Blackpool Fylde & Wyre Hospitals NHS Foundation Trust Peer Support Visit 23 RD July 2009 Feedback Report Contents Paul Davies Consultant Stroke Physician & Network Clinical Lead North Cumbria University Hospitals NHS Trust 1
Contents Page Background.. 3 Introduction & National Sentinel Audit Results. 4-6 Blackpool Stroke Pathway 7 A&E Department.. 8 Imaging Department. 9-10 Clinical Decisions Unit.. 11 Acute Stroke Unit 12-13 Speech and Language Department 14 Department of Nutrition & Dietetics 15 Physiotherapy Department...16 Occupational Therapy Department.17 Post Acute Care 18 Assessment & Rehabilitation Centre. 19 Recommendations.. 20 Summary 21 Appendix 1 22 Appendix 2 23 Appendix 3 24 2
Background The Blackpool Fylde & Wyre Hospitals NHS Foundation Trust serves a population of approximately 330,000 residents of Blackpool, Fylde & Wyre. The area has a large elderly population and there are varying levels of deprivation. A large proportion of the population only live in Blackpool transiently. Stroke admissions for 2008/09 totalled 781 and the hospital currently provides a thrombolysis service for acute ischemic stroke five days per week between 9am -5pm, however, there are plans underway to provide a 24 hour, seven days a week service. The stroke service also provides a five day a week neuro-vascular clinic that assesses 800 patients per year of which approximately half are TIA s. The stroke service is staffed by 2.5 WTE medical consultants; Dr Mark O Donnell, Dr Jim McIlmoyle and Dr Gulati. The hospital currently has the only Stroke Nurse Specialist within the Lancashire & Cumbria area and a Stroke Research Nurse. 3
Introduction A team from the Cardiac and Stroke Networks in Lancashire & Cumbria visited Blackpool Victoria hospital on the 23rd July 2009. The purpose of the visit was to allow exchange of good practice between various departments and Trusts within the Network. The team visiting Blackpool included Consultant Physicians, an A & E Physician, Physiotherapists, Occupational Therapists, Nurses, Managers, Social Workers and a member of the Stroke Association. Amongst the team, five different Trusts were represented. The day comprised of meetings with Chief Executives of the Acute Trust and the PCT, meetings with staff on the Acute Stroke Unit, A&E, Imaging, Physiotherapists, Occupational Therapists, Speech and Language Therapists and meetings with teams that provide rehabilitation following discharge from hospital. All involved in the visit felt that it had gone very well and were very positive about the care that is provided at Blackpool Victoria Hospital for stroke patients. We were very impressed with the individuals that provide the care and we were impressed with the attitude that drives continuous development and that was clearly seen in many departments that we visited. The following report is based on the meetings and feedback that the team had during the day. We hope that it is helpful for the team in Blackpool in further developing their services. The team at Blackpool were the first in the Network to introduce thrombolysis for Acute Ischemic Stroke. They are also among the first to develop five day neuro-vascular clinics. They are also a high recruiting centre for clinical trials within the North West Stroke Research Network. Members of the team are also contributing to the development of stroke services throughout Lancashire and Cumbria Network. Dr O Donnell is a clinical lead for the Cardiac and Stroke Networks in Lancashire & Cumbria, Dr McIlmoyle is a lead for the North West Stroke Research Network and Joanne Howard is the lead for the Stroke Research Nurses in Cumbria and Lancashire. National Sentinel Audit Results The National Sentinel Audit is completed every other year. Every Trust in the country submits data on their stroke services that allows benchmarking of services compared to standards set in the Royal College Guidelines for the management of stroke. The audit is in two parts; an audit of organisation and an audit of process. The audit of process is a retrospective review of the notes of the first 60 patients admitted with stroke from April 2008. The Organisation score from the 2008 national sentinel audit was 68 which placed Blackpool in the middle half of the national table. This is an improvement on the 2006 score of 50, when Blackpool was in the lower quartile. Blackpool scored very highly for dedicated consultant physician time and continuing education. They also scored highly for acute care organisation. There was evidence from the visit that areas that had been identified as needing improvement were being addressed. 4
