1 Stroke Services at HWPH NHS Foundation Trust “Getting It Right” Dr Derek Hilton Consultant Stroke Physician Annual Members Meeting 18 th September 2013
Dec 16, 2015
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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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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
0
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
25
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
27
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