Ayrshire and Arran NHS Board

Transcription

1 Paper 11 Ayrshire and NHS Board Monday 19 October 215 Hyper Acute Stroke Service Author: Jean Hendry, Assistant Director of Acute Services University Sponsoring Director: Liz Moore, Director for Acute Services Dr Sandip Ghosh, Lead Clinician, Stroke Service Managed Clinical Network/Clinical Director Date: 3 September 215 Recommendation The NHS Board is asked to note the review of acute stroke care led by the Ayrshire and Managed Clinical Network (MCN) for Stroke Services against National Stroke Standards. The Board is asked to approve the recommended actions, in order to continue to deliver, develop and sustain Hyper Acute Stroke Services (thrombolysis) in NHS Ayrshire &. Summary The development of Hyper Acute Stroke Services (thrombolysis) commenced in NHS Ayrshire and in 29 and has continued to evolve to the present day. The service was initially developed on the University Ayr (UHA) site and provided from 9 am to 4.3 pm on weekdays, and all patients with suspected stroke after that time required to be transferred to the Southern General (SGH) in Glasgow. A similar weekday service started on the University (UHC) site in April 21. Since April 215 a 24 hour, 7 day week service commenced in Ayrshire, and stroke patients no longer require to be transferred to Glasgow for treatment. Currently both UHA and UHC provide this service Monday - Friday hrs; at all other times Hyper Acute care (thrombolysis) is provided from UHC. A safe, sustainable 24/7 service is only possible through local Stroke Consultants working in partnership with NHS Lanarkshire, which commenced on 1 st April 215. Stroke Consultants from both Boards have formed a joint acute stroke rota for the out of hours period, using telemedicine, supporting this service for both Boards. 1 of 13

2 Five Stroke Physicians support the thrombolysis service across UHA and UHC sites. Of the five posts, one post is currently vacant and unable to be filled due to a National shortage of Accredited Stroke Physicians, a second stroke consultant will leave the organisation in November 215, a third will retire in April 216 and a fourth consultant is likely to retire in the next two years, creating a critical consultant workforce shortage in this specialty. Senior clinicians and mangers from both acute sites have considered how to respond to this critical staffing situation and propose that as from the beginning of December 215, after the second consultant leaves, the Hyper Acute stroke service should be provided Monday to Friday, 83 to 163 hrs, on the UHC site. The service is provided on the UHC site at all other times. This will ensure the service is safe, can be sustained and prevents patients from being transferred to the Queen Elizabeth in Glasgow for treatment. This will mean that patients presenting with a suspected stroke will receive the first 48 hours of their Hyper acute care (thrombolysis) at UHC and thereafter patients from the UHA locality will be transferred to UHA to receive care and treatment in the stroke unit at UHA (Station 16). Key Messages: continues to develop, deliver and monitor local Stroke Services in line with National Stroke Standards performs well against the National Stroke Standards The Hyper Acute component (includes thrombolysis) of the Stroke pathway (first 48 hours) has been developing and evolving in Ayrshire, negating the requirement for patients to transfer to Glasgow for this initial care and treatment. The aim is to deliver and sustain the Hyper Acute component in Ayrshire Medical workforce challenges have emerged in recent weeks which require a plan to be put into place to sustain and to continue to develop a local Hyper Acute service in Ayrshire Glossary of Terms BFBC CAU FAST HASU MCN NHSAA NA H&SCP NA UHC UHA RNs SSCS SGH WTE Building for Better Care Combined Assessment Unit Face, Arm, Speech, Time Hyper Acute Stroke Unit Managed Clinical Network NHS Ayrshire and North Ayrshire Health and Social Care Partnership Nursing Assistant University University Ayr Registered Nurses Scottish Stroke Care Standards Southern General Whole Time Equivalent 2 of 13