National Sentinel Audit Results Table 2: Summary of key organisational results by hospital including waiting time for scan, presence of neurovascular/tia clinic and involvement with patients Site name (name of trust or hospital within a trust) Average CT scan waiting time weekdays Average CT scan waiting time weekends Average MRI scan waiting time weekdays Average MRI scan waiting times weekends Neurovascular clinic TIA Service Neurovascular clinic average waiting time All high risk TIA patients seen and investigated within All low risk TIA patients seen and investigated within Patient/carer views sought on service Report produced within 12 months analysing Overall position in 2008 Overall position in 2006 Blackpool Fylde & Wyre Foundation Trust East Lancashire Hospitals NHS Trust LTH Foundation Trust (Chorley) LTH Foundation Trust (Preston) UHMBT Furness General Hospital UHMBT (Royal Lancaster Infimary) UHMBT (Westmorland General) NCA (Cumberland Infirmary) NCA (West Cumberland) 5-24 5-24 25-48 5-24 5-24 5-24 5-24 0-4 0-4 25-48 25-48 5-24 25-48 5-24 5-24 25-48 25-48 25-48 25-48 5-24 25-48 25-48 Yes Yes 14 No No No No Yes Yes 10 No No Yes Yes Yes Yes 14 No No Yes No Yes Yes 10 No No Yes No Yes Yes 7 No No No No No Yes N/A No No No No Yes Yes 2 No No No No Yes Yes 5 No Yes Yes No Yes Yes 0 Yes Yes Yes Yes N/A This table includes average estimated waiting times for scans, whether the trust has a neurovascular/tia clinic and involvement with patients. The total organisational score is an aggregated score across all domains. The best organised 25% of hospitals are in the upper quartile designated by the symbol, the least well organised hospitals for stroke care are in the lower quartile designated with the symbol, the middle half lie between the two designated by the diamond Key: Upper Quartile Middle Half Interquartile Range Lower Quartile The process audit can be summarised by analysing the nine key process indicators. Scores for these key indicators correlate well with the total audit score. Blackpool scored 60 points for the nine key process indicators which place the Trust in the lowest quartile. Furthermore, no patients received the complete bundle of all nine process indicators. This result was not in keeping with what we would expect from a service that is providing good care in many parts of its stroke service. 5
Table 3: The 9 key indicators for all hospitals Above National % Site name Below (name National of % trust or hospital Above National % within a Below trust) Above National % Below National % Number of cases in the audit Screening for swallowing disorders <24 after admission (%) Brain scan within 24 of stroke (%) Physiotherapist assessment within 72 of admission (%) Occupational therapy assessment within 4 working days of admission (%) Patient weighed during admission (%) Patient s mood assessed by discharge (%) Rehabilitation goals agreed by the multidisciplinary team (%) Aspirin or clopidogrel by 48 after stroke (%) Patients spent at least 90% of stay on a stroke unit (%) Percentage of eligible patients receiving all 9 Overall position in 2006 Overall position in 2008 National Results % (11369) 72% 59% 84% 66% 72% 65% 86% 85% 58% 17% Network Results % 65% 48% 76% 45% 58% 54% 79% 80% 54% 6% Blackpool Fylde & Wyre Foundation (58) 50 32 84 24 61 58 69 90 77 0 Trust East Lancashire Hospitals NHS Trust (62) 72 55 80 66 64 11 48 87 62 0 N/A LTH Foundation Trust (Chorley) (40) 44 16 29 42 41 35 55 35 LTH Foundation Trust (Royal (51) 72 71 66 33 62 91 92 82 52 19 Preston) UHMBT Furness General Hospital (42) 50 51 86 64 49 66 80 41 32 0 UHMBT Royal Lancaster Infirmary (63) 67 54 73 43 17 35 90 92 53 0 UHMBT Westmorland (20) 89 0 73 0 65 56 91 100 100 0 General Hospital NCA Cumberland Infirmary (59) 67 53 85 75 81 76 96 93 62 20 NCA West Cumberland (53) 79 65 89 31 86 65 97 91 58 11 Key: Upper Quartile Middle Half Interquartile Range Lower Quartile Above National % Below National % The audit showed that 77% of patients were spending ninety per cent of the admission within the stroke service which is in the top quartile. However, problems were identified around completing swallowing screening within 24 of admission, accessing CT head scans within 24 and early assessment by occupational therapists. We noted on the visit that all these areas for improvement highlighted in the audit were in the process of being addressed by the Blackpool team. 6
