The Royal Liverpool & Broadgreen Hospitals NHS Trust Peer Support Visit Report 13 th May 2013 Visit Clinical Lead: Dr Deborah Lowe Consultant Stroke Physician & Geriatrician Cheshire and Merseyside Strategic Clinical Network Wirral University Teaching Hospital NHS Foundation Trust 1
Contents Page 1.0 Background 3 2.0 Introduction & National Sentinel Audit Results 6 2.1 Overview of Royal Liverpool Stroke Pathway 9 3.0 Peer Support Findings 3.1 A&E Department 11 3.2 TIA Clinic 14 3.3 Imaging 16 3.4 Acute Stroke Unit 17 3.5 Stroke Review Clinics 20 3.6 Stroke Rehabilitation Unit 21 3.7 Early Supported Discharge (ESD) 23 3.8 Life After Stroke 25 3.9 Research 26 4.0 Data Collection & Performance Monitoring 27 5.0 Overall Recommendations 5.1 Summary 28 5.2 Recommendations 29 6.0 Addendum 30 Appendix 1 Peer Support Visiting Team 31 Appendix 2 Peer Support Trust Hosting Departments 32 2
1.0 Background The Royal Liverpool University Hospital Broadgreen Hospital Background The 2011 census identified the population of Liverpool at 466,415. The population is rising for the first time in decades. Approximately 34,027 (7.3%) are aged over 65 years, 23,709 (5.1%) are aged 75 years and above, and 7,730 (1.7%) are aged 85 years and over. The city contains a broad mixture of residential areas and although 4.9% of households consist of one or more dependent pensioners with no-one under pensionable age, family support remains cohesive. 44.5% of residents in the 65 plus group have limiting long term illness, and across the North West make up 17% of in-patient stays and occupy 46% of hospital beds. The Royal Liverpool & Broadgreen Hospitals NHS Trust comprises of three hospitals based on 2 sites, the Royal Liverpool University Hospital, Liverpool Dental Hospital and Broadgreen University Hospital. The trust serves a resident population of 750,000 within a total catchment area of more than 2 million providing treatment to patients across the North West, North Wales and the Isle of Man. The city of Liverpool has some of the country s most 3
deprived areas and its population has a significantly lower life expectancy than the national average. There are approximately 65,700 people over the age of 65. The Royal Liverpool University Teaching Hospital has a very well established Stroke Service. The stroke team received approximately 2100 referrals last year, this includes outpatient and inpatient referrals. It has a large well developed service with an excellent reputation and outstanding performance in the National Sentinel Audit Program over the past couple of years. The Royal Liverpool University Teaching Hospitals Stroke Service benefited from 3 million pump priming investment in 2009 to ensure an exceptional level of stroke care could be delivered to the city. This involved the appointment of two further stroke consultants, five specialist nurses and sixteen additional therapists to provide a 7 day a week 24 hour service. The Stroke Service is provided across two sites with acute services at Royal Liverpool University Teaching Hospital in the centre of the city and Rehabilitation Services being provided at Broadgreen Hospital approximately 4 miles to the east. The Acute Stroke Unit has 11 hyper acute beds, 10 step down beds and the remainder of the ward is Gerontology. There is also access to 20 beds on the Stroke Rehabilitation Unit, based at Broadgreen Hospital. The stroke team have delivered stroke thrombolysis since August 2006. Currently approximately 620 acute stroke patients are treated per year, with approximately 750 TIA referrals per year. The Trust provides hyper-acute stroke care 24/7 which is consultant led and provided by the 4 whole time Stroke Physicians. The stroke team operates a Stroke Physician of the week rota, with a 2 week hot block every 8 weeks. They offer a 7 day a week high risk TIA assessment service with week day clinics for TIA s and ward follow-ups. The Stroke Service has a very well developed pre-hospital pathway with alerts to the Accident & Emergency Department via the paramedic crew when a potential thrombolysis patient is being admitted. It benefits from one of the busiest and best performing A&E Departments in the region. The Stroke Service has access to a well developed radiology department with rapid access to CT and MRI scanning. There is rapid availability of Doppler ultrasound for assessment of patients with significant carotid disease. This service has continued to improve over the last 6 months following the hospitals designation as the North of the Mersey Vascular Centre. The Unit contributes to Sentinel and SINAP/SSNAP national audits. They are the most highly performing Trust in the region in terms of stroke research. They have a very well resourced research team and this has paid dividends in terms of being the highest recruiting stroke unit in the region. The team is part of the North West Stroke Research Network and was awarded a Certificate of Excellence 2011-2012. The team was also awarded the Warlow prize from the UK Stroke Forum for the Best Research Platform Abstract in 2012. The Stroke team won the Trust AQ Team of the year award in 2012 and has been shortlisted for the Trust Team of the Year Award 2013 for its telemedicine service. The stroke service is staffed by 4 WTE medical consultants; Dr Paul Fitzsimmons (Clinical Service Lead) Dr Aravind Manoj Dr Fatima Hussain Dr Shabib Abboud (locum cover for Dr Loharuka) Dr Shankar Loharuka (at the time of the visit was on sabbatical) 4
The consultants are supported by; One Advanced Nurse Practitioner Seven Specialist Stroke Nurses. The Stroke Service has a well developed team of doctors, nurses and therapists who are all extremely passionate about their service. The medical teams have shown extreme dedication in committing to a 1:4 stroke rota but have been innovative in designing a stand alone telemedicine system in the last month, to support their out of hours working. The service also provides in-reach at Liverpool Heart & Lung Hospital and to date 10 patients based within the Cardiothoracic Wards have been thrombolysed, most of these patients being post-procedure stroke patients. The team are hoping to develop a mechanism for remote assessment and delivery of thrombolysis to reduce the door to needle time in this high risk patient group. The team is also hoping to develop a transcranial Doppler service by training in-house 2 of the Stroke Consultants to enable assessment of the carotid circulation and also assessment for patent foramen ovale. 2.0 Introduction 5
