Clinical Network-PenCLAHRC improvement project in stroke thrombolysis- What have we learnt from taking part in the project and what are we doing differently now? Feedback from Royal Cornwall Hospital team 21/07/2016

RCHT Stroke Thrombolysis set up Thrombolysis delivered by ED consultants Support from 1 stroke nurse practitioner 9-5 /4/7 Accelerated CT pathway- direct transfer to CT Stroke assessment and lysis in ED resus Lysed patients transferred to CCU Monthly Stroke review at ED governance meeting – patients lysed/ protocol violations/missed patients/difficulties with pathway (provided by stroke consultant) E-learning teaching tool developed for education

Project time line and aims PENCLAHR and RCHT team meeting Summer 2015 (ED, Ambulance, Rad, Stroke team, junior doctor) Data collection covered: Jan 2013-Dec 2014 PENCLAHR presentation: November 2015 Action plan: to be completed by Jan 2016 Plan for re-audit Spring 2016

PENCLAHR Key Observations 1.Excellent door to CT times (15 min) 2.Low know stroke onset time 42% (nat. 67%) 3.Low lysis rate of patients presenting within 30 min alteplase lysis time left (25% of those to mild/too severe) 4.Low number of patients with too mild/too severe strokes thrombolysed

Gains to be made

Action plan

Actions Ambulance team- ensured documentation of time of onset and communication to ED Stroke nurse- liaised with data collector re importance of documentation of time of onset, changes to stroke proforma to make timing clearer, ongoing reminder ED doc to use stroke proforma

Audit: recording of onset time Prospective analysis of patients admitted via ED – Confirmed diagnosis of stroke on discharge – November 2015 and March 2016: n = 329 Pre-Alert Forms (ATMIST) Stroke onset time : Recorded in 87% – including wake up/unknown – Previously 42% (Nat 67%) 46% had specific time – Stroke Pathway Specifics Only completed in 18% Questions (Y/N) – Stroke or FAST+ – Seizure or Sudden Headache – Anticoagulant – Meets thrombolysis Criteria – Stroke ProForma Used in 48%

Stroke Proforma

Actions Consultant in liaison with stroke team and Simulation training team developed simulation session of thrombolysis patient for stroke unit team (3 delivered so far) and ED Business case for additional nurse staff (stroke nurse support of lysis in ED) approved –June 2016 Stroke unit now for stroke admissions only-May 2016 Consultant- presented findings of report to ED consultant team 6/1/2016 including case studies

ED consultant team meeting Consultants receptive and interested in report They asked for guidance on mild strokes for lysis to be included in protocol (is included) Reported that one of the blocks for lysis was slow radiology reporting time (30min), this has been discussed with radiology team who will try to expedite and requested ED clarify side of stroke consistently and document patient is for stroke lysis on request (fed back to ED) Discussed training middle grade doctors to provide lysis e-module and face to face training with stroke consultant (not yet achieved) Agreed to DATIX any patient that was not thrombolysed but should have been (ongoing through ED governance meetings) Use of CAPTUREStroke data system to generate quick reports of patients lysed/ not lysed

Results

On-going Challenges ED locum consultants, high staff turn over ED pressure high patient numbers Stroke Unit development of hyper acute stroke unit with sufficient level of staffing (medical and nursing) to take patients directly from ED post lysis and if unstable Ongoing “Ring fencing” of stroke beds Ongoing engagement with partnership trust to ensure stroke pathway works efficiently (ESD, community stroke units, community stroke nursing team)

New CE Kathy Burns May 2016 Walked CE round stroke pathway 20/06/2016 Ring fencing of stroke beds achieved July 2016 ED focus on getting stroke patients to stroke unit within 3.5 hours Only 1 breach this month of daily exception reporting of stroke patients not getting to stroke unit Support from operational team and executives Stroke Lysis:

Stroke Lysis July % !!!!

Thank you Carol Massey and PENCLAHRC team Martin James Clinical network for ongoing support RCHT wider stroke team Paul Bostock, new chief operational officer RCHT

Questions