Hyper-Acute Stroke Management: Educational Project Lynn Reid Lead Training Coordinator 2011-2012 1 LR 2012
Contents: 1. Acknowledgements... 3 2. Introduction and rationale... 3 3. Project summary of initial activity (Phase 1)... 3 Figure 1 Delegates by profession n= 211... 3 Figure 2 Delegates by NHS Board... 4 4. Expenditure analysis... 4 5. Phase 2 of project... 5 Learning Outcomes... 5 Figure 3 Table of study days and venues... 5 Figure 4 - Delegates by professional role (n = 67)... 6 6. Evaluation from the SAS study sessions and points raised... 6 7. Acute stroke management in the emergency department... 7 South East study day... 7 Figure 5 Delegates by profession n=12... 8 Figure 6 Delegates by NHS Board... 8 North study day... 9 Figure 7 Delegates by profession n=21... 9 Figure 8 Delegates by NHS Board... 10 8. Expenditure analysis of phase 2 of the hyper-acute stroke project... 11 9. Conclusion... 11 Figure 9: Delegates by profession throughout phase 1 and 2 (n=311)... 12 Figure 10: Delegates by NHS Board throughout phase 1 and 2... 12 10, References... 13 11. Appendix One... 14 2 LR 2012
1. Acknowledgements Chest Heart and Stroke Scotland were approached by the National Advisory Committee for Stroke (NACS), to coordinate a project of stroke training that would support the hyper-acute stroke pathway in Scotland. Funding was agreed by CHSS executive committee and the stroke training project began in 2009.This project has been a great success due to the support and enthusiasm of members of NACS, British Association of Stroke Physicians (BASP), Scottish Ambulance Service (SAS), Scottish Centre for Telehealth and Telecare (SCTT) and the stroke training team of Chest Heart and Stroke Scotland (CHSS). For a full list of contributors to phase 2 of this project refer to Appendix One. 2. Introduction and rationale SIGN 108 (2008) and the Better Heart Disease and Stroke Care Action Plan (2009) recommend that all patients, who are considered eligible, should be offered thrombolysis treatment following acute ischaemic stroke. NHS QIS Clinical Standards for Stroke Services (2009) indicate that 80% of patients, who are eligible for thrombolysis treatment, should commence treatment within one hour and that this service is monitored and recorded by the stroke Managed Clinical Networks (MCN). This project was developed to support the education and training needs of those healthcare professionals that would be involved in the hyper-acute stroke journey with the aim of enhancing service provision. 3. Project summary of initial activity (Phase 1) Six study days were developed and offered from May 2009-Sept 2010 to support this initiative. Initially these days were specifically for physicians, however as the project progressed each regional study day was designed to meet the perceived needs of the hyper-acute stroke pathway within each region. In some areas this included nursing and ambulance staff. (See figure 1 for an outline of professions attending and figure 2 by NHS Boards). Figure 1 Delegates by profession n= 211 Participant by Profession 90 80 70 60 50 40 30 20 10 0 Physicians SAS Sroke Specialist Nurses Ot her 3 LR 2012
Figure 2 Delegates by NHS Board Participants by NHS Board 40 35 30 25 20 15 10 5 0 Fife Grampian Dumfries & Galloway Western Isles Ayrshire & Arran Highland Lanarkshire GG & Clyde Lothian Borders Tayside Forth Valley Orkney Shetland The initial remit for this project was to offer 6 study days, 2 per region: South East (SE), North and West. The outcomes and objectives of the project were met under budget, leaving an under spend of 4,606.66. 4. Expenditure analysis Venues Expenses Catering STARs ** Expenditure in 2009-10 200.00 200.00 679.75 2,000.00 Expenditure 1 April - 31 October 2010 1,392.78 384.20 1,536.61 1,592.78 584.20 2,216.36 2,000.00 ** Radiological scans were formatted for the SE training were added to the STARs Thrombolysis module. Total expenditure - 6,393.34 For a full copy of the initial project evaluation summary (Phase 1) please contact: Lynn Reid Lead Training Coordinator at CHSS lynn.reid@chss.org.uk 4 LR 2012
5. Phase 2 of project Throughout phase 1 of this project, based on feedback from the delegates attending, it became apparent that to ensure the hyper-acute stroke pathway progressed effectively, the SAS had to be included in any educational initiatives related to improving services. It was therefore decided that the under spend monies would be used to organise and facilitate study sessions specifically for the SAS. The aim of these sessions was to ensure that the SAS were able to correctly identify stroke patients and transfer these patients in an efficient manner to the appropriate hospital emergency department for treatment. Learning Outcomes By the end of this training event delegates would: Have a critical understanding of the evidence base in relation to hyper-acute stroke treatment. Demonstrate improved knowledge in relation to the diagnosis and management of TIA. Demonstrate improved confidence in clinical decision making in relation to possible stroke mimics. Critically debate the implications and limitations of thrombolysis treatment in acute stroke. Figure 3 Table of study days and venues Region Venue Delegate Numbers North 24.06.11 Suttie Centre Aberdeen 19 West 07.09.11 LTCA Hub Glasgow 31 SE 08.11.11 Vine Venue Dunfermline 17 n = 67 At each event there were approx 8 cancellations within 48 hours. 5 LR 2012
