Cardiff and Vale University Health Board. Stroke Delivery Plan / Progress Report September 2017

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1 Stroke Delivery Plan / Progress Report September Overview (CaV UHB) has made progress during the past year in the following areas: - Thrombolysis improvement both in the number of eligible patients thrombolysed and the door to needle thrombolysis times. - Overall SSNAP score has improved from 16 in Q3 of 2013 to 79 in Q4 of 2016 giving a B-rating. - Percentage of Stroke Patients who spend up to 90% of their stay on Acute Stroke Unit has increased. - Provision of CT scan within 12 hours and within 1hour (target 95% and 50% respectively) has remained consistently above target. - Atrial Fibrillation project supported by Welsh Government has excelled and will be rolled out across Wales and has been shortlisted for a National Award (Oct 2017) day Hospital survival has improved. - Participation in two research trials : PROMIS to look at the best method for delivering a 6 month review for post-stroke patients and a trial looking at specific cognitive deficits occurring with thalamic strokes. RESTART - a study to look at REstart or STop Antithrombotics Randomised Trial - In Public Health - Smoking cessation - Implementation of the Healthy Weight Framework - Alcohol consumption 1

2 The overall activity of emergency stroke admissions to University Hospital of Wales has increased year on year over the past 8 years Emergency stroke admissions to University Hospital of Wales have increased year on year over the past 8 years (apart of 2015/16, which saw a small drop) The average yearly stroke admissions to UHW was 508 during the first 4 year period illustrated compared with 664 in the most recent 4 year period. 2. Key Achievements in Progress with National Priorities The number of emergency admissions for stroke within CaV UHB has remained consistent with that expected of its population with a total of 808 admissions during (range per month). Thrombolysis: Eligibility Other than one month (May 2016) 100% of eligible patients were thrombolysed, this has continued into 2017 with 100% during April August % 80% 60% 40% 20% 0% Percentage of eligible patients thrombolsyed, Health Board Wales The CaV UHB thrombolysis average (mean) rate is 18.8% compared to the Welsh average of 12.5%; as can be seen in the table below: Percentage of All Strokes Thrombolysed Apr 16- Mar 17 C&VUHB Wales Apr % 12.6% May % 13.2% Jun % 10.6% Jul % 12.7% Aug % 14.9% Sep % 10.1% Oct % 14.7% Nov % 11.1% Dec % 13.4% 2

3 Jan % 13.1% Feb % 11.4% Mar % 12.4% MEAN 18.8% 12.5% The highest achieving period of thrombolysing eligible patients was Dec 2016 at 28.6% compared to 15% for Wales in August and October % Percentage of all strokes thrombolsyed, % 20% 10% 0% Health Board Wales It is believed that Cardiff and Vale UHB performance has had a positive impact on the All Wales average. The % of pts thrombolysed within 1hour has increased year on year with Swallow Screen within 4-hours Since Jan 2016 the % of patients receiving swallow screen within 4hours has increased from 50% to 80% in Sept 2017, with a peak of 82.9% in April The improvement is attributed to ongoing training within the Emergency and Assessment Unit nursing staff and improvement in admitting to the acute stroke unit within 4hours. It is anticipated that improvement will continue with the introduction of 7-day therapy and ongoing training programme. 3

4 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Percentage of Patients CT scan The percentage of patients receiving CT scan within 12hours is consistently % (score A) % of patients receiving CT scan within 12hour of arrival April 2014 to August % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % of Patients who had CT Scan within 12 Hours of Admission Patients receiving CT scan within 1hour consistently and significantly exceed the aspirational target of 50%. % of patients receiving CT scan within 1hour of arrival April 2014 to August

5 Percentage of Patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % of Patients who had CT Scan within 1 Hour of Admission Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 SSNAP score during the period Dec 2016 to March 2017 the overall score was B rating. During the period Q1-Q Cardiff and Vale UHB s SSNAP score increased from 50 to 79, this can be attributed directly to 7-day working (consultant and therapists) and Code Stroke being fully implemented However, with the cessation of the 7-day therapy pilot, performance dipped in Q 4 of 2016/17. SSNAP score: C&VQ to Period 16 inclusive C&V Achieving score A in Domains 1, 9 and 10: - Domain 1 Scanning: % scanned within 1 hour, % within 12 hours and median time to scan 5

