25)
(26-35)
Length of hospital stay (days)
Total Stroke admissions – 769
ESD service seeing approximately 28% of stroke patients
(35+)
Existence of other community services
• Intervention: fixed term or as long as patients
needs?
• Existence of other community services
• Local considerations for implementation
• Commission ESD as part of stroke care pathway
• ESD and Community Stroke team
• Plan what happens after ESD
• Consider link/impact on social care
Effectiveness
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Is the ESD team functioning effectively?
Functional benefits for patient: rehab at home
Accelerating discharge: Measuring length of stay (cost)
No increase in institutionalisation, readmission rates
Who monitors readmission & institutionalisation rates?
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Barthel Score
• Functionality: use of
outcome measures
• Increase in ADL
• Robust methods
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Admission
Discharge
Success - Cost
• The annual cost of the ESD team should be less or equal to the
annual savings made by reduction in length of stay in hospital.
• Are savings realised? Only by unbundling tariff
• Commissioner/ provider & national/local
• Early discharge (7-14 days): unbundling options
• Earlier discharge: following provision of rehab on hospital
wards - How to unbundle?
• Range and distribution of length of stay for ESD patients
• What proportion of patients can, and are, discharged early (e.g.
within 7 -14 days)?
• What proportion of the total stroke population are ESD eligible?
• Are we clear on how to monitor readmissions?
Recommendations
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Review service provision in hospital and community
Commission ESD and community stroke teams
Ensure pathway for more severe patients is planned
Robust data collection: define and monitor length of
stay and readmission rates
Analyse retrospective data - two ESD streams and
proportions of patients eligible for ESD
Joint commissioning across organisations
Joint data monitoring
Involve social care (esp. community stroke teams)
Summary
• ESD consensus provides core elements of ESD
• Guidelines for the implementation of ESD
services in practice – are benefits still evident?
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Multidisciplinary team composition: Role of Physician
Model: Early, Responsive, Intensive intervention
Eligibility: mild to moderate, medically stable
Plan what happens after ESD
Effectiveness: patient functionality
Early & Earlier: tariff consequences
Whole pathway commissioning based on robust data
ESD vs Community Stroke Teams
Early Supported Discharge Team
Community Stroke Service
Team Composition
ESD consensus specifies OT, Physio,
SALT, Physician, nurse, social worker,
rehab assistant(?)
To be defined. Likely to include OT,
Physio, SALT, nurse, social worker
Multidisciplinary Team Model
Coordinated stroke specialist
multidisciplinary team; plans
discharge from hospital & provides
rehabilitation and support at home.
Key worker system.
Joint decision making between
hospital ward staff and ESD team.
Coordinated multidisciplinary team;
provides rehabilitation and support
for stroke patients in the community.
Therapists work as a team, however
manage their own caseloads.
Decisions made by hospital staff;
accepted on basis of eligibility criteria.
Based in part on level of disability (e.g.
barthel score of 10-17), ability to
transfer, medical stability and whether
patient can patient live safely at
home.
Patient would benefit from intensive
rehabilitation facilitated by continued
medical support at home.
Based on medical stability and
whether patient can live safely at
home. Patient needs to manage with
maximum of one visit per week.
Can be up to (and beyond) 30 days –
however, aim is to reduce length of
stay.
Decision based on when best to
transfer patient.
Referral Decisions: By Whom
Eligibility Criteria
Referral Considerations
Hospital Length of Stay
Patient would benefit from some
rehabilitation at home i.e. has
community focused goals
ESD vs Community Stroke Teams
Responsiveness
Caseload
Days per Week
Intensity of Intervention
Components of Intervention
Length of Intervention
Early Supported Discharge Team
Community Stroke Service
ESD team is responsive and
agile. Take referrals
immediately; visit patient
within 24-48 hours of them
arriving home.
Usually around 16 patients at
any one time.
Operates a waiting list per
clinician.
5-7 days
Daily visits to patient,
sometimes twice per day.
Short-term goals focusing on
activities of daily living, speech
and mobility. Social care issues
are addressed.
5 days
Once or twice weekly visits.
Fixed time period, usually 6
weeks
Patients are prioritized if
necessary.
Caseload number varies;
caseload is managed by waiting
lists.
Activities of daily living and
mobility; focus also on longer
term goals including vocational
issues, participation in social
activities and re-integration.
Social care issues are
addressed.
As long as patient needs or
team operates a standard
length of intervention.
The ESD Research Team
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Marion Walker
Rebecca Fisher
Fiona Nouri
Micky Kerr
Kay Gaynor
Hazel Sayers
Amy Moody
Iskra Stariradeva
Christine Cobley
Marie Ashmore