Tele Stroke ( Telemedicine in Practice)

Transcription

1 Tele Stroke ( Telemedicine in Practice) Site Royal Surrey County Hospital East Surrey Hospital Frimley Park Hospital NHS Foundation Trust Ashford and St Peter's Hospital NHS Trust Epsom Hospital Surrey Heart & Stroke Network Pathway Stroke - Stroke Diagnostics Stroke - Acute stroke unit Status Key impact areas Shared Technological Improvement Source of improvement Other Added by David Watts 16/12/ :24:13 Please keep your text in the boxes provided below to ensure a successful upload Summary: It had been identified some time ago, back in 2008/09 that the Surrey Heart and Stroke Network needed a solution to providing a 24/7 stroke service of good quality clinical instead of having a fragmented stroke service across Surrey with patchy provision with only daytime services being provided by many Trusts or a limited evening service and no actual weekend services provided in many cases. It was decided to investigate the possibility of using telemedicine as a way forward for providing a 24/7 stroke service across the County of Surrey. A project team was established to identify the need and procure a technological system in providing a solution to this problem. The use of telemedicine as a solution is not a new idea or concept but new to Surrey and its consultants and the services it provides. The project team recruited the services of an IT Project Manager from within the Surrey PCT to oversee the IT Procurement and its development through to the delivery of the system into operation. Together with this a Service Improvement Manager from within the Network was tasked with the Clinical Pathway work stream to ensure that the clinical aspects of the project were followed to streamline the processes and to ensure good governance across the Network for the implementation of the project. The scope of the project was to cover 5 acute Trusts in Surrey all linked in with the Tele 1

2 stroke ( telemedicine solution) The following aspects would have to be reviewed : 1/ To review current technical systems available ( this would involve demos, contributions from Consultants and specifications contributions from the Consultants on " what do they want the system to do? ") 2/ SLA agreements to be drawn up to ensure that clinicians were given the right working conditions, agreements within their Trusts and other organisations- including clinical governance and any other arrangements such as information sharing. 3/ To appoint a clinical Lead Consultant for Tele medicine. 4/ To set up and review clinical pathways from all acute Trusts in Surrey- ensuring that processes were as standardised as possible. 5/ To set up Clinical Governance meetings involving all Consultants, senior managers, stroke nurses and other senior nurses involved in Stroke services and ensure these groups have buy in to the Tele stroke methodology and vision. What was the problem?: It had been identified some time ago, back in 2008/09 that the Surrey Heart and Stroke Network needed a solution to providing a 24/7 stroke service of good clinical quality d instead of having a fragmented stroke service across Surrey with patchy provision with only daytime services being provided by many Trusts or a limited evening service and no actual weekend services provided in many cases. It was decided to investigate the possibilities of using telemedicine as a way forward for providing a 24/7 stroke service across the County of Surrey. A project team was established to identify the need and procure a technological system in providing a solution to this problem. Options were a hub and spoke system which was not favoured by the Consultants and other clinicians as this can have problems across wide geographical areas, as in Surrey. The preferred option was to look at a Tele Medicine solution- this is called Telestroke in Surrey. A brief summary of the vision is below: To pursue the use of telemedicine to allow patients with acute stroke to receive high quality care at their local hospital from a dedicated specialist stroke team To reduce variation in access to services To improve and standardise outcomes across Surrey 2

3 What was done?: A vision of what the Consultants wanted was drawn up by one of their group and was presented at an initial meeting of all Consultants to set out the Vision: a summary of which is below: Outline of Vision To pursue the use of telemedicine to allow patients with acute stroke to receive high quality care at their local hospital from a dedicated specialist stroke team To reduce variation in access to services To improve and standardise outcomes across Surrey Key members Stroke Consultants at each of the following Acute Trusts:- Ashford & St Peters NHS Trust Frimley Park NHS Foundation Trust Royal Surrey County Hospital Surrey & Sussex Healthcare Trust Epsom & St Helier NHS Trust Together with the Consultants other members included IT Professionals from each organisation as well as Senior Managers and Senior Nurses How the system would operate? Usual 9-5pm thrombolysis service at each trust (? Epsom patients) On call rota 5pm-9am Individual trusts to consider how to staff this Expect 2 consultants from each trust Process of call 1 in 8/9 stroke??? 3

