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Stroke Service South West Essex

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Stroke Service South West Essex

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									                         www.ecsnetwork.nhs.uk




    Stroke Service South
        West Essex




JK/BS 13.10.2009 FINAL                      1
This document has been refreshed by The Essex Cardiac and Stroke Network
Assistant Director - Stroke Lead and the Stroke Coordinator at Basildon and
Thurrock NHS Foundation Trust and replaces the 2007 initial scoping
document. The information within the document has been provided by the
direct stroke team within secondary care and the identified stroke PCT leads.

The data provided within this scoping exercise has been taken from the
National sentinel audit 2008 and/or has been provided by the acute stroke
team.




JK/BS 13.10.2009 FINAL                                                     2
      Stroke Service Basildon and Thurrock NHS Foundation Trust

Basildon and Thurrock NHS Foundation Trust has an established
rehabilitation stroke ward (Lister Ward) consisting of 24 beds and has 27
bedded acute stroke unit (Pasteur Ward).

Key staff
Secondary care
Dr Huwez Stroke - Consultant for rehab ward
Dr Walters - Consultant Medicine for the Elderly (acute stroke beds)
Dr Umasankar - Consultant Medicine for the Elderly (rehab stroke beds)
Dr Rangasamy - Consultant Medicine for the Elderly (acute stroke beds)
Beth Smyth - Rehab Stroke Co-ordinator
Jennifer Marshall - Ward Manager, Pasteur Ward
Sara McGowan - Ward Manager, Lister Ward
Rob Warren- OT
Srikanthan Ravindran - Physiotherapy
Miriam Mitchell - SALT
Sue Garner - Data/Audit Clerk
Mr Lisk - Neurologist
Mr Abbas - Neurologist
Mr Malaspina - Neurologist
Mr Jeddy - Vascular surgeon
Mr Memon - Vascular surgeon

Other staff
Catherine Green - Head of Nursing
Karen Fashanu - Service Manager

Key staff
Primary care
Carol Wilson - Transformation lead
Claire Burns - Commissioning
Brid Johnson - Provider Services
Jackie Wood - Head of Admission Avoidance

Patient pathway Stroke

Admission and Assessment
Referral Process
Patients are referred to A&E or MAU via GP, 999 or self referral. Once
referred to the hospital patients are referred to stroke nurse on call. Pathways
and protocols are set up for assessment of thrombolysis, hyper acute care
and investigations for all stroke patients and direct admission the acute stroke
unit (Pasteur ward) and then onto the acute rehabilitation unit (Lister ward) if
required.




JK/BS 13.10.2009 FINAL                                                        3
Local protocol in place between ambulance services and receiving
hospitals for a rapid response for stroke patients;

There is an East of England Ambulance pre hospital pathway

Triage system in A&E
Patients who are FAST positive or have symptoms of stroke or TIA will be
referred via mobile to the on call stroke nurse. Assessment will take place in
A&E and pathways will be followed. Direct admission will be arranged if the
patient is suitable. The LOS on Pasteur will be between 5-7 days and then
transferred to Lister ward if the MDT feels the patient requires further
rehabilitation, the aim is for an overall LOS of 28 -30 days.

Clinical assessment using (ROSIER) Recognition of stroke in the
emergency room.
This is used

Investigations
CT scan
24 -hour access to scans with stroke/neuroradiological specialist
advice;

There is 24 hour access to C.T scanning and this has improved greatly since
the 2006 sentinel audit. Within the 2008 national sentinel audit only 53%
received a scan within 24 hours. However since this audit positive steps have
been taken to improve the overall scanning for acute stroke patients. An in-
house audit has shown April-June 09 that 73% were scanned within 24hours.

Proportion of people who have had a stroke who are receiving a scan
Within three hours of symptom onset; Facilities to provide immediate
scans
Yes.

Skilled interpretation readily available. Reading the scan who and how
long does it take.
CT scans are interpreted by the radiologists. Scans are interpreted shortly
after the CT scan is performed. Stroke consultants can view the scan
immediately after it has taken place using the PACs system and via remote
access out of hours.

