1. Stroke Services at HWPH NHS Foundation Trust
“Getting It Right”
Dr Derek Hilton
Consultant Stroke Physician
Annual Members Meeting
18th September 2013

2. What is a stroke?

4. TIA / “Mini-strokes”

5. ¼ all stroke – working age
Rule of ⅓
6% NHS expenditure
£2.8 bn
Does not include social care
Average LOS 28 days
¼ all stroke – working age

6. A Comprehensive Stroke Service

7. TIA: “Medical Emergency” High Risk patients
Seen within 24 hours
Surgery within 7 days
Low Risk patients
Seen within 7 days
Surgery within 14 days from onset

8. “Thrombolysis” within 3 hours
Extended to 4.5 hours

10. Rehabilitation at home works Creation of Community ESD Teams
For a specific cohort of patients
Creation of Community ESD Teams
Well-defined service specification

12. A Comprehensive Stroke Service

13. Low Risk ‘One Stop’ TIA Clinic
Heatherwood Hospital
Mon, Weds, Fri Clinics
Summer 2012
Morning: Doppler, ECHO, Bloods
Afternoon: Consultant review

14. Hyperacute Services & High Risk TIA Clinics

17. Acute Stroke Unit

18. Acute Stroke Unit
Later-presentation stroke patients
Receive Bucks repatriated patients < 72 hours
17-bedded Unit
Stabilisation
Therapy Assessment for rehab potential
Significant proportion of patients go home or to NH from ASU

19. Rehabilitation – Ward 8 HW
12 rehab beds
6 weeks therapy
ESD Early Supported Discharge
Community-based therapy
6 weeks
Home Sooner
Better outcomes

21. Performance – Bed capacity

22. Performance – Bed capacity

23. Length Of Stay

24. Performance – Diagnostics

25. Performance – Therapies & Nursing

26. Performance – Therapies & Nursing

27. Performance – Therapies & Nursing

28. Why missing inpatient targets?
Problem
Mitigating actions/plans
Diagnosis
Receiving late referrals from A&E & wards [process]
Levels of skill to diagnose in A&E & wards [education]
Default position should be to query stroke [education]
Knowledge of stroke pathway [education]
Sharing data with A&E
Stroke lead consultant identified on A&E
Training for A&E nursing and medical staff on Stroke pathway and diagnosis – Slot on A&E induction & sporadic teaching sessions
Consultant and ANP walkabout – junior doctors
24/7 Stroke coordinator
Targeting individual doctors
Diagnostics
Doppler's - Patients wait (from 2 days to 2 weeks) whilst on ASU due to capacity on sonographer’s list.
CTs – generally done on time. Breaches occur due to late referrals/late diagnosis
Gold standard is for patients to receive Doppler's and CT scans whilst on a Stroke ward within 24 hours of request.
Division B are aware of the need for extra capacity for Doppler's.
Capacity
Bed modelling suggests we have enough beds to support the number of patients admitted.
ASU admit a range of between 0-5 patients per day. However, using the 80/20 rule, ASU must be able to accept 4 patients per day.
In times of capacity pressures in the Trust, medical patients are admitted to ASU.
Not consistently repatriating patients within 72 hours from HASU at Wycombe – risk of financial penalties if consistently fail.
2 ring-fenced beds on the assessment unit once modular ward opens
Increase awareness Trust wide
Development of ESD service for Berkshire East will ensure some patients go home much earlier (target of 41%) – will help flow through ASU and decrease LOS. Due to start Autumn Better rehab outcomes for patients. ESD service will support ASU in maintaining 4 discharges daily.
Increased communication between stroke coordinators in ASU and HASU. HASU will give us 24hrs warning of a patient becoming medically fit and in return we will endeavour to repatriate that patient to ASU within 24 hours.
Staffing
Stroke coordinator post was vacant from May to Sept – vital role in executing the stroke pathway
SaLT post vacant – difficult to get a SaLT therapist to do communication assessment within allotted timeframe
Stroke coordinators in post since September
Stroke coordinators on weekdays are therapists and therefore cannot be pulled.
New locum SaLT therapist starts this month who will focus on communication assessments.

29. Good news…….
Infection Control
Target
NOV
OCT
SEPT
AUG
JULY
JUNE
MAY
APRIL
Trend
Hand Hygiene (%)
100.0
100% ►
VIP (%)
Environment (%)
MRSA protocol (%)
Patient Experience
Compliments 15 20 23 18 12 10 ▲
Name bands
Consistently performing in infection control and patient experience

30. ASU “Friends & Family” Questionnaire
Jan – August 2013

31. CQC Report:
In contrast, on the acute stroke unit, patients and their relatives felt very well informed about their treatment plans and told us they were involved in making decisions about their care. One patient told us, "we have been given great family support."

32. The Future…..

33. Thank you