Organising stroke services Martin Dennis

Organising services This session is about stroke Principles might be applied to other problems Parkinsons Fractures Dementia Organisation of comprehensive service or just one aspect?

Questions to be addressed Which population is to be served? What is the size of the problems? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

Questions to be addressed Which population is to be served? What is the size of the problems? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

What population? Your hospitals catchment population Region e.g. Lothian Country e.g Scotland Will all aspects of service be delivered locally?

Questions to be addressed Which population is to be served? What is the size of the problem? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

Size of the problem Incidence Prognosis Prevalence Who does it affect? Age, sex, subtypes etc Prognosis Prevalence Where do you get this information? Pros and cons of each source?

Sources of information Local population based incidence study Published data from similar populations Locally available routine data SMR01 GP registers Locally collected hospital data Hospital based register Audit

Questions to be addressed Which population is to be served? What is the size of the problems? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

Pathway Early recognition Call for help Initial assessment Hyper-acute care Stroke unit care or ambulatory care Rehabilitation Secondary prevention Longterm care/ monitoring

Questions to be addressed Which population is to be served? What is the size of the problems? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

Evidence based treatments Thrombolysis Hemicraniectomy Aspirin Stroke unit care Secondary prevention Antiplatelets Statins Blood pressure reduction Warfarin for those in AF Carotid Surgery Early supported discharge Effect size? What % of patients benefit? Impact?

Other essential elements Nursing care for disabled people Information for patients, carers etc Longterm support Palliative care

Questions to be addressed Which population is to be served? What is the size of the problems? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

Some choices? Ambulatory or inpatients care for TIAs and minor strokes? Centralised or distributed thrombolysis? Stroke units – acute, rehab, comprehensive? Stroke services for “young patients”? Inpatient or community rehabiltation? Who does the secondary prevention?

Questions to be addressed Which population is to be served? What is the size of the problems? What are the needs of the individuals with the problem? Which needs are most important to meet? How should services be delivered? What resources are available? What is the gap?

Resources People Skills / Knowledge Training Consultant Pas – Job plans Doctors in training / SAS Nurses AHPs Radiology/radiography A & C staff Social work/ social care Skills / Knowledge Training

Other resources Stroke unit beds Outpatient rooms Scanners IT – PACS, Electronic patient records Day hospitals Day centres Access to other specialties – vascular, neuro etc Geography is crucial

Services to not organise themselves! Somebody has to coordinate them To ensure performance is measured Gaps in services and poor services identified Make best use of resources Coordination of staff Communication IT To identify additional resources

Local examples Collect info on consultant PAs for stroke Compare with other areas Get agreement of PAs needed to deliver service Identify any GAP Make case to management for additional PAs

Neurovascular clinics Standards – 80% seen within 7 days Frequency – Mon, Tues, Wed, Frid Capacity – 30-35 new patients per week Imaging on day of appointment Delays in communication with GPs

High early risk of stroke after TIA 14 OXVASC OCSP 12 10 8 Risk of stroke (%) 6 10% risk of stroke by 7 days 4 2 7 14 21 28 Days Lancet 2005; 366: 29-36

GP TIA/stroke Hotline GP TIA hotline/ thrombolysis service single phone number Answered by Stroke Consultant/ Stroke Neurologist 24/7

Taking a call on the hotline at home

Process Listen to details of event Sometimes take history from patients over phone If TIA likely give GP an appointment time Ask them to take bloods Initiate immediate aspirin & statin Ask for SCI Gateway referral Deflect a significant number of referrals

GP, OOH and SAS guidelines Distinguishing those with transient and ongoing symptoms Ensuring patients enter the most appropriate pathway Hyperacute admission Routine admission Same day assessment Neurovascular clinic Other service No further action required

Neurovascular clinic booking (often next day)

TIA hotline introduced

TIA Hotline Has dramatically reduced delays to: Optimum medical treatment Specialist assessment & investigation Referral for carotid surgery Plan to extend service to: A&E staff Out of hours medical services Eye Pavilion

Rapid pick-up and routing Rota Router GP A&E Rapid pick-up and routing 536 1019. The regional On call Specialist Paramedic

Improvements Advance planning of clinic staffing to maintain constant capacity Links with GPs via SCI Gateway Web based access to clinic availability on call physician patient letters results

Challenges “Chaotic” front doors of hospitals Recent examples of bad practice Rapidly rotating staff – difficult to train Delivering “specialist” input as early as possible. 24/7 telephone/telemedicine access EPR with decision support

Thrombolysis Stroke centres Hub and spoke Telemedicine

The technology Gateway Broadband VC recorder