NHS Lanarkshire. Local Report ~ November Stroke Services: Care of the Patient in the Acute Setting

NHS Lanarkshire Local Report ~ November 2005 Stroke Services: Care of the Patient in the Acute Setting

NHSScotland Regional Breakdown 13 12 15 1 NHS Argyll & Clyde 2 NHS Ayrshire & Arran 3 NHS Borders 9 7 4 NHS Dumfries & Galloway 5 NHS Fife 6 NHS Forth Valley 7 NHS Grampian 1 6 14 5 8 NHS Greater Glasgow 9 NHS Highland 10 NHS Lanarkshire 11 NHS Lothian 8 2 10 11 3 12 NHS Orkney 13 NHS Shetland 14 NHS Tayside 15 NHS Western Isles 4

Local Report ~ November 2005 Stroke Services: Care of the Patient in the Acute Setting Stroke is one of the main causes of death and disability in Scotland. Whilst it is a major illness, many patients will make a partial or full recovery with the aid of specialist investigations and a variety of specialist care. The NHS Quality Improvement Scotland (NHS QIS) Stroke Services Project Group developed four standards which focus on the patient s journey of care in hospital, from initial referral, through rehabilitation and secondary prevention, to discharge. The standards therefore represent what are considered to be the key elements of care and treatment for people who have had a stroke or transient ischaemic attack (TIA). This report presents the findings from the peer review of performance against the standards.

NHS Quality Improvement Scotland 2005 ISBN 1-84404-342-8 First published November 2005 NHS Quality Improvement Scotland (NHS QIS) consents to the photocopying, electronic reproduction by uploading or downloading from the website, retransmission, or other copying of the findings contained in this report, for the purpose of implementation in NHSScotland and educational and not-for-profit purposes. No reproduction by or for commercial organisations is permitted without the express written permission of NHS QIS. Copies of this report, the Clinical Standards for Stroke Services: Care of the Patient in the Acute Setting, and other documents produced by NHS QIS, are available in print format and on the website. www.nhshealthquality.org

Contents Contents 1 Setting the Scene 5 1.1 How the Standards were Developed 6 1.2 How the Review Process Works 6 1.3 Reports 8 2 Summary of Findings 10 2.1 Overview of Local Service Provision 10 2.2 Summary of Findings Against the Standards 11 3 Detailed Findings Against the Standards 15 Appendix 1 Glossary of Abbreviations 36 Appendix 2 Details of Review Visit 37 Appendix 3 Stroke Services Project Group Members 38 Appendix 4 Timetable of Review Visits 40 3

1 Setting the Scene NHS Quality Improvement Scotland (NHS QIS) was set up by the Scottish Parliament in 2003 to take the lead in improving the quality of care and treatment delivered by NHSScotland. NHS QIS does this by setting standards and monitoring performance, and by providing NHSScotland with advice, guidance and support on effective clinical practice and service improvements. About this Report The Clinical Standards for Stroke Services: Care of the Patient in the Acute Setting were published in March 2004. These standards are being used to assess the quality of services provided in the acute hospital setting throughout NHSScotland. This report presents the findings from the peer review of NHS Lanarkshire. This review visit took place on 21 September 2004, and details of the visit, including membership of the review team, can be found in Appendix 2. 5

1 Setting the Scene 1.1 How the Standards were Developed In March 2002, a Stroke Services Project Group was established under the chairmanship of Professor Ross Lorimer, former President of the Royal College of Physicians and Surgeons, Glasgow, and previous Chairman of the Scottish Executive Health Department s Coronary Heart Disease/Stroke Task Force. Membership of the Project Group includes both healthcare professionals and members of the public (see Appendix 3). The Group oversees the quality assurance process of: developing standards reviewing performance against the standards throughout Scotland, using self-assessment and external peer review reporting the findings from the review. When developing the stroke services standards, a Scotland-wide consultation process was undertaken. The views of health service staff, patients, carers and the public were sought, and all the relevant evidence available at the time was taken into account. Draft standards were also piloted at two sites: Caithness General Hospital, Wick, and Glasgow Royal Infirmary. 1.2 How the Review Process Works The review process has two key parts: local self-assessment followed by external peer review. First, each NHS Board assesses its own performance against the standards. An external peer review team then further assesses performance, both by considering the self-assessment data and visiting the NHS Board to validate this information and discuss related issues. The review process is described in more detail below (see also the flow chart on page 9). Self-Assessment by NHS Boards On receiving the standards, each NHS Board assesses its own performance using a framework produced by NHS QIS. This framework includes guidance about the type of evidence (eg guidelines, audit reports) required to allow a proper assessment of performance against the standards to be made. The NHS Board submits the data it has collected for this self-assessment exercise to NHS QIS before the on-site visit, and it is this information that constitutes the main source of written evidence considered by the external peer review team. 6