3 1. Situation This paper describes the evolution of the Hyper Acute Stroke Service in Ayrshire and over the past six years and the work taken forward by the Stroke Services MCN to develop, deliver and continuously review acute stroke arrangements against published Acute Stroke Standards. The paper highlights current workforce challenges associated with the further development and sustainability of the Hyper Acute Service and asks the Board to approve the Hyper Acute component of the pathway being provided on the UHC site. 2. Background 2.1 Hyper Acute Stroke Service All patients admitted with acute stroke require hyper acute stroke management in the first 48 hours of their presentation, involving intensive monitoring of physiological parameters and neurological observations with rapid clinical intervention to prevent brain cell death. These patients should be admitted directly to a Hyper Acute Stroke Unit (HASU) for their first 48 hours of care, to support the best clinical outcome. Patients with a suspected stroke (Face, Arm, Speech, Time FAST process), admitted within 4.5 hours of onset of symptoms, will be assessed for their suitability for thrombolysis which is a clot busting treatment. If this treatment is provided within this optimal timeframe, patients can make a full recovery. A nurse who has received additional training and with the relevant experience coordinates the assessment of the patient on arrival at hospital, linking in with the stroke physician. The stroke physician will decide whether thrombolysis is the appropriate treatment based on the thrombolysis protocol. Patients deemed suitable for thrombolysis will be administered the clot busting treatment. Intensive monitoring of these patients is required, with the patient receiving 1:1 nursing care for the first 8 hours and then 1:2 nursing care for 16 hours post stroke. 2.2 Stroke Service Configuration There are 36 acute stroke beds within NHS Ayrshire and. These are located in University Ward 4D (21 beds) and University Ayr - Station 16 (15 beds). Within these wards there are an additional 6 beds used for Hyper Acute Stroke care. These beds are located in a six bedded room within the wards and are referred to as Hyper Acute Stroke Units. In addition, there are 35 stroke rehabilitation beds, located at Ayrshire Central (2 beds in Pavilion 1) and at University Ayr, Station 12 (15 beds). 2.3 Stroke Managed Clinical Network The Ayrshire and Managed Clinical Network for Stroke Services has a specific working group to review the service against National published Stroke Standards. The group includes acute and community staff groups and public representatives. The group undertakes specific work to compare the opportunities and challenges for the further development of the service against the published standards. An extraordinary meeting of the group was held on 3 th July 215 to discuss the imminent critical workforce issues. It was recognised at this point that urgent action to sustain the Hyper Acute service in Ayrshire would require to take place in response to the service delivery challenges. 3 of 13

4 2.4 History of Hyper Acute Stroke Services in Ayrshire and The development of Hyper Acute Stroke Services (Thrombolysis) started in NHS Ayrshire and in 29. A six bedded room (Hyper Acute Stroke Unit HASU) was converted within the existing stroke unit at UHA in 29 and at UHC in 21. Stroke patients are admitted to a HASU for Hyper Acute care and remain in the unit for 48 hours before transferring into the acute stroke ward. The HASU has on site access to stroke consultants Monday to Friday 9-17 hrs and patients are reviewed at least daily. The HASU model has been developing over time in Ayrshire against National Stroke Standards, which includes the phased implementation of the thrombolysis service as detailed below. When the service started, thrombolysis was offered Monday Friday hrs, at UHA only, and at all other times the service was provided by the then Southern General, Glasgow. In April 21, the thrombolysis service was extended on a Monday to Friday basis, hrs, on the UHC site. Patients were transferred to SGH at all other times. In January 212, telemedicine technology was introduced into Stroke Consultants homes to allow them to extend the service for Ayrshire patients at UHA to 2 hrs. Patients from across Ayrshire admitted to UHA for Hyper acute care with a UHC postcode were transferred to UHC within 48 hrs, after their Hyper Acute phase of care. The SGH in Glasgow continued to provide the thrombolysis service out of hours (after 2 hrs weekdays) and over weekends. In May 213 there was a further development of the thrombolysis service, with both UHA and UHC s able to provide the service, 8-22 hrs Monday Friday, and also on a Saturday and Sunday when a stroke consultant was on call, on four out of six weekends. Over the remaining two weekends patients were transferred to SGH. The weekend service alternated between UHA and UHC, depending on where the stroke consultant was on call. Alternating the service at weekends by hospital site carried a risk of confusion for both the Scottish Ambulance Service and Accident & Emergency Departments, and a potential clinical risk if patients had been taken to the wrong hospital, resulting in a delay in treatment. To reduce this risk the MCN agreed to deliver the weekend service from the UHC only. This site has a 24/7 laboratory service and access to two CT scanners, providing assurance that one scanner would continue to be available in the event of any breakdown. Patients still required to go to Glasgow at all other times for thrombolysis. From April 215 a 24 hour, seven day week thrombolysis service commenced and stroke patients no longer needed to travel to Glasgow for thrombolysis. Both UHA and UHC currently offer thrombolysis Monday - Friday hrs and at all other times thrombolysis is provided at UHC. This 24/7 Ayrshire service from April 215 is only possible through NHS Ayrshire and Stroke Consultants working in partnership with NHS Lanarkshire. Stroke Consultants have formed a joint thrombolysis rota for out of hours cover (163 8 hrs, Monday Friday and weekends) using telemedicine technology. 4 of 13