6 - Domain 9 Standards by Discharge: % screened for nutrition NAD seen by dietitian by discharge, % have continence plan in place within 3/52, % assessed for mood and cognition - Domain 10 Discharge Process: % receiving joint health and social care plan, % discharged with stroke skilled ESD, % in AF discharged on warfarin or with a plan to start warfarin. % discharged with a named contact.during the period Dec 2016 March 2017 (SSNAP report) Cardiff and Vale UHB is the only Health Board in Wales achieving score A in this domain (47%) Achieved level B in Domain 6, Physiotherapy: % requiring PT. Median minutes per day when PT received, median % of days PT received. Compliance (45 minutes for 5/7 days for 85% of patients) Therapy assessment within 24 and 72 hours A successful pilot was completed where all Therapies participated in 7 day working on the Acute Stroke Unit over a period of 20 consecutive weekends from June to October There was then a limited extension providing 6-day working through to early January During the pilot the therapy team provided 769 additional contacts; 262 (34%) of these were new assessments. All SSNAP targets were achieved at 100% by October The number of minutes of therapy provided over the course of the project increased by 18% for PT, 21% for OT and 23% for SLT. All patients with a nasogastric feeding tube were assessed by a dietician within 1 day of its insertion. The average length of stay for stroke patients on the ASU reduced by 2.5 days to 5.1 days. Patient and carer satisfaction was high, with positive feedback received about availability of therapists at weekends, and the commencement of rehabilitation without delay. Staff satisfaction was high with all focus group attendees and questionnaire respondents favouring the 7-day model for service delivery. There was also improved therapy performance against 24 hours Therapies assessment and 72 hour individual profession specific (during 7 day working project plus early day). The Percentage of Stroke Patients who spend up to 90% of their stay on an acute stroke unit has increased from 42% in April 2012 to 83.2% in Feb 2017 (peaked at 90.2% in November 2016 at the time when the 7-day working was piloted) 6

7 Apr-2012 Jun-2012 Aug-2012 Oct-2012 Dec-2012 Feb-2013 Apr-2013 Jun-2013 Aug-2013 Oct-2013 Dec-2013 Feb-2014 Apr-2014 Jun-2014 Aug-2014 Oct-2014 Dec-2014 Feb-2015 Apr-2015 Jun-2015 Aug-2015 Oct-2015 Dec-2015 Feb-2016 Apr-2016 Jun-2016 Aug-2016 Oct-2016 Dec-2016 Feb % 80% 60% 40% 20% 0% Percentage of Stroke Patients who spend up to 90% of their stay on ASU, to Health Board Wales 30 day Hospital survival During the past 10 years, the 30-day Hospital survival rate has increased from 73% in to 80.2% in with a peak of 84.2% in : 30 Day Hospital Survival Rates - Age Group 75+ Years Source: PEDW Notes: Stroke cases included where primary diagnosis = I61, I63 or I64 Year Wales C&VUHB % 73.0% % 71.7% % 78.4% % 77.7% % 73.9% % 74.8% % 76.3% % 84.2% % 82.6% % 80.2% Stroke survivors help others with life after a stroke People who have experienced a stroke now have access to support through a new book, following its development by a team of psychologists and a group of stroke survivors and carers. Rebuilding Your Life After Stroke was developed with stroke survivors in partnership with psychologists from Cardiff and Vale and Cwm Taf University Health Boards and supported by Cardiff University. 7