External Peer Review An external peer review team then visits and speaks with local stakeholders (eg staff, patients, carers) about the services provided. Review teams are multidisciplinary, and include both healthcare professionals and members of the public. All reviewers are trained. Each review team is led by an experienced reviewer, who is responsible for guiding the team in its work and ensuring that team members are in agreement about the assessment reached. The composition of each team varies, and members have no connection with the NHS Board they are reviewing. Both of these factors facilitate the sharing of good practice across NHSScotland, and ensure that each review team assesses performance against the standards rather than make comparisons between one NHS Board and another. At the start of the on-site visit, the review team meets key personnel responsible for the service under review. Reviewers then speak with local stakeholders about the services provided. After these meetings, the team assesses performance against the standards, based on the information gathered during both the self-assessment exercise and the on-site visit. The visit concludes with the team providing feedback on its findings to the NHS Board. This includes specific examples of local initiatives drawn to the attention of the review team (recognising that other such examples may exist), together with an indication of any particular challenges. Assessment Categories Each review team assesses performance using the categories met, not met and not met (insufficient evidence), as detailed below. Met applies where the evidence demonstrates the standard and/ or criterion is being attained. Not met applies where the evidence demonstrates the standard and/or criterion is not being attained. Not met (insufficient evidence) applies where no evidence is available for the review team, or where the evidence available is insufficient to allow an assessment to be made. A final category not applicable is used where a standard and/or criterion does not apply to the NHS Board under review. 7

1 Setting the Scene 1.3 Reports After each review visit, NHS QIS staff, with clinical input as appropriate, draft a local report detailing the findings of the review team. This draft report is sent to the review team for comment, and then to the NHS Board to check for factual accuracy. The local report is published only after all the visits for that topic have been undertaken nationwide. Once a national review cycle is completed, the relevant project group reconvenes to examine review findings and make recommendations. The project group then oversees the production of a national overview of service provision across Scotland in relation to the standards. This document includes both a summary of the findings (highlighting examples of local initiatives and challenges for the service) and recommendations for improvement. Part of the remit of NHS QIS is to report whether the services provided by NHSScotland, both nationally and locally, meet the agreed standards. This does not include reviewing the work of individual healthcare professionals. In achieving this aim, variations in practice (and potential quality) within a service will be encountered and subsequently reported. Please note all reports published are available in print format and on the NHS QIS website. 8

The Review Process After Visit During Visit Prior to Visit Standards published and issued Self-assessment framework finalised and issued NHS Board undertakes self-assessment exercise and submits outcomes to NHS Quality Improvement Scotland NHS Quality Improvement Scotland sends information from self-assessment submission to peer review team Two-way presentations covering background on NHS Quality Improvement Scotland and local service provision Draft local report produced and sent to review team for comment Review team meets stakeholders to discuss local services Review team assesses performance in relation to the standards Review team feeds back findings to NHS Board Draft local report sent to NHS Board to check for factual accuracy Project Group considers findings of local reviews and drafts national overview NATIONAL OVERVIEW AND LOCAL REPORTS PUBLISHED 9

2 Summary of Findings 2.1 Overview of Local Service Provision Lanarkshire is situated in central Scotland and has a population of around 556,114. The majority of the population live in urban areas, of which Cumbernauld, Hamilton and Motherwell are the largest in the region. The proportion of older people in the population is below the national average, whereas levels of illness and deprivation are relatively high. Local NHS System and Services The Board of NHS Lanarkshire is responsible for improving the health of the local population and for the delivery of the healthcare required. It provides strategic leadership and has responsibility for the efficient, effective and accountable performance of the NHS in Lanarkshire. At the time of the review visit, the NHS Board area contained two NHS operating divisions: Lanarkshire Acute Hospitals Division (acute care services); and Lanarkshire Primary Care Division (primary care services). The NHS Board is accountable for both continuously improving the quality of their services, and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish (framework of clinical governance). Further information about the local NHS system can be accessed via the website of NHS Lanarkshire (www.show.scot.nhs.uk/nhslanarkshire). Within NHS Lanarkshire, acute stroke services are provided at Wishaw General Hospital; ; and Monklands Hospital, Airdrie. There are three stroke units, one at each acute site, with a total of 73 dedicated stroke beds. There are neurovascular clinics held at each acute hospital with access to computerised tomography (CT) scanning. Within the period of September 2003 July 2004, a total of 825 patients were admitted with a diagnosis of stroke, excluding those patients with transient ischaemic attack (TIA). 10

