REPORT OF:
Greater Manchester & Cheshire Cardiac & Stroke
Network
DATE OF PAPER:
02.08.2012
SUBJECT:
GMISS Stroke Development Workshop 18.07.2012
IN CASE OF QUERY, PLEASE CONTACT
Kate Ritchie, Quality Improvement Manager
kate.ritchie@nhs.net
PURPOSE OF PAPER:
Please insert brief summary of content of paper and outcome required.
This paper describes the discussions held at the GMISS Stroke Development Workshop on
Wednesday 18th July 2012.
Document History
DATE
VERSION
CONSIDERED BY
NOTES/DECISION
GMISS Stroke Development Workshop
Executive Summary
This report describes the discussions held at the GMISS Stroke Development Workshop on Friday 18th
July 2012, where the potential model for further centralisation of Greater Manchester Stroke Services was
discussed in greater detail following on from the first workshop on 22nd June 2012.
1
Agenda
1.1
The programme for the day:
Programme180712.p
df
2
Introduction
2.1
The following presentations were delivered during the first session:
Context Setting, Overall Vision for Service and Expected Timescales – Janet Ratcliffe,
Director of Networks:
JR slides
SWOT Analysis – Prof. Pippa Tyrrell, Senior Lecturer, University of Manchester / Honorary
Consultant in Stroke Medicine, SRFT / GMCCSN Stroke Clinical Lead:
PT2 slides - SWOT
analysis.ppt
Presentation from London Stroke Networks – Lucy Grothier, Director, South London Cardiac
and Stroke Network:
LG slides 180712.ppt
3
Breakout 1: Hyperacute Stroke Units
Attendees split into groups for a “World Café” style facilitated discussion. The topics discussed
3.1
had been identified from the June workshops and were considered in more detail in light of the
proposed operating model:
1. False positives and non-stroke repatriations / FAST negative and atypical presentations
2. 23:00 – 7:00 presentations / cross city rota
3. 6 week review / End of Life care
4. TIA
5. Repatriations / patient choice
3.1.1
False positives and non-stroke repatriations / FAST negative and atypical presentations
False positives
-
Two groups:
o
“Other” diagnoses admitted to the stroke unit, such as tumour or seizure
o
False positives reviewed in A&E and passed to medics (MAU capacity)
-
Need to be clear about the pathways into neurology and neurosurgery
-
There are different tumour pathways in the PSCs compared to the CSC
-
There may be complaints if these patient are not managed properly or go on to have a poor
outcome
-
What about stroke patients with onset over 3 or 4 days ago?
-
Need clarity for NWAS; may need to adopt ROSIER?
-
How does London handle these patients?
-
Is there any data on false-positives reviewed in A&E?
-
Pressure on MAU / EAU
-
Need to consider the impact on the C/PSC and A&E / medicine within these centres
-
Regarding tariffs; the primary need is to get patient care right, and the money should follow the
patient
FAST negatives and atypical presentations
-
These patients can miss out on ESD / rehabilitation pathways
-
Where do functional strokes fit into the pathway?
3.1.2
23:00 – 07:00 presentations / cross-city rota
23:00 – 07:00 presentations
-
The less exceptions from a pathway, the better; the example of Primary PCI is to keep the pathway
as simple as possible
-
It would be better to have all patients going to the CSC, or to have all three centres open overnight
-
The principle should be simple, as per the London model
-
Possibly the majority of patients presenting in the middle of the night would be within the
thrombolysis window anyway and therefore would go to the CSC anyway
-
The consensus therefore was for the idea that all strokes go to an open HASU
Cross-city rota
-
Need to be clear about exactly what this would entail and what the backfill for DSCs would be
-
Would the staff be resident or come in on an ‘on call’ basis as per PPCI?
-
High intensity or low intensity – whilst this works well in context of Primary PCI, it was felt that it
would not work in stroke if centres are opening at different times.
-
How would handover work in the morning if a clinician was not local?
-
Financial considerations – who would fund the sessions with cross-organisational working?
-
Perhaps should extend to therapists and nurses and could increase job satisfaction
-
Mandatory or optional?
-
Inclusion of radiographers – MR / CT / CT angiogram?