The Cheshire and Merseyside Strategic Clinical Network have introduced a peer support visiting programme, the purpose of which is to explore and share good practice among all the stroke units within the Network. The inaugural visit was conducted at Wirral University Teaching Hospital in April 2012, subsequent visits to Whiston, Warrington, Macclesfield and Aintree Stroke Services have taken place. The visiting team included Consultant Stroke Physicians from around the region, Stroke Specialist Nurses, Stroke Specialist Therapists, Senior A&E and Stroke Nurses, Stroke Unit Ward Managers, Clinical Psychologist, a representative from the Stroke Association and observers from the Mersey & Cheshire Strategic Clinical Network. The day comprised an introductory meeting with the Stroke Clinical Lead, followed by visits to all component parts of the stroke service. All members of the visiting team felt the visit had gone very well and enjoyed the opportunity of experiencing another service. We were very impressed with the team work and obvious commitment of all the people we met, to develop and deliver high quality services for stroke patients. The following report is based on the meetings the team had with the various departments, and their subsequent feedback. The majority of findings were presented to the Trust on the day of the visit. We hope this report helps The Royal Liverpool & Broadgreen Hospitals to continue to develop their excellent stroke services. National Sentinel Audit Results The Stroke National Sentinel Audit is a biennial exercise, with all acute stroke services in the country submitting data. The dataset allows for benchmarking against the standards set out in the Royal College of Physicians Stroke Management Guidelines, and against other Trusts, regionally and nationally. The audit is in 2 parts; an audit of the organisation and an audit of process. The process audit was conducted by a retrospective review of the case notes of the first 60 consecutive admissions with stroke from April 2010. The Royal Liverpool University Teaching Hospital features in the top quartile of the organisational aspect of stroke care in the SINAP 2012 Acute Organisational Audit Report. When compared to previous 2010 Sentinel Audit they have maintained their upper quartile position. The total organisational score for the hospital was 89.9, the upper quartile scores ranging from 80.4-97.7. This score paced the hospital in the top 10% performing trusts in the audit. The Trust is also very highly performing within the Advancing Quality Programme in stroke with the most recent data showing excellent Trust performance from April 2012 March 2013 with a composite quality score of 95% and an appropriate care score of 85%. This suggests that this hospital is the most highly performing Trust within Mersey & Cheshire in terms of delivering the quality markers within AQ. 6
Number of cases in the audit Screening for swallowing disorders within 24 hrs after admission Brain scan within 24hrs of stroke Physiotherapy assessment within 72 hrs of admission Occupational therapy assessment within 4 days of admission Patient weighed during admission Patients mood assessed during admission Rehabilitation goals agreed by discharge Rehabilitation goals agreed within 5 days Aspirin or clopidogrel by 48hrs after stroke National Sentinel Audit Results National Results 11353 83% 70% 91% 83% 85% 80% 94% 78% 93% Table 1A Trust Name (Site Name) Aintree University Hospitals NHS Foundation Trust Countess of Chester Hospital NHS Foundation Trust 60 98 73 98 89 89 97 100 95 98 60 80 81 94 95 96 98 94 74 92 East Cheshire NHS Trust 60 93 78 92 95 100 87 97 37 90 Mid Cheshire Hospitals NHS Trust 60 94 90 100 96 100 92 96 90 96 Warrington & Halton Hospitals NHS Foundation Trust Royal Liverpool & Broadgreen University Hospitals NHS Trust 60 83 78 96 96 94 98 100 93 100 63 97 54 98 98 100 100 100 100 100 Southport & Ormskirk Hospital NHS Trust 60 82 59 98 100 87 100 100 100 87 St Helens & Knowsley Hospitals NHS Trust 59 100 76 81 83 75 85 98 85 86 Wirral University Teaching Hospital NHS Foundation Trust 68 94 66 95 100 95 100 100 100 89 7
Patient spent at least 90% of stay on stroke unit Swallow assessment within 72 hours Patient initially admitted to a general assessment unit* Patient initially admitted to a stroke unit Diagnosis discussed with patient Admitted to stroke unit within 4 hours Received all key 9 indicators in 2008 Received all key 9 indicators in 20010 Received all key 12 indicators in 2010 Overall position in 2008 Overall position in 2010 National Results 60% 86% 57%* 36% 80% 38% 17% 32% 16% Table 1B Trust Name (Site Name) Aintree University Hospitals NHS Foundation Trust Countess of Chester Hospital NHS Foundation Trust 52 100 30 53 96 43 44 55 44 62 96 23 72 72 22 31 42 27 East Cheshire NHS Trust 78 86 30 65 92 62 6 74 14 Mid Cheshire Hospitals NHS Trust 50 87 42 52 61 49 0 52 11 Warrington & Halton Hospitals NHS Foundation Trust Royal Liverpool & Broadgreen University Hospitals NHS Trust 65 95 58 40 97 42 10 52 29 74 91 95 3 100 46 18 47 0 Southport & Ormskirk Hospital NHS Trust 57 83 57 27 34 24 4 33 29 St Helens & Knowsley Hospitals NHS Trust 64 97 47 53 100 47 22 22 16 Wirral University Teaching Hospital NHS Foundation Trust 65 73 65 31 98 33 48 54 20 Table 1B is a continuation of Table 1A. The overall position is calculated from the total process score from each site. This is an aggregated score across all domains with the top 25% of scores represented by the symbol, the middle half designated by the diamond and the bottom 25% designated with the symbol.* a high score denotes less good patient care 8
2.1 Overview of Royal Liverpool University Teaching Hospital Stroke Pathway There is a very well established Acute Stroke Pathway with FAST test used by Northwest Ambulance and a pre-alert call to Accident & Emergency +/- a phone call through to the Stroke Nurse Specialist mobile phone. The patient is usually greeted in the Accident & Emergency department by an A&E nurse and Stroke Specialist Nurse. The nursing teams work together to do an initial assessment and arrange rapid investigations. It was suggested on the day of review that approximately 70% of suspected stroke patients were admitted via Accident & Emergency and 30% via the Medical Assessment Unit. However, the team have had further feedback to suggest that the split is more likely to be 90% via Accident & Emergency and 10% via the Medical Admissions Unit. It was suggested that patients often get sent through to the Medical Assessment Unit as they are a delayed presentation or due to the fact that there are a lot of Locum GP s within the referring primary care group