1. Sarah Rickard (Manager)
Implementing a successful and sustainable centralised 7-day hyper acute stroke service: lessons from Greater Manchester
Sarah Rickard (Manager)
@GMStrokeODN

2. Our journey of improvement

3. 2010
2011
2014
2015
2016
2017
Partial centralisation of acute care in GM, full centralisation in London
Internal review of pathway concludes further change is needed
NIHR research demonstrates superiority of full centralisation
PAT rationalises stroke services to one site
Work to improve community services commences
GM implements full centralisation
Greater Manchester began centralising its stroke services in It introduced a partially centralised model delivering hyper acute care at three Hyper Acute Stroke Units (Salford Royal, Stepping Hill and Fairfield General) for patients presenting within <4 hours of onset with everyone else taken to their local stroke unit called District Stroke Centres. At the same time, London moved to a fully centralised pathway where all patients were taken directly to a HASU.
An NIHR research project examined the impacts of the two differing models and showed the London model was superior in terms of mortality.
Following a local review in 2011, national audit data and the publication of this evidence, it was recommended that GM moved to the fully centralised model, which went live in March The ODN was established in the summer of that year and initially focused on supporting the pathway to ensure its sustainability and high performance.
During the last 3 years, the region has also reduced its stroke units to concentrate the quality of care, with Pennine Acute rationalising its services to one site in 2014, and Macclesfield’s unit closing in 2016.
ODN reviews of the redesigned hospital pathway at 1 and 2 years has shown significant improvements in the quality of care provided to all GM residents, with everyone now having access to 7 day 24/7 hyper acute care that is A rated by the national stroke audit.
The network is now focused on ensuring that community rehabilitation is as equitable and of a similar high standard throughout the region.
ODN established
Macclesfield stroke unit closes
Annual review of acute pathway shows improvement
GM achieves ‘A’ acute care for all residents

4. The GM stroke pathway
Around 85% of our suspected stroke patients are taken to the nearest HASU by ambulance on the GM stroke pathway. There, they receive the hyper acute stroke care bundle (which may include thrombolysis) and are either transferred to their local DSC within 3 days for inpatient rehabilitation, or are sent straight home where many (but not all) will commence community rehabilitation via specialist services.
Around 10% of suspected strokes are directly admitted to DSCs as they have a time of onset >48 hours, are inpatient strokes, or are FAST negative and not immediately diagnosed as a stroke.

5. GM stroke providers 3 Hyper Acute Stroke Units
6 District Stroke Centres
16 community rehabilitation teams
The region is served by 3 HASUs and 6 DSCs, with Salford open overnight serving the whole of GM and all stroke units are commissioned using a standard service specification with associated quality standards. We are actively considering how we could further reduce the number of units to help ensure services can be sustained in the longer term as staffing issues become more critical.
Our specialist community rehabilitation services are much more variable, with 16 separate teams serving 12 CCGs.

6. Acute pathway performance
PAT re-organisation
GM full centralisation
2014
2015
2016
2017
CCG
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Apr-Jul
Aug-Nov
Dec 16-Mar 17
Eastern Cheshire D C B A
Bolton X
Bury
Central Manchester
Heywood, Middleton & Rochdale
North Manchester
Oldham
Salford
South Manchester
Stockport
Tameside & Glossop
Trafford
Wigan Borough
One of the roles of the ODN is to monitor and support improvements in the stroke acute pathway. The most recent national audit data shows:
GM now has best scoring hospital stroke pathway in the country
Stroke patients in all 13 CCGs receive ‘A’ rated care
All 3 HASUs are rated ‘A’ and in the top 10 units in the country (out of 224)
An ODN audit of patient flow in 2017 showed the pathway has broadly stabilised with 93% of all GM admissions via a HASU with 94% of stroke patients admitted to a stroke ward
There have been some changes in the last year:
Increased proportion of stroke patients presenting <4hours at HASUs – more people now eligible for thrombolysis at HASUs
Large decrease in stroke assessments in DSC A&Es and admission at DSCs
Large increase in directly admitted stroke patients at DSCs placed on non-stroke wards – often due to internal bed management issues
Reduction in non-strokes (stroke mimics or Transient Ischaemic Attacks) admitted to HASU stroke wards – better detection, triage and management of patients by stroke services freeing up stroke beds for stroke patients
ODN benchmarking of compliance with the 2016 National Clinical Guideline for Stroke showed compliance of teams with their relevant recommendations as HASUs - 91%; DSCs 93%. Areas of non-compliance (e.g. access to clinical psychology) were usually due to lack of or insufficient local commissioning.

