Consultant Stroke Physician

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Stroke A National Perspective
Damian Jenkinson
Consultant Stroke Physician Royal Bournemouth
Christchurch NHS Foundation Trust
National Clinical Lead NHS Stroke Improvement
Programme
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(No Transcript)
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Opportunity 1 Redesigning Whole Systems
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Opportunity 2 Working Together

• Stroke networks should be establishedbringing
  together key stakeholders and providers to
  review, organise and improve delivery of services
  across the care pathway
• National Stroke Strategy

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Opportunity 3 Involving Patients and Public
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Opportunity 4 Growing the Workforce

• Improving staffing numbers and skill mix
• New skills based educational framework
• Developing leadership
• Merging practice with research
• Front-line staff challenging existing practice

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Opportunity 5 More Research in Stroke
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Stroke Improvement Programme Priorities

• Support the development of Stroke Care Networks
• Share information, resources and improvement
  stories on developing stroke services
• Undertake national projects to inform and
  accelerate local change

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Network elements
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3
2
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Network stroke work plans Network title
incorporates stroke Stroke Clinical Lead
Stroke Network Manager

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The Role of Stroke Care Networks

• Enable networking along
• whole pathway
• Involve patients and carers
• Train and support staff
• Develop leadership
• Support service improvement

• Bridge to commissioners
• Guide commissioning process
• Delegated commissioning authority

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New National ProjectsFocused service improvement
work at 10 sites

• Managing RiskFocus on atrial fibrillation in
  primary care
• Transient Ischaemic Attack (TIA)Developing rapid
  assessment and treatment
• Acute stroke careThrombolysis and beyond
• RehabilitationIntegrated and effective
  rehabilitation
• Transfer of CareBridging the gap between health
  and social care

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Service Improvement Tool Bag
Team Development
Patient and Public Involvement
Process Mapping
Demand and Capacity
Statistical Process Control
Whole System Redesign
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Team and Leadership Development Programme

• Teams of health and social care professionals
• 9 month programme
• Local network staff and clinical leads support
  implementation

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Everyones Challenge

• QM1 Improve public and professional awareness of
  stroke symptoms
• QM2 Managing Risk
• same risk factors as other vascular conditions
• incorporate stroke into existing prevention
  programmes
• targeted support for disadvantaged groups and
  ethnic communities most at risk
• QM3 Information, advice and support for people
  who experience stroke
• QM4 Involving individuals and their carers in
  developing and monitoring services

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Rapid recognition of symptoms and diagnosis

• Launch 9 February 2009
• Promote 'FAST' (Face, Arm, Speech, Time to call
  999)
• Campaign messages on TV, press, radio and on-line
  channels.
• Local work should ensure campaign message reaches
  as many members of the public and healthcare
  professionals as possible.
• The materials will be available via SIP eBulletin

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HIP AF Project

• 18 Networks
• Variety of projects addressing
• Detection of AF in primary care
• Auditing anti-coagulant practice
• Referral pathways
• Rapid access AF clinics
• Models of delivery of anti-coagulant care

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Time is Brain

• QM5 6 High-risk TIA patients need to be
  assessed by experts and, wherever possible,
  scanned using Magnetic Resonance Imaging within
  24 hours of experiencing symptoms lower risk
• groups need
• to be seen
• within seven
• days

ABCD2 score
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Out-of-Hospital Management of TIA
Low Risk
High Risk
South Western Ambulance Service NHS Trust
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Time is Brain

• QM7, QM8 and QM9
• Stroke is a medical emergency.
• People with acute stroke symptoms
• need to be transferred by ambulance
• directly to a receiving hospital that is
• able to provide hyper-acute stroke
• care to include 24-hour access to a
• stroke specialist, an urgent brain scan
• and expert interpretation and able to deliver
• thrombolytic (clot-busting) treatment.
• They should be cared for on a dedicated acute
  stroke unit.
• Not everyone will be able to receive thrombolysis
  but all will still benefit from specialist acute
  stroke care.

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Changes in Provision of Acute Stroke Care
RCP Sentinel Audit 2008
But proportion of admissions receiving
thrombolysis only risen from 0.2 to 0.8
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Hyperacute Stroke Services

• Local Redirection
  Telemedicine

Collaborative
2.5 (1.4 3.6) n21,417
3.8 (3.0 4.5) n10403
Thrombolysis rate per 100 stroke cases
DASH Study Chris Price et al
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Characteristics of Acute Stroke Units

• Continuous physiological monitoring
• Access to scanning lt3h of admission
• Direct admission from AE
• Specialist ward round 5/week
• Acute stroke protocols/guidelines
• All

75 84 58 78 100 42
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West Dorset - Dorchester Hospital
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Cheltenham Gloucester
Bristol N S
Swindon
Weston
Yeovil
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Developing an Emergency Department Training
ProgrammeAvon, Gloucestershire, Wiltshire
Somerset Network