2.2 Summary of Findings Against the Standards A summary of the findings from the review, including examples of local initiatives drawn to the attention of the review team, is presented in this section. A detailed description of performance against the standards/ criteria is included in Section 3. Organisation of Hospital Stroke Services for Scotland The review team commended NHS Lanarkshire for the provision of a stroke unit at each acute hospital site. Each stroke unit is a defined area within the hospital where acute stroke care and rehabilitation of stroke patients is provided. Patients admitted to a stroke unit are cared for by a specialist multidisciplinary team, co-ordinated by a consultant with a specific interest in stroke. The review team noted that the percentage of patients admitted to a stroke unit, within 24 hours of admission to hospital with a diagnosis of stroke, is rising; however, the overall percentage is below 70% and presents an ongoing challenge for NHS Lanarkshire. The review team noted that the Lanarkshire Stroke Managed Clinical Network (MCN) is progressing the equitable provision of clinically effective stroke services across NHS Lanarkshire. The stroke MCN is instrumental in developing and monitoring protocols for the management of stroke care, including the local shared protocol for referral to the neurovascular clinics and admission to the stroke units. The monthly stroke multidisciplinary education programmes are well received and regularly attended by staff involved in stroke care. Stroke stakeholders forum events are also held approximately twice a year. These educational events cover a wide range of topics and are open to all professions involved in stroke care across NHS Lanarkshire. Example of a local initiative An audit on visual stroke-related deficiencies was carried out and the findings have informed the development of a local orthoptics initiative for the ophthalmological care of stroke patients. The stroke team at Hairmyres Hospital has held events to share information with orthoptists on the benefits of a multidisciplinary working approach to assessment and rehabilitation of stroke patients, and how to set up a stroke orthoptic service. Stroke patients at Hairmyres Hospital have dedicated orthoptic support and orthoptists regularly attend the stroke multidisciplinary team meetings. 11

2 Summary of Findings Acute Stroke and Rehabilitation (Management of Patients Admitted to Hospital) The review team noted the comprehensive dissemination of stroke protocols across NHS Lanarkshire. Staff in discussion groups verified the awareness of the protocols effective input to the facilitation of stroke care. The review team commended the percentage of stroke patients that have computerised tomography (CT)/magnetic resonance imaging (MRI) within 48 hours of admission to hospital. Audit data provided by NHS Lanarkshire indicate that aspirin treatment is not initiated within 48 hours of admission to hospital for all patients in whom a haemorrhagic stroke, or other contraindication, has been excluded. The review team noted that the percentage of patients for whom aspirin treatment is initiated within 48 hours is increasing; however, this remains an on-going challenge for NHS Lanarkshire. Audit data collected on the percentage of patients that have a swallow screen assessment performed on the day of admission did not demonstrate the practice reported by staff in discussion groups. Staff identified that they are addressing challenges around recording the swallow screen assessment and communicating its completion to colleagues. Example of a local initiative The review team commended the admission and discharge information packs provided to stroke patients. The admission pack includes information about the stroke unit and the multidisciplinary team which provides stroke care. The discharge pack was produced by the Lanarkshire Stroke MCN in conjunction with Chest, Heart and Stroke Scotland (CHSS); it provides a guide to communication problems, ongoing support and useful contact detail information for stroke patients and carers in Lanarkshire. Secondary Prevention There are comprehensive written protocols in place across NHS Lanarkshire for the management of secondary prevention. An immediate discharge document, based on SIGN Guideline 65, has recently been revised and is in use at Monklands Hospital and Wishaw General Hospital. Stroke nurses took the lead in redesigning the immediate discharge document to incorporate information on lifestyle 12

issues, secondary prevention, CT results, follow-up arrangements and the key criteria to populate GP registers. The review team noted that discharge documentation is not standardised across NHS Lanarkshire; therefore, documented risk factors are not shared with stroke patients at Hairmyres Hospital. Staff reported the intention to adopt the immediate discharge document at Hairmyres Hospital in the near future. The Lanarkshire MCN Health Promotion and Prevention Group has developed a valuable initiative to assess the common themes which run through the established MCNs to inform health promotion initiatives across NHS Lanarkshire. Example of a local initiative There is a local pharmacy initiative in North Lanarkshire which recruits GP practices to refer patients for a community pharmacist home visit. The pharmacist is able to discuss medication issues with the patient and, where appropriate, the carer, to check compliance and offer counselling on the use of medication for secondary prevention. Staff reported the intention to roll out this initiative across NHS Lanarkshire. Discharge The review team commended the co-ordinated multidisciplinary and multi-agency discharge planning which begins as soon as the patient s clinical condition permits. Patients can be referred to the early supported discharge service; this joint health and social care service can offer a rehabilitation programme for patients in their own home for up to 6 weeks after discharge from hospital. The early supported discharge service adopts the single shared assessment process; staff reported that work is ongoing to identify the most appropriate ward staff to receive single shared assessment training to further facilitate the discharge process. 13

2 Summary of Findings There is a Lanarkshire Patient and Carer Group, supported by acute staff to address strategic issues. The review team commended this proactive working which develops carer skills and provides a Lanarkshire-wide support network. Examples of local initiatives A stroke passports to health project is currently being developed to tailor stroke information to the patient s individual needs. The project will use web-based software to enable staff, patients and carers to produce patient-specific, locally relevant advice packs. Digital imaging is used in occupational therapy for access visits, home assessments and patient therapy. With the patient s consent, images of the home environment are used to discuss further treatment options with the patient and can be shared with other agencies to inform post-discharge services. Currently, digital imaging is used at Wishaw General Hospital and staff reported the intention to roll out the initiative across NHS Lanarkshire. 14