Figure 4 - Delegates by professional role (n = 67) 6. Evaluation from the SAS study sessions and points raised The evaluations were very positive with an emphasis on the value the delegates placed on being able to discuss cases and experiences with the stroke consultants and senior members of the SAS. Delegates who attended thought that the study days were relevant to their role and in a format that suited their learning needs. They specifically liked: Being able to discuss cases and issues with colleagues from different regions/nhs Boards. Working on case studies using the ROSIER and ABCD2 scores. The informal learning environment. The opportunity to give feedback and their own reflections on stroke pathways. There were some interesting points that were discussed at each event: Confusion related to blue light issues around suspected stroke; there was some disagreement around what the criteria was for blue lighting a suspected stroke patient. Categories A transport of a suspected stroke patient; again there was some confusion regarding what the criteria for Category A was. TIA management; in some areas para-medics could refer to a neuro-vascular clinic whereas others could not. 6 LR 2012
In some areas para-medics could pre-alert A&E, in other areas this was discouraged by A&E staff. There were several comments given in the evaluation feedback regarding how the presentations offered clarity around the difficulties related to stroke diagnosis and assessment: The TIA presentation was eye opening. Interesting talk around stroke mimics I thought it was only me that found it tricky but clearly it is very complicated. Now I feel like Dr Baird strokes are complicated. Evaluation of the study day generally: 1 st class course, should be rolled out to service as a whole. Very informative day, look forward to further such opportunities I feel that the acute stroke management day has been very useful to us. Wish there was more training days like this. If you would like a copy of the evaluations for the individual SAS study days please contact: Lynn Reid lynn.reid@chss.org.uk 7. Acute stroke management in the emergency department Following the 3 study days for the SAS there were some funds left and it was decided to use these funds to offer hyper-acute stroke training to emergency department staff. Two days were organised and facilitated; a day in the South East (Lothian) and a day in the North (Aberdeen). South East study day This day was facilitated at the Royal Infirmary of Edinburgh on the 23 rd November 2011. There were only 12 delegates on the day, 22 were booked but 10 did not arrive or cancelled on the day. Those who attended engaged particularly well and it was a very thought provoking and stimulating session. (See figure 5 for delegates by profession and figure 6 for delegates by NHS Board). The main points discussed were: The importance of pre-alert from the SAS. The importance of alerting the stroke consultant promptly when a patient suspected of having a stroke was identified. How communications could be improved between the emergency department staff and the stroke consultant. 7 LR 2012
How to manage more difficult diagnosis/cases. Figure 5 Delegates by profession n=12 Figure 6 Delegates by NHS Board Although this day was not well attended the evaluations were really positive, a great deal of discussion took place and many issues were clarified. There were particularly active discussions between the different health board areas regarding policies and protocols. The evaluation suggested that the delegates found the presentation by the SCTT interesting and useful, however some delegates felt that the practical demonstration of the tele-medicine equipment was not relevant to them at present. Comments from the event: Great opportunity to discuss issues. Excellent update More days like this please 8 LR 2012
For a copy of the full evaluation contact: Lynn Reid lynn.reid@chss.org.uk North study day The Lead Stroke Clinician at Aberdeen Royal Infirmary had requested that a study day was offered in Grampian to emergency department staff. This particular study day presented a specific challenge as there were 21 delegates, all participating via video conferencing facilities. It was an interesting study day as the only people present at the venue were the presenters and the facilitators. The VC facilities at the Suttie Centre are excellent and there was no significant difference from having the delegates in attendance. There was one issue with the VC link which was corrected within 5 minutes and the evaluations reflected the enthusiasm on the day from the delegates and presenters. The feedback in the evaluations indicated that the delegates were happy with the VC link option for study sessions of this type, a couple of people commented that they would rather meet face to face but that this was not an economically viable option for them. They felt that the presentations were clear and concise and that the presenters were approachable and knowledgeable. The only negative comments given were that it would have been useful to have the presentations beforehand to review during the talks and also in one area the screen showing the presentation was very small. (See figure 7 for delegates by profession and figure 8 for NHS Board). Figure 7 Delegates by profession n=21 9 LR 2012