Overview of the Blackpool Stroke Pathway Patients are usually admitted through the A&E department. The pathway that they follow to the Stroke Unit depends on whether they are eligible for thrombolysis and also depends on the time of day that they are admitted. Patients who meet the criteria for thrombolysis and are admitted between 9am-5pm Currently, thrombolysis is provided for patients with acute ischemic stroke who meet the criteria on a 9am-5pm basis, Monday to Friday. We were made aware of plans to introduce a 7 day thrombolysis service and of plans to extend it to a 24 hour basis. In time, this may be assisted by telemedicine. Patients that are currently admitted between 9am-5pm and are appropriate for thrombolysis are identified quickly in A&E, get an urgent CT scan in the next available slot and are transferred immediately to the Acute Stroke Unit. If no bed is available on the Acute Stroke Unit the patient is boarded out to allow access to the Acute Stroke Unit for thrombolysis. This process clearly works very well for those patients that meet the criteria for thrombolysis. Patients who do not require thrombolysis but are admitted between 9-5pm If beds are available on the Acute Stroke Unit they are transferred there directly, the majority get CT head scans before transfer to the Acute Stroke Unit, but some may need to return to the CT scanner from the Acute Stroke Unit for their head scan and chest x-ray. Patients admitted after 5pm After 5pm and at weekends most stroke patients are transferred from A&E to the Medical Admissions Unit rather than to the Acute Stroke Unit. The reasons for this are:- 1. Lack of beds on the Acute Stroke Unit. 2. No doctors available on the Acute Stroke Unit to clerk patients after 5pm on a weekday or at weekends. Doctors are based on the combined assessment unit and patients are clerked there. Stroke patients are usually transferred to the Acute Stroke Unit the following morning but maybe transferred to the Stroke Unit before they have had their CT head scans. Patients who remain on the Medical Assessment Unit are sometimes assessed by stroke therapy staff if their transfer to the Stroke Unit is delayed but this does not seem to be routine practice. 7
A&E Department Visiting group:- Julia Charnock Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Stuart Durham Consultant in Emergency Medicine (Lancashire Teaching Hospitals NHS Foundation Trust) Sue Melling Commissioning Support Officer Adult Services (NHS Central Lancashire) Kay Smith Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) The A&E department was visited by the above members of the team. We were very impressed by using A&E as a single point of access for stroke patients from which they could be triaged and the possibility of treatment with thrombolysis could be assessed for appropriate patients. It was very clear that the A&E team felt well supported by the stroke physicians who they know on a first name basis. It appeared that the pre-alert from the North West Ambulance Service was not being consistently applied. It was felt that some crews who were more aware of the thromboylsis service were providing A&E with a pre-alert but other crews were not. It was not clear what the current recommendations to NWAS are and whether there has been any formal contact with NWAS to encourage the pre-alert and this is something that could be explored. It was very clear that a lot of the changes that have developed in the stroke service in Blackpool have come through developing the thrombolysis service and that there are very clear routes to the Acute Stroke Unit during daytime for patients that require thrombolysis. For TIA s a very impressive service has been developed by the physicians at Blackpool Victoria Hospital. The neuro-vascular clinics are held each working day with same day ultrasound and frequently same day CT head scans is a very good service. Patients who attend A&E will get an ABCD 2 score to assess their short term risk of stroke and often get a clinic appointment the same day or within 48. Out of direct admissions to the Stroke Unit is dependent on bed availability. If no bed is available on the Acute Stroke Unit patients are admitted to the clinical decision unit. A&E staff were fully aware of the future aspirations of trying to develop a 24 hour stroke service and the obvious implications upon A&E when this is developed. 8
