STROKE DELIVERY PLAN 2014/15 1. BACKGROUND AND CONTEXT Together for Health was published in December 2012 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations of the NHS in Wales to tackle Stroke in people of all ages, wherever they live in Wales and whatever their circumstances. This Plan is designed to enable Cardiff and Vale University Health Board to meet the needs of people at risk of a Stroke or affected by a Stroke. It sets out: Current areas of service delivery, what we do well and where the constraints are; The outcomes from treatment and support to return to health and independence we expect; How we will ensure that we deliver the level of performance we expect; How we will continue to develop the service across the whole patient pathway, working in partnership. 2. DRIVERS FOR SERVICE IMPROVEMENT There are clear reasons why stroke remains a top priority for the Cardiff and Vale University Health Board (UHB); It is one of the top three causes of death It is estimated that there are around 11,000 stroke events, including 6,000 new strokes, per year in Wales 1. 25 per cent of strokes occur in people who are under the age of 65 It is a leading cause of adult disability 2 It has a higher risk for certain ethnic minorities 20 30 per cent of people who have a stroke die within a month What do we want to achieve? s Delivery Plan sets out actions to improve outcomes in the following key areas between now and 2016: 1 Estimated figures based on the Welsh population and incident rate. 2 National Audit Office, 2005, Reducing Brain Damage: Faster access to better stroke care, London, NAO Figures relate to England and Wales. 1
Preventing stroke Encouraging people living a healthy lifestyle, make healthy choices to minimise risk of stroke. Detecting stroke quickly - Stroke is detected quickly where it does occur or recur. Delivering fast, effective care - People receive fast, effective treatment and care, so they have the best chance of living a long and healthy life. Supporting life after stroke - People are placed at the centre of stroke care with their individual needs identified and met so they feel well supported and informed, able to manage the effects of stroke. Improving Information collecting the right information, ensuring it is reliable and valid, using it to improve performance Targeting research engaging in the most relevant projects/trial Engaging with key stakeholders and support services - early in the patient's journey Early engagement with the Patient's Families and Carers - from admission to support the pathway until discharge. Patient outcome and recovery milestones will be realistic and achievable 3. ORGANISATIONAL PROFILE Delivery of clinically effective and evidence based care to stroke patients is a key organisational priority. There is Board level Executive leadership for the Stroke Plan. There are 18 beds at the Acute Stroke Unit at the University Hospital of Wales (ward A6S), four of which are designated hyper-acute, and 35 Beds at the Stroke Rehabilitation Centre at University Hospital, Llandough. The patient pathway aims for timely transfer from acute to rehabilitation care, and the first phase of an early supported discharge team has been established to identify patients suitable for intensive targeted rehabilitation at the earliest possible stage There are two full time, and two contributing (total of eight sessions) specialist Stroke Physicians, one full time Stroke Specialty Registrar and two nursing Stroke Service Co-ordinators. Overview of Local Health Need and Stroke Challenge A recent internal review of the current Cardiff and Vale Stroke Services against the expectations set out for 2016 has been undertaken and has been used to inform this Delivery Plan. In addition to this, the Stroke multidisciplinary team are identifying options for working differently to improve current services and to set more short term priorities for 2014/2015 within this Plan. The main area of constraint to optimal delivery of the current service has been the UHB s performance against Bundle 2 of the Intelligent Targets. This includes issues relating to: 2
Acute Stroke Physician being off site out of hours CT Radiographer being off site out of hours Impact of patients not being able to access a bed on the Acute Stroke Unit from the emergency stream at times of emergency pressures Delays in Social Work allocation following referral Delays in transfers from the Acute Stroke Unit to the Stroke Rehabilitation Centre Delays in discharging patients from the Acute Stroke Unit and from the Stroke Rehabilitation Centre to the Community Resource Team within the three days target Delays in repatriation of patients to other Health Boards Limited capacity of the current early supported discharge service 4. OUR VISION - WHAT CARDIFF AND VALE UHB WANT TO ACHIEVE For our population want: To develop a service whereby people of all ages have a minimised risk of having a stroke and, where it does occur, they have an excellent chance of surviving and returning to independence as quickly as possible. People who access stroke care in to have stroke incidence and mortality rates comparable with the best in Europe. The key deliverables