that are not aware of the stroke pathway. Patients referred via MAU often have atypical stroke symptoms and are generally GP referrals. The stroke consultant often attends Accident & Emergency directly to assess patients and will often bring a junior doctor with them to aid assessment and also to educate the team. Accident & Emergency doctors seemed particularly involved in the process and it felt very much like a team approach to enable the most streamlined assessment of stroke patients within the Accident & Emergency department. There was rarely any delay in CT scanning and the patients were often transferred directly from CT to ASU. There didn t seem to be any delay in portering and often the stroke specialist nurse would ask a HCA from the Acute Stroke Unit to assist portering up to the Unit to ensure the 4 hour target was met. Beds were arranged via the stroke nurse and Bed Manager and there was a feeling of a very supportive bed management team to facilitate direct stroke unit admission. Beds are protected by very active bed management but are not officially ring fenced. Previously 2 male and 2 female ring fenced beds existed but following winter pressures of 2012/13 this was no longer the case. Monday to Friday between 9-7 pm, a stroke consultant is on-site and Saturday and Sunday between approximately 9am to 1pm. A more recent innovation has been the delivery of telemedicine using a system which uses CE approved equipment and business grade commercial software, tested as part of the Trusts governance procedures, telemedicine started in April 2012. It had only been operational for one month prior to this visit. The stroke consultants provide a stroke physician of the week model consisting of a 2 week block stroke physician of the week and then 2 weeks as an acute DME consultant. They did not participate in any Elderly Care on-call but took part in a 1:4 acute stroke rota. The Stroke Service has a well staffed Acute Stroke Unit with 5 trained and 5 HCA staff during the day and 3 trained and 2 HCA staff at night time. There was an ASU ward round 7 days a week that covered 11 hyper-acute stroke unit beds and 10 step down beds, the step down beds were not necessarily reviewed on a daily basis. The length of stay on the Acute Stroke Unit was approximately 4.6 days. Approximately 58% of patients are currently discharged directly home with support from the Early Supportive Discharge Team. Patients not ready for discharge from ASU would be transferred to the Stroke Rehabilitation Unit at Broadgreen Hospital which is a 20 bedded unit, with a length of stay of approximately 30 days. If not suitable for stroke rehabilitation they would be 9
transferred to Venmore Community Care Centre, rehabilitation centre, with 6 specialised neuro-rehabilitation beds. The hospital has a well developed Early Supportive Discharge Team which is integrated with the Community Trust and functions as a combined ESD and Community Therapy Service. It runs a 6 month pathway and if a patient still needs ongoing support they are referred on to a small specialised neuro-rehab team after the 6 month pathway is completed. It was clear that there was excellent team working from the start of the patient journey to the end. Of note was the exemplary team working between Accident & Emergency and the Stroke Team, a focused ESD Team and highly effective ward rounds on the Acute Stroke Unit. There was obviously a high level involvement from the Directorate Manager for Emergency Care and Elderly Care demonstrated on the day of the visit. There has been a recent public health campaign within the city to promote stroke symptoms within the city and this was felt to have been very successful. 10
3.0 Peer Review Findings 3.1 A&E Department The visiting team were; Vicki Little Stroke Nurse Specialist (Wirral University Teaching Hospital NHS FT) Dr Syed Haider Clinical Lead for Stroke (Countess of Chester NHS FT) Dr Raj Kumar Consultant Stroke Physician (Aintree University Hospitals NHS FT) Roger Jones Advanced Paramedic (NWAS) Chris Kennedy Snr Nurse, Acute Care (Wirral University Teaching Hospital NHS FT) Helen Isik Ward Nurse Manager (Aintree University Hospitals NHS FT) The visiting team were greeted in the Accident & Emergency Department by Dr Ann Marie Brown, Consultant in Emergency Medicine and several of the senior nursing team who were frequently involved in the assessment of stroke patients. They were welcoming and knowledgeable about stroke assessment. The environment was excellent with a large recently expanded resuscitation area and the atmosphere felt calm and controlled. The large well equipped A&E department had benefited from a recent expansion and resuscitation beds. It was clear that all the A&E department were aware of the importance of rapid assessment for stroke patients and were very aware of the stroke pathway. There was evidence of a good working relationship between the lead A&E and Stroke Consultant. There are a team of six Stroke Specialist Nurses that work predominantly within the A&E department to ensure rapid assessment of stroke patients. They often attend the department and triage TIA patients and ensure their rapid referral to clinic in addition to assessing all patients referred as stroke. Unfortunately there was no Stroke Specialist Nurse available at any point during the visit to speak to. Patients with FAST positive stroke arrive via the Emergency Department following a prealert. Although there was an awareness of the ROSIER Assessment Tool, the A&E team admitted that they very rarely use this as a stroke nurse if often present within minutes of the initial registration of patients and stroke doctors often review the patients very rapidly within the A&E department. Approximately 10% of patients are admitted via the Medical Admission Unit and it was suggested that the pathway for assessment on MAU was not quite as smooth as within A&E. It was very clear that there was a good relationship between A&E, the Stroke Team and Radiology. There was very rarely a delay for emergency CT scanning which was often done within 5-10 minutes of presentation. There was evidence of rapid combined assessment of the stroke patient and A&E were seen to facilitate rapid review rather than leaving the Stroke Team to lead the assessment. Patients are transferred from A&E to CT and usually directly up to the Acute Stroke providing the CT scan did not show an alternative diagnosis. If the patient had been clerked by an A&E doctor and was stable the patient didn t wait for a further medical review as it was acknowledged that this delayed the admission process and was unnecessary. Patients were generally thrombolysed on the Acute Stroke Unit but if no beds were available then they had previously been thrombolysed in Accident & Emergency. The thrombolysis rate has ranged between 10-20% over the last 12 months but during the last quarter of January - April 2013 the thrombolysis rate was an impressive 20%. The fastest door to needle time was 17 minutes and the team had set an ambitious target of 80% of strokes being thrombolysed within 60 minutes and 40% within 30 minutes. The visiting team had no doubt having seen 11
