ANEURIN BEVAN HEALTH BOARD Stroke Delivery Plan Template for 2009/2010 Objective Action Desired Output / Monitor and manage all those at risk of stroke and, refer as appropriate to smoking cessation services, alcohol services, walking for health schemes, exercise referral schemes, and any other relevant local lifestyle initiatives Primary Prevention Review current performance/ issues within primary care (via QOF) LHB Medical Directors - Dr Southan On-going Primary care presentation issues to be explored. Patients understanding & education and self help services. Primary care performance indicators owned and joint training and audit programmes developed Stroke Association Work ongoing across the five localities to develop a joint approach to primary prevention of cardiovascular disease, involving CVD lead nurses and practice nurses. Schemes in place targeting smoking cessation, BP checks, exercise referral schemes amongst other. Intermediate care services reinforcing health promotion messages and providing sign posting to services. Pathway on Map of Medicine also this will link to National pathways on Generic chronic conditions management, Smoking cessation and Heart failure. Assessment at individual GP practice level of individual practice prevalence and outcomes from QOF 08/09 Recent work at a WAG level via All Wales Vascular Project Group to develop a Vascular Risk Assessment Policy with consideration of review of current service provision and potential recommendation for implementation of a systematic CVD ABHB Draft Stroke Action Plan 1 09/12/2009
prevention strategy. Refer all TIA patients within 24 hours of onset of symptoms to a one-stop assessment and investigation service in line with Royal College of Physicians guidelines Access to TIA clinics Pathway Confirm intention of Trust to provide same day/next day access to TIA clinics Implement project plan to address any requirements for delivery of universal services Primary care has access to same day/next day TIA clinics Individuals at risk being identified in timely manner TIA task and finish group led by Prof Khanna April 09 South Gwent - TIA clinics at RGH in place since 12/10/09. On going development of service is being managed by the local TIA Clinic Operational Group. CT scan ordering protocol written and agreed locally to be trialled. 5 day a week North - 5 day a week TIA clinics at NHH in place since 1/3/09. On going development of service is being managed by the Nurse Specialist in conjunction with the Consultant Information packs sent to all GPs on access process for clinics and successful recognition of symptoms and diagnosis. Pathway on Map of Medicine. Protocol to be explored with WAST for direct access to TIA clinics. Direct admission of suspected stroke patients to a stroke bed if appropriate health professional has made the preliminary diagnosis First Contact Pathway Agreement of protocols among unscheduled care providers through A&E and MAU Finalised July 09 First contact ensures that individuals have access to Welsh Ambulance Service / Primary Admission flow process agreed and being monitored for patients being fast tracked through A&E straight to MAU. ABHB Draft Stroke Action Plan 2 09/12/2009
Implementation of Face Arm appropriate care Speech Test (FAST) pathway Direct admission for WAST prehospital FAST positive patients to a dedicated/co-located or ringfenced acute stroke bed Care/ Secondary Care Pathway on Map of Medicine. Risk Issues Access and pressure on beds across the acute sites including Stroke which inhibits smooth throughput. Wider ABHB pressure issue and incorporated by the Division into discussions with patient flow work stream. WAST remain concerned regarding the Pre-Hospital admission of suspected stroke patients to the A&E Departments at both sites regarding the availability of a dedicated / colocated or ring- fenced bed at these locations on our arrival. In line with the stroke programme of work, if an appropriate health care professional has made the preliminary diagnosis, suspected stroke patients should have direct admission to a stroke bed. All WAST operational staff have been trained in the FAST assessment test and are practicing to the latest JRCALC clinical practice guidelines for Stroke / Transient Ischaemic Attach therefore will be undertaken an appropriate preliminary diagnosis. This needs further discussion and agreement between ABHB and WAST leads at a higher level. ABHB Draft Stroke Action Plan 3 09/12/2009
Admission of suspected stroke patients from A&E Departments and Medical Emergency Assessment Units to appropriately sited and staffed stroke beds or units Direct and Timely Access to Assessment and Diagnostics Identify incidence of patients admitted to Trust with query stroke across both sites Establish and test achievability across two acute admitting sites Work with radiology directorate to agree protocols for access to CT scan 24/7 including immediate Establish and test achievability across two acute admitting sites Develop implementation framework All patients admitted to Gwent Trust with query stroke admitted to a unit which has the capability to assess and diagnose Stroke, i.e. access to urgent brain scan to support diagnosis and care planning Establishing future thrombolysis feasibility of this across the two acute sites. Dr Sullivan & Dr Reed & Prof Khanna November 09 CT scanning provided via A&E/emergency