5 2.5 Staffing Five Stroke Consultant posts in Ayrshire support the thrombolysis service. One post is currently vacant due to a National shortage of Accredited Stroke Physicians. A second stroke consultant is leaving at end November 215, and a third will retire in April 216 with a fourth consultant likely to retire in the next two years. This has created a critical consultant workforce challenge and a risk to the sustainable delivery of the service. To run a speciality stroke unit with Hyper Acute Service provision, more than one consultant requires to be onsite, to enable multidisciplinary meetings and clinical discussions with care teams to ensure the best quality of care for patients. From November 215 when the second consultant leaves, it will only be possible to deliver safe and effective Hyper Acute stroke care on the UHC site. For nurse staffing, a minimum of 2 Registered Nurses are required 24/7 for each HASU to meet the needs of all acute stroke patients plus one Nursing Assistant per six beds. The HASU staff at UHA report through the Senior Charge Nurse in the Stroke Unit at UHC. 3. Assessment is expected to achieve and maintain the Scottish Stroke Care Standards and good progress had been made to date. There are, however, areas requiring further development and the MCN is working towards full achievement (see latest outcomes against stroke standards attached at Appendix 1). The priority for this service is to optimise patient care and ensure that the service model can deliver all of the Standards. It is therefore recommended that from December 215, the Hyper Acute service is provided at the UHC site. This configuration will result in stroke patients in Ayrshire receiving the first 48 hours of their hyper acute care, including thrombolysis, at UHC. This will allow the Stroke Physicians to continue to develop and deliver hyper acute care safely. It will further allow optimal nurse staffing levels to provide HASU care and further achievement towards National Stroke Standards. At 48 hours patients admitted to the HASU at UHC from South Ayrshire will be transferred to UHA to receive continued acute stroke care in the acute stroke unit in Station 16. The proposed Acute Stroke Pathway is described at Appendix 2. The nursing staff working in the six-bedded Hyper Acute Stroke Unit at Station 16, UHA, will transfer to Ward 4D, UHC. These staff currently work on both sites, and report through the Senior Charge Nurse in the Stroke Unit at UHC. 3.1 Engagement and consultation on development of the proposal The Stroke MCN has been central to the review of acute stroke standards and been fully engaged in the process. The changes proposed in this paper have been discussed and agreed by the Care of the Elderly Directorate which is responsible for stroke services on both acute sites, and the UHA and UHC site management teams. 5 of 13

6 Nursing staff in both HASUs have been employed on the basis of working at both UHC and UHA, as required by the service needs. There is a current programme of staff engagement and communication ongoing associated with the Building for Better Care developments and specifically the Combined Assessment Unit on the UHC site, and a meeting was held on 14 August 215 to discuss the potential changes to stroke and care of the elderly services. Further staff meetings will be held to plan the detailed operational changes. 4. Recommendations NHS Ayrshire and Board is asked to note the work led by the Ayrshire and Stroke MCN to review acute stroke care against National Stroke Standards and to support the following recommended actions: 1. In response to consultant workforce challenges, to provide the Hyper Acute Stroke Service (providing care for patients in the first 48 hours post stroke) on the UHC site from 1 December 215; after the first 48 hours patients from South Ayrshire will be transferred to UHA for the remaining part of their care. 2. The Stroke MCN to continue to develop, deliver and monitor the service against the National Stroke Standards. 6 of 13