Imaging Visiting Group:- Julia Charnock Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Meg Davey Business Manager (East Lancashire Hospitals NHS Trust) Paul Davies Consultant Stroke Physician (North Cumbria University Hospitals NHS Trust) Beverly Drake Assistant Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Stuart Durham Consultant in Emergency Medicine (Lancashire Teaching Hospital NHS Foundation Trust) Chris Winster Acute Stroke Ward Manager (Lancashire Teaching Hospitals NHS Foundation Trust) Support from imaging departments is required for the management of acute stroke and TIA. In addition, imaging departments need to be responsive to urgent referrals for thrombolysis or complications following stroke. Strong links between stroke departments and imaging departments do foster good relations and help developments. It was clear from our visit that there are strong links between the imaging and stroke department in Blackpool. There have been a number of significant developments over recent months that have improved the service. The addition of a second multi-slice CT scanner has enabled most patients to get a CT head scan on the same day it is requested. Furthermore, access to MRI scans is likely to improve when a second MRI scanner run by the PCT opens in the near future. Currently, most patients admitted with a stroke via the A&E department will receive a scan before going to the Acute Stroke Unit. All scans that meet the criteria for an urgent scan are done within the appropriate timeframe. All other patients get their scans within 24. The department is looking to adopt a practice for 7 day working and this will enhance the service further. Currently, out of the CT scan radiographer is not resident but can return to scan within 1 hour. The impact of a 24 hour service for thrombolysis for acute ischemic stroke on the imaging department will need to be monitored. Neuro-Vascular Clinic The imaging guideline for the National Stroke Strategy is likely to cause more change in the imaging of TIA patients than stroke patients. The guidance recommends MRI imaging with DWI as the preferred method of imaging. This will be difficult to deliver but MRI for selected cases will be available more rapidly for TIA patients when the new MRI scanner off loads some routine work from the Imaging department. Currently, in Blackpool there are TIA clinics 5 days a week and the vascular ultrasound service is sub-contracted to a company called IVS. Initially, there did seem to be some internal problems with accessing the imaging for the Trusts PACS system but we believe that this has been put right. The ultrasound team provide the neuro-vascular clinic with same day ultrasounds most of the time. Patients can get CT head scans on the same day in the majority of cases. 9
The imaging team within the department did mention one of two frustrations that can arise when they hold a slot for a patient requiring a CT head scan urgently and the patient fails to appear from A&E. It was not clear whether this is always because of the patient s medical condition requiring more time to stabilise or whether there are problems with the availability of porters or nurses to accompany the patient. We believe it would be useful to explore this in terms of its frequency and the cause of the problem as there maybe some relatively simple solutions that would help the CT department in continuing to provide its excellent service. 10
Clinical Decisions Unit (CDU) Visiting group:- Julia Charnock Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Meg Davey Business Manager (East Lancashire Hospitals NHS Trust) Paul Davies Consultant Stroke Physician (North Cumbria University Hospitals NHS Trust) Stuart Durham Consultant in Emergency Medicine (Lancashire Teaching Hospitals NHS Foundation Trust) Kay Smith Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Chris Winster Acute Stroke Ward Manager (Lancashire Teaching Hospitals NHS Foundation Trust) The CDU is located near the A&E department and the Imaging department. This is some way from the Stroke Unit. The CDU is a 30 bed medical admissions unit taking all acute medical admissions over a 24 hour period. The CDU averages about 60 admissions per day of which 1-2 may be stroke patients. Stroke patients are commonly admitted to the unit out of working and the main reasons for this were either lack of beds on the Acute Stroke Unit when required or, in the evenings there were too few doctors to cover admissions to the Acute Stroke Unit. Therefore, patients are admitted via the CDU for clerking by the