OOH. RGH have agreed protocol for Stroke specialist nurses to request same working day CT scan for suspected stroke patients. At NHH CT scanning requests from Stroke Team are managed within 24hours. Weekend CT service available for acute strokes between 09.00-17.00. At RGH, scanning slots for head CT are available on a daily basis. Planning towards a weekend CT service continues. Pathway on Map of Medicine. CT out of hours is currently covered by radiologists and radiographers on call. Train all radiographers who work the hospital 24/7/ 365 shift system to undertake CT head scans. This will provide support for the 7 day access to CT. Training will take place outside of normal working hours so that the out of hours and shift staff have access to specific lists of CT head scans booked for training and the dedicated time of the experienced CT radiographers To support 7 day access to CT for stroke patients would require additional support for the radiographer on call system as they have to travel to site for the calls as well as work their normal substantive hours Dr B Sullivan 24/7 routine cover for CT scan available at NHH. 5 day routine cover available at RGH (M-F). Weekend emergency cover provided at RGH. Development of protocols needed and to be inserted into Map of Medicine. Risk Issues Scanning at weekends and managing of on call rota. ABHB Draft Stroke Action Plan 4 09/12/2009
Develop a national protocol and quality requirements, in line with professional body recommendations, for implementation through local policy for timing and range of rehabilitation assessments and interventions that should be available on the acute specialist stroke unit MDT Acute Phase Identify shortfalls within Team across the two acute sites September 2009 Delivery of Acute Stroke care requires dedicated staff across A&E, Radiology, Therapies and Nursing Senior Nurses and Service managers Training deficits across both sites identified & rolling programme established weekly for local ward training. STAR, NIHSS and ROSIER training completed for all staff in NHH and RGH. 0-7 Day Acute Pathway A. Hyper Acute Stroke Unit B. Acute Stroke Unit Understand current process for hyper and acute care for patients Patients receiving the best care, in the right place at the right time Senior Nurse J Mould September 2009 Universal pathway agreed in line with SSIP guidance and Map of Medicine. Includes all elements of care from individual and MDT professionals to identify workforce and skills that are required for the patient and carer. Early screening for safe swallowing Audit compliance with care pathway Review training needs of key staff groups to support assessment (Nursing, A&E, MAU and paramedics) All patients have early screen for safe swallowing recorded in care plan Dr Stroud / Trust Senior Nurses September 2009 Swallow training complete for staff at RGH & NHH (this will form part of rolling programme to capture all new staff). Swallow assessments part of daily patient review following MUST assessment and recorded in care plan. Pathway on Map of Medicine standard forms can be added once pathway is published. ABHB Draft Stroke Action Plan 5 09/12/2009
All patients suspected of or confirmed as having had a stroke must be admitted to dedicated and collocated acute stroke beds staffed by a specialist multi-disciplinary acute medical and rehabilitation stroke team. NB As a milestone towards delivering this target, the co-location of beds must be delivered from May 2008 Access to acute stroke unit Prof P Khanna April 09 [A stroke unit will have: a consultant physician(s) with responsibility for stroke policy for direct admissions from A&E, MAU continuous physiological monitoring Access to scanning within 1 and half hours of admission Specialist ward rounds daily Acute stroke protocols/ guidelines provision of information to patients and carers about stroke continuing education programmes for staff Agree designation of protected ring fenced capacity to provide acute stroke care at both RGH and NHH Agree and implement appropriate staffing model to support the acute stroke units through refocusing existing resources Review long term model for acute stroke unit and cost/benefit of providing on one or two sites for Gwent Receive care on dedicated stroke unit which has access to physiological and neurological monitoring and intervention, early mobilisation and care planning (target = 0% outliers). Reduced lengths of stay for acute stroke patients Improved outcomes and recovery Ring fenced beds in place on both sites by June 09. Continued development needed for adherence of policy. This will be audited early 2010. Stroke Physician funding secured in place by 2010. Physiological monitoring equipment in place. Specific project plans in place covering Ward B6 RGH and Ward 2/4 NHH for improvement of management of high risk patients. ABHB Draft Stroke Action Plan 6 09/12/2009