8 The book and its accompanying materials aim to normalise the psychological effects of stroke, providing advice and support for people following a stroke while also providing tips and strategies to make life easier. With insight from many people who have experienced a stroke, this book focuses on what stroke survivors can do, rather than what they cannot. Using exercises to help move towards an acceptance of the long-term side effects, this book delivers a positive message to help survivors of strokes live a better and happier life. This book and its accompanying resources have been in production for 18 months and is now available in both Welsh and English. Research by the Care Quality Commission in 2011 highlighted that services to support psychological issues after stroke were often inadequate while the Stroke Association in 2013 reported that survivors and carers can feel abandoned after leaving hospital. The group of authors joined forces with stroke survivors and carers to develop the self help book which gives an insight into the psychological difficulties after stroke, for both survivors, and their families. The book was funded by the Stroke Implementation Group which is a Welsh Government and NHS Wales funded body. Progress with Local Priorities Thrombolysis within 1 hour Cardiff and Vale UHB has increased its percentage of patient thrombolysed within 1 hour year on year from 19.4% in to 44.5% in which is a 25.1% improvement; the Welsh average increased 14.1% (from 25.7% to 40.8%). There has been a positive reduction of 25.1% in the number of patients receiving thrombolysis in over one hour from 80.6% in 2013/14 to 55.5% in 2016/17; the All Wales figure reduced by 15.1% from 74.3% in 2013/14 to 59.2% in 2016/17. 8

9 100% Percentage of all patients thrombolysed within 1 hour, to % 60% 40% 20% 0% Health Board thrombolysed <1hr Health Board thrombolysed >1hr Wales <1hr Wales >1hr This achievement is attributed to the embedding of the Code Stroke model with senior clinical presence at the front door. As can be seen in the table below, during the period Jun 2017 Aug 2017 Cardiff and Vale UHB has achieved a median time of 50mins 30secs, the All Wales median for the same period is 1hr 11mins: The Business case for 7-day working was approved earlier this year (2017) and will deliver a sustainable 7-day working model with the weekend Consultant provision already in place and 7-day therapy provision being phased in from Oct-Nov It is anticipated that the improved performance demonstrated during the pilot will be recovered upon full 7-day implementation. Atrial Fibrillation (AF) The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the preceding 3 years (excluding those patients with a previous CHADS2 or CHA2DS2- VASc score of 2 or more) is 98.6% which together with Hywel Dda UHB is the highest in Wales. Wales 97.7% ABMUHB 98.1% ABUHB 96.1% 9

10 BCUHB 97.4% C&VUHB 98.6% CTUHB 95.9% HDUHB 98.6% PtHB 97.5% Of those patients identified with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anticoagulation is 84.0%. Wales 86.5% ABMUHB 83.2% ABUHB 84.0% BCUHB 85.7% C&VUHB 84.0% CTUHB 86.9% HDUHB 88.2% PtHB 89.8% 28% of patients in AF in the community are either not anti-coagulated or are receiving anti-platelet agent. These patients fall into the category of exceptional reporting within Primary Care, the CaV Stop a Stroke project has seen an increase in anti-coagulation in this group of patients by 83%. This is a significant achievement, the work has been supported by the Welsh Government Stroke Improvement Group and the work is now being rolled out across all Health Boards in Wales. The Cardiff and Vale Atrial Fibrillation project has been shortlisted for the Anticoagulation Achievement Awards (Centre best able to demonstrate adherence to NICE Quality Standards for atrial fibrillation). Presentations will be made in the House of Commons on 11 October Multidisciplinary working - CaV UHB received support from the Delivery Unit during 2016 to undertake an Accelerated Redesign of the stroke pathway/services. One of the key areas that came out of the event was the desire to work very differently and in a more integrated way on the SRC, work is ongoing to achieve this and is outlined in the actions for 2017/18. Development of self management philosophy using the Bridges Selfmanagement Training Programme: Bridges is an innovative and evidenced based programme where self management support is integrated within every interaction an individual has. It has the potential to impact on the patient s experiences and satisfaction and lead to better utilisation of health and social care resources. 80 health practitioners from stroke and neurological services in Cardiff and Vale UHB have been trained in the Bridges approach to self management support. 10