how well the A&E Team and Stroke Team work that this is a deliverable target. We were informed that most of the time patients could be admitted into the Acute Stroke Unit within 4 hours. One area of outstanding practice is the Performance/Breach meeting that convenes weekly and is attended by the A&E Consultant, Stroke Doctors, A&E and Stroke Nurses and Radiology staff. During these meetings any breaches of 4 hour targets, delayed thrombolysis, delayed scanning or failure to hit any other local or national targets are discussed. Any breaches are recorded in a formal root cause analysis and lessons learnt format to ensure that there is real time performance management based on performance in the preceding week s activity. A Stroke Consultant is generally available to review patients in the A&E department between 9am and 7 pm. This was facilitated by the Stroke Physician of the Week rota. The Stroke Physician of the week is available generally 9am-5pm, with other members of the stroke team available on site usually between 5 to 7 pm. Door to needle times have improved significantly over the last 12 months. In April - June 2011 the average on time was 100 minutes. Over the same period in 2012 the average time was 50 minutes. The A&E department have access to 3 CT scanners, all 64 slice. There are well developed fast scan protocols in place and there is very rarely a delay in imaging. 30% of patients have a scan before arriving on the Acute Stroke Unit currently. MRI is never done first line for late presentations, POCI strokes or atypical presentations, as there is such a high demand for MRI slots from other departments in the hospital. There didn t appear to be any delay in CT imaging out of hours. Telemedicine Within the last month (April/May) the team have been piloting the use of telemedicine out of hours between 7 pm and 9am. The telemedicine cart uses commercially available (and procured) software and hardware. The telemedicine service is being run as a stand alone service and is not part of any of the regional telemedicine hubs. The consultants have taken an active decision not to record the consultations for governance and information control reasons. The Stroke Nurse is at the patient end and the Consultant Stroke Physician at home with a Trust laptop and fast broadband access. The decision is made by the consultant to thrombolyse and an e-mail prescription is sent. The thrombolysis is delivered by the on-call medical registrar or SHO. Prior to this service starting the team did several dummy runs to ensure the IT back up was sufficient and there were no problems with e-prescribing. Within the last one month 15 calls had been made, 2 required the consultant to come in from home to assess further and one of these was felt to be functional stroke. It was unclear how the post thrombolysis review is completed but the team assumed that this was done by the Stroke Nurse. The Stroke Consultant then reviews the patient the next morning on the Acute Stroke Unit. This is an extremely innovative way of providing out of hours cover and should provide some respite for the stroke consultants that currently work a demanding 1:4 on-call rota. The visiting teams were concerned that currently there is a single cart in use and the service is being run as a stand alone rather than utilising a pre-existing telemedicine hub. 12
Consultations are not recorded which would be a recommendation for the future as this occurs within other established telemedicine services. 13
3.2 TIA Clinic The visiting team were; Roger Jones Advanced Paramedic (NWAS) Dr Raj Kumar Consultant Stroke Physician (Aintree University Hospitals NHS FT) Dr Syed Haider Clinical Lead for Stroke (Countess of Chester NHS FT) Helen Isik Ward Nurse Manager (Aintree University Hospital NHS FT) The Royal Liverpool University Teaching Hospital has a well developed TIA Service offering formal clinics Monday to Friday, these clinics are located next to the Vascular Clinics. At the weekend higher risk TIA patients are seen on the Acute Stroke Unit by the on-call Consultant. The clinics offer a one stop service with access to dopplers, echocardiograms and brain imaging if required. There is access to CT and MRI at weekends if required. There is not currently access to carotid doppler imaging at the weekend but CTA or MRA can be performed to assess carotid circulation, with two MRA slots being available. There was lack of clarity during the visit as to how frequently patients are sent for CT or MRI. Although there is no difficulty getting CT scans, it was suggested that CT s are only routinely performed for suspected TIA patients if the plan is for patients to be started on Warfarin from clinic. It was suggested that MRI s are very infrequently done, although there seemed to be variation between different clinicians as to how frequently these were ordered. There is, however, limit access to MRI scanning and there is not availability directly from the TIA Clinic. Although MRI tries to offer 2 slots per day, these are not guaranteed. There is a very well embedded pathway for the assessment and management of TIA and minor stroke from the A&E department and pathways are available on the Trust intranet. The clinics are coordinated by the Stroke Specialist Nurses and the Stroke Secretaries and seem to run well. Referrals to the TIA Clinic are received via fax directly to either the Stroke Secretaries or the Stroke Specialist Nurses. Referrals are received from the Accident & Emergency Department, AMU, St Paul s Eye Hospital and Primary Care. The service receives approximately 60 referrals per month and it was reported that approximately 20% of patients referred as possible TIA s were felt to have had definite TIA s. There are 8 clinic slots per day on a consultant and SpR list and 2 of these slots are kept for high risk TIA patients. One of the week day clinics is run by the Stroke ANP with no Consultant presence but the Stroke Physician of the day is available for support when needed. The referral s are vetted by the Stroke