Figure 8 Delegates by NHS Board Comments from the evaluations: I don t really like VC but this worked well! This highlighted that pre alert needs to be discussed more with our SAS colleagues, we will organise this VC was still interactive This session made us aware that we need to work closely with the SAS and we will arrange further discussions with them. Thought this was very informal, everyone seemed very relaxed. I felt able to ask questions during discussions. Really really enjoyed it, thank you. Thank you for a very good teaching session. I particulary valued the discussions around tricky cases. 10 LR 2012
8. Expenditure analysis of phase 2 of the hyper-acute stroke project Total Budget: 2010-2012 = 4,606.66 Venues Expenses Catering Total Expenditure 807.38 900.15 940.90 2,648.43 Balance : 1,958.13 9. Conclusion This project has met the initial aim of offering stroke study sessions to staff that may have a role in the safe and effective management of patients suspected of having had a stroke. The project changed and evolved throughout but this was appropriate to meet the identified needs of the target groups. Evaluations were wholly positive and the delegates attending were lively and enthusiastic throughout. I believe that the study sessions may have led to enhanced communication between professional disciplines and NHS Boards. The project also highlighted the benefits of the NHS and the voluntary sector working together to support stroke education in Scotland. It also funded the series of scans which have now been developed into a Thrombolysis Masterclass on the Stroke Training and Awareness Resource (STARs) e-learning resource. The only negative aspect noted throughout the project was the difficulty regarding staff being granted study time to attend. In each of the 3 SAS study days there were at least 8 late cancellations, due to shift change or sickness cover, and on the SE emergency staff study day there were 10, all at late notice. It was never the intention to offer a large number of places on each day due to the practical manner of the workshops and also to allow the speakers plenty of opportunity to work closely with the delegates, however each day could have accommodated more delegates. In total there were 311 delegates attending over 11 study days, from all NHS Boards in Scotland. Many of these delegates were senior members of staff, some with an educational remit, therefore it is hoped that they may use their learning to educate others in relation to effective acute stroke management. (For delegate professions throughout project see figure 9 and by NHS Board see figure 10). 11 LR 2012
Figure 9: Delegates by profession throughout phase 1 and 2 (n=311) Figure 10: Delegates by NHS Board throughout phase 1 and 2 I would like to take this opportunity to thank all the Stroke Consultants, Anne Reoch from the Scottish Centre for Telehealth and Telecare and the CHSS Stroke Training Team who supported this venture by offering their knowledge, skills and time. Lynn Reid Lead Training Coordinator CHSS 12 LR 2012
10, References NHS Quality Improvement Scotland (2009) Stroke Services: Care of the Patient in the Acute Setting, Clinical standards Update, NHS Quality improvement Scotland, Edinburgh. Scottish Intercollegiate Guidelines Network (2008) Management of Patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention, SIGN, Edinburgh. Scottish Government Health Directorates (2009) Better Heart Disease and Stroke Care Action Plan, Edinburgh. 13 LR 2012
11. Appendix One Project Contributors (Phase 2) Dr Tracey Baird Consultant Neurologist - NHS Greater Glasgow and Clyde Mr Campbell Chalmers Stroke Nurse Consultant NHS Lanarkshire Dr Nichola Chapman Consultant Stroke Physician - NHS Fife Dr Vera Cvoro Consultant Stroke Physician NHS Fife Professor Martin Dennis Lead Clinician, Stroke Services NHS Lothian and Chair of NACS Ms Jill Fletcher Clinical Governance and Quality Lead, North Division- Scottish Ambulance Service Ms Hazel Fraser Stroke Coordinator NHS Fife Dr Simon Hart Consultant Stroke Physician NHS Lothian Mr Paul Kelly Clinical Governance & Quality Lead, East Central Division Scottish Ambulance Service Dr Gillian Kerr Consultant Stroke Physician and Geriatrician NHS Lanarkshire Dr Mary Joan Macleod Consultant Stroke Physician and Lead Stroke Physician, ARI NHS Grampian 14 LR 2012
Dr Christine McAlpine Lead Stroke Physician NHS Greater Glasgow and Clyde Professor Keith Muir SINAPSE Chair of Clinical Imaging University of Glasgow/NHS Greater Glasgow and Clyde Dr John Reid Consultant Neurologist NHS Grampian Mrs Anne Reoch Cardiac and Stroke Clinical Lead, Scottish Centre for Telehealth and Telecare Mr Andrew Wemyss Head of Strategy Implementation & Quality Improvement Scottish Ambulance Service Dr Stephen Wilkinson Consultant in geriatric Medicine NHS Grampian Chest Heart & Stroke Scotland Executive Committee Members Allocating funding for the project Chest Heart & Stroke Training Team: Heather Bryceland SCoT Project Manager Heather.Bryceland@chss.org.uk Desmond Chrystal Stroke Training Coordinator NHS Grampian desmondchrystal@nhs.net Gillian Currie Stroke Training Coordinator NHS Lothian Gillian.Currie@chss.org.uk 15 LR 2012
Joanne Graham Stroke Training Coordinator NHS Fife Joanne.Graham@nhs.net Elaine Grubb Stroke Training Coordinator NHS Dumfries and Galloway Elaine.grubb@nhs.net Margaret Somerville Director of Advice and Support, CHSS Project facilitated /report written by; Lynn Reid Lead Training Coordinator Lynn.reid@chss.org.uk For further information regarding CHSS educational initiatives visit; www.chss.org.uk 16 LR 2012