Other investigations during stay
ECHO
Carotid Doppler,
Bloods – Cholesterol, glucose
ECG
24 Hour tape
MRI if required




JK/BS 13.10.2009 FINAL                                                      4
Thrombolysis
Thrombolysis started September 2008 at Basildon, 9-5 Monday – Friday, and
extended hours 1st September 2009 8am-8pm 7 days. The Trust commenced
24/7 thrombolysis from 6th October 2009.

        Acute Stroke Unit Pasteur / Acute Rehabilitation Unit Lister

Pasteur ward comprises of 27 beds providing 6 hyper acute beds and 4 acute
with the ability to extend this number if the need arises. The intention of the
acute stroke unit is to provide beds for acute stroke patients and to ensure
rapid admission, diagnosis, assessment and stabilisation in line with best
practice. Early rehabilitation is also commenced and once the acute phase
has ended the pathway to acute rehabilitation on Lister will be provided. They
also have a team of specialist staff trained to care and treat stroke patients to
promote and maximise independence and functional return. Patients will
receive 45 minutes per relevant therapy per day, currently this is a five day a
week service.

Proportion of patients treated in a stroke unit at any time during their
stay
The 2008 sentinel audit has shown an improvement in the overall % of time
patients spend on the stroke unit during their admission, with 58% spending
90% of their time on the stroke unit

In-House data:

Month            % who have
                 spent 90%
                 or more on
                 the stroke
                 unit
April 2009       81%
May 2009         75%
June 2009        76%

Proportion of patients being admitted to the acute stroke unit on day
one
The aim for Basildon hospital is to admit all acute stroke patients to the acute
stroke unit within 4 hrs, direct admission protocol is in place and audits and
reviews are completed monthly to identify improvement in this target. With the
increase in stroke nurses on duty 24 hrs 7 days a week will assist in achieving
this target.

Selection Process protocol for acute stroke unit
There is an operational policy for the acute stroke beds which includes direct
admission criteria and clearly identifies the aims of the service. The admission
criteria are that the patient is over 18 years old and has a primary diagnosis of
acute stroke. They will be assessed by the stroke team who are available
24/7.



JK/BS 13.10.2009 FINAL                                                         5
Treatment
All ischemic strokes receive anti platelet medication after CT scan.
BP stabilisation
Satins
Warfarin for AF
Cardiac monitoring

Length of stay
3-7 days on the acute stroke unit and overall LOS including admission to
Lister is 28-30 days.

Integrated care pathways
There is an integrated care pathway for acute stroke and TIA which follows
the patients through into the rehabilitation unit if this is required.

Physiological monitoring
This is available on Pasteur for all acute stroke patients there are 6 fixed
cardiac monitors and one portable

Staffing across the Stroke service.
Establishment for Pasteur ward 27 beds
Am 6 trained and 4 untrained
Pm 5 trained and 3 untrained
Night 4 trained and 2 untrained
This includes the Band 6 stroke nurse on every shift

Establishment for Lister ward 24 beds
Am 3 trained and 4 untrained
Pm 2 trained and 4 untrained
Night 2 trained and 2 untrained

Doctors
4 consultants
2 SHO
4 Middle grades

OT
Acute stroke unit
1 band 5
1 band 3
It is the aim that an O.T assessment will occur within 4 days

Rehabilitation unit
1 band 7
1 band 6
1 band 5
2 band 2




JK/BS 13.10.2009 FINAL                                                    6
Physio
Acute stroke unit
1 band 7
1 band2

Rehabilitation unit
2 band 7
1 band 5
1 band 3
1 band 2
It is the aim that a physio assessment will occur within 72 hours

Speech and language
All patients have dysphagia screening which takes place within 24 hours of
admission. This is undertaken by the speech and language therapist if in
working hours Monday to Friday. Out of hours and weekends a dysphagia
screening assessment is undertaken by one the Dysphagia trained nurses on
the ward and a referral is made to the speech and language therapist for
follow up advice. The Dysphagia trained nurses have undertaken a specific in
house training course and have been deemed competent. The in house
training course has now been replaced by the ARU course. The speech and
language department are currently happy to mentor nurses on this course.
There are dysphagia trained nurses on most of the other acute medical
wards.