3 Detailed Findings Against the Standards Standard 1: Organisation of Hospital Stroke Services for Scotland Standard Statement All patients with symptoms of a stroke or TIA have access to specialist stroke services, which will include a neurovascular clinic and stroke unit, for rapid diagnosis, assessment, acute treatment and rehabilitation according to an agreed written local protocol, based on national guidelines. Essential Criteria 1: There is a shared, written local protocol, agreed between primary and secondary care, for referral to neurovascular clinics and admission to the stroke unit. There is a shared, written protocol for referral to neurovascular clinics and admission to the stroke units within NHS Lanarkshire. The protocol was developed by stroke physicians in partnership with Lanarkshire Stroke Managed Clinical Network (MCN) GP advisers and is agreed between primary and secondary care. The protocol is approved, reviewed and monitored by the Lanarkshire Stroke MCN Evaluation Project Group, and has recently been updated. The protocol has been disseminated to Local Health Care Cooperatives (LHCCs), to all GP practices and to the out-of-hours co-operatives across Lanarkshire. In discussion groups, primary care staff commended the protocol and the referral forms which are used to access the fast-track transient ischaemic attack (TIA)/stroke clinics. For speed of referral, the forms can either be faxed or, to some clinics, sent electronically. Staff from Hairmyres Hospital reported the intention to have electronic referral to the fast-track TIA/stroke clinic in place within the next year. Staff from reported that accident and emergency (A&E) staff can also refer patients via a voicemail message, leaving the patient s details for a member of the stroke team to make contact. 15

3 Detailed Findings Against the Standards 2: A consultant physician with a special interest in stroke is responsible for the management of stroke patients. A consultant physician with a special interest in stroke is responsible for the management of stroke patients within each acute hospital in NHS Lanarkshire. The review team noted that the consultant physicians responsible for patient care at Monklands Hospital and rely on locums to cover leave of absence. Staff reported that there are currently five vacant consultant geriatrician posts within NHS Lanarkshire and identified appointing a second stroke consultant at both Monklands Hospital and as a priority. 3: There is a stroke unit comprising a defined area with designated beds for acute care and rehabilitation of stroke patients. There are three stroke units within NHS Lanarkshire: a 24-bedded stroke unit at Hairmyres Hospital; a 24-bedded stroke unit at Monklands Hospital; and a 25-bedded stroke unit at Wishaw General Hospital. Each stroke unit is a defined area with designated stroke beds within the hospital where organised acute stroke care and rehabilitation of stroke patients is provided by a multidisciplinary team with a special interest in stroke. The review team commended NHS Lanarkshire for providing a dedicated stroke unit within each acute site. 16

4: 70% of all patients admitted to hospital with a diagnosis of stroke are admitted to the stroke unit within 24 hours of presentation at hospital, and remain in specialist stroke care until in-hospital rehabilitation is complete. STATUS: Not met STATUS: Not met STATUS: Not met Audit data provided by NHS Lanarkshire indicate that less than 70% of all patients admitted to hospital within NHS Lanarkshire with a diagnosis of stroke are admitted to a stroke unit within 24 hours of presentation, and remain in specialist stroke care until in-hospital rehabilitation is complete; therefore, this criterion is not met. The review team identified this as a particular challenge for NHS Lanarkshire. It was noted, however, that the percentage of patients admitted to the stroke units at Hairmyres Hospital and Monklands Hospital within 24 hours of presentation at hospital is increasing, and of those patients admitted, most remain in the stroke units for the majority of their stay in hospital. 5: The stroke unit includes a co-ordinated multidisciplinary team, consisting of healthcare staff with specialised knowledge who have a weekly meeting to discuss problems, goals, progress and discharge plans. The core membership of the team is staffed in accordance with SIGN Guideline 64. It also includes appropriate involvement of other healthcare professionals. Each stroke unit within NHS Lanarkshire includes a co-ordinated multidisciplinary team, consisting of healthcare staff with specialised knowledge, in accordance with Scottish Intercollegiate Guidelines Network (SIGN) Guideline 64. The review team was informed that staff recruitment is an issue and identified this as an ongoing challenge for NHS Lanarkshire. In discussion groups, dietetic staff reported that they did not benefit from a recent recruitment intake and that the dietetic service is overstretched across the three acute sites. There are weekly multidisciplinary team meetings within each stroke unit to discuss problems, goals, progress and discharge plans. Attendance at the weekly multidisciplinary team meetings is recorded by a diary system at and Hairmyres Hospital, and by a register attached to the 17