• Thrombolysis training programme developed by ED,
  Stroke and Radiology
• Participation dependent on completion of
  web-based accredited NIHSS training (AGWS
  register kept)
• 38 trained since November 2007
• Rota of stroke clinicians across Network support
  ED consultants SPRs in delivery of stroke
  thrombolysis with telemedicine support
• All thrombolysing Trusts participate in SITSMOST

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Greater Manchester Stroke Care Network
The need to change
10 PCTs commission services 9 NHS providers on
13 sites Single ambulance service
No cross Trust cooperation No jointly agreed
guidelines Referrals for hyperacute care (young
strokes, neurosurgical intervention)
disorganised No consistency of service Cant
fulfil NICE guidelines Only 2 Trusts provide tPA
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Greater Manchester Stroke Care NetworkRedesigning
Early Hours Pathway
Defining agreeing optimum pathway
Defining agreeing operating model
Inviting bids against agreed criteria
Commissioning procurement
Stakeholder engagement
Communication
Establishing governance
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PRIMARY STROKE CENTRES (2 of 3 bids) C. Man S.
Man Bolton Stockport Pennine Acute
24/7 SU IV tPA
24/7 SU IV-IA tPA D/P MRI PCT CTA DSA ICU
COMPREHENSIVE STROKE CENTRE (1 bid) Salford RHFT
DISTRICT STROKE CENTRES (3) Trafford Tameside
Wigan
Post 48h SRU
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Life After Stroke

• QM 10 Stroke unit care from a specialist
  multidisciplinary team is the single biggest
  factor that can improve a persons outcomes
  following a stroke
• Intensive rehabilitation, ideally operating
  across the seven-day week, can also limit
  disability and improve recovery
• QM 11 For those who are likely to die as a result
  of their stroke -good quality end of life care
• QM 12 There is also scope to improve the
  transition from the hospital to the community

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Life After Stroke

• QM 13 A range of services needs to be locally
  available to support the individual long-term
  needs of people who have had a stroke and their
  carers
• QM 14 After stroke, people need to be offered a
  review of their health, social care and secondary
  prevention needs, typically within six weeks of
  leaving hospital, before six months, then
  annually.
• QM 15 16 Opportunities to participate in
  community life and to return to work should be
  provided
• In line with outcomes set out in Our Health, Our
  Care, Our Say.

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Joint Commissioning For Early Supported Discharge
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Role of the Social Worker within ESD
Hospital discharge

• Integral member of hospital / inpatient MDT as
  well as community / ESD MDT
• Holistic assessment of need incorporating
  expertise as ESD SW
• Fast process strong communication

Community support

• Crisis management particularly where carers not
  coping
• Work closely with team and family to ensure care
  plan stays responsive to clients changing needs
• Help client and carers to come to terms with what
  has happened

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Social Care Supporting Stroke ADASS Survey of
the RingfencedStroke Strategy Funding (150
Councils)

• 84 Councils responded (56)
• 34 Councils have LA Stroke posts (40.5)
• 19 Councils have Stroke Co-ordinator (22.6)
• 11 Stroke Social Workers (13.1)
• 13 Other Stroke related posts (15.5)
• Source ADASS Survey
  January 2009

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Number of Councils and of Councils Who
Responded and Ranked Quality Markers Priorities
Source
ADASS January 2009
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Access to Life Project

• Care Network across all of Cornwall created and
  led by Connect in partnership with
• Adult Social Care
• Cornwall the Isles of Scilly PCT
• Royal Cornwall Hospitals NHS Trust
• The Stroke Association
• Peninsula Cardiac and Stroke Network

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Vision for the Access to Life Pathway
Primary prevention TIA services
Person has stroke with impact for family
Admission to acute hospital for /- 7 days
Transfer to Community Hospital Stroke Rehab Unit
Transfer to Early Supported Discharge
Discharge home
Referral to any or all of these services and
opportunities Peer support for people with
stroke and their families

1 Home care package
2 Housing aids adapt-ations
3 Carers support service
4 Comm-unity Rehab
5 Secon-ary prev-ention
6 Inform-ation Review
7 Building confid-ence and skills
8 Support
9 Access to work
10 Shaping services
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Working Together

• QM 18 People with stroke need to be treated by a
  skilled and competent workforce
• QM 19 Commissioners need to review and plan their
  workforce with an added investment in posts and
  an emphasis on leadership and training

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UK Forum for Stroke Training Project Plan
Awareness and Information

• For each Quality Marker
• Service requirements
• Knowledge and understanding
• Necessary skills

Time is Brain
Task Groups
Life After Stroke
Steering Group agrees drafts
Steering Group Meeting
Implementation
Consultation opens
Consultation closes
Final Framework
Task group meetings
June 08
Dec 08
Jan 09
March 09
June 09
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EvaluationVital Signs - Quarter 2 Reporting
England
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www.improvement.nhs.uk/stroke