Nurses and appointments offered based on the risk score provided. Patients are not necessarily contacted for additional information or the ABCD2 score reassessed. The time of TIA is recorded as the time the referral is received by the Stroke Service. Exact figures were not available on the day of the visit concerning performance in IPMR i.e. all high risk TIA s being seen within 24 hours. The feeling was, however, that there is adequate capacity to see all high risk patients in clinic or ward within 24 hours. It was reported to the visiting team that it is difficult to see the lower risk patients within 7 days due to clinic capacity. There was also the suggestion on the day the team visited that a portion of the high risk TIA s were actually admitted to be assessed, but it is unclear whether this was actually a misunderstanding as this was not corroborated by the Clinical Lead for Stroke. The service has benefited from recent developments in terms of the Regional Vascular Unit being currently located at the same Trust. There has been much closer working with the 14
Vascular Surgeons and very fast access to a vascular opinion and carotid endarterectomy as required, often within 2-3 working days. Sometimes patients are referred as TIA but clinically have had a minor stroke. We were informed that all strokes were admitted to enable adequate in patient assessment rather be seen in clinic setting. Patients referred with a delayed presentation of TIA symptoms, but still scoring 4 or more were still seen within 24 hours. There is currently no pathway in place for rapid anticoagulation of patients with AF and recent TIA or stroke. Currently patients are not started on low molecular weight heparin and Warfarin from the TIA clinic as per recent RCP guidance and the stroke lead acknowledged that a clear pathway needed to be developed and a protocol for the newer novel anticoagulants needed to be in place within the Stroke Unit. 15
3.3 Imaging The visiting team were; Dr Valerie Gott Associate Specialist (Wirral University Teaching Hospital NHS FT) Wendy O Connor Quality Improvement Lead CVD Cheshire & Merseyside SCN Chris Kennedy Snr Nurse Acute Care (Wirral University Teaching Hospital NHS FT) The Stroke Service at the Royal is supported by a well developed and proactive Radiology Department. There is no difficulty performing CT or CTA and this is available 24/7 including weekends. There are 3 CT scanners available which is closely located to the A&E department and only 5 minutes walk from the Acute Stroke Unit. The Radiology Department staff were very well informed and energetic. They were well aware of the stroke targets. There was evidence of excellent team working. Stroke nurses were able to request CT but not MRI scans. There are fast scan protocols available for head CT s for acute thrombolysis patients. Usually an unenhanced CT is performed within 30 minutes of arrival, but often more rapidly than this. The remainder of patients were all scanned within 24 hours with 30% of patients being scanned before transfer to the Acute Stroke Unit i.e. within 4 hours. It was more difficult to get access to MRI scan and it was reported that MRI was never used as a first line of imaging, even in atypical presentations or posterior circulation strokes. MRI and MRA are available 7 days a week 8-8pm on request. Carotid ultrasound is used as first line imaging for TIA and minor stroke patients. There was excellent access to doppler imaging 9-5pm Monday to Friday with a clear referral pathway to the Vascular Surgeons and rarely any delay in getting access to getting carotid endarterectomy. On the day of the visit no estimates of the current wait for carotid endarterectomy surgery were available but this is felt to be less than 2 weeks. On discussion as to how the carotid circulation is imaged in patients with uncertain levels of stenosis, we could not ascertain whether the preferred imaging modality was MRI or CTA. The visiting teams impression was that this was clinician dependent rather than protocol driven. There is a weekly MDT meeting with the Vascular and Interventional Radiology Consultant and a weekly regional Carotid MDT. In addition to this there are twice weekly Consultant led Neuro-radiology MDT s. As mentioned earlier in the report, it was suggested during the visit that there appears to be inconsistency in the frequency and modality of brain imaging applied to the initial management of TIA patients. There is a need to standardise practice in terms of imaging to conform to National guidance. 16
3.4 Acute Stoke Unit The visiting team were; Vicki Little Stroke Nurse Specialist (Wirral University Teaching Hospital NHS FT) Dr Syed Haider Clinical Lead for Stroke (Countess of Chester FT) Wendy O Connor Quality Improvement Lead CVD (Cheshire & Merseyside SCN) Dr Raj Kumar Consultant Stroke Physician (Aintree University Hospitals NHS FT) Roger Jones Advanced Paramedic (NWAS) Chris Kennedy Snr Nurse Acute Care (Wirral University Teaching Hospital NHS FT) Helen Isik Ward Nurse Manager (Aintree University Hospitals NHS Trust) The visiting team were impressed with the overall atmosphere and organisation of the Acute Stroke Unit. The Stroke Unit has 21 beds with 11 hyper-acute monitored beds and 10 step down beds. There are also 8 elderly care beds on the unit covered by the Stroke Team. There are no mixed sex bays and there is a specific male HASU bay and female HASU bay. The Ward was welcoming and although it was very busy there was a controlled calm. There was evidence of a lot of nursing staff who seemed very energetic and enthusiastic. The Acute Stroke Unit is well staffed compared to other Stroke Units in the region. It has 5 trained and 5 untrained staff during the day and 3 trained with 2 untrained at night time. Sister Barclay reported that staff were relatively well protected and although staff were occasionally taken to support other less well staffed areas, this was less frequent than had previously been the case. Nursing documentation on the Acute Stroke Unit was well developed with the use of SNOBS and standardised nursing stroke pathways. There was a patient group directive for prescription of Aspirin by nursing staff and also the majority of nursing staff on the Unit were trained to do a formal swallow assessment. The nurses on the Unit all seemed experienced in monitoring thrombolysis and confident in management of acute stroke patients. The length of stay on the Ward is currently 4.2 days which is very impressive. Beds are not ring fenced but there is a very supportive bed management structure that means the majority of