3 Detailed Findings Against the Standards casenote trolley at Monklands Hospital. The main points of discussion are recorded in the individual patient case records and in the records of each profession. Allied health professionals reported that they are working towards standardising the documentation of patient s goals and progress by adopting the use of subjective objective assessment plan (SOAP) notes. The intention is to improve communication amongst all healthcare professionals and to display assessment, problems and plans in an organised format to facilitate the care of the patient. Other appropriate healthcare professionals also attend the multidisciplinary team meetings when required, including a liaison dietitian, a pharmacist and members of the early supported discharge team. In addition, staff reported strong links with the liaison community psychiatry nursing service. The review team noted that the core multidisciplinary stroke teams within NHS Lanarkshire do not always include social work staff. However, staff reported a good working relationship with social work services. Stroke liaison nurses work with social work staff to meet the needs of stroke patients and a social worker can be allocated to a patient if a more complex assessment is needed. The review team noted the delay in accessing clinical psychology services. The review team commended the orthoptics initiative. Staff from Hairmyres Hospital reported that an audit on visual stroke-related deficiencies was carried out; this resulted in dedicated orthoptic support for stroke patients and regular attendance of orthoptists at the stroke multidisciplinary team meetings. Staff from all three hospitals also reported that informal meetings are held between core team members on a daily basis. The review team commended the multidisciplinary working and communication between healthcare professions at each stroke unit. 6: There are planned stroke education and training programmes for all staff involved in stroke care. Comprehensive multidisciplinary education programmes are in place at each stroke unit. The planned stroke education and training programmes are open to all staff involved in stroke care and are held at each acute hospital on a monthly basis. Staff reported good attendance levels at each education and training event. In discussion groups, staff reported that they have access to a Lanarkshire-wide stroke clinical community (for nursing), stroke special interest groups (for occupational therapy and physiotherapy) and links to a national stroke group (for speech and language therapy). Stroke stakeholders forum events are held approximately twice a year and have included topics such as: training and development needs; spiritual and religious needs of stroke patients; addressing the needs of ethnic minority groups; multidisciplinary documentation and protocols; the needs of younger people with stroke; and health promotion and secondary prevention. Staff reported that the Lanarkshire Stroke MCN stroke information pack is widely disseminated 18

across NHS Lanarkshire to the stroke units, emergency admission wards, early supported discharge teams and day hospitals. The pack includes information on: national guidance for stroke services; the Lanarkshire stroke care pathway; the Lanarkshire smoking cessation strategy; the Lanarkshire stroke operational policy; and an information pack for the NHS Education for Scotland e-library. The review team commended the approach to developing competency training: nurses and allied health professionals contribute to meeting training needs by utilising the skills of in-house staff to train colleagues. This novice to expert approach is based on the developing Stroke MCN competency framework. A post has recently been created to assess training needs, develop a multi-agency stroke training module and to facilitate the delivery of training to a wide range of staff within NHS Lanarkshire partner agencies. The stroke awareness trainer is a 2-year fixed term post, from May 2004, funded by the New Opportunities Fund. A training needs assessment database for stroke staff is under development; currently, this holds training details of 750 staff. 7: 80% of new patients are seen within 14 days of receipt of referral to the neurovascular clinic. STATUS: Not met STATUS: Not met Audit data collected by NHS Lanarkshire indicate that over 80% of new patients are seen within 14 days of receipt of referral to the neurovascular clinic at ; therefore, the review team concluded that meets this criterion. A secretary is trained to process the referral forms. There are two clinics with dedicated computerised tomography (CT) slots. Under 80% of new patients are seen within 14 days of receipt of referral to the neurovascular clinics at Hairmyres Hospital and Monklands Hospital; therefore, neither hospital meets this criterion. Staff from Hairmyres Hospital reported some recent difficulties with the fast-track stroke clinic due to the number of patients being referred to the clinic. A second fast-track service linked with A&E is planned and nursing support is currently being identified. 19

3 Detailed Findings Against the Standards Desirable Criterion 8: 80% of new patients are seen within 7 days of receipt of referral to the neurovascular clinic. STATUS: Not met STATUS: Not met Audit data collected by NHS Lanarkshire indicate that over 80% of new patients are seen within 7 days of receipt of referral to the neurovascular clinic at ; therefore, the review team concluded that meets this criterion. Under 80% of new patients are seen within 7 days of receipt of referral to the neurovascular clinics at Hairmyres Hospital and Monklands Hospital; therefore, neither hospital meets this criterion. 20

Standard 2: Acute Stroke and Rehabilitation (Management of Patients Admitted to Hospital) Standard Statement All patients admitted to hospital with a diagnosis of stroke are managed according to a local, written management protocol, based on national guidelines. Essential Criteria 1: There is a local, shared, written management protocol in place, based on national guidelines for acute stroke and rehabilitation. (This protocol applies to all patients, including those not admitted to a stroke unit.) There is a Lanarkshire stroke services operational protocol which outlines the core professionals involved in Lanarkshire s stroke services, their roles and responsibilities, and the protocols which underpin the management of acute stroke and rehabilitation. The stroke-specific protocols include the admissions guideline and fast-track referral form, and provide guidance on the management of: tertiary referral; swallow screen; deep vein thrombosis (DVT) prophylaxis. There are also Lanarkshire stroke MCN protocols for acute monitoring and interventions/investigations and secondary prevention. There are generic protocols for: nutritional assessment; continence; pressure care; early supported discharge referral; smoking cessation; and discharge planning. The protocols are based on SIGN Guidelines 13, 14, 20, 24 and 64. The Lanarkshire Stroke MCN Evaluation Group was involved in the development of the stroke protocols, in partnership with multidisciplinary working groups and stroke neurologists at the regional centre at the Southern General Hospital, Glasgow. Staff reported that the stroke protocols have been shared with Lanarkshire Stroke MCN GP advisers, the General Medical Services (GMS) Contract Group, emergency care leads and out-of-hours redesign groups. The protocols have been distributed to each emergency admissions unit and are available on the medical education intranet. Staff in discussion groups verified the awareness and effectiveness of the stroke protocols across NHS Lanarkshire. 21