4 On call stroke pre-alert Stroke team to meet the patient at receiving hospital Stroke consultant to access stroke cart/pacs and video conferencing link to allow assessment of patient to make informed decision re diagnosis of stroke and delivery of thrombolysis Documentation at each assessment and electronic transfer to receiving hospital for inclusion in patient notes from a clinical governance point of view. Other Considerations All sites should be registered with SITS? acronym? Need to consider consultant core competencies and staff training Monthly review meetings Governance Becomes complex when multiple trusts involved Review other models Cumbria and Lancashire opted for lead provider to act as host organisation We need to consider how to deliver the clinical service we want to part of IT and use of telecart practical issues The project team recruited the services of an IT Project Manager from within the Surrey PCT to oversee the IT Procurement and its development through to the delivery of the system into operation. Together with this a Service Improvement Manager from within the Network was tasked with the Clinical Pathway work stream to ensure that the clinical aspects of the project were followed to streamline the processes and to ensure good governance across the Network for the implementation of the project. The scope of the project was to cover 5 acute Trusts in Surrey all linked in with the Tele stroke ( telemedicine solution) The following aspects would have to be reviewed : 1/ To review current technical systems available ( this would involve demos, contributions from Consultants and specifications contributions from the Consultants on (" what do they want the system to do? ") 2/ SLA agreements to be drawn up to ensure that clinicians are given the right working conditions, agreements within their Trusts and other organisations- including clinical governance and any other arrangements such as information sharing. 3/ To appoint a clinical Lead Consultant for Tele medicine. 4/ To set up and review clinical pathways from all acute Trusts in Surrey- Ensuring that processes were as standardised as possible. 5/ To set up Clinical Governance meetings involving all Consultants, senior managers, stroke nurses and other senior nurses involved in Stroke services and ensure these groups have 4

5 buy in to the Tele stroke methodology and vision. 6/ Together with these local arrangements being put into place - there are also SHA regional meetings for Telemedicine of which Surrey Heart and Stroke Network are members What was achieved?: Once the Consultant group was established at the beginning of 2011 monthly meetings were taking place in order to facilitate the procurement of the system and development of the implementation programme to a commencement date. These meetings have now transferred to being Clinical Governance Meetings which are held on a Monthly basis where cases are reviewed by the Clinical Teams. Although originally the go "LIVE" date was set for April 2011, some technical difficulties had been experienced and the system actually went "LIVE" on the 6th September to date patients have experienced a medical consultation with a Consultant opinion via Tele Stroke, not only stroke patients have benefited from Tele stroke Service but decisions have been made on "suspected stroke patients" who had other medical conditions where a medical decision was made remotely and advice given to medical teams at the receiving hospital site. The joining up of five acute Trust organisations was complex both Technically and clinically. This project was nominated for UK Public Sector Digital Awards 2011 and we became finalists in two categories, one "Best example of an ICT- enabled Innovation and enterprise" and secondly "Best Sustainability Initiative" There were over 2000 applicants. David Watts Surrey Heart and Stroke Network Ideas tested which were successful: Once the preferred system was procured and ordered a rigorous testing period commenced early on in both from a technical point of view as well as from a process one. All hospital sites across Surrey of the five Acute Trusts had their pathways tested-in additional to this there were individual Hospital visits conducted by Dr Adrian Blight Lead Consultant for Tele stroke and David Watts service Improvement Manager Surrey Heart and Stroke Network. A formal discussion together with a Consultant competency checklist was checked through at each stage of the list. This included levels of training required, experience of having done Thrombolysis treatment previously together with any Tele medicine experience or knowledge. The list incorporated the checking of each sites readiness and preparation for a going "LIVE" date. 5