11 Staff from all grades and professions across the stroke pathway received the training and have been empowered to support self management and shared decision making. Bridges champions have been identified to ensure the approach is sustained. 9 champions attended a Bridges Master Class in January 2017 Further Bridges training is planned for November 2017 The approach is being incorporated in the How can we help you project underway on the SRC at UHL. Technology The use of ipads by therapy teams using apps to support therapy interventions/ rehabilitation and self management. Also environmental images/video to provide information on access visits/home assessment which improves efficiency (e.g. reduces some visits to community setting) which in turn supports complex discharge planning. One issue to arise from the Community Neurosciences review was lack of robust governance relating to the use of technology. It was therefore decided to convene a Therapies Technology Forum which has scoped current and future opportunities for technology usage as well as develop a governance framework to ensure the safety and security of information of users. The best practice guideline for use of technology within Therapy is planned for launch in October 2017 with training plan to follow. Community Neurological Rehabilitation Service (CNRS) In a project was undertaken to scope community rehabilitation services (including stroke) available to people living with a neurological condition in Cardiff and the Vale of Glamorgan. A new service model has been developed that integrated the current condition based and uniprofessional services within a framework that offered a stepped approach to providing needs led rather than condition based rehabilitation. The aim of this approach is to begin to address the inequalities and gaps in service provision identified in the scoping exercise. 11

12 This stepped model of rehabilitation has 4 levels: Level 1 Level 2 Level 3 Level 4 Empowering living well with a neurological condition through coproduced education and support. Group programmes that are not condition based. Group rehabilitation programmes that address specific rehabilitation needs but are not condition based. E.g. upper limb activity group and conversation groups Specialized group rehabilitation programmes & 1:1 programmes that are delivered by trained support staff. These may be specific to a condition. Interventions & programmes delivered 1:1 by specialist staff and teams E.g. Early supported discharge team for stroke The project funding has been utilised to provide clinical leadership for the integrated service and to implement Level 1 and Level 2 programmes. The new programmes will widen availability to services and will support people to step down from specialized Level 3 and 4 services such as ESD. The newly appointed CNRS clinical lead post will start in post in October This role will initially provide clinical leadership to ESD for Stroke alongside developing Level 1 and 2 programmes. The role will evolve and aim to move the other community / outpatient neurological rehabilitation services into its remit once the programmes are established. It is anticipated that outcomes from these initial developments will include: 1) Improvements in the ESD pathway - referral process / capacity management 2) Impact of Level 1 and 2 programmes PROMs / links with organisations outside of UHB/ service user involvement / pathway management for specialist neuro rehab teams A rehabilitation technician has also been appointed to support the Level 1 &2 programmes and some administrative support. Research and Development Recruitment into R&D studies has been challenging over the last few years with limited success. 12

13 50 Recruitment to Stroke CRP studies, to However, there has been some improvement this year with plans in place as follows: Following the move to double the national recruitment of stroke patients in to research trials within Wales, CaV UHB has engaged with the Welsh stroke research lead to identify stroke research leads within the UHB. The decision was made in CaV UHB to allocate two leads, Claire Butterworth and Benjamin Jelley; a clinical specialist physiotherapist and consultant stroke physician respectively. The purpose of this is to increase research capacity and activity across the Allied Health Professionals teams as well as the medical teams. As a result of this there have been 2 additional portfolio trials adopted by CaV UHB; PROMIS which will look at the best method for delivering a 6 month review for post-stroke patients and a trial looking at specific cognitive deficits occurring with thalamic strokes. The former trial is targeted to recruit patients and the latter is aiming to recruit 15 patients. The thalamic stroke trial will have shared funding credit with psychology but is also our second trial to build links with the The Cardiff University Brain Research Imaging Centre (CUBRIC). The recruitment for both of these trials commences September Agreement has been secured to extend the first trial being run through CUBRIC looking at neurofeedback in moderate upper limb functional deficit which has also been accepted on to the research portfolio. One of our consultants had been engaged with Health Care Research Wales (HCRW) to run the Paramedic Acute Stroke Treatment Assessment trial (PASTA) and the UHB was the highest recruiting site involved, but unfortunately HCRW support had to be terminated recently. However, trial recruitment is continuing with two of our stroke consultants having taken on this direct recruitment themselves. The commencement of REstart or STop Antithrombotics Randomised Trial (RESTART) in the UHB is being finalised, this is a trial that aims to answer an 13