3 Detailed Findings Against the Standards 2: 80% of patients have CT/MRI imaging within 48 hours of admission, unless there is a documented contraindication. Audit data collected by NHS Lanarkshire indicate that more than 80% of patients have CT/magnetic resonance imaging (MRI) within 48 hours of admission to hospital, unless there is a documented contraindication. The review team noted that the percentage of patients that have CT/MRI imaging within 48 hours has recently increased and identified this as a particular strength of NHS Lanarkshire s stroke services. 3: Aspirin treatment is initiated within 48 hours of admission for all patients in whom a haemorrhagic stroke, or other contraindication, has been excluded. STATUS: Not met STATUS: Not met STATUS: Not met Audit data collected by NHS Lanarkshire indicate that aspirin treatment is not initiated within 48 hours of admission to hospital for all patients in whom a haemorrhagic stroke, or other contraindication, has been excluded; therefore, this criterion is not met. Staff reported that the out-of-hours team at Monklands Hospital is carrying out a review of aspirin treatment to try and address the delay. The review team noted the percentage of patients at Monklands Hospital that have aspirin treatment within 48 hours of admission has increased significantly over the last few months. 22

4: All patients have an initial swallow screen test performed on day of admission, unless there is a documented contraindication. STATUS: Not met (insufficient evidence) STATUS: Not met (insufficient evidence) STATUS: Not met (insufficient evidence) Audit data collected by NHS Lanarkshire indicate that not all patients have an initial swallow screen assessment performed on the day of admission when there is not a documented contraindication. Staff reported difficulties in collecting these audit data. The screening checklist can be entered into the medical casenotes/care plan or admission proforma, however, its completion is not always documented or successfully communicated to the relevant staff. Consequently, staff identified that the audit data are not reliable and that, in practice, patients do have an initial swallow screen assessment carried out on day of admission. Staff acknowledged the challenge of recording and communicating the completion of the swallow screen assessment on the day of admission and reported that work is ongoing to address these issues. In-service swallow screen training is provided for nursing staff by a senior speech and language therapist. A nursing protocol for the initial swallow screening of stroke patients was put in place in September 2004, identifying the staff responsible for monitoring the swallow screen assessments through annual audit. The review team concluded, however, that the documentation and communication issues have contributed to the provision of audit data which does not support staff reports that the swallow screen assessment is performed on the day of admission; therefore, there is insufficient evidence to meet this criterion. 5: All patients are assessed by a member of the multidisciplinary team for rehabilitation needs within 48 hours of admission. All patients in each acute hospital are assessed by a member of the relevant stroke multidisciplinary team for rehabilitation needs within 48 hours of admission. The written protocol for the assessment of rehabilitation needs is contained within the Lanarkshire stroke service operational policy. The review team noted that there is no allied health professional service at weekends and assessment of rehabilitation needs may be carried out by a member of the stroke services medical team. 23

3 Detailed Findings Against the Standards 6: There is information, advice and support from the multidisciplinary team for patients (and, with their consent, carers) with provision of information in a variety of formats, taking account of each patient s communication abilities. The stroke multidisciplinary teams are able to provide information, advice and support to patients and carers in a variety of formats. The review team commended the admission and discharge information packs provided to stroke patients. The admission pack includes information about the stroke unit and the staff involved in stroke care. The discharge pack includes advice on common problems and feelings a patient may experience, their recovery and wellbeing, and details of ongoing support available from different services. Staff reported that patients communication abilities are individually assessed and information is provided in a suitable format. Staff are aware of the translation services available for patients and the different formats in which publications are available from Chest, Heart and Stroke Scotland (CHSS). 7: Thrombolytic therapy with rtpa is only used in accordance with the criteria defined in its provisional licence, or within the context of a randomised controlled trial. STATUS: Not applicable STATUS: Not applicable STATUS: Not applicable Thrombolytic therapy is not prescribed by NHS Lanarkshire stroke services; therefore, this criterion is not applicable. 24

Standard 3: Secondary Prevention Standard Statement All patients admitted to hospital, or seen at the neurovascular clinic, diagnosed with a stroke or TIA, have their risk factors assessed, documented and treatment offered. Essential Criteria 1: Investigation: The following is documented before discharge and communicated to the patient and their GP: Blood pressure (BP) measurements. STATUS: Not met An immediate discharge document has recently been re-designed and is in use at Monklands Hospital. The immediate discharge document, which has a specific field for detailing the patient s blood pressure measurement, is completed electronically and a copy given to the patient and forwarded to their GP. The review team concluded, therefore, that Monklands Hospital meets this criterion. An interim discharge notification and prescription form is used at. This form details the patient s diagnosis and recommended medicine to be continued. Staff complete a patient profile which includes some clinical information, a social assessment and a discharge checklist. Staff also complete the re-designed immediate discharge document which details the patient s blood pressure measurement. Copies of the interim discharge notification and prescription form, the patient profile and the immediate discharge document are given to the patient and their GP; therefore, the review team concluded that meets this criterion. A patient discharge information summary is in use at Hairmyres Hospital which includes details of the patient s main discharge diagnosis, operations or procedures carried out, follow up arrangements, discharge medication and any additional information on diet and exercise. On discharge, a copy of this summary is given to the patient, their GP and the community stroke nurse. Staff reported that the patient s blood pressure measurement is documented in the patient s casenotes before discharge. A letter detailing clinical information is forwarded to the patient s GP with the discharge information summary. However, blood pressure measurement is not communicated to the patient, therefore, Hairmyres Hospital does not meet this criterion. Staff reported the intention to adopt the use of the immediate discharge document in the near future. The review team commended a recent initiative by the community pharmacy service in North 25