6 The checklist was invaluable to ensure compliance and helped refocus minds to the task in hand. The same process was followed for Nursing staff. These are referred to as the Consultant and Nursing Competences. As a requirement all Consultants have to have undergone a Stroke thrombolysis Master class and be registered with SITS. The technical testing was a challenge of joining up 5 acute Trusts to one system: Each Consultant has a Laptop configured to accessing the Tele stroke system, PACS and can review scans and images via this methodology as well as access to the Polycom Telemedicine system. Each Trust have two carts to each site and these are usually based in the ED and Stroke ward/unit- access to the system is via a secure connection and tested daily for many weeks before going LIVE. It must be remembered that Royal Surrey Hospital was already using a Telemedicine from the same supplier and they were already quite advanced in its use from a user/ consultant point of view. A rigorous testing period took place testing connections between sites, Consultant Laptops Ideas tested which were unsuccessful: There were no ideas that did not really work. How this improvement benefits patients and carers: TELESTROKE NETWORK PROJECT BENEFIT REALISATION For Patients: Increased access to stroke thrombolysis Reduced number of patients left with a disability post stroke Reduced length of stay in hospital. Treated at their local hospital making it easier for family and carers. No repatriation of patients back to their local hospital and therefore continuity of rehabilitation and discharge will not be interrupted or delayed. 6

7 Patients will be seen by their local community team prior to discharge improving perception of continuity of care. Transferability of the telemedicine solution being utilized in an urgent care setting for the management of a wide range of other clinical conditions for clinical decision making Quality: Faster access to specialist assessment Reduced death and disability for stroke victims Decrease in both event to needle times and door to needle times, vital for thrombolysis treatment. 24/ 7 access to a stroke specialist clinicians. Increase in time spent on a specialist stroke unit instead of general wards Patient reported outcome measure (satisfaction, timely assessment, patient and carer) Shared knowledge between providers in the network Delivery against the Best Practice Tariff for Stroke (2010/11) Productivity: Reduction in on-call consultant hours and costs Reduced length of hospital admission. Reduced costs of long term care. Vital Sign (90% of in-patient stay in stroke unit) Improvement in National Stroke Sentinel Audit key indicators. Potential for transferring the model to other areas of service Benefit Realisation Measures: Number of patients who access thrombolysis treatment within Surrey within national guidance per annum aiming for 100% Door to needle time SECAMB call to door time Average Length of Stay for stroke patients overall Patient experience / patient reported outcomes Development of clinical outcome measures Clinical metrics development linked to the Enhancing Quality Programme SEC SHA Delivery of QM8 and 9 of the National Stroke Strategy 2007 Compliance with the standards outlined within the RCP SENTINEL Audit Competent skilled workforce within each DGH in line with the DH Stroke Strategy Education Framework 2009 Care Closer to Home: Delivering thrombolysis at each DGH within the network will ensure the provision of high quality equitable acute stroke service across Surrey Full compliance with the criteria of the stroke best practice tariff 7

8 The introduction of Tele stroke in Surrey based on predicted figures would benefit at least 216 people per annum, however this number will possibly be higher with other groups of patients who present with possible Stroke but actually have other medical conditions. How this improvement benefits the organisation: A reduction of average Length of Stay (LOS) TO 4 DAYS for Stroke Patient who has been diagnosed via tele stroke with saving of 142k and will rise to 244k as more patients come on line using the service. The saving would be a direct saving in bed costs. The benefits also include timely diagnosis and treatment resulting in reduced or no disability in the long term. Please see chart below for numbers for stroke and Tele medicine since going LIVE on the Total No Of Thrombolised Patients Data Covering Period Between Sep-11 To Jan-12) Total Numbers Total teleconferences 55 Total Thrombolised 21 % Thrombolised 38.18% The table below shows the numbers of Tele stroke calls Proportion of strokes from overall total Data Covering Period BetweenSep2011 To Jan 2012 Total cases of teleconference 55 Confirmed Strokes 42 8

9 Percentage 76.36% Breakdown of Strokes (Monthly) Data Covering Period Between Sep-11 To Jan-12 Total No of Month teleconferences Confirmed Stroke Percentages Sep % Oct % Nov % Dec % Jan % As time progresses the numbers of patients will increase as staff will be more confident in calling the Consultant on call out of hours for a Consultation. Likewise the Consultants will be more used to the system and confidence will grow. PRESS CUTTING from March please see below: Media release 05 March 2012 improvements Region s NHS committed to further stroke care Stroke patients across Kent, Sussex and Surrey are benefitting from improved care with more patients than ever spending most of their hospital stay on specialist stroke units. More than three quarters of stroke patients (76.7%) spent at least 90% of their stay on a stroke unit according to the latest figures for between July and September a 10% increase in 18 months. The percentage of patients who suffered a mini-stroke or transient ischemic attack (TIA) and were scanned in hospital within 24 hours also improved in the same period up from 43.4% to 59%. All general hospitals across the region now have a specialist stroke unit and stroke patients can now be seen by a stroke specialist 24/7. This is thanks to advances in telemedicine technology which enables senior 9