the time beds can be made available to facilitate acute stroke admissions. There are frequently elderly patients with a non-stroke diagnosis in the HASU beds. On the day of review 5 out of the 11 beds had elderly care patients in them. It was reported that elderly patients are often moved 1 to 2 weeks into their inpatient stay onto other elderly care wards to facilitate bed availability on the Acute Stroke Unit. Patients discharged from the Acute Stroke Unit go home with or without ESD, to Stroke Rehab Unit or Venmore Community Care Centre if they still require rehabilitation in an in patient setting. The nursing staff also recorded nurse led therapy and this included a patient transfer in out of bed if they had been shown how to do this by a physiotherapist. There was a very efficient and effective white board in use. At 8.30am Monday to Friday there was a therapist board round to decide on priorities and the day s timetabling of therapy assessments. At 12 noon there was a board round that therapists, nursing and medical staff attended to drive discharges and assess progress of patients. At 4pm there was a nurse and stroke physician of the week round up board round to chase discharges and review progress during the day. The Ward benefited from a full time Ward Clerk and a full time Case Manager who was responsible for patient flow, discharges and sorting out the administrative and social care elements for patient s discharges. The Case Manager had been a positive influence on discharges with decreased complaints from families. It was felt, however, that there were increasing demands on the role and the threat that each Ward would no longer continue to 17
have its own individual Case Manager. It was reported that there was limited Pharmacy support available over the weekend. There was evidence of a large therapy team available within the Acute Stroke Unit with good provision of Occupational Therapy, Physiotherapy, Speech and Language Therapy and Dietetics. The therapists were all experienced and very dedicated to stroke. Physiotherapists and Occupational Therapists were available 7 days a week to cover ASU only. The 7 day service did not extend to 7 day availability for ESD and Stroke Rehabilitation Unit cover. The Occupational Therapists were responsible for doing cognitive assessments and when asked if anyone else was responsible for mood assessment, it was reported that nursing staff ticked the box for mood screen but rarely have any further involvement in mood assessment. There was a very well developed Dietetics Service available to the Stroke Team. FEES was available for dysphasic patients although is only used in approximately 10% of patients who were unable to go down for video fluoroscopy. The ASU did not have a stroke specific Social Worker and the visiting team were informed that no Social Workers are currently based within the acute Trust. There is an experienced Stroke ANP that is a vital member of the team. His role has evolved over time and now he has limited input into the Stroke Unit and is predominantly involved in Stroke Clinics and Domiciliary Clinics for patients unable to attend outpatient clinics within a nursing home. The Acute Stroke Unit is staffed by 4 Stroke Physicians. They provide a daily ward round 7 days a week with prospective cover. They also participate in the family case conferences on request. They provide a stroke physician of the week rota and do 2 weeks on and 6 weeks off. There is no leave allowed during the hot weeks. Although the Consultants also do acute geriatric medicine for 2 weeks out of an 8 week cycle they do not take part in the general medical on-call rota. The 11 bedded HASU has a consultant Ward round daily. The step down patients that are remaining and 8 elderly care patients are seen 2 to 3 times a week in addition. The stroke physician of the week is available for thrombolysis calls and will often go to A&E to review new admissions. The consultants also review TIA referrals in A&E. They do not have any outpatient clinic responsibility or SPA during the hot week. Another colleague provides cover 5 till 7 pm and on-call cover during the hot week. It is clear that the Hyper Acute Unit works phenomenally well. It was of some concern to the visiting team that a 1:4 rota and Stroke Physician of the Week rota that was so intense would lead to a risk of burn out for the consultant staff. It was felt by the visiting team that to maintain this level of excellence additional consultant staff would be needed or as an alternative a shared out of hours rota or further development of the telemedicine model to decrease the out of hours workload for the medical staff. There was good provision of junior doctor cover with 2 SHO s and 2 Registrar s available to the Acute Stroke Unit. Currently however the Trust has vacancies within junior doctor posts in the Stroke Department and this has created additional pressure for the Stroke Team. On entering the Unit there was were posters demonstrating the stroke unit s outstanding performance in AQ and SINAP. There was also evidence of Stroke Association leaflets, although these were one year out of date. There was no evidence of national or local stroke guidelines in a patient friendly format. There is no Stroke Association Information Support and Advice Worker commissioned for this service. The Stroke Unit has a clinic room for the assessment of TIA patients at the weekend. It also has the research nurses and data clerks office. 18
The hospital has two full time band 4 Data Clerks that do all data collection for IPMR, AQ and SINAP/SSNAP. This data collection appears to occur in isolation from clinical practice. Several nursing staff and therapists were asked about some of the targets within AQ and SINAP and had little or no awareness of what these targets were. The team felt that although the Data Clerks do an extremely good job, there was a danger that removing performance monitoring and data collection entirely from the clinical teams may lead to some error in interpretation of clinical notes and performance. Based on the CQCRC Psychiatrists report from February 2013 provided by the Trust within the Peer Review Documentation Booklet, there is a very high level of satisfaction amongst staff, MDT, consultants, management and most importantly patients. The environment within the Ward was not specifically adapted to help patients with mobility difficulties. There were no raised toilet seats and it was not particularly wheelchair friendly. It was explained, however, that few patients are ready for wheelchair assessment on the Acute Unit and this is often done on the Stroke Rehabilitation Unit. The service has no Neuropsychology provision and if acute patients required Psychology they were generally referred to the Mental Health Team. There was no quiet room, day room or lounge available to patients or relatives. 19