medical team on call. Initial investigations could be completed, the patients observed in a safe environment and, when appropriate, some treatments commenced. Stroke patients admitted to the CDU were often transferred to the Stroke Unit early the next morning, sometimes without having a CT head scan which meant that the patient had to travel back to the main hospital later in the day. By its nature the CDU is an emergency assessment ward and not a stroke specialist ward. Not surprisingly, there was incomplete awareness of some of the stroke protocols and staff on the unit were not able to provide some of the initial stroke assessments for nutrition, swallow, weight etc. However, most patients are transferred to the Acute Stroke Unit within 24 where these assessments can be completed. We were not clear how many stroke patients may be discharged home directly from the CDU and what follow up arrangements would be made if they were. There is no routine outreach to the CDU from specialist therapists, nurses or speech and language therapists from the ASU. The team acknowledged how difficult it would be to manage new stroke admissions on a busy CDU. The team could also understand why stroke patients were admitted there after working. However, the ideal situation would be direct transfer form A&E following imaging to the Acute Stroke Unit. This may be possible when the stroke unit relocates to the centre of the hospital. 11
Acute Stroke Unit Visiting Group:- Lilian Campos Dietician (Lancashire Teaching Hospitals NHS Foundation Trust) Sarah Clay Assistant Regional Manager (Stroke Association) Meg Davey Business Manager (East Lancashire Hospitals NHS Trust) Paul Davies Consultant Stroke Physician (North Cumbria University Hospitals NHS Trust) Sue Melling Commissioning Support Officer Adult Services (NHS Central Lancashire) Nicola Richards Speech and Language Therapist (North Cumbria University Hospitals NHS Trust) Paul Satterley Physiotherapist (North Cumbria University Hospitals NHS Trust) Andrea Willimott Acting Divisional General Manager (Lancashire Teaching Hospitals NHS Foundation Trust) Chris Winster Acute Stroke Ward Manager (Lancashire Teaching Hospitals NHS Foundation Trust) The Acute Stroke Unit is a 31 bedded unit which is roughly divided into 16 acute and 15 rehabilitation beds. It is sited some distance from the A&E and the main imaging department and this probably causes some difficulties. We are aware that there are plans to try and relocate the Acute Stroke Unit more centrally when the new surgical block is built and some of the current surgical wards are vacated. The current location is remote to the CDU where the admitting doctors are based after working. Consequently, few stroke patients are admitted directly to the Acute Stroke Unit outside working. Occasionally, the admission of stroke patients to the Acute Stroke Unit can be blocked because some beds are occupied by patients with diagnoses other than stroke. This has to be minimised to provide effective and efficient care for stroke patients. However, the care provided on the Acute Stroke Unit is very good. Once patients get to the unit they spend their whole time within the stroke service. We understand that 90% of the stroke admissions in June spent 90% of their time within the stroke service which is very impressive. We were also very impressed by the detailed stroke register. The staff have also developed discharge booklets for patients giving them more information about stroke and their appointments. There are examples of good multi-disciplinary working and all members of the team were developing their services in-line with current guidelines and are re-auditing areas of perceived weakness. The Network team noted the difficulties with access to clinical psychology services. On discharge the patients get a standardised discharge booklet on discharge. Patients are discharged with help of supported discharge teams and are occasionally transferred to community hospitals. Some concerns about the availability of specialist equipment such as wheelchairs at the time of discharge were noted. Further comments on post-acute care are on page 16. Concerns raised by staff on the Acute Stroke Unit were about lengthy waits for psychology referral which is similar to many areas. They also had concerns about difficulties in referring to dietetics and using the MUST tool for screening for patients who are at risk from poor nutrition. 12