in this Plan will support the recommendations made by the Sentinel Stroke National Audit Programme (SSNAP) November 2012; o Quality and care will be audited against national standards o An annual report of patient experience will be completed o Aspire to work towards seven day a week therapy service o Early supported discharge will be available to all appropriate patients o Rehabilitation will end only when the patient no longer benefits significantly from it o All confirmed new acute stroke patients will be admitted to UHW where thrombolysis and other hyper-acute care is available, unless this is considered not to be in the patient s best clinical interests. o All patients will be admitted from EU to the Acute Stroke Unit in a timely manner o The Acute Stroke Unit will deliver the key standards for the SSNAP report o All staff involved in the Stroke Patient Pathway will be trained and have the skills to deliver expert care, and will also prepare the UHB for complying with the requirements of the data collection for SSNAP 2013-14. The will focus significantly on the areas recently highlighted by a small working group which looked at constraints in the 3
pathway. This resulted in the development of the Cardiff and Vale UHB Operational Policy for the Flow of Acute Stroke Patients from Admission to Discharge (March 2013.) How will we achieve this: Timely and prompt assessment for acute stroke patients within the Emergency Unit (EU) and other inpatient areas across the UHB Prompt identification of appropriate acute stroke patients for admission to priority beds on the Acute Stroke Unit within four hours of arrival in EU Early initiation of the rehabilitation process measured by the Orpington Predictor Tool within 48 hours of arrival in EU Early identification of patient outcome to ensure all stroke patients enter the correct stream on the stroke pathway, to support discharge and facilitate early multidisciplinary support Timely transfer of patients from the acute stroke unit to the stroke rehabilitation centre, with the aim of ensuring effective flow seven days a week. Improved integrated team working across clinical specialities and the multi-disciplinary teams to inform stroke treatment/care plans and support patient flow to the right bed first time Improved quality of care by ensuring the appropriate patient is cared for in the appropriate environment to support the rehabilitation process to maximise the potential and outcomes for patients Timely and proactive communication between key stakeholders to improve the patient journey supporting early discharge of the stroke patient 5. SUMMARY OF THE PLAN - THE PRIORITIES FOR 2014/15 Highlights from 2012/13 and 2013/14 Improvement in the thrombolysis pathway Delivery and operation of mechanical clot retraction service at Regional level Dedicated and functioning multi-disciplinary Acute Stroke Unit Appointment of Stroke Specialist Registrar (rotational post) Save time, save brain initiative launched to raise awareness All Wales Stroke forum established Specialist Stroke training programme for multidisciplinary staff Educational programs undertaken for Primary Care Physicians 4
Other Challenges Identified Through Local Improvement Work Introduction of seven day working for specialist stroke team Lack of available therapy staff during week days & at week ends Lack of Social Worker at the MDT meeting Dedicated funding for educational programs Shortage of junior Medical Staff due to commitment to on call Inability to accommodate stroke patients to be admitted directly to the acute stroke unit Access to Acute and Rehabilitative Stroke care for outlying stroke patients Degree of dependence on office hours staff for 24 hour service delivery The priorities for 2014/15 are: General Actions to Address above Challenges Innovative ways to reorganise Stroke Consultants Direct Clinical Care sessions to enable seven day working Explore how the UHB can dedicate more therapy staff to Stroke Service to provide seven day service Reorganisation of junior Medical Staff working pattern Work with Local Authority/Integrated Discharge Service to provide social worker attendance at multidisciplinary team meeting & provide better continuity cover absences due to annual leave etc. Better coordination of repatriation of out of area patients Engage with Social Services to facilitate timely care home placements Preventing stroke To be able to assess all high risk TIAs within 24 hours by Stroke Specialists seven days of the week To be able to assess all low risk TIAs within a week To implement All Wales Anticoagulation guidelines for atrial fibrillation effectively To promote early referral of symptomatic carotid stenosis patients for carotid endarterectomy within 2 weeks of symptom onset. Ensure faster access to echocardiogram & cardiac monitoring in appropriately selected TIA patients with suspected cardiogenic embolism Ensure that all patients with TIAs receive appropriate evidence based treatment Develop plans with the Welsh Stroke delivery group to develop screening services for atrial fibrillation. Detecting stroke quickly Ensure that primary and secondary care and the public treat stroke as a medical emergency Work with GPs to raise their awareness of symptoms 5