3.5 Stroke Review Clinics The visiting team were: Dr Sophie Campbell Principal Clinical Psychologist (Aintree University Hospital NHS FT) Kate Charles Senior Coordinator (Stroke Association) Jill Wright Clinical Specialist Physiotherapist (Warrington & Halton Hospitals NHS FT) Susanne Carlton Speech & Language Therapist (Ormskirk Hospital NHS Trust) Dr Valerie Gott Associate Specialist (Wirral University Teaching Hospital NHS FT) Lisa Roberts Clinical Business Manager (Aintree University Hospital NHS FT) These clinics are run from the Alexandra Wing at Broadgreen Hospital. There is a separate basement entrance which is ambulance accessible which leads directly in to the Day Hospital and surrounding consulting rooms. This is a spacious welcoming environment which felt very calm and reassuring to the visiting team. There are very nice homely touches such as a grandfather clock, pictures on the walls and piano which much be a very pleasing environment for visiting patients and relatives. There is a tea and toast host and nurse coordinator, this personal touch impressed the visiting team. The environment was spotlessly clean and welcoming. Service users reported a high level of satisfaction. There are daily clinics Monday to Wednesday which tend to run either in the morning or afternoon. There were three consulting rooms available for these clinics. On arrival nurses perform a Barthel score and Rankin prior to the doctor reviewing the patient. The visiting team were informed that there was generally no nurse chaperone or escort with the consultant in the Stroke Clinics. There was also no standardised date for reviewing patients; this doesn t follow national guidance of a suggested 6 week and 6 month review as a minimum. The standardised proforma suggested a 6 week, 6 month and 12 month review but there was lack of clarity from the nursing staff and clinicians as to the portion of patients receiving which type of follow-up. On further discussion with the Clinical Lead there have been recent changes to ensure that patients post stroke actually leave hospital with a 6 week and 6 month appointment pre-booked. There were limited diagnostics available on the same day of clinic review apart from phlebotomy which was available within this department There is a therapies gym adjacent o the clinic, with the availability for review of patients by the Early Supported Discharge Therapist if required within the clinic setting. The therapists reported that they see on average 4 patients per clinic, some of these patients are still receiving therapy from ESD at home. There is a dietician available as required. A nursing home review service is offered by the ANP in Stroke which adds a very high quality aspect to this service. This is provided for patients in nursing homes or those that cannot attend the outpatient clinic due to mobility issues or other complex care issues. TIA patients are often followed up in the Broadgreen clinic but it was stated that not all TIA patients receive follow-up. If TIA patients are followed up in clinic and require further investigations there is no facility for these to be done on the same day. New patients are not usually seen in this setting. The visiting team were impressed by the environment of the Stroke Review Clinics. It was suggested that there were capacity issues in ensuring that patients could be offered the appropriate follow-up appointments and there was lack of clarity or standardisation when patients are reviewed and post stroke. It was suggested that many TIA patients do not receive the suggested one month follow-up in the Stroke Review Clinic. A more standardised process for 6 month reviews perhaps needs to be looked at in order to meet suggested national standards. 20
3.6 Stroke Rehabilitation Unit The visiting team were; Dr Sophie Campbell Principle Clinical Psychologist (Aintree University Hospital NHS FT) Kate Charles Senior Coordinator (Stroke Association) Jill Wright Clinical Specialist Physiotherapist (Warrington & Halton Hospitals NHS FT) Susanne Carlton Speech & Language Therapist (Ormskirk Hospital NHS Trust) Dr Valerie Gott Associate Specialist (Wirral University Teaching Hospital NHS FT) Lisa Roberts Clinical Business Manager (Aintree University Hospitals NHS FT) The Stroke Rehabilitation Unit is housed on Ward 8 at the Alexandra Wing, Broadgreen Hospital. This unit is approximately 4 miles away from the Royal Liverpool University Teaching Hospital and has 20 beds. SRU has located here for the last 7 years. Although not a purpose built Unit it was bright, had adequate space around the bedside and was again spotlessly clean. There are two other Elderly Care Rehabilitation Wards at this site. The visiting team were met at the Unit by the Deputy Ward Manager who was very welcoming. The Unit is covered by 2 SHO s and one medical SpR who visits the Unit approximately twice a week. There are 3 Consultant Ward Rounds per week but it was noted there was no continuity between the Acute Consultant and the Rehabilitation Consultant as not all Acute Stroke Consultants have rehabilitation beds. There was a large white board visible on the Unit displaying patient s details and estimated date of discharge. The estimated date of discharge, however, was out of date on several patients or just not documented. This was used 3 times a week for a nurse led MDT to facilitate discharge planning. It was reported that the average length of stay is approximately 30 days. Laminated timetables were visible for each patient and This is me dementia packs if appropriate. It was noted that speech and language therapist don t currently use the laminated timetables but they are used by Physiotherapy and Occupational Therapy. The inpatient group at the time of the visit were quite dependent and the visiting team were told that a large proportion of these patients were not expected to return home. They reported significant problems with delayed discharges due to patients requiring major packages of care or institutional care. On the day of assessment there were no visible wheelchairs in use on the Ward and it was unclear if these were actually available. There were 4 tilt and space chairs in use and there seemed to be adequate space around the bed for therapy assessment and input. Although the Ward had initially its own Case Manager to facilitate discharges, on the day of review there was one Case Manager between 5 Wards and it was felt that this had led to a much slower flow through the ward. There were no gym or therapy areas on the Ward and these were shared with other Wards. There was one gym shared with Musculoskeletal Services and one gym downstairs shared with Rheumatology, Neurology and Early Supported Discharge. There was one day room off the Ward but this was rarely used. There were no patient televisions and it was reported that some patients bring in their own TV s but are asked to use headphones. There was no facility for daily communal dining. There is unfortunately no Psychology input available for this patient group and patients requiring psychological support are referred to the Mental Health Teams. 21
