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Stroke Service South West Essex
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
"Stroke Service South West Essex"