7 Monitoring Form Policy/Strategy Implications Workforce Implications This recommendation will require to be considered alongside the system wide review of care of the elderly services being led by North Ayrshire Health & Social Care Partnership. Stroke consultant staff will cover one HASU; there will be job plan implications for the Clinical Director for Care of the Elderly services who is based on the UHA site. The Clinical Director fully supports the recommendations. There will be limited implications for nursing staff, as all HASU nursing staff work across both hospital sites, under a single manager at present. The changes will impact on the wider nursing workforce in Ward 4D at UHC. This is associated with accommodating additional HASU beds within the ward. Detailed discussions will be held with staff side organisations in the context of the wider changes impacting on care of the elderly services. Other staff associated with the delivery of the HASU service AHPs, Scottish Ambulance Service, Clinical Physiology, Medical Imaging, have been involved in the Stroke MCN review process and have identified their own service arrangements to respond to further developments. Financial Implications Consultation (including Professional Committees) Risk Assessment There are expected to be no additional costs associated with these developments. The process has been led by the Stroke MCN with wide engagement. There is a critical risk that the existing local acute stroke service cannot be sustained or further developed, and the recommendations in this report will reduce this risk. There is a safety risk associated with the current service delivery model which involves moving the thrombolysis service from one site to the other, as these arrangements could cause confusion for staff and support services. There is a risk on the UHA site associated with the more limited availability of equipment such as CT scanner. (UHC has two scanners and UHA Ayr has one.) 7 of 13

8 Best Value - Vision and leadership - Effective partnerships - Governance and accountability - Use of resources - Performance management Compliance with Corporate Objectives Single Outcome Agreement (SOA) The recommendations in this paper have been developed to sustain and deliver the best possible service to the population of Ayrshire and : the 2 acute stroke wards will continue to deliver services at UHA and UHC with rehabilitation services continuing in current locations; patients will return to their local geographical area for their acute stroke care 48 hours after being treated in the HASU at UHC. The UHC HASU will address workforce and safety risks and reduce the risk of not being able to sustain and develop a Hyper Acute Stroke Service for Ayrshire residents. This paper is focused on the delivery of safe, effective care for patients; caring for the wellbeing of staff and making best use of resources. N/A Impact Assessment An Equality Impact Assessment (EQIA) has not been carried out specifically for this paper as it is part of the wider review of the acute stroke service led by the Stroke MCN. 8 of 13

9 Percent Percent Appendix 1 Scottish Stroke Care Standards 215 National Report () 1. Percentage of stroke patients receiving an 'appropriate' Stroke Care Bundle Percentage admitted to a Stroke Unit within 1 day of admission of 13

10 Percent Percent Percentage with swallow screen on day of admission Percentage with brain scan within 24 hours of admission of 13

11 Percent Percent Percentage of ischaemic stroke patients given aspirin within 1 day of admission Note: standard reduced to 95%, commencing 1 st January Percentage seen at specialist stroke/tia clinic within 4 days of receipt of referral of 13

12 Percent Percent Percentage receiving thrombolysis bolus within one hour of arrival at hospital Percentage undergoing carotid endarterectomy for symptomatic carotid stenosis within 14 days of the event Note: NHS A&A percentages on tables 2 8 calculated by local MCN Office based on numerators and denominators for Ayr and s Source: 1) ISD Scottish Stroke Care Audit 215 SSCA 215 National Report () Publication Summary issued 7 July 215 2) ISD Scottish Stroke Care Audit 215 SSCA 215 National Report: Stroke services in Scottish s Data relating to Tables & charts issued 3/4/15 NHS A&A Stroke MCN, 17 July of 13

13 Appendix 2 Hyperacute Stroke Patient Pathway Patient develops stroke symptoms UNIVERSITY HOSPITAL AYR (UHA) (SELF PRESENT) Patient assessed in Accident & Emergency Diagnosis of stroke confirmed UNIVERSITY HOSPITAL CROSSHOUSE (UHC) (999, GP, SELF PRESENT) Patient assessed in Accident & Emergency Diagnosis of stroke confirmed and patient assessed for suitability for thrombolysis NO Patient admitted to appropriate ward at University Ayr Patient develops stroke as an inpatient. Contact on call stroke consultant transfer patient to HASU UHC unless medical condition prevents transfer Acute Stroke Unit University Ayr 13 of 13 YES Patient transferred to UHC NO If patient medically stable patient transferred to UHA otherwise admit to UHC until medically stable for transfer NO Patient transferred to Acute Stroke Unit University Ayr If no bed available at UHA transfer to Acute Stroke Unit UHC awaiting bed at UHA YES Patient admitted to Hyper Acute Stroke Unit for 48 hours At 48 hours is the patient s local hospital University YES Patient transferred to Acute Stroke Unit