1. Audit of ACRT's service against NICE stroke rehabilitation guidelines
Authors: Guy Slade (OT), Fred Baron (PT), Adult Community Rehabilitation Team (ACRT) Supervisor: Simon Grobler (Deputy Head of Service, ACRT) Project reference Number: 1875/2185 Year: f

2. Introduction and Background
NICE clinical guideline Stroke rehabilitation in adults (CG162) published June 2013
No previous audit of Adult Community Rehabilitation Team (ACRT) service against guidelines recommendations
Local consensus that ACRT is performing well against recommendations, except in relation to early supported discharge (ESD).
ESD services provided by Integrated Independence Team (IIT), but concern that small number of clients (e.g. vocational rehab) may come direct to ACRT with ESD needs, and ACRT not funded or organised to meet these.
Audit covers current practice in ACRT, and referrals for calendar year 2015. f

3. NICE clinical guideline Stroke rehabilitation in adults (CG162)
84 recommendations for organisation and delivery of rehabilitation following stroke
Key themes:
MDT organisation – including social care
Smooth transition between inpatient to community care, including Early Supported Discharge
Goal setting, support for patient and carers, regular reviews
Evidence-based intensity of therapy and some treatment types
Whole person approach: Physical, emotional, psychological and social needs f

4. NICE clinical guideline Stroke rehabilitation in adults (CG162)
Early supported discharge definition:
“A service for people after stroke which allows transfer of care from an inpatient environment to a primary care setting to continue rehabilitation, at the same level of intensity and expertise that they would have received in the inpatient setting”.
Intensity:
Initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved.
Timing:
Patients should be followed up after discharge by stroke rehab team within 72 hours f

5. Pan London Stroke Strategic Clinical Network (NHS England) (2015) Early supported discharge: Service specification.
Additional guidance, aimed primarily at CCGs.
Includes additional standards for ESD service:
ESD team should become involved in 24 hours from referral
Each patient has outcome measures and assigned a key worker within 3 days
Personalised assessment results, goals and a rehabilitation programme should be provided to the stroke survivor
Various standardised outcome measures should be applied on entry to and exit from ESD
Goals to be set and agreed within one week of admission f

6. Methodology MDT discussion of whether ACRT is meeting NICE guidelines.
Sample of all ACRT clients in 2015 whose diagnosis on referral was for stroke.
Data collected through RiO
Analysis of referrals directly from hospitals to determine if ACRT is receiving ESD referrals and probable reasons for this. g

7. Results “New strokes” and Early supported stroke discharge
166 clients referred to ACRT with “Stroke” as diagnosis on referral.
68 were “new strokes” (referred as part of continuous pathway following hospital admission) g

8. Results
Reasons for ACRT receiving clients discharged directly from hospital within 6 weeks of their stroke (therefore possibly categorised as ESD and not treated in line with NICE guidelines):
• Unclear diagnosis/suspected stroke (8 people)
• IIT exclusion due to certain goals: outdoor mobility, voc rehab, driving (5 people)
• Client is resident in another borough but has City & Hackney GP (3 people)
• IIT pass on referrals for higher level cognitive assessment (2 people)
• SLT-only referrals when reduced SLT staffing in IIT (now resolved) (2 people)
(not evident in audit, but nursing home residents would also be referred to ACRT)
Limitation of audit is no access to IIT notes and assessments, therefore some reasons have been estimated and not always clear if IIT saw clients before referring on to ACRT g

9. Results – NICE guidelines
8 of 84 NICE stroke rehabilitation guidelines not being followed by ACRT (not including ESD guidelines).
Section
Guideline
Reason?
Planning rehabilitation
Give people copies of goals after goal setting
Gas-light to reduce administration
Person with a stroke to have a key contact from the rehab team
Key-worker system was trialled across ACRT and was not feasible to be in place for all clients.
Providing support and information
Review person’s information needs at 6-month and annual stroke review and at start and completion of intervention period
ACRT do not offer a formal 6 month or annual review. It is expected this is completed by the Consultant review process
Emotional functioning
When new or persisting emotional difficulties are identified at the person's 6-month or annual stroke reviews, refer them to appropriate services for detailed assessment and treatment.
Vision
Offer eye movement therapy to people who have persisting hemianopia after stroke and who are aware of the condition.
Swallowing
Offer swallowing therapy at least 3 times a week to people with dysphagia after stroke who are able to participate, for as long as they continue to make functional gains.
Staff resources allow 1-2 sessions per week
Communication
When persisting communication difficulties are identified at the person's 6-month or annual stroke reviews, refer them back to SLT for detailed assessment, and offer treatment if there is potential for functional improvement.
Make sure that all written information is adapted for people with aphasia after stroke.
This is completed on a needs basis.  g

10. Results – NICE guidelines
74 of 84 NICE stroke rehabilitation guidelines being followed by ACRT.
6 identified as followed, but with room for improvement
Section
Guideline
Comment
Providing support and information
Identify information needs and how to deliver them
Information needs if identified are documented in initial assessment form, however, no prompt to ask regarding needs for condition- related information (e.g. understanding of condition / injury, long term complications).
Movement
Assess people who are able to walk and are medically stable after their stroke for cardiorespiratory and resistance training appropriate to their individual goals.
ACRT neuro assessment form includes space for cardiovascular fitness and resistance outcome measures, but experience suggests CV fitness measures less routinely used.
Onward referrals to appropriate exercise options completed routinely.
Provide information for people with stroke and their families and carers on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain.
Pain and risk factors for pain (subluxation, abnormal movement patterns, sensory disturbance, past medical history, severe paresis) assessed routinely.
Treatment options routinely provided – positioning (including training carers), active and passive movement, microstim, TENS, orthotics (Omo-neurexa).
ACRT upper limb assessment form not routinely used. f