-
Training and mentoring
-
GP with special interest?
-
Is there are place for telemedicine?
3.1.3
6 week review / End of Life Care
6 week reviews
-
Guidelines do not state who should deliver 6 week reviews but do stipulate MDT involvement (GPs
have no connection to the MDT)
-
Not currently done systematically, there are inconsistencies across GM
-
Reviews should be standardised and should be delivered by the treating team who know the
patient. There may be a need to refer on into local services or get medical input for patients with
comorbidities
-
If a patient is discharged directly from C/PSC, and needs further investigations, where would these
take place?
-
There are no resources in general practice for 6 week reviews, and GPs do not see enough stroke
patients each year to deliver the reviews
-
Could there be an incentive to provide the service?
-
There may be a role for the ESDT
-
Could nurses deliver these reviews? Could nurses / therapists be involved as a development
opportunity?
-
Could extended scope practitioners deliver these reviews, with the option to buy in consultant
support if required?
-
Need to consider how these reviews can be meaningful to the patient; it shouldn’t be a purely
medical model but should also include mood, cognitive and functional reviews as well as secondary
prevention
-
Should also be provided to those in residential and nursing care, possibly via telephone?
End of Life Care
-
-
Two groups of patients:
o
Patients on the Liverpool Care Pathway
o
Patients in the last 6-12 months of their life
Timely referral to social care and/or specialist palliative care services and District Nurses (working
well in Salford)
-
Advanced care planning and implementation in nursing homes
-
DNA CPR process on transfer home
-
If the stroke service is further centralised, need to consider patient choice and carer involvement
around repatriation to local DSC or home, or remaining in current place of care
-
Ambulance transfers – conversations needed around awareness of risks
-
Fast-tracking is working well in some, but not all, areas
-
Communication: need patient/carer involvement from the start and integrated care. Need to ensure
that conversations take place and patients / families know what is available
-
Opportunities to involve PTS?
-
NWAS timely non-medical transfers may take longer; requesting a paramedic does not guarantee
speed as resources are allocated based on clinical need and resource availability
-
Cause for Concern register (GSF)
-
Is it appropriate to transfer the patient?
-
Transfers of care at end of life work better in own locality
-
If transferring from e.g. Salford to Bury locality there are lots of hoops to jump through. We need
network-wide access to palliative care information
3.1.4
-
TIA
The only way in which high risk patients can be seen at weekends, without being admitted, is with a
networked service provided by some but not all centres
-
Currently there is an inequity for TIA patients presenting at the weekend and on bank holidays
-
The demand for a weekend service is difficult to quantify as the numbers appear low, and because
there has never been a weekend service it is difficult to draw on historical activity
-
The C/PSCs will have weekend input from a stroke consultant, specialist nursing staff and access
to scanning for stroke patients so there is an opportunity to exploit this as a “drop-in” service for TIA
patients
-
Would this be offered to all TIA patients or just high risk patients?
-
A significant proportion of the activity which goes into TIA clinics is not TIA; how would these
patients be handled? Could there be a filter mechanism such as a “TIA phone” carried by a
member of the stroke team at weekends in order to filter out inappropriate referrals?
-
There could be issues around patient transport and access to vascular services
-
One other option would be to hold the weekend TIA services in the two vascular centres
-
Should a weekend service be set up, would there be an issue with having a different service
provided at the weekend compared to the week?
3.1.5
Repatriations / patient choice
Repatriations
-
Repatriation of mimic strokes can cause delays in transport and a breach of the 4 hour target; a
previous solution has been to commission a private ambulance
-
Could we clarify whether the 35% of patients discharged home directly from a London HASU
included stroke mimics?
-
Need to ask specifically for the appropriate NWAS team
-
Approximately 25% of suspected strokes arriving at the centres are mimics – could NWAS do
ROSIER or ask two additional questions to reduce this:
-
o
Has the patient had a blackout?
o
Has the patient had a fit?