The patients get a standardised discharge booklet on discharge but sometimes this is missed but they are trying to be better at providing this. Patients are discharged with help of supported discharge teams and are occasionally transferred to community hospitals. Concerns about the availability of specialist equipment such as wheelchairs were noted. 13
Speech and Language Therapy Visiting group:- Meg Davey Business Manager (East Lancashire Hospitals NHS Trust) Stuart Durham Consultant in Emergency Medicine (Lancashire Teaching Hospitals NHS Foundation Trust) Nicola Richards Speech and Language Therapist (North Cumbria University Hospitals NHS Trust) Chris Winster Acute Stroke Ward Manager (Lancashire Teaching Hospitals NHS Foundation Trust) The speech and language therapy department wishes to provide a better service for stroke patients but was unable because of low staff numbers. Even when staff returned from maternity leave the service would be restricted. The SLT team were trying various ways to improve the service with SLT assistants to help with language difficulties and dysphagia trained nurses to help screen for swallowing problems. In addition, the team are in the process of developing a CD Rom for nursing staff as a self learning tool for the theory of the swallow assessment prior to attending a practical session run by the SLT department. Other areas of good practice are the strong links to community dysphasia support and there are good communications within the team and with other therapists. Swallowing screens performed by the nurses and the SLT team are now documented in the notes. The staff felt that generally they were meeting targets for swallow assessments but there were some issues with documentation that could be easily addressed. However, there are concerns that the waiting times for patient requiring Speech and Language therapy between hospital discharge and being picked up in the community by the community SLT teams are between 6-13 weeks. In addition, there are concerns that a community rehabilitation team is being developed without any additional speech and language therapist being funded. We noted that attempts to find suitably qualified and experienced locums to cover maternity leave were proving difficult. Examples of good practice: Development of an aphasia friendly booklet so that all staff are aware of an individuals likes/dislikes, family relationships etc Restart of group therapy for aphasic patients 14
Dietetics Visiting group:- Lilian Campos Dietician (Lancashire Teaching Hospitals NHS Foundation Trust) Julia Charnock Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) The Dietetics team is very stretched with commitments throughout the whole hospital. Currently there is only one dietician to ten wards, however there were vacancies at the time of the visit. Consequently, they are unable to attend the stroke multi-disciplinary team meetings. However, they do provide a service on a referral basis. Nutritional assessment of stroke patients is made with the MUST tool but it is not clear whether the MUST tool triggered an automatic referral or whether referrals to the department had to be made by another means. Usually, the MUST nutritional monitoring tool should prompt referrals to the dietitians but nursing staff have not been trained to use the MUST tool properly. Dieticians are involved in the management of patients fed by NG tube and PEG tubes but this is also via a referral system which sounded rather bureaucratic than lean. There were no nutrition nurses or nutrition link nurses. An out of feeding regime is used on the wards and this has been shared with the dietetics department at Lancashire Teaching hospitals NHS Foundation Trust. 15
Physiotherapy Visiting group:- Lilian Campos Dietician (Lancashire Teaching Hospitals NHS Foundation Trust) Julia Charnock Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) The physiotherapists were met during the Acute Stroke Unit visit. They seemed to have a well staffed, well organised comprehensive service. They have aspirations to develop a 7 day service which will be the first seven day therapy service for stroke within the Lancashire and Cumbria Stroke Network. The Physiotherapists have adequate therapy areas and good equipment. We noted that a discharge team was being developed with good physiotherapy involvement. 16