7. Direct admissions

8. Crude mortality

9. Review at 2 years
27% decrease in stroke assessments in A&E at District Stroke Centres (DSC) – reducing the burden on A&E
Overall, 85% of stroke patients conveyed by ambulance to hospital; 10% self/GP referral , with 65% of strokes diagnosed by ambulance; 21% by hospital; 9% FAST -ve – unchanged from 2016
Overall, 9% increase in % of strokes <4hours time of onset and 13% decrease in % of strokes 4-48 hours – suggests better recognition and rapid conveyance to hospital
Increased proportion of stroke patients with time of onset <4hours at HASUs with a decrease at DSCs where there was an increase in >48 hours – more patients are presenting at HASUs eligible from thrombolysis
93% of stroke admissions are via a HASU with 94% of stroke patients admitted to a stroke ward – unchanged from 2016
Significant increase in directly admitted stroke patients at DSCs treated on non-stroke wards – often due to lack of ring fenced stroke beds, with repatriations often prioritised over direct admissions

10. Mimics and TIAS
Reduction non-strokes (mimics and TIAs) admitted to HASU stroke wards – better detection, triage and management of patients by stroke services
9% decrease in volume of overall admissions (direct and repatriations) at DSCs; 16% increase in repatriations. All direct admissions at DSCs are appropriate and all eligible patients discussed with HASU
9% decrease in proportions diagnosed as non-stroke (mimics or Transient Ischaemic Attacks) in HASUs, 62% of assessments in A&E are now given a stroke diagnosis
Mimics and TIAs presenting at HASUs are much more likely to be self-referrals and FAST negative than those diagnosed as stroke; ~50% have a time of onset of <4 hours
72% decrease in volume of mimics and TIAs at HASUs – potentially better recognition by ambulance crews

11. Bed utilisation
Around 40-50% of DSC stroke bed capacity is being utilised by patients not requiring specialist stroke care
Audits have revealed:
Bed availability for stroke patients hampered by high numbers of medical outliers – around 21% of beds at some DSCs
Delayed discharges also impacting availability; most DSCs have 20-25% of beds occupied by people ready to go home;
Timely repatriation remains problematic with several DSCs regularly breaching separate patients and 230 excess bed days for the last quarter or >900 days/year
Proportion of inpatient stay on a stroke ward is below national average at 70-75% at 5 DSCs

12. Lessons learnt and future plans
Sarah Rickard (Manager)

13. Key learning
Realistically model changes in patient flow and consider future developments e.g. IAT, ICH pathways
Minimise number of stroke units (and community teams) to improve quality of care and efficiency
Redesign community services at the same time and consider combining with neuro rehabilitation teams – service specifications developed and available
Measure impacts across whole patient journey

14. Key learning Manage patient flow effectively:
Collaboratively agree SOPs to support pathway
Agree at CEO level robust processes to ensure timely repatriation
Ensure sufficient support to manage increased patient flow at HASUs
Improve recognition of stroke and A&E hand off to reduce assessments and admissions of false positives at HASUs
Ensure ASUs are still able to treat direct admissions appropriately
Consider pathway exclusions (e.g. time of onset cut off) and referral pathways (carotid artery etc)