Develop a national protocol and quality requirements in line with professional body recommendations for implementation through local policy for a thrombolysis service Development of Thrombolysis Service Develop plans in line with South East Regional Network. 9-5 service 5 days a week on each site Agree Diagnostic Need and Staffing Agree coding and data recording and monitoring of patient flows through acute sites Understanding of interim planning for both acute sites for 24/7 access ahead of a proposed S3C Compliance with RCP Guidelines for 2010. Prof Khanna North & South Thrombolysis groups through to AB wide Thrombolysis Group K Smith WAST lead December 09/March 10 Detailed project plans in place for North and South units covering: Assessment criteria & documentation Education CT scanning Pathway Operational set up issues Detailed action plans include providing a 9-5 day service being agreed for implementation from 1 st December 09 and 24/7 service options appraisal and resource requirements for AOF target of 1 st April 2010. Pathway on Map of Medicine. Risk issues Nurse staffing ratios should be 1:1 for stroke patients at this stage. All nurses on each shift should be trained in hyper acute care. Resus beds and A&E full so emergency throughput for both A&E and WAST remain a major issue. 24/7 Radiography services (regional issue). ABHB Draft Stroke Action Plan 7 09/12/2009
Develop a national protocol and quality requirements, in line with professional body recommendations, for implementation through local policy for timing and range of rehabilitation assessments and interventions that should be available on transfer from acute stroke beds to rehabilitation stroke beds where early discharge home is not appropriate Objective Action Desired Output / Responsible Timescale Progress at October 2009 Consider national protocol and quality requirements, in line with professional body recommendations and implement through local policy Consider Professional body recommendations, range of assessments required and timeframes for assessment. Local position established against national protocol Develop care pathway Link to care pathway Care pathway developed Explore and develop links to Work/ Education and link to pathway. Explore existing services e.g. pathways to Work to link with this workstream Agree framework to support regular patient and carer review in partnership with primary care Gwent Stroke Rehabilitation Group/ Gwent Stroke Rehabilitation Complete Professional bodies no longer specify assessment tools within the RCPL guidelines. Complete Development of model for community/outreach services Life- Long Patient/Carer Support To be lined into pathway and service developments/ modelling Develop plans to extend current stroke outreach services working in partnership with other key services in line with CF and Setting the Direction. Reduced overall length of stay Levels of disability reduced on Rehab Group/ Clinical Champions GP Group, & Plans being developed in line with rehabilitation/early discharge models of care. ABHB Draft Stroke Action Plan 8 09/12/2009
discharge CNS Pathway on Map of Medicine to be signed off. Stroke CNS role to be reviewed. Delayed transfers of care eliminated Regular patient reviews undertaken Strong partnership working with voluntary sector CNS role mapping undertaken includes Nurse Consultant role. Wider discussions within modelling process on roles and responsibilities. Mapping exercise across 5 Boroughs to understand services and staffing being undertaken by December 09. Risk Issues Agreement on model for Stroke Hospital Rehab Services and community support teams across health and social care. Potential for changes in team structures and workforce. Implement through SSIP Rehab Care Bundles work stream. Linking through Stroke Board Rehabilitation subgroup for consistency of approach/join up of other themes to enable operational service delivery e.g., education and training objectives, documentation, care pathway development, stroke model development etc Bundles implemented across inpatient rehabilitation units in phase 1 Model to be agreed Role out to Community in phase 2 Locality SSIP Leads CNS s/senior nurses/ Service Managers SSIP Rehab Care Bundles work stream. Leads identified. Membership of Rehabilitation group revised to provide consistency across work streams. Consider national Intelligent Targets, Develop local bundles implementation group with agreed Project Lead - Michelle Graham with National protocol provided via Stroke Services Improvement Partnership (SSIP) in the form of Care Bundles/ Intelligent ABHB Draft Stroke Action Plan 9 09/12/2009
leads and project Lead with link back to lead/ rehabilitation Group for professional MDT support/ steer from CNS/ PODS to communicate progress standardise approach where possible. locality SSIP leads. targets approach. for local implementation WHC(2007) 082 December 2007 Development of rehabilitation stroke bundles Develop Local Policy Policy in place TBC Establish representation and communication link with the National Education / Training Framework Group Consider local application/ identifying competencies/ training needs Review therapy staffing and training, specialist nursing and health care support workers Carer and family support available to support pathway. Develop High level education/ training plan to guide local Lead Dietician for Stroke represents ABHB at the National Education Group Information linked to Rehabilitation Group. PODS have explored professional training available / competencies. Meetings ongoing to develop / agree competency / training framework for professional / non professionals in Gwent, linking with the frailty workforce planning / programme Lead. Meetings scheduled 2/ 12/09 and 14/12/09 JB/ collating data with Rehab Group. Michelle linking with JB? Rehab group and Executive Director Nursing re: nursing and CNS roles. Michele/ Jo B linking work streams re: SSIP work and rehabilitation where possible through rehab group. ABHB Draft Stroke Action Plan 10 09/12/2009