Audit the pathway for people diagnosed with a stroke and act on findings to improve services for early detection. Delivering fast, effective treatment and care Work with the Welsh stroke delivery group to explore the reconfiguration of stroke services in Wales including the development of hyper-acute Services in Wales All stroke patients will have prompt assessment, diagnosis and early treatment in EU to achieve relevant performance targets and ensure optimal patient outcome, Code Stroke All confirmed stroke patients will be transferred to the Acute Stroke Unit within four hours of arrival in EU, initially aiming for an interim 12 hour maximum in 100% of cases. All stroke patients will be cared for in the appropriate clinical area to support their needs until discharge Early engagement with families and all stakeholders is key to service delivery Identify and develop a process to ensure a prompt and timely response to deliver the same care 24/7 Provide timely access 24/7 to thrombolysis. Deliver thrombolysis within 30 minutes of admission Deliver regional interventional neuroradiology and neurosurgery for appropriately selected stroke patients. Supporting life after stroke Work with the Welsh Stroke delivery group to benchmark community rehabilitation services for stroke Further development of the early supported discharge team, to increase capacity and ensure optimal patient flow through the stroke pathway. Through Goal Planning meetings, develop appropriate care plans to agree care and support, based on the needs of individuals, following a diagnosis of stroke Ensure review of stroke survivors, as needed, with residual impairment Ensure stroke survivors are screened for visual impairment and psychological needs Involve stroke patients and their carers in the development of future services including creative ways of supporting them, listening to what they have to say about decisions that affect them and to provide Provide accessible and meaningful information and training when needed Plan and deliver palliative and end of life care services as locally as possible Improving Information 6
Work with stroke survivors, their carers and the Third Sector to ensure effective signposting to sources of information and support. Assess, record and meet the information needs of people through the use of joint care plans. Publish regular and easy to understand information about the effectiveness of their local stroke services. Record and use clinical information in planning and service provision Monitor performance against stroke clinical indicators and use the results to inform and improve service planning and delivery. Survey the views of stroke patients and their carers in respect of their experience and outcome of treatment. Targeting Research Offer all appropriate patients access to relevant clinical trials. Participate in the the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) trial a UK research studycomparing IV rtpa alone with IV rtpa and adjunctive mechanical thrombectomy in patients, eligible for treatment with IV rtpa, that have a large vessel carotid territory arterial occlusion (as confirmed on angiographic imaging) Maximise the use of Welsh Government funding for NHS research. Ensure that the UHB provides effective and efficient research governance processes to enable a speedy start and delivery of clinical trials. Support and encourage protected research time for clinically-active staff. Collaborate effectively with other Local Health Boards and NHS Trusts, Universities and industry in Wales to enable a speedier application of research, and introduction of new technology into the NHS. 6.0 PERFORMANCE MEASURES / MANAGEMENT produced their first annual report in September 2013, which reviewed the progress against the to date. The next annual report will be completed in September 2014. To measure success the following indicators will be used as a guide:- 80% of all new Stroke patients will be admitted to the Acute Stroke Unit within four hours of attendance, working towards 90% to comply with SSNAP guidance later this year 100% of all new stroke patients will be admitted to the Acute Stroke Unit within 12 hours of attendance 90% of all Stroke patients will have an Orpington Predictor Tool completed within 48 hours of admission to support the rehabilitation pathway Two clinically appropriate patients are discharged or transferred from the Acute Stroke Unit by noon daily 1-2 clinically appropriate patients are discharged or transferred from 7
the Stroke Rehabilitation Centre by noon daily Where a patient with an uncertain stroke diagnosis is admitted to the Acute Stroke Unit and subsequently confirmed as non-stroke, they should be transferred from the unit within 48 hours Any instance of a stroke patient having to be admitted to a ward other than the Acute Stroke Unit should be treated as an untoward incident Length of Stay on both the acute and rehabilitation units will be performance managed in line with national benchmarks 8