15. Reducing mimics Local training/awareness in A&E and with stroke teams
Stroke consultant involvement to reduce inappropriate admissions to ward
Measuring via audit
Training of ambulance crews to select the right stroke unit quickly
Ambulance service app
Online training
Teaching at university on paramedic course
Incident reporting via ODN – feedback to crews

16. Workforce
Staffed according to relevant service specifications (based on RCP guidance)
HASUs - Middle grade rota, physician associate, ANPs. Regional rota not in place; medical staffing remains an issue at Salford!
ASUs – little change in preparation for centralisation but staff had to cope with change in case mix and work (no IVT)
Wards – need to minimise number and encourage shared working
Managing repatriation workload – HASU Flow co-ordinators, IS support

17. Funding model Fixed tariff for HASU – 47% Fixed Tariff for ASU – 53%
Above include Best Practice Tariff
Mimics get paid at HASU rate

18. Critical success factors
Decision to centralise based on robust evidence - hearts and minds won!
Collaborative approach built relationships and trust over time; included patient voice
Effective use of data to demonstrate impacts – ensures sticky change

19. Change not just about HASUs
Foster ‘One team’ ethos – HASU, DSC & community with focus on improving outcomes for patients
Changes to hyper acute pathway will impact on staff in DSCs & community services
Avoid perception that only concerned about HASU
Managed Network
Have in place before any changes
Involve community providers & voluntary sector – Stroke Association
Need visible community stroke leadership
Everyone needs to feel involved
Celebrate success

20. What would we do differently?
ODN in place before implementation
Whole care pathway approach
Integrated community stroke team model across the whole region – standardised post-acute services
Fewer stroke units - future proof staffing and more efficient
Even share activity across HASUs - Salford is too big
? Mothership for Thrombectomy
Regional consultant OOH HASU rota
More training paramedics pre launch pathway
Infrastructure (i.e. people, IT and processes) to manage patient flow
Cast iron repatriation policy including mimics – CEO level sign off & financial incentives

21. What is an ODN and why you need one!

22. What is the GMSODN?
Established in July 2015; pump primed by SCN and now provider funded (~£200k/annum)
Only Stroke ODN in the country
Non-statutory body constituted from all public sector stroke provider organisations across Greater Manchester, including NWAS
Providers, in partnership with the Host (SRFT), are collectively responsible for delivery of the functions of the network

23. Established in 2015 and funded by providers of stroke care
Small team
Our vision

24. Hospital Clinical Lead Community Clinical Lead
Meet the team
Sarah Rickard
Manager
Chris Ashton
Co-ordinator
Dr Jane Molloy
Hospital Clinical Lead
Tracy Walker
Community Clinical Lead
Supported by Administrator Lisa Chadwick; shared with Neuro Rehab ODN

26. Continuous improvement
Mortality
Patient information
Stroke unit capacity
Community services
Service developments
TIA services
Shared clinical SOPs
Measuring performance
ICH pathway
Regional IAT service
Sector Forums
Audit
Patient flow
Training & Education
Competency frameworks
Training programme
Annual conference
Induction training
Online training
Teaching at universities
Secondary prevention
Cardiology services
SaLT
Rehabilitation
Life after stroke
Vocational rehabilitation
Driving
Use of assessments

27. Designed posters and leaflets
Advised on stroke prevention training packages
Involved in Connected Health Cities project
Reviewed self management tools
Informed design of local stroke services

28. Networks add value
Focal point for stroke in GM and increasing our national profile
Governance structures through which organisations can hold each to account, with mechanisms to identify and address issues and risks
A voice for patients and carers, and involving the voluntary sector
Involving a wide range of stakeholders and providing opportunities for networking and peer support, and sharing of best practice
Strategic approach to improving local stroke services across the whole care pathway and providing a clear vision for the future
Forums for discussion, agreement, implementation and resolution of operational issues and facilitating service improvements

30. Get in touch sarah.rickard@srft.nhs.uk Jane.molloy@srft.nhs.uk
@GMStrokeODN