Occupational Therapy Visiting group:- Lorna Fazackerley Senior Occupational Therapist (Lancashire Teaching Hospitals NHS Foundation Trust) Tracy Walker Community Stroke Rehab Team Leader (NHS Blackburn with Darwen) Occupational therapists were met on the Stroke Unit. They are a good team who have developed a number of screening tools and protocols for screening for mood and returning to driving. The OT team is half the size of the physiotherapy team and there were some concerns about the level of experience that the team members had and that they were supervised from rather a distance. The team recognised the level of supervision was not ideal and was a consequence of vacancies within the department. However, the work of individuals seemed to be of a high standard. The staffing levels for OT were as follows: Acute: 1 x Band 6 OT Rehab: 1 x Band 5 OT Early Supported Discharge Team: 1 x Band 7 OT (also provides supervision and support to Band 5 and 6 OT s on acute and rehab) 2x OT Technical Instructors Band 3 and 4 (work as part of ESD but will support the Band 5 and 6 OT staff on acute and rehab too) Ward based OT staff i.e. Band 5 and 6 are fairly new to working in the clinical field of stroke. They are requiring guidance and training from the Band 7 OT who is very experienced in the area of stroke. The band 7 OT works according to evidenced based principles in keeping with current developments in stroke both through professional and personal career aspirations but due to reduced staffing resources, is finding it difficult to do this as well as keeping all acute, rehab and ESD services running efficiently. Examples of good practice are: good use of outcome measures, driving screening assessment, mood screening assessment, development of ESD service (see patients up to 12 weeks post hospital discharge) 17
Post Acute Care There seemed to be a number of different teams that patients could be discharged with following their time within the Stroke Unit in Blackpool Victoria Hospital. There seemed to be an early supported discharge team that would take some patients. A community neuro-rehabilitation team is being developed and there are several other teams that would pick up patients who have had a stroke. Overall, it seemed that there were a high number of specialist and non-specialist teams providing rehabilitation to stroke patients after discharge from hospital. We thought that a mapping exercise, if it has not already been done, to explore these different services, what could be provided, and where the deficiencies are would be worthwhile. Potential service for rehabilitation for stroke patients following discharge from stroke unit Domiciliary Resident Blackpool community stroke team Peripheral hospitals Early supported discharge team for stroke. 3 months max rehab Stroke Unit Assessment and rehabilitation Centre Enablement team 6 weeks rehab Outreach Complex conditions team (care packages) 18
Assessment and Rehabilitation Centre Visiting group:- Paul Davies Consultant Stroke Physician (North Cumbria University Hospitals NHS Trust) Beverly Drake Assistant Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Lorna Fazackerley Senior Occupational Therapist (Lancashire Teaching Hospitals NHS Foundation Trust) Sue Melling Commissioning Support Officer Adult Services (NHS Central Lancashire) Paul Satterley Physiotherapist (North Cumbria University Hospitals NHS Trust) Kay Smith Service Development & Improvement Manager (Cardiac and Stroke Networks in Lancashire & Cumbria) Tracy Walker Community Stroke Rehab Team Leader (NHS Blackburn with Darwen) Andrea Willimott Acting Divisional General Manager (Lancashire Teaching Hospitals NHS Foundation Trust) A number of the team visited the Assessment and Rehabilitation Centre (ARC). This is a 21 bedded intermediate care facility in Blackpool. There is another 9 bedded unit in the North of the town. The ARC admits about 230 patients per year with a wide range of problems. There is a mixture of step-up and step-down care. Step-down care can be from elderly care wards, surgical or orthopaedic wards. There are few transfers from the stroke unit. The staff recognised the limits of their skills and could call on guidance from the community stroke team. The ARC is, a very good example of health and social services working together. We did note that there was no GP input and we did note that they would like stronger links into the hospital if possible. 19