Stroke mimics should be repatriated to medical wards and not stroke units, although some may not
be well enough for repatriation – need other solutions e.g. acute neurology unit / neuroscience
-
Hyperacutes may need to keep the sicker neurology patients, or send on to CSC
-
Need clarify around postcodes for repatriation (e.g. Trafford / Wythenshawe border)
-
Documentation accompanying patient needs to be comprehensive otherwise the patient may need
to be reassessed (duplication of resources) and would ideally include detail of conversations held
with patients / family / carers
-
Issues around DSC patients being repatriated out-of-area, including visitors to Manchester, which
can cause 5 or 6 week lengths of stay in GM hyperacutes
-
DSCs need capacity for repatriation
-
Current escalation policy for repatriation includes stroke patients – do we need an escalation policy
for the repatriation of stroke mimics?
-
How long should the centres wait for an ambulance for repatriation? Where should the patient stay
if the ambulance does not arrive in time?
-
What are the acceptable hours during which patients can be repatriated? How much flexibility is
there around this in terms of waiting for ambulances?
-
It is difficult to model the repatriation flows until the service has been operational e.g. after 6
months
-
C/PSC need to start the discharge planning whilst the patient is still with them
-
Need to learn from the Primary PCI pathway, where repatriation is not questioned as patients
expect it, because they understand the pathway
-
GM may need a repatriation protocol / look-up like London’s
Patient choice
-
Some complex patients may choose to be repatriated not to their local DSC e.g. a kidney care
patient may wish to go to MRI if that is their renal centre
-
Patient anxiety – management of expectations and sharing of information – patients need to
understand why they are being repatriated and feel confident that they are going to a high quality
district stroke unit
-
Repatriation experience; repatriation should not feel like “abandonment”
-
Quality – need conversations around social care, possible role for the voluntary sector
-
Whose responsibility is it to inform the patient / family about discharge? Conversations need to
begin earlier
-
Giving information is not the same as shared decision-making
-
How is patient choice involved when there are no stroke beds at the DSC?
-
Need greater awareness of the stroke pathway
4
Breakout 2/3: Post-72 hours
4.1
Delegates attended two of the following three facilitated sessions:
1. Tariffs and Commissioning
2. District Stroke Units
3. Community Stroke Services
4.1.1
Tariffs and Commissioning
-
Variable lengths of stay
-
Potential discharges – impact on ESD
-
Need breakdown at GM level
-
ESD tariff and excess bed days starting earlier: could incentivise for an ESD service
-
Whole care package
-
Impact modelling – London
-
Potential to simplify – could 13/14 PbR be used?
-
Top ups? Proportional funding?
-
Difficulty in unpicking rehab funding local/community/block arrangements
-
Earlier discharge – the right bundle of care given / delivered? This is still to be agreed
-
Variability around when patients are clinically suitable for discharge
-
DSC standards – revision / tariff
-
If DSC service is squeezed and staff de-skill with lower numbers, need to ensure the DSC remains
viable and important, not just focusing on the “Rolls Royce” hyperacutes
-
This is an opportunity to unpick the current funding i.e. guaranteed levels of income and top up
funds
4.1.2
District Stroke Units
-
Can the inequities of ESD provision be fed back to the CCGs?
-
Assessment within 72 hours should be included in the acute bundle delivered by the hyperacutes
-
Performance management framework:
o Clinical governance issue on how to manage the service
o Current performance management frameworks don’t sufficiently capture this for
commissioners
o Additional indicators could be added
o If this is done it needs to be added to an existing system e.g. SSNAP / community dataset
o Needs to include handover from acute and community
o Need dashboard of key measures
o Outcome driven and person centred
o Those present agreed a bundle of rehabilitation would be useful
o Standards for rehabilitation: version 6 was presented along with comments and responses
from previous consultations. Current version was supported by those present. Suggestion
to amend title to reflect involvement of community services.
o Accountability
-
Need clarity on what acute bundle includes
-
Modelling required on numbers repatriated to DSCs
-
Who is held to account for performance?