14 important clinical question about the continued use of blood thinning agents after a primary intracerebral bleed. Despite the difficulties with PASTA progress has been made in building strong links with HCRW over the last 12 months and as a result of the study Delivery of Patient Reported Health Status Questions in Stroke (previously known as PROMIS), links with the Clinical Research Facility in UHW are being strengthened with positive indications about further trial involvement focusing on stroke patients. Various posters (2017): showcased at Stroke Conference: e.g. How You Can Help Me (PT/Cons) Hydration of Patients on a Busy Stroke Unit-MDT (Dietetic Lead/Cons) Public Health Key achievements in Tobacco The percentage of adults reporting being a current smoker or using e- cigarettes has reduced to 15% for Cardiff and Vale of Glamorgan (Cardiff 12% and vale of Glamorgan 13%). This is a decrease from 18% for Cardiff and Vale UHB have achieved the Welsh Government smoking prevalence target of 16% by 2020 Whilst numbers of smokers accessing smoking cessation services and setting a firm quit date ( Treated Smokers ) have reduced from , the percentage of those quitting smoking at 4 weeks (CO validated) has increased to 56% from 46% ( ) achieving Welsh Government s Tier 1 target of 40% (4 week CO rate) All 3 specialist smoking cessation services in Cardiff and Vale of Glamorgan (Stop Smoking Wales, (UHB) Smoking Cessation Service and Level 3 Smoking Cessation Enhanced Service Community Pharmacies) achieved over 50% 4 week CO validated quit rates with the UHB s in-house service achieving 63% and the Level 3 Pharmacy scheme achieving 71% 20 Community Pharmacies in areas of high deprivation now offer a Level 3 Smoking Cessation Service across the UHB (an increase from 15 in ) 80% of community based smoking cessation groups run in venues of high deprivation the majority of which, are based at GP Practices Over 80% of all new referrals to SSW ( ) are via GP Practices with 66% having a direct e-referral pathway The numbers of smokers challenged by the UHB s No Smoking Enforcement Officer at UHW have decreased during to 3,300 from over 5,000 during Visitors continue to be the highest percentage of smokers (60%) A study carried out by Cardiff Metropolitan University on behalf of the UHB into behavioural Insights of Young People and Smoking (November, 2016) showed that the most important factor in influencing a young person to try 14

15 smoking, is whether the mother smokes. The most important factor relating to the use of e-cigarettes by young people is whether a sibling or peer is using e- cigarettes. The study showed that young people that had never smoked were using e-cigarettes 7 Primary Schools in Cardiff and Vale of Glamorgan launched a Smoke Free School Gates initiative during with TV and radio coverage during March 2017 Healthy weight Implementation of the Healthy Weight Framework Cardiff and Vale Eating Well Plan developed and agreed with key partners, implemented with a focus on providing nutritional information and providing advice and training within community settings Hospital restaurant food standards implemented and audited to ensure a 75-25% split in favour of healthy options in all UHB restaurants and food retail outlets. Lowest levels of obesity (17%) and overweight/obesity (54%) in Wales Continued roll out of adult Level 3 obesity service (84 new patients referred in 2016/17) Level 2 Obesity service saw 525 new patients in group sessions in 2016/17, of which 57% completed the course Physical activity plan on track for Year 2 delivery during 2016/17 Alcohol 196 people attended Alcohol Brief Intervention training in 17 training sessions. Alcohol consumption levels in Cardiff & Vale have generally been falling, but this is not the case amongst all population groups, with older groups either drinking the same or increasing consumption, and younger groups decreasing consumption 30 participants from organisations working with older people took part in training around older people and alcohol, focusing on developing skills and confidence to have a conversation and deliver a brief intervention with this population group 3. The Challenge for Cardiff and Vale UHB Stroke Delivery Group Thrombolysis We will aim to further reduce the mean door-to-needle time to improve compliance against the 45minute indicator. We aim to review current processes through process mapping and applying service improvement methodology. 4 hours admit 47.3% in April 2016 and 47.6 in March 2017 with a peak of 67.6% in November 2016; analysis of this performance show that the 4hour breaches are in the main due to availability of beds or bed of the correct gender mix. 15