implementation. Risk Issues Therapies capacity gap with inequity of services. Develop a national protocol and quality requirements in line with professional body recommendations, for implementation through local policy for MDT and multi agency discharge planning and care that include agreement of a long-term care plan with patient and carer, which can also include referral to: - rehabilitation stroke beds or discharge with management by a stroke out reach team/ assisted discharge team and / or; community based specialist rehabilitation services, such as communication support, that are designed to meet the needs of all patients including those of younger people and /or; day hospital or out patient therapy family and carer support and information for secondary prevention advice and on-going support within the community Specialist follow up for long term support services Social Services for community support including home adaptations Education and support for self-help, including return to work, secondary prevention, medicines management and oral hygiene Discharge planning to be incorporated in care pathways and standardisation of approach to documentation across units/ community where possible to support local implementation MDT approach to documentation to be agreed,based upon UA, incorporating professional record keeping, MDT approach to person centred integrated individualised stroke plan//treatment plan Standardised paperwork across ABHB Agreement of documentation to guide use in Reablement Teams Once documentation agreed/ Implementation plan to be developed and agreed Jo Beecham/ Marie Nixon / Michelle Graham/ Rehabilitation Group December 2009 Discussions ongoing. Professionals have considered national / local paperwork and opportunity to standardise the professional / MDT approach across units / professions where possible. Rehabilitation meeting scheduled for 19 th November to progress further. Proposals from the group will be reported to Heads of Service and Stroke Board who will guide onwards process for sign off. Process linked in pathway. Documentation to be added once agreed. Rehabilitation Group incorporates Health ABHB Draft Stroke Action Plan 11 09/12/2009
and Social Care partners to agree processes and facilitate a seamless transition of care, move towards more integrated working. WHC action above Documentation and pathways work to assist in guiding process to achieve seamless transition of care, MDT goal planning, weekly MDT /reviews allocation of key worker Care bundles included in the care pathway and SSIP work will be used to implement the inpatient rehabilitation pathway with aim to extend to community providing Community stroke model agreed. Ongoing progressing well via Rehabilitation Group linking with ABHB UA coordinator. Risk Issues Therapies capacity gap with inequity in service. Determine need for intensive multi-disciplinary longer term rehabilitation within an appropriate community environment where appropriate Review of model of care with specific reference to the need for inpatient stroke rehabilitation on one or two sites. Reduced overall length of stay Levels of disability reduced on discharge Delayed transfers of care eliminated Service Managers, Lead Nurses & J Beecham December 09 Regular patient reviews undertaken Strong partnership working with ABHB Draft Stroke Action Plan 12 09/12/2009
voluntary sector 7 day stroke rehabilitation Increased Nurse Rehab interventions will reduce length of stay Refer all stroke patients, whether in hospital, continuing care or at home to palliative care and end of life care, where appropriate Longer Term Reduced overall Management length of stay Develop plans to extend current stroke outreach services working in partnership with other key services Agree framework to support regular patient and carer review in partnership with primary care Life- Long Patient/Carer Support Levels of disability reduced on discharge Delayed transfers of care eliminated Regular patient reviews undertaken Clinical Champions GP, Rehab, & CNS 2009/10 Plans being developed in line with rehabilitation/early discharge models of care. Pathway on Map of Medicine to be signed off. OTHER AREAS OF WORK SSIP Stroke Bundles Develop local bundles implementation group and take forward at both sits for data from April to September 09 Strong partnership working with voluntary sector Understanding of timeline for each services for acute patients to enable CNSs/senior nurses/ service Managers/ Ongoing Early bundles implemented. Review of compliance monthly action s plans needed for areas of non compliance. ABHB Draft Stroke Action Plan 13 09/12/2009
Development of rehabilitation stroke bundles focus of priorities NLIAH Intelligent Targets added to pathway on Map of Medicine. Awaiting guidance from SSIP team. Regional Priorities Ensure lead clinician and manager are represented for ABHB Ensure that local and regional priorities are interlinked and complimentary Prof Khanna/Sam Crane Ongoing Regional meeting in place since January 2009. Risk Issues Regional Acute site agreement for Thrombolysis Services. Telemedicine Services across the Region. Radiographers 24/7 on each site Regional rota. Neurosciences review. ABHB Draft Stroke Action Plan 14 09/12/2009