PDSA Presentations Cardiff and Vale

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					               AWSSIC
Cardiff and Vale NHS Trust Storyboard




                 Learning Session Two
                   25th March 2009

   Supporting NHS Wales to Deliver World Class Healthcare
            All Wales Stroke Services Improvement Collaborative

      Thankyou for asking me to present

• Newcomer
• On sabbatical (in Llandrindod ?!)
• Hope to contribute in the future..




Slide 2
                 All Wales Stroke Services Improvement Collaborative

          Cardiff and Vale NHS
                  Trust

    Is one of the largest NHS
        Trusts in the UK. It
       provides day-to-day
        health services to a
       population of around
     500,000 people living in
       Cardiff and the Vale
     In 2008/2009 the Trust's
       total income is £634
      million and we employ
      approximately 14,000
                staff
Slide 3
                  All Wales Stroke Services Improvement Collaborative

                      A driver for change
          Death, dependency and good outcome in
           randomized trials of rt-PA given within
             3 hours of acute ischaemic stroke
            (3 trials, n=869)
                                                                           NNT         10
                                                                         Alive and
            100
                                                                         independent
                                                   30.2
             80           44.3                                           Alive but
                                                                         dependent
             60
                                                                         Dead
             40                                    51.4
                          38.4
             20
                          17.3                     18.4
              0
                      Thrombolysis                Control
            Differences/1000: 141 extra alive and independent (P<0.01)
                              130 fewer dependent survivors (P<0.01)
                              12 fewer deaths (NS)
                                                              Cochrane Library 2003



Slide 4
                All Wales Stroke Services Improvement Collaborative

          Will tPA redefine acute medicine and acute
                           neurology?

• An overload of dilemma
    • An evolving story
           • Patients haven’t worked out what they can and
             can’t do
    • Immature motor signs
           • Motor signs: immature, mature, mature with
             musculoskeletal complications
    • Sensory signs often at their best
    • Visual fields and eye movements are useful
    • Cognitive deficits
           • Can be difficult to get the doctor and patient to
Slide 5      focus
               All Wales Stroke Services Improvement Collaborative

      Will tPA redefine acute neurology?

    • A normal (or normalish) CT scan
          • Neuroradiologist needs to call the shots
    • A dangerous but effective treatment, often for a syndromic
      diagnosis
          • Stroke seems too crude a diagnosis to make
    • A health service not used to dealing with stroke as an
      emergency (3-6 hours)
          • No pain or bleeding, no spots or screaming
    • Lack of neurology experience amongst junior general medics




Slide 6
           All Wales Stroke Services Improvement Collaborative

 How could we start the thrombolysis ball rolling?


• Start at the front door
• How are people assessed?




Slide 7
                                                       All Wales Stroke Services Improvement Collaborative
                                                         CARDIFF AND VALE NHS TRUST
                                                    YMDDIRIEDOLAETH GIG CAERDYDD A’R FRO



          MEDICAL ADMISSIONS : MULTIPROFESSIONAL RECORD


                                                                                                                                Admissions proforma
      DATE: ___________________ TIME: _____________                 CONSULTANT: ________________________________
 ADDRESSOGRAPH                                                                                     OBSERVATIONS
 Or
                                                                                    BP                    ___________________
 NAME:                                                                              PULSE                 ___________________
                                                                                    O² SATS               ___________________
 ADDRESS:
                                                                                    O² GIVEN              __________ % GIVEN
                                       DATE OF BIRTH/AGE:                           RESP RATE             ___________________
                                                                                    TEMP                  ___________________
                                                                                    BM                    ___________________
 TELEPHONE No:
                                                                                    PEAK FLOW             ___________________
 MARITAL STATUS:                  RELIGION:
                                                                                    GCS                      A V P U
 OCCUPATION:
                                                                                    VISUAL ACUITY         ___________________
 GP NAME:                                                                           CAP REFIL TIME        ___________________
 ADDRESS:                                                                           URINE                 ___________________
                                                                                    MSU SENT              Yes / No
 TELEPHONE No:                                                                      PREG TEST             Yes / No: Result:

PRESENTING COMPLAINT
S


O


A


P


PAIN SCORE                 0      1       2     3         4         5           6      7       8      9       10

TRIAGE NURSE _____________                TRIAGE TIME          _____________           TRIAGE CODE 1 2              3 4   5
NEXT OF KIN:
1. Name:                                                       2.       Name:

    Address:                                                            Address:

    Contact No:                                                         Contact No:

    Relationship to Patient:                                            Relationship to Patient:

    Aware of Admission          YES      NO                           Aware of Admission          YES      NO

Past Medical History                                                Current Medication




                                                                    Allergies




 Slide 8
                   All Wales Stroke Services Improvement Collaborative

                                                  Admissions proforma 2005




          ABDOMEN


                                                      PR:




          NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONS




          OTHER RELEVANT FINDINGS (Oral, Hands, Breast etc)




Slide 9
                     All Wales Stroke Services Improvement Collaborative

                                Admissions proforma 2007
           Remember, if it is an acute stroke (< 6 hours of symptoms) they may be eligible for thrombolysis

           NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONS
           Conscious level        Eye opening       Motor response        Verbal response
           Mini-mental test score
           Coverings of the nervous system
               Head            Neck            Spine
           Posture
           Gait                     Romberg’s test
           Cranial Nerve

             II Acuity                                               II, III
                Visual Fields                                         Pupil responses
                Optic fundus

             III, IV, VI                                             V    Sensory
                  Eye movements                                           Motor
              VII
              VIII
              X Palatal movement                           XI                           XII
                   Cough
                   Swallowing
                   Phonation
           Limbs
             Inspection
             Tone
             Strength
             Coordination
             Reflexes
              Sensation




Slide 10
               All Wales Stroke Services Improvement Collaborative
    Why are people not being randomised into trials of thrombolysis?




• IST 3 trial                            • Do the ethics application
• External validation                    • Sort out paperwork
     • Your centre is ok to be           • Organise visit by IST3
       involved                            coordinator
     • Audit done by someone
       else                              • Satisfy research
                                           standards in UHW
• Plugged in to a research
  mentality                              • Start!




Slide 11
           All Wales Stroke Services Improvement Collaborative

   Since October 2007; 9-5, Mon-Friday.

• 3 patients randomised              • Need to extend to out of
  into the trial                       hours
• 4 patients treated on              • Need to involve more
  licence                              people on the rota
                                     • Needs to become part of
                                       the dumpety-dump of
                                       the acute medical take
                                     • Education, education,
                                       education...


Slide 12
            All Wales Stroke Services Improvement Collaborative


      Aspirin administration as identified in a
                  previous audit
• All stroke patients to receive aspirin in a timely
  fashion unless clinically contra-indicated

• If patient was unable to swallow safely there
  was no consistency in considering PR or NG
  administration




Slide 13
           All Wales Stroke Services Improvement Collaborative



                             Where

• Acute admission areas
• EU and MAU on one hospital site




Slide 14
            All Wales Stroke Services Improvement Collaborative

           Aspirin in the first 24 hours

                                      • Pharmacist agreed to
                                        collect data
                                        prospectively
                                      • Over two weeks five
                                        patients on the acute
                                        medical unit had aspirin
                                        prescribed on admission
                                      • None had it written as
                                        po/pr/ng
                                      • How could we raise the
                                        aspirin profile?
Slide 15
                            All Wales Stroke Services Improvement Collaborative




•   Dear All,
•
•   The recent RCP and NICE guidelines recommend that Aspirin 300mg
    daily be given to all patients presenting with acute stroke in whom
    intracerebral haemorrhage has been excluded by brain imaging.
    This should be continued for two weeks.
•
•   This dose of Aspirin can be given by mouth, through an NG tube, or
    rectally.
•
•   To ensure that Aspirin is given to this group of patients, many of
    whom have a swallowing problem, please prescribe
    Aspirin 300mgs daily PO/NG/PR.
•
•   Thankyou,
•   Tom Hughes
•   Hamsaraj Shetty




Slide 16
           All Wales Stroke Services Improvement Collaborative

                We fancied a logo!




Slide 17
                            All Wales Stroke Services Improvement Collaborative




•   Dear All,
•
•   The recent RCP and NICE guidelines recommend that Aspirin 300mg
    daily be given to all patients presenting with acute stroke in whom
    intracerebral haemorrhage has been excluded by brain imaging.
    This should be continued for two weeks.
•
•   This dose of Aspirin can be given by mouth, through an NG tube, or
    rectally.
•

                                                                               Reliable
•   To ensure that Aspirin is given to this group of patients, many of
    whom have a swallowing problem, please prescribe
    Aspirin 300mgs daily PO/NG/PR.
•
•   Thankyou,
                                                                             comparable
•
•
    Tom Hughes
    Hamsaraj Shetty
                                                                          (before and after)
                                                                          data not available
                                                                                 yet.

Slide 18
           All Wales Stroke Services Improvement Collaborative



                      Lessons learnt

• Meaningful data are difficult to obtain
• It is very time consuming
• Someone needs to have dedicated time to do it
  during the working week and it has to be part
  of the routine service
• It is possible to introduce change, particularly if
  you can become the change



Slide 19
                                All Wales Stroke Services Improvement Collaborative

                                                   Physiotherapy

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 20
                                All Wales Stroke Services Improvement Collaborative

                              Physiological monitoring

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 21
                                All Wales Stroke Services Improvement Collaborative

                                                 OT assessment

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 22
                                All Wales Stroke Services Improvement Collaborative

                                                                 Aspirin

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 23
                                All Wales Stroke Services Improvement Collaborative

                                         CT within 24 hours

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 24
                                All Wales Stroke Services Improvement Collaborative

                                 Aspirin within 24 hours

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 25
                                All Wales Stroke Services Improvement Collaborative

                       Manual handling assessment

                % patients who have a manual handling assessment in first 72 hours
                                      AWSSIC Stroke patients
                                    from Feb 2008 to Mar 2009



       120


       100


           80


           60


           40


           20


           0




                                                                       Months




Slide 26

				
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