16 100% 80% 60% 40% 20% 0% <4-hours care performance indicator, Health Board Wales Swallow Screen A review of the Swallow screen tool in ED is currently underway with a comparison between HEADS and the Yale tools; this work is being led by the Dysphagia lead in conjunction with Stroke physicians and nursing leadership 24 hours The assessment by consultant and nurse has continued to improve. The assessment by one of OT, PT or SLT performed well during the period of the 7-day pilot in It is anticipated that the drop in performance since then will improve from Oct/Nov 2017 onwards as the sustainable arrangements are put in place for 7-day therapy services in acute stroke. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% <24-hours care performance indicator, Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Health Board Wales 72 hrs 16

17 There was an improvement in the performance during the period of the pilot. In addition the Speech and Language Therapy service had received some additional investment as well as changing their model of assessment. Oct % Nov % - this being during the 7-day pilot March % Following the completion of the pilot a successful case was made for investment to provide the service on a substantive basis with changes to therapist job plans to deliver 7 day working. Staff consultation has been completed and implementation will progress during Sept-Nov The sustainability of the 72 hour standard in the interim has been challenging particularly SLT. Added to which there have been vacancies and new appointments in SLT which has impacted on their capacity to deliver within the required standard. The SLT service is now entering a period of stability where they have additional dysphagia trained staff. The challenge will be to recruit the required staff in some of the smaller professions to operationalise the 7-day working on a sustainable basis. <72hours care performance indicator, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Health Board Wales Patient Flow Patient flow through the pathway is dependent on their being good processes in place within the acute, rehabilitation and community components of the pathway. Much work has been undertaken to focus on A6South which is the acute admitting ward for stroke. The UHB has seen an improvement in flow from A6S but this continues to be a challenge for the Stroke Rehabilitation Centre at University Hospital Llandough. A focussed piece of work has been undertaken reviewing the 17

18 delayed transfers of care and reasons for delays. In addition focused work on predicted dates of discharge has commenced. The average length of stay (ALOS) has decreased during recent months as a result of this work. o June 2016 March 2017 ALOS range days o April August 2017 ALOS range days It has been identified that the use of a standardised predicted length of stay of 42 days did not suit the needs of the SRC. There were frequent breaches and patients identified as DTOCs which was unhelpful for planning discharge and predicting flow. The team undertook an audit of patients and compared LOS with the categories utilised by the Orpington predictive tool for mild/moderate and severe. In addition the PDD uses the descriptor of Medically fit for discharge which again is unhelpful in a rehabilitation setting as it fails to capture those patients still on an active rehabilitation pathway. Using the evidence from this audit the team have developed a new descriptor called clinically expected length of stay (CELOS) o Clinically expected length of stay (CELOS) has been developed onto the existing WCWS and replaces Planned Date of Discharge (PDD), this is currently a pilot within our stroke pathway from point of entry through to discharge. The CELOS is generated following an assessment of physical functionality and stratifies them according to mild/moderate/severe stroke differentiating patient who are medically fit but still require therapy intervention. o The Ward Clinical Workstation (WCWS) has the functionality to record discharge delays but relies on the manual selection in an optional field which is often not completed. Staffing and recruitment There continue to be challenges in relation to recruitment across a number of professions including medicine, nursing and some therapies. Strategies are in place to address these and there has been some improvement particularly in nursing. Stroke Association Post Stroke Review Update A six month pilot has been implemented by the Stroke Association; the project is supported by the Stroke Improvement Group to provide 6 month follow up for post stroke patients. The project has, to date, completed just over 60 post stroke reviews. The pilot will run to the end of December 2017 following which a full evaluation will be published. 4. Areas for Improvement The UHB continues to work on refining the acute stroke pathway in UHW including; - Door to needle time process map - 4 hour admit - continue with breach analysis 18