Delivery of SSNAP Audit standards Cardiff and Vale University Health Board Summary Action Plan to Support 2014-2017 Objective Actions in 2014/15 Actions by 2016/17 Lead Initial target of 100% of patients transferred Achieve steady progress towards 100% of to acute stroke unit within 12 hours of transfers to acute stroke unit within 4 hours. admission, and 75% transferred within 4 hours. Lead Consultant Participate in national discussions regarding hyperacute Services in Wales Achievement of thrombolysis delivery times Implement further development of full Early Supported Discharge (ESD) model Progress plans for seven day working across acute stroke services Participation in Welsh Stroke delivery group to determine appropriate model of care Implementation of Code Stroke with initial target of >50% achievement of 30 minute door to needle time. Participate in Welsh benchmarking of community rehabilitation services for stroke Refine detail of original ESD business case against the learning from Proof of concept, performance data and evidence base. Review of medical staffing resource and required changes. Initial report and recommendations for implementation within current resources. Progress to implement nationally agreed model >90% achievement of 30 minute door to needle time. Further development of the ESD model and steady improvement in performance/ outcome data Consider resource plan to implement full seven day consultant working across acute stroke and TIA service. Medicine HOD Directorate Manager, Gerontology Lead consultant Nation stroke clinical lead Director Therapies and Health Science Medicine HOD Medicine HOD Directorate Manager, Gerontology Lead Consultant Directorate Manager, Gerontology Stroke Consultants Director and Asst Director of Therapies and Health Science Clinical Board Directors (Medicine and Specialist Services) Stroke Consultants Review of therapy staffing resource and required changes. Initial report and recommendations for implementation within Consider resource plan to implement full seven day therapy working across acute stroke service. Stroke Executive Lead Asst Director of 9
Objective Actions in 2014/15 Actions by 2016/17 Lead current resources. Therapies Local Authority to confirm arrangements to Consistent timely provision of social work provide seamless social worker cover to support, with no resultant discharge delays acute and rehabilitation Units Ensure best practice in respect of bed management and timely discharge Chief Operations Officer Clinical Board Nurses Directorate Lead Nurses Ensure compliance with All Wales Repatriation Policy Ensure timely facilitation of care home placements within the Choice Policy Implement regional interventional neuroradiology and neurosurgery for appropriately selected stroke patients Promote and monitor primary and secondary prevention for stroke, including raising awareness of atrial fibrillation Ensure maximum public awareness of stroke and required pre-hospital responses Progress and implement arrangements in respect of Life After Stroke initiative Sign up to the processes in place by respective UHBs. Work with Local Authority to agree enforceable timescales. Formal review of pilot service, activity levels, clinical outcomes and parallel financial arrangements. Confirm continued commitment to service across South Wales. Participate in all Wales work on AF Gather primary care data and identify areas for future focus Further programme of public awareness e.g. FAST, Save Time Save Brain. Further GP education programme Review all programme requirements. Implement robust six month follow arrangements. Consistent application of policy, with no lost bed days as a result of delayed out of area repatriation. Consistent operation of policy, with no subsequent lost bed days as result of delays. Agree formal guidelines for future clinical management of cases, and long term financial arrangements as required. Measure, monitor and where identified improve primary and secondary prevention in primary care Consistent high recognition levels from public surveys. Ongoing education and training programmes for public and professionals, and demonstrate evidence of more timely emergency calls being received from public. Consistent application of all LAS principles across Cardiff and Vale Chief Operations Officer Clinical Board Nurses Directorate Lead Nurses Chief Operations Officer Clinical Board Nurses Medical Director Clinical Board Directors, Medicine and CD&T Lead Clinicians Stroke Clinical lead Primary community Intermediate care Clinical Board and lead GP Public Health Director Communications Team PCIC HOD Community Directors Stroke Consultants Stroke Consultants Asst Director of Therapies 10
Ensure maximum benefit achieved from Stroke Association service level agreement. Participate in PISTE Trial Recruit according to plan Continue recruiting until trial complete Consultant Interventional Radiologist Ensure strong ongoing links with third sector to develop stroke services Agree and finalise service level agreement for services provided by Stroke Association. Agree strategy for meetings / partnership based on future patient / service need. Continuing close relationship with Stroke Association and regular review of services provide in light of patient need. Directorate Manager, Gerontology Lead Consultant 11