3 Detailed Findings Against the Standards Lanarkshire. GP practices are recruited to refer stroke patients for a home visit by a community pharmacist. The pharmacist talks through the patient s medication with them, checking compliance and offering counselling on the use of medication for secondary prevention. Staff reported the intention to roll out this initiative across NHS Lanarkshire. The review team commended the Lanarkshire MCN Health Promotion and Prevention Group for assessing the common themes which run through the established MCNs to inform health promotion initiatives across NHS Lanarkshire. 2: Investigation: The following is documented before discharge and communicated to the patient and their GP: Blood glucose measurement. STATUS: Not met At Monklands Hospital and, the patient s blood glucose measurement is documented in the immediate discharge document which is shared with the patient and forwarded to their GP. The document has a specific space for detailing this information. The review team concluded, therefore, that Monklands Hospital and meet this criterion. Staff at Hairmyres Hospital reported that the patient s blood glucose measurement is documented in the patient s casenotes before discharge. Staff complete a patient discharge information summary which is forwarded to the GP with a letter detailing clinical information. However, blood glucose measurement is not communicated to the patient, therefore, Hairmyres Hospital does not meet this criterion. 3: Investigation: The following is documented before discharge and communicated to the patient and their GP: ECG report. STATUS: Not met At Monklands Hospital and, the patient s electrocardiogram (ECG) report is documented in the immediate discharge document which is shared with the patient and forwarded to their GP. The document has a specific space for documenting this information. The review team concluded, therefore, that Monklands Hospital and meet this criterion. Staff at Hairmyres Hospital reported that the patient s ECG report is documented in the patient s casenotes before discharge. Staff complete a patient discharge information summary which is 26

forwarded to the GP with a letter detailing clinical information. However, the ECG report is not communicated to the patient, therefore, Hairmyres Hospital does not meet this criterion. 4: Investigation: The following is documented before discharge and communicated to the patient and their GP: Lipids result. STATUS: Not met At Monklands Hospital and, the patient s lipids result is documented in the immediate discharge document which is shared with the patient and forwarded to their GP. The document has a specific space for documenting this information. The review team concluded, therefore, that Monklands Hospital and meet this criterion. Staff at Hairmyres Hospital reported that the patient s lipids result is documented in the patient s casenotes before discharge. Staff complete a patient discharge information summary which is forwarded to the GP with a letter detailing clinical information. However, the lipids result is not communicated to the patient, therefore, Hairmyres Hospital does not meet this criterion. 5: Investigation: The following is documented before discharge and communicated to the patient and their GP: Smoking history. STATUS: Not met At Monklands Hospital and, the patient s smoking history is documented in the immediate discharge document which is shared with the patient and forwarded to their GP. The document has a specific space for documenting this information. The review team concluded, therefore, that Monklands Hospital and meet this criterion. Staff at Hairmyres Hospital reported that the patient s smoking history is documented in the patient s casenotes before discharge. Staff complete a patient discharge information summary which is forwarded to the GP with a letter detailing clinical information. However, this information is not communicated to the patient, therefore, Hairmyres Hospital does not meet this criterion. 27

3 Detailed Findings Against the Standards 6: Investigation: The following is documented before discharge and communicated to the patient and their GP: Identification of other adverse lifestyle risk factors. STATUS: Not met At Monklands Hospital and, other adverse lifestyle risk factors that may affect a patient s health are documented in the immediate discharge document which is shared with the patient and forwarded to their GP. The document has specific spaces to document this information. The review team concluded, therefore, that Monklands Hospital and meet this criterion. Staff at Hairmyres Hospital reported that other adverse lifestyle risk factors that may affect the patient s health are documented in the patient s casenotes before discharge. Staff complete a patient discharge information summary which is forwarded to the GP with a letter detailing clinical information. However, this information is not communicated to the patient, therefore, Hairmyres Hospital does not meet this criterion. 7: Assessment: Written protocol for assessment of carotid artery stenosis. There is an NHS Lanarkshire written protocol for assessment of carotid artery stenosis. Staff reported that the protocol was revised in June 2004. The review team commended the written protocols in place for the assessment and treatment of risk factors associated with stroke, and the dissemination of these protocols across NHS Lanarkshire. 28