Acute stroke unit
0.5 WTE band 5

Rehabilitation unit
1 band 6
1 band 3

Dietician
0.5 wte available on the stroke unit

Social Worker
Requested as needed via Essex and Thurrock Social Services Depts.

Pharmacy
The unit has pharmacy input

MDT meetings
MDT meetings are held on a Tuesday for acute stroke patients and include
OT physio, doctor and nurses. Not all patients will have a MDT assessment
whilst on the acute stroke unit as they may have been transferred to Lister
ward before this can occur, these patients will have their first MDT
assessment on Lister ward which takes place every Wednesday. A patient
MDT meeting takes place on a Thursday afternoon. 6 patients and their
carers are seen during the course of an afternoon. This meeting includes: -
consultants, ward staff, OT, physio, social worker. The aim is for the patients


JK/BS 13.10.2009 FINAL                                                       7
to be offered patient MDT 1-2 weeks after admission so goals can be
discussed and discharge planning commenced at an early stage.
The ward has a discharge facilitator to help plan for early discharge

Discharge/transfer criteria
Multidisciplinary rehab occurs on both the acute and acute Rehabilitation unit.
Patients are assessed on admission taking into consideration their physical
ability, past medical history and level of activity before the stroke. The patient
is placed in one of three rehabilitation categories:-

   •   Acute rehab
   •   Fast track
   •   Slow stream

The expected length of stay is 5-7 days on the acute stroke unit if transfer to
Lister the aim is to provide an overall 28-30 LOS

Lifestyle advice
Lifestyle advice is given by the staff on the stroke unit and patients are given
the stroke association leaflets

Future reviews
All patients discharged from the acute/ rehab wards are followed up by the
consultant at 2, 4 or 6 months

Competencies
Competencies are being developed with the Stroke and Cardiac network.

Training and education
Courses offered to trained staff

ARU stroke course Graduate certificate – Acute stroke management and
rehabilitation

ARU Adult Dysphagia training for healthcare professionals (DE315001S) 15
credits at

ARU Mentorship in Public services

ARU Hypertension course

Further in house training is offered in areas such as
   • Manual handling
   • Speech and language awareness
   • In house dysphagia assessment course

A rolling In house training programme is delivered every Wednesday 1pm-
2pm. This is offered to ALL MDT and includes an MDT approach. All staff
across both units are expected to attend if on duty and a register is kept to
monitor attendance.


JK/BS 13.10.2009 FINAL                                                          8
Audit and research
Monthly Audits take place with the assistance of the Clerical Assistant. The
audits measure the nine key vital signs on a monthly basis to demonstrate
improvement in the service this includes review of the TIA service. The Essex
Cardiac and Stroke network also produces figures on service improvement.
Stroke research has commenced at Basildon possible research trials that
have been identified are: IST3. TARDIS, AVERT, SO2S

Neurologist Support
There are 3 neurologists who are available to discuss and advise the Stroke
Consultants on any neurological problems.

Neurosurgical Support
Via referral to Queens Hospital

PPI Involvement
Thurrock support group – Beryl Langman, Long Lane Leisure centre, long
lane, Grays, 01376 370909.

Janet Craven stroke association Basildon 01268 561600

Others Services available and offered
Patients go home and are independent, go home with support of the
community rehab team for a period of 6 weeks or are referred for slow stream
rehab. The community rehab team consist of nurses, OT, physio and visit the
patient depending on requirements. They visit for up to 6 weeks after this
these patients would receive continued support via social services.