10 stroke clinicians to assess patients via computer. All trusts in Surrey and Kent have telemedicine in place. In Sussex, Princess Royal Hospital in Haywards Heath and Royal Sussex County Hospital in Brighton are using telemedicine and it is anticipated all Sussex hospitals will have the technology in place by April this year. Professor William Roche, NHS South of England Medical Director (East) said: The NHS in the South East is working very hard to ensure people have the very best stroke care 24 hours a day, seven days a week, no matter where in the region they live. Through the hard work and dedication of clinicians, nurses, healthcare workers and management teams we have seen great improvements to the care people in the region now receive. In the South East we have also made very good progress in the development of telemedicine. This technology enables patients to be assessed and treated quickly following a stroke through the use of computers in A&E departments which gives patients direct access to senior stroke clinicians 24 hours a day, seven days a week. I am obviously pleased with these successes but there is still room for further improvement and we will encourage the sharing of best practice across the region to help drive this. Stroke is the third largest cause of death in England with 110,000 people having a stroke each year. Close to 6,000 people suffered a stroke in the region in A quarter of strokes occur in people who are under 65 and usually without warning. During a stroke brain cells die, so fast action is needed to stop further brain injury, improving chances of survival and helping to prevent disability. NHS South of England is committed to further improving stroke care and is calling on members of the public to help by spotting the signs of a stroke. The Act FAST campaign has hit TV screens again last week with the striking adverts running until March 25. The adverts help people identify the symptoms of stroke by acting FAST. People should look for: Face - Has their face fallen on one side? Can they smile? Arms - Can they raise both arms and keep them there? Speech - Is their speech slurred? Time - Call 999 if you see any one of these signs. 10

11 Notes to Editor Ends What is a stroke? Almost three quarters of all strokes are ischaemic, caused when blood flowing to the brain is blocked. A haemorrhagic stroke is when blood vessels burst. Both types of stroke reduce the blood supply to the brain which causes brain cells to die, so quick action is needed to stop further brain injury. Thrombolysis dissolves blood clots in ischaemic strokes, the most common kind, caused when blood flowing to the brain is blocked. A third of people who have a stroke are left with a long-term disability. Following is a statement from Felicity Dennis, Network Manager Surrey Heart and Stroke Network The availability of 24/7 stroke thrombolysis in Surrey is a major innovation which will save lives, reduce disability and enhance the quality of life for many stroke patients across the county. September 6 th 2012 saw the launch of Surrey Telestroke Network. From Sept Dec patients have already benefited from expert stroke physician assessment outside of noraml working hours and 13 additional stroke patients have been treated with thrombolysis using the telestroke model ( 36% of consultations). There are over 1800 strokes in Surrey per annnum, and the Royal College of Physicians recommends that at least 15% of all stroke patients should benefit from thrombolysis treatment. ( about 270 in Surrey). Going forward, the out of hours access to thrombolysis via the Surrey Telestroke Network 11

12 means that an additional 125 stroke patients per annum should be able to receive and benefit from treatment.( based on the premise that about 50% of stroke patients present outside of normal working hours) The DH National Stroke Strategy Impact Assessment identifies the average ten year cost of dependent stroke as 56,381 per person, so modeling for Surrey suggests that there are potential savings of around 7,000,000 across the whole of health and social care over a 10 year period as a direct result of the implementation of the Surrey Telestroke Network. The newly- forged hospital relationships, IT links and key learning which have been developed through the Surrey Telestroke Network should provide an excellent foundation for the implementation of wide range of innovative health care initiatives in Surrey. Felicity Dennis Network Manager February

13 Estimated number of patients helped in a year 216 Name and title David Watts Phone number david.watts@nhs.net Other contacts Colin.Lee@nhs.net ( IT Project Manager) Colin.Lee@surreypct.nhs.uk Felicity.Dennis@nhs.net (Network Manager) Adrian.Blight@nhs.net (Clinical Lead) 13