8: Management: Written protocol for management of blood pressure lowering. The NHS Lanarkshire Stroke MCN has a written protocol for management of blood pressure lowering. Staff reported that the protocol was revised in February 2004. 9: Management: Written protocol for management of diabetes. The NHS Lanarkshire Stroke MCN has a written protocol for management of diabetes. Staff reported that the protocol was revised in February 2004. 10: Management: Written protocol for management of atrial fibrillation. The NHS Lanarkshire Stroke MCN has a written protocol for management of atrial fibrillation. Staff reported that the protocol was revised in February 2004. 29

3 Detailed Findings Against the Standards 11: Management: Written protocol for management of cholesterol lowering. The NHS Lanarkshire Stroke MCN has a written protocol for management of cholesterol lowering. Staff reported that the protocol was revised in February 2004. 12: Management: Written protocol for management of smoking cessation. There is a joint written protocol for the management of smoking cessation at Monklands Hospital and. Staff from Hairmyres Hospital confirmed that smoking cessation services are community based and can be accessed through the stroke unit using a referral form. A recently employed pharmacist talks to each patient about their smoking history and encourages use of the smoking cessation service. A member of the stroke team can refer a patient to the East Kilbride Local Health Care Co-operative smoking cessation service, or a community service in their home area. 13: Management: Written protocol for implementation of antiplatelet therapy policy. There is an NHS Lanarkshire stroke MCN written protocol for implementation of antiplatelet therapy policy. Staff reported that the protocol was revised in February 2004. 30

Standard 4: Discharge Standard Statement All patients admitted to hospital with a stroke have timely assessment of discharge needs and the development of a discharge plan. There is consultation with the patient, carer, primary care and community services so that the immediate and ongoing needs for rehabilitation and support are addressed. Essential Criteria 1: There is timely planning of discharge in consultation with patient and carers. Discharge planning, in consultation with patients and carers, begins as soon as the patient s clinical condition permits. A multidisciplinary admission record is used across NHS Lanarkshire, in which staff record the patient s social history, including housing, home circumstances, social services/home support and potential discharge problems. Should potential discharge problems be identified, the discharge co-ordinator is informed. The multidisciplinary admission record also includes a section to record all communication with carers and family, and a section to detail discharge information, including medication on discharge. Staff reported that the admission record is regarded as a core document to which each profession adds their own notes throughout the patient s stay in hospital. In addition to the multidisciplinary admission record, staff at Hairmyres Hospital also use a clerking proforma for stroke patients which includes a section to record the patient s homecare details. Staff reported that the Lanarkshire Stroke MCN Patient and Carer Group was consulted on the acute services discharge protocol which has now been adopted throughout NHS Lanarkshire. The discharge planning group developed and produced the discharge planning guidelines and the accompanying staff education pack in January 2003. The discharge planning guidelines contain the specific discharge protocols for each acute hospital, the social work acute services discharge protocol and information on the early supported discharge service. Staff reported that the named nurse is responsible for co-ordinating a patient s discharge and developing a discharge plan. The named nurse is supported by the stroke nurse and the multidisciplinary team. Staff at complete a Lanarkshire stroke MCN patient profile which includes a discharge checklist. Staff at Hairmyres Hospital and Monklands Hospital use a Lanarkshire Stroke MCN discharge checklist to verify when the different factors of discharge planning are completed, including consultation with patients and carers. Patients in each hospital can be referred to the early supported discharge service which operates throughout NHS Lanarkshire. This is a joint health and social care service which can offer a rehabilitation programme for patients in their own home for up to 6 weeks after a patient has been 31

3 Detailed Findings Against the Standards discharged from hospital. The service adopts single shared assessment and care management principles and all team members have rapid access to a joint equipment store, community alarm and homecare resources. The early supported discharge referral forms include referral criteria, a summary and ongoing needs description from each discipline within the stroke team, and equipment needs. 2: An immediate discharge summary is provided to the patient and GP, based on SIGN Guideline 65, which gives a detailed diagnosis. At Monklands Hospital, an immediate discharge summary, based on SIGN Guideline 65, is provided to the patient and to the GP. The review team concluded, therefore, that Monklands Hospital meets this criterion. Staff at reported that the immediate discharge document also used in Monklands Hopital, is completed and a copy is given to the patient and their GP. The review team concluded, therefore, that meets this criterion. At Hairmyres Hospital, a patient discharge information summary, based on SIGN Guideline 65, is provided to the patient and their GP on discharge; therefore, the review team concluded that Hairmyres Hospital meets this criterion. However, staff reported the intention to adopt the use of the more detailed immediate discharge document, as used at Monklands Hospital and Wishaw General Hospital, in the near future. 3: An information pack is provided for patients and carers on, or prior to, discharge. This pack is tailored to the patient s individual needs and communication abilities, and includes a contact telephone number for a liaison healthcare professional who can provide both early and ongoing contact with stroke patients after discharge. Stroke nurses assess each patient s communication abilities and provide discharge information in a suitable format. A stroke information discharge pack for patients and carers is provided on discharge. The discharge pack includes advice on common problems and feelings a patient may experience, their recovery and wellbeing, and details of ongoing support available from different services. The telephone numbers of the stroke nurse team and the young stroke support worker who can provide early and ongoing contact with stroke patients are included in the discharge pack. 32