There was no evidence of any voluntary organisation involvement except for one luncheon club a week; there was no stroke specific volunteer group involvement. The visiting team enquired about a daily volunteer input into the Ward as mentioned in the proforma provided by the Trust but the ward staff could not confirm that this happened. There was a once weekly Art Group which had been very well received and a desire to develop a Dance Therapy Group and increase luncheon club provision. The therapists shared an office space with the Early Supported Discharge Team and there was Physiotherapist, Occupational Therapist and Speech and Language Therapist support in the Unit. The level of therapy input could not be ascertained by the visiting team but it appeared to be much less than therapy support on the Acute Unit. The therapists reported that they were able to deliver 45 minutes of care every weekday for the patients that required it there was no weekend therapy cover. Dietician support was available and the MUST nutrition score was used as a standardised assessment tool. There was good team working with the Early Supported Discharge Team and weekly meetings are held to facilitate transfer of care but the patients were not seen by Early Supported Discharge therapists prior to discharge home. Consultant ward rounds generally occurred once a week, with one weekly MDT and family case-conference as required. This was usually conducted with a nurse, consultant and a therapy lead. The visiting team inquired about the personal rehabilitation pack that had been mentioned in the Trust proforma. We were told that none were available and none of the staff that a member of the visiting team spoke to recalled having used one recently. The staff reported that occasionally non-rehabilitation patient s move to the Unit in a bed crisis, but there was only one non-stroke patient on the Unit on the day of the visit. SINAP/SSNAP data is entered manually to data collection forms and left in the patient casenotes. When the patient s notes are returned to the Royal Liverpool University Teaching Hospital for discharge letters to be completed, the data entry sheets are collected at this point by the Data Clerk who then transfers the therapist data collection onto another data collection form. Therapists reported that they completed SINAP/ SSNAP data collection forms but there was no time within their timetable to allow for this activity. 22
3.7 Early Supported Discharge (ESD) The visiting team were: Jill Wright Clinical Specialist Physiotherapist (Warrington & Halton Hospitals NHS FT) Susanne Carlton Speech & Language Therapist (Ormskirk Hospitals NHS Trust) Dr Sophie Campbell Principal Clinical Psychologist (Aintree University Hospital NHS FT) This hospital has a well established Early Supported Discharge Team which has been running for 5-6 years. There was outstanding team morale and a real sense of pride in the service that is delivered. Staffing for the service included a physiotherapist, occupational therapist, speech and language therapist, specialist nurse and dietician. There was no provision of Neuropsychology or voluntary sector support within ESD in the form of the Stroke Association or similar organisation. The ESD pathway is available up to 6 months post discharge for those that require it. Patients requiring ongoing therapy after the 6 month point could be referred onto a small neuro-rehabilitation team. An electronic referral system existed for patients to be referred to ESD. The service did not have any form of vocational rehabilitation services. Patients generally had a 6 month cognitive review in terms of an ACE-R assessment and mood assessment if required. On average 58% of patients enter Early Supported Discharge on discharge from hospital. Initial assessment was generally by a physiotherapist and/or occupational therapist within 3 days. Speech and language therapist generally reviewed within 3-5 days depending on level of urgency. Dieticians are available to review with 24 hours on week days. Patients under the care of ESD were discussed every 2 weeks at the ESD MDT meeting. The ESD therapists were available to support and review patients at the Stroke Review Clinics run at Broadgreen Hospital as and when required. There was excellent patient centred treatment and goal setting with collaborative working between health and social care. Patients were regularly referred to the Crossroads Service for exercise programmes or carer respite. There was also input from Local Solutions Support Team. On the day of the visit the ESD team had not registered for SSNAP ESD data collection, it is planned however, that they will be inputting into this data set. There was rotation of staff within ESD, Stroke Rehabilitation Unit and Acute Stroke Unit team to share expertise. The staffing levels appeared good within the team. The Speech and Language Therapist reported that they sometimes switch between SRU and ESD depending on demand. It was unclear if physiotherapist and occupational therapists had this level of flexibility. There was no regular patient satisfaction survey conducted. The Dieticians have started doing their own patient survey. It was clear that the team provides an excellent service. They are (based on current staffing levels) unable to provide the recommended level of therapy input, as if patient s were inpatients (daily 45 minute sessions). This service was only available 5 days a week with no provision for weekend working. The therapists reported that although they often put care plans and therapy plans in place on patients discharged to nursing and residential homes they did not have the time to enable the care home staff to deliver this therapy. It was unclear whether nursing home staff had the willingness to actually deliver this therapy. 23