Recommendations 1. Formalise agreement with NWAS for pre-alert of stroke patients who may be eligible for thrombolysis. 2. To explore whether members of the Specialist stroke team could include CDU on morning ward round to assess patients for swallowing and arrange for CT head to be performed on the way to ASU. 3. To identify frequency of delayed transfers from A&E to CT scanner and the reasons why. 4. To consider whether direct admission for stroke patients would be possible outside working day when the stroke unit is more centrally located. 5. To consider ring-fencing up to 3 stroke beds to allow better access for direct admissions. 6. To consider business cases to increase therapy staff for OT, Dietetics and Speech and Language to provide a better service for stroke patients. 7. To establish nutrition link nurses. 8. To increase the number of nurses trained to assess swallowing. 9. To establish links with Clinical Psychology. 10. To establish reasons for delay in providing equipment for discharge, eg wheelchairs. 11. To map the pathways to rehabilitation following discharge from the acute hospital. 20
Summary The visit to the stroke services at Blackpool Victoria Hospital was the first of a series of Peer Support visits that are planned by the Lancashire and Cumbria Stroke Network. The Stroke team are clearly well-motivated and have made a lot of changes since the Sentinel Audit results of 2008. One of the very impressive features was the way staff in several departments continually wanted to improve the service and among these we noted plans for 7 day therapy and plans for 7 day radiology. Particular areas of good practice were around education, and achieving a high proportion of stroke patients spending 90% of their time within the stroke service both of which were very impressive. However, for a number of reasons, the staffing levels of Occupational therapists, Dieticians and Speech and Language therapists seemed low compared to the number of stroke admissions per year. The pathway for stroke patients from the emergency department to imaging and on to the acute stroke unit works very well for some patient at some times of the day. The challenge is to make it work at this high standard for all patients. Overall, the impression was that the stroke service in Blackpool is providing a good service but may be constrained by some staffing and logistic issues. The staff are well aware of the problems and are motivated to keep improving the system 21
Appendix 1 Blackpool Fylde & Wyre Hospitals NHS Foundation Trust Site Map 22
Appendix 2 Peer Support Visiting Group 1 Consultant Stroke Physician & Network Clinical Lead 2 Consultant in Emergency Medicine 3 Commissioning Support Officer Adult Services 4 Acting Divisional General Manager Dr P Davies Mr Stuart Durham Sue Melling North Cumbria University Hospitals NHS Trust Lancashire Teaching Hospitals NHS Foundation Trust NHS Central Lancashire Andrea Willimott Lancashire Teaching Hospitals NHS Foundation Trust 5 Business Manager Meg Davey East Lancashire Hospitals NHS Trust 6 Service Development & Improvement Manager Julia Charnock Cardiac and Stroke Networks in Lancashire & Cumbria 7 Acute Stroke Ward Manager Chris Winster Lancashire Teaching Hospitals NHS Foundation Trust 8 Speech & Language Nicola Richards NHS Cumbria Therapist 9 Physiotherapist Paul Satterley NHS Cumbria 10 Community Stroke Rehab Tracy Walker NHS Blackburn with Darwen Team Leader/Clinical OT 11 Dietician Lillian Campos Lancashire Teaching Hospitals NHS Foundation Trust 12 Senior Occupational Therapist Lorna Fazackerley Lancashire Teaching Hospitals NHS Foundation Trust 13 Assistant Regional Sarah Clay Stroke Association Manager 14 Service Development & Improvement Manager Kay Smith Cardiac and Stroke Networks in Lancashire & Cumbria 15 Assistant Service Development & Improvement Manager Beverly Drake Cardiac and Stroke Networks in Lancashire & Cumbria 23
Appendix 3 Peer Support Hosting Departments Acute Stroke Unit Alison Stewart Stroke Specialist Nurse Karen Medcalf Stroke Co-ordinator Anita Tunstall Community Matron Alison Ingham Discharge Co-rdinator Karen Waywell OT Acute Stroke Unit Caroline Box Physiotherapist A&E Sue Hegarty A&E Co-ordinator Clinical Decisions Unit Stephen Mellars CDU/MAU Ward Manager Imaging Roger Bury Radiologist Sarah Proctor Radiographer Ruth Brookes Admin Manager OT Department Kate Jackson Senior Occupational Therapist Assessment & Rehabilitation Centre Maureen Daly Home Care Manager Janice Howarth Home Care Manager Judith Buffham Residential Rehab Services Manager Speech and Language Lorraine Wackrill Speech and Language Therapist Physiotherapy Caroline Box Physiotherapist Department of Nutrition & Dietetics Hayley Robertson Dietician 24