Slow stream rehab is offered at Brentwood community hospital which offers
an 8 bedded capacity, this however is still a new facility and it is working hard
to ensure the correct skill mix and staff to offer the correct level of care. A new
stroke Hub team is being developed.

Other services available include CCT, CTT and Reablement team (under 65
year old teams)

Follow up by GP and secondary prevention
A comprehensive typed discharge summary is sent to the GP on discharge.
Advice on lifestyle, diet etc is given on discharge as well as information on the
services available post discharge.

Voluntary services used
Stroke association representative visits on a Tuesday
A volunteer from the Chaplin service visits on a Thursday
Carers Support officer - Michelle Turner is advised on all admitted stroke
patients and visits the stroke unit




JK/BS 13.10.2009 FINAL                                                           9
Palliative care available
All stroke patients requiring palliative care remain in the acute/rehab unit. An
end of life care pathway is available and support from the palliative care team
is offered.
TIA

(Immediate Referral for urgent specialist assessment should be
considered for all recent TIA/ minor stroke. Urgency for referral for TIA
based on the likely early risk of potentially preventable recurrent stroke.
ABCD2 system
A Age
B Blood pressure
C clinical symptoms TIA
D Duration of symptoms
Low risk 0-3 high risk 4-7

TIA clinics take place within Basildon and Thurrock NHS Foundation Trust,
daily Monday to Friday
There are approximately 400 TIA referrals per year
TIA clinics are undertaken by the stroke consultant’s
TIA referrals are received via MAU, A/E or GPs and are categorised into
urgency.
All low risk patients are seen within 7 days of referral and we aim to admit all
high risk TIAs for investigation. The aim is to deliver a 1 stop TIA clinic in the
future.

Process in TIA Clinic
Assessment, history taking and clinical examination
Medication review
Risk assessment BP, cholesterol, diabetes, smoking, weight, AF
Lifestyle advice

Investigations are ordered as neither clinic is one stop at present. The
investigations needed are based on clinical need and include bloods, ECG,
ECHO, carotid Doppler.

MRI scans available within 24 hours
MRI scans are ordered if clinically identified and there is the availability of MRI
DWI, access and timings depend on patient’s clinical urgency

Carotid imaging available how long wait
Carotid imaging for high risk TIA has improved from 4-6 weeks wait to 6 days
(data April to August 09). Low risk (April – August 09) is 13.3 days. Work is
ongoing to develop a 1 stop TIA clinic and this will improve access further.

Carotid Endarterectomy
Carotid Endarterectomy can be performed at Basildon. There is ongoing work
with the network to identify pathways.




JK/BS 13.10.2009 FINAL                                                          10
Follow up 1 month after TIA in primary or secondary care
Patients are followed up in secondary care once all investigations are
completed and further follow ups given if necessary.

Planned TIA service development
Working towards 1 stop TIA clinics. Currently have daily clinic available
Monday – Friday. High risk TIA patients are admitted.

                  New innovation/ service developments
   •   24/7 Stroke thrombolysis to commence 6th October 2009
   •   Direct admission to the stroke unit within 4 hours
   •   7 day a week 1 stop TIA clinics
   •   Consultant stroke ward round at the weekend
   •   7 day a week therapy service
   •   Reduce LOS on Lister ward
   •   Competencies of staff being developed for all staff groups

                               Overall challenges
   •   The PCT need to develop admission and discharge criteria for the
       community beds and determine the best usage of the beds in these
       hospitals. The best place for continued stroke rehab needs to be
       determined between primary and secondary care and services
       developed in the appropriate place
   •   Agreed care pathways need to be determined between primary and
       secondary care
   •   No psychology support is available.
   •   TIA clinic is not one stop
   •   Improve access to all radiology services in line with service
       developments
   •   Work needs to continue to ensure that staffing is increased as
       workload increases and service development occurs and to ensure the
       right staff are appointed
   •   Work needs to continue to educate staff within the organisation on the
       acuteness of stroke




JK/BS 13.10.2009 FINAL                                                    11

								
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