11. Results – NICE guidelines
6 identified as followed, but with room for improvement (continued)
Section
Guideline
Comment
Movement
Offer people repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs).
UL treatment provision:
GRASP (active, repetitive, functional movement), saeboflex, task- specific exercises.
Lack of standardised treatment approaches, but Trust-wide UL pathway under development
Assess the effectiveness of the ankle–foot orthosis for the person with stroke, in terms of comfort, speed and ease of walking.
Comfort and walking speed routinely assessed when provided. Effort (e.g. Borg scale) not routinely used in provision of standard AFO.
Long-term health and social support
Provide information so that people after stroke are able to recognise the development of complications of stroke, including frequent falls, spasticity, shoulder pain and incontinence.
Yes, within the remit of the professions working within the team.
Don’t routinely provide written info on complications and self- management. f

12. Discussion
Some stroke patients are discharged home from hospital less than 6 weeks after their stroke with functional goals – but not offered an ESD service as recommended by NICE guidelines.
The number of people offered ESD by IIT and IIT’s reasoning for referring potential ESD clients to ACRT is not always clear from current documentation available on RiO.
ACRT mostly following NICE guidelines for stroke rehabilitation.
Some guidelines not followed:
to reduce administrative burden
because they were trialed and considered unnecessary
they are being followed by other services for City & Hackney stroke patients (6 month/annual review, ESD)
Other guidelines are not followed or partially followed, and could more easily and appropriately be implemented/trialed (see recommendations) g

13. Recommendations Early Supported Discharge:
Resolve problem of people who have City and Hackney GP but are residents of other boroughs not being seen by IIT.
Screeners to direct both suspected and diagnosed new CVAs who would qualify as ESD to IIT – if not eligible, document reason and categorise as Urgent
If new stroke referred from IIT, ACRT Screening to:
speak with IIT if reason for onward referral is unclear
document if offered ESD and seen by IIT
if not offered ESD, document reason for this. g

14. Recommendations Recommendations for NICE guidelines not being met:
Section
Guideline
Recommendation
Vision
Offer eye movement therapy to people who have persisting hemianopia after stroke and who are aware of the condition.
Recommendation: Explore feasibility of offering eye-movement therapy intervention for people with hemianopia.
Communication
Make sure that all written information (including that relating to medical conditions and treatment) is adapted for people with aphasia after stroke.
Recommendation: Development of aphasia-friendly materials in line with the Trust-wide accessible information project (in development). g

15. Recommendations
Recommendations for NICE guidelines being met but which could be improved:
Section
Guideline
Comment
Providing support and information
Identify information needs and how to deliver them
Recommendations:
To include information needs prompt on Face Rapid form and induction materials
To review what published patient information about stroke, symptoms and complications is available and appropriate for therapists to provide to patients.
To consider where in St Leonard’s stroke related information can be displayed.
Movement
Assess people who are able to walk and are medically stable after their stroke for cardiorespiratory and resistance training appropriate to their individual goals.
Recommendation: CV fitness outcome measures to be included in neuro-physio assessment form
Provide information for people with stroke and their families and carers on how to prevent pain or trauma to the shoulder if they are at risk of developing shoulder pain.
Recommendation: ACRT upper limb assessment form to be reviewed following introduction of Trust-wide upper limb pathway to include assessment of risk factors for shoulder pain. f

16. Recommendations
Recommendations for NICE guidelines being met but which could be improved (continued):
Section
Guideline
Comment
Movement
Offer people repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (such as sit-to- stand transfers, walking and using stairs).
Recommendation: ACRT to adopt Trust- wide upper limb rehab pathway
Assess the effectiveness of the ankle–foot orthosis for the person with stroke, in terms of comfort, speed and ease of walking.
Recommendation: Standardised outcome measures to be put in induction materials
Long-term health and social support
Provide information so that people after stroke are able to recognise the development of complications of stroke, including frequent falls, spasticity, shoulder pain and incontinence.
Recommendation: see previous f

17. Action Plan f Recommendation Actions to be implemented
Responsible person
Expected date of implementation 1.
Discuss with IIT issue of people who have City and Hackney GP but not borough residents.
Donna Underwood
April 2016 2.
Explore feasibility of offering eye-movement therapy intervention for people with hemianopia.
Guy Slade
End April 2016 3.
Development of aphasia-friendly materials in line with the Trust-wide accessible information project (in development).
Simon Grobbler
TBC 4.
To include information needs prompt on Face Rapid form
Fred Baron
June 2016 5.
To review what published patient information about stroke, symptoms and complications is available and appropriate for therapists to provide to patients.
To consider where in St Leonard’s stroke related information can be displayed.
Neuro Band 7s
(for ? Rotational project) 6.
CV fitness outcome measures to be included in neuro-physio assessment form
Standardised AFO outcome measures to be put in induction materials
Rachael Cottier
Achieved 7.
ACRT to adopt Trust-wide upper limb rehab pathway and review ACRT upper limb assessment form include assessment of risk factors for shoulder pain.
Neuro OT / PT Band 7s 8.
Update guidance for ACRT screeners re: handling and documenting stroke referrals
Fred Baron / Patricia Griffin f