-
CQUIN already collects some information
-
District Stroke Units have three roles:
o Post-acute care
o Rehabilitation
o ESD
-
Role of Network: the network advocates processes within ESD services (as detailed in the ESD
service spec and stroke rehabilitation standards), however, no particular single model of delivery is
advocated. This is for local agreement as to most suitable. However, SIP have produced a recent
document “Stroke Rehabilitation Commissioning for Improvement” which provides 6 models of ESD
delivery http://www.improvement.nhs.uk/documents/Stroke_Rehab.pdf
4.1.3
Community Stroke Services
This breakout group discussed what the ideal post-discharge patient pathway should be, with the second
group building on the points which the first group had already identified. Key points to emerge were:
Principles
-
The entire pathway should be seamless, including on weekends and bank holidays
-
There should be holistic, person-centred planning; patients should not be passed “from pillar to
post”
-
Health and social care should be joined up, with active case management and coordination of care
including other services such as housing and mental health
-
All services involved in the patient’s care, as well as the patient themselves and their family / carers
should be aware of a plan for post hospital care as well as clear goals for the patient
-
Ownership needs to be clear for each aspect relating to care e.g. Section 2, arrangements for
equipment
-
Stroke survivors should be involved in service redesign
-
There should be equity of access to services, irrespective of final discharge destination
-
Self-care, independence and empowerment should be maximised as part of this pathway
Prior to discharge
-
Social services are open to receive referrals from the point that the patient is admitted, rather than
receiving them just prior to discharge
-
Community services and reablement should in-reach into the pre-discharge MDT including the
patients’ family
-
Individualised, long-term planning should begin
-
Discharge should not be delayed due to waits for community health or social services
-
Contact numbers for all services and / or a single point of contact should be provided
Post discharge
-
All services involved in the patient’s care, as well as the patient themselves and their family / carers
should be aware of a plan for post hospital care as well as clear goals for the patient
-
The needs of carers as well as patients should be considered
-
Patients should be contacted within 24 hours of leaving hospital, and a physical visit should be
made within 24 hours if this is in line with the patient’s wishes
-
Provision of specialist equipment should be made irrespective of discharge destination
-
Continuity of GP and social worker involvement
-
Reablement team and stroke team should work to a common goal, with agreement on how to
reach it
-
There should be staged reviews and shared decision-making
-
Care should be available for as long as it is needed
6 and 12 month reviews
-
There is a need to cross-check the patient with the GP register; a specific discharge letter should
clearly identify stroke so that the patient is added to the stroke register
5
-
There should be equity of access to the right standard of care delivered by the appropriate person
-
Everyone should know how to get the support the need, when they need it, from the right person
-
Data should be captured so that we know how people are
-
Mood and emotional support should be reviewed
-
There should be a way for patients to access help at e.g. 5 or 7 months if they are in crisis
-
GPs should be pro-active about contacting their stroke patients
-
The reviewers should be mindful that some things may be frightening or embarrassing to discuss
Next Steps
There was a consensus that the proposed operating model should be amended to remove the 23:00 –
07:00 diversion of patients outside the thrombolysis window away from the CSC to their nearest “off-duty”
PSC. With that amendment, there was consensus that the proposed model detailed in appendix A is
appropriate.
It was evident that the workshop’s discussions had raised a significant number of questions, and although
the breakout sessions had in some cases begun to look towards solutions, there was still a need for a
forum to take the work forward. The outcomes of both the GMISS development workshops will inform the
impact assessment of the proposed centralisation, but there was a feeling that smaller, topic-focused
groups would be helpful to take forward some of the work streams identified by these workshops.
The following topics have been identified to take forward, with the forums in brackets:
-
DSC bundle (new task / finish group)
-
ESD referral routes from hyperacute centres (Joint Implementation Team / ESD group)
-
Finance / tariffs (Commissioning Projects Committee)
-
Workforce review (Workforce Development Group)
-
6/52 review (Joint Implementation Team)
-
Cross-city rota (Joint Implementation Team)
A
Appendix A – Proposed Hyperacute Operating Model
Dial 999 or
self-present to
hospital
Suspected
stroke
YES
FAST +VE?
NO
Exit stroke pathway
N
W
A
S
Presenting
7am - 11pm?
YES
Nearest C/PSC for
entire acute
bundle
Repatriation
District Stroke
Centre for postacute and ongoing
rehabilitation
Repatriation
District Stroke
Centre for postacute and ongoing
rehabilitation
NO
To CSC for entire
acute bundle