19 - Review code stroke out of hours and 24/7 how it is working? In addition further work is required to strengthen the pathway from acute to rehabilitation and community. The Delivery Unit facilitated an accelerated redesign workshop during September A review of the action plan has been undertaken and a number of the actions identified by staff across the pathway remain outstanding. There has been a significant change in the structure of the nurse leadership structure and one of the priorities over the last year has been to stabilise the current nursing workforce establishment. The leadership structure is now well embedded. The Stroke Rehabilitation Centre at UHL have also reviewed the composition and constitution of their improvement group and identified a number of projects from the accelerated redesign report to focus on to give the maximum amount of benefit. The following priorities have been identified; Joint working; further work is required to develop an integrated workforce. Establishment of the Key worker role, Improve patient involvement and engagement Effective and efficient communication; Streamlining the number of meetings and improving the effectiveness across the MDT Comprehensive pathway; Stratification of patients according to need. Appropriate rehabilitation in the community; this is addressed within the CNRS model incorporates stroke services and the appointment of the Clinical lead will progress this work to next steps as outlined earlier in the report. Provision of a sustainable 6 month review service Delivering an Integrated education and training model for all professions. 5. Priorities for National Priorities HASU development following the publication of A new Hyperacute stroke service for Wales (Dec 2016) the UHB is considering the work ahead within its Stroke Strategy Improvement Group Repatriation (incoming and outgoing) ensuring all residents can return to their own Health Board in a timely manner to purse ongoing stroke care, this will be particularly important where HASU exist to facilitate flow and appropriate utilisation of hyper acute services. Thrombectomy service / interventional radiology; the mechanical thrombectomy service continues to be uncommissioned by WHSSC. The UHB is currently working with other Health Boards across Wales and WHSSC to establish if this service can be commissioned on a sustainable basis. In the meantime the UHB has developed a pathway to provide a service to Cardiff and the Vale of Glamorgan residents only until a sustainable service is in place. 19

20 Patient related outcome measures and patient reported experience measures (PROMS & PREMS); There is a national project underway and the National Stroke Improvement Group is considering rolling this out to include stroke. The UHB is awaiting confirmation of the preferred approach to be adopted but already has key personnel in place within informatics to support. It is anticipated that learning from the pilot in intermediate care will be utilised. Early Supported Discharge: The UHB is progressing this work within the framework of the new Community Neurorehabilitation Model in conjunction with Community Resource Teams. The Clinical lead has now been appointed and will be developing an action plan which will focus on ESD in the first instance. Local Priorities 4 hour admit: we will continue to analyse all 4hour breaches to monitor and develop appropriate actions to reduce the number of breaches, this will include continually ensuring acute beds are available. Mechanical thrombectomy for acute ischaemic stroke (Section 3.5 RCP 5 th Edtn 2016) the mechanical thrombectomy service continues to be uncommissioned by WHSSC. The UHB is currently working with other Health Boards across Wales and WHSSC to establish this service on a sustainable basis. In the meantime the UHB has developed a pathway to provide a service to Cardiff and the Vale of Glamorgan residents only until a sustainable service is in place. Swallow screen: there has been a significant recruitment in nursing workforce in the Emergency department which has resulted in a large number of nursing staff who will require training in swallow screening. The training schedule and the screening tool are currently under review with a plan to deliver anticipated by end of November A review of the assessment tool will also be undertaken. Consultant review: the majority of patient are now receiving consultant review within 24 hours and with the continued 7-days working this should be achievable. Ffurther work to be undertaken to ensure inpatient stroke pathway is activated immediately upon stroke being suspected 7 day therapy: Following a period of consultation through the organisational change policy the delivery of a sustainable model of 7 day therapies is expected to be fully implemented by November Physiotherapy has already recommenced the service using voluntary overtime in anticipation of the recruitment of staff. Thrombolysis times: Delivering sustainable improvement in door to needle times as well as onset to needle times. Hyper Acute Stroke Unit: The UHB is awaiting the final report and recommendations from SIG in relation to the HASU model for Wales. In the meantime it will be undertaking a review of the requirements to deliver a hyper acute stroke unit for the residents of Cardiff and Vale. Following this an options appraisal will be submitted to the Management Executive for consideration and decision. 20

21 Community Neuro-rehabilitation service: establish and consolidate the leadership role for the community neuro-rehabilitation services, ensure the delivery Level 1 and Level 2 programmes and evaluate their efficacy in particular the ability to support step down from specialised Level 3 and 4 services such as ESD. The clinical lead role will continue to evolve and look at the feasibility of including other community / outpatient neurological rehabilitation services within its remit. SLT: Dysphagia training: a new dysphagia lead has been appointed in SLT and is currently reviewing the capacity of the dysphagia trained staff. A training needs and resource gap analysis will then be developed. Incorporation of clinical psychology/clinical neuropsychology, dietetics and Orthoptics expertise into the multidisciplinary stroke rehabilitation team: The lack of dedicated dietetic resource in ESD to facilitate discharges with NGT s means a small number of patients remain in hospital purely because of swallow impairment and they are then transferred to SRC or remain on the acute ward until their swallow improves or a PEG becomes more suitable. It is anticipated this will be addressed within the CNRS plan and financial envelope. There is already a well established dedicated psychology resource within the stroke service. Links with orthotics will be reviewed to identify if there are any gaps in the pathway. Stroke Rehabilitation Centre: Joint working; further work is required to develop an integrated workforce. Establishment of the Key worker role, all staff are now acting as key workers Improve patient involvement and engagement by implementing the How can we help you project incorporating the Bridges philosophy Effective and efficient communication; The SRC are currently undertaking a short test of change to the MDT/Medical ward round structure to reduce the number of meetings that the team have to attend and streamline/simplify the communication process. Further development of the integrated record developed on the acute unit and needs to be rolled out in SRC. Comprehensive pathway; Stratification of patients according to need and development of the CELOS model which transfers with the patient throughout the pathway Appropriate rehabilitation in the community; this is addressed within the CNRS model incorporates stroke services and the appointment of the Clinical lead will progress this work to next steps as outlined earlier in the report. Provision of a sustainable 6 month review service subject to the evaluation of the pilot currently underway with the Stroke Association. Integrated education and training model for all professions. Development of a research delivery plan to increase the level of research activity and increase the number of patients recruited into research trials. Work is already underway by the R&D leads and Health Care Research Wales (HCRW) to identify resources to support the recruitment into the Restart trial 21

22 6month follow up evaluation of the current project led by the Stroke Association Stroke survivors help others with life after a stroke - further evaluation of the resource Rebuilding Your Life After Stroke which was developed with stroke survivors in partnership with psychologists from Cardiff and Vale and Cwm Taf University Health Boards and supported by Cardiff University. Public Health Key priorities for and Tobacco The role of the GP in supporting smokers to quit smoking and referring to a specialist support service is a key promotion priority. As such, a key action is to increase the number of GP Practices with e-referral pathways to the Help me Quit call centre. A mapping exercise has been completed to identify those without formal log-in referrals and GP Practices in areas of high deprivation are being prioritised to set this service up To increase the number of Community Pharmacies in areas of high deprivation offering a Level 3 Enhanced Service for Smoking Cessation To remove the exemption that allows mental health in-patients to smoke (outside, in enclosed gardens) from the UHB s No Smoking and Smoke Free Environment Policy To increase the number of primary schools offering a Smoke Free School Gates Policy Healthy weight Continue with implementation of the Cardiff & Vale Eating Well Plan Further develop the UHB restaurant standards to include external outlets and trolley services for wards Development of three year food and physical activity plans Continued expansion of adult level 3 obesity service (2017/18 and 2018/19) Finalise and implement the Cardiff Planning & Well-being Supplementary Planning Guidance Implement and evaluate the promotion of physical activity within the primary care setting Develop commissioning intentions for child level 2/3 obesity service (2017/18 and 2018/19) Continued development and integration of the level 2 and level 3 adult obesity services (2017/18 and 2018/19) Implementation of compact nutrition training for midwives to support healthy weight in pregnancy (2017/18 and 2018/19) Alcohol Prioritise targeting older segments of the population, through continued training of service providers, a pilot initiative with Taith (substance misuse service) who are working with older people in GP practices to help reduce 22

23 their alcohol consumption, and continuing to offer ABI training (particularly in primary care) as this is the intervention with the strongest evidence base. 6. Priorities for National Priorities The focus will be on the development of sustainable HASU model and implementation of a commissioned mechanical thrombectomy service if agreed by WHSSC. Local Priorities The focus will be on the HASU and Mechanical thrombectomy model. In addition the completion of the Cardiff and Vale AF Stroke project will be completed in 2018 and the focus will be embedding a sustainable service. 23