1. Supporting NHS Wales to Deliver World Class Healthcare AWSSIC Cardiff and Vale NHS Trust Storyboard Learning Session Two 25 th March 2009

2. Slide 2 All Wales Stroke Services Improvement Collaborative Thankyou for asking me to present Newcomer On sabbatical (in Llandrindod ?!) Hope to contribute in the future..

3. Slide 3 All Wales Stroke Services Improvement Collaborative Cardiff and Vale NHS Trust Is one of the largest NHS Trusts in the UK. It provides day-to-day health services to a population of around 500,000 people living in Cardiff and the Vale In 2008/2009 the Trust's total income is £634 million and we employ approximately 14,000 staff

4. Slide 4 All Wales Stroke Services Improvement Collaborative A driver for change

5. Slide 5 All Wales Stroke Services Improvement Collaborative Will tPA redefine acute medicine and acute neurology? An overload of dilemma An evolving story Patients haven’t worked out what they can and can’t do Immature motor signs Motor signs: immature, mature, mature with musculoskeletal complications Sensory signs often at their best Visual fields and eye movements are useful Cognitive deficits Can be difficult to get the doctor and patient to focus

6. Slide 6 All Wales Stroke Services Improvement Collaborative Will tPA redefine acute neurology? A normal (or normalish) CT scan Neuroradiologist needs to call the shots A dangerous but effective treatment, often for a syndromic diagnosis Stroke seems too crude a diagnosis to make A health service not used to dealing with stroke as an emergency (3-6 hours) No pain or bleeding, no spots or screaming Lack of neurology experience amongst junior general medics

7. Slide 7 All Wales Stroke Services Improvement Collaborative How could we start the thrombolysis ball rolling? Start at the front door How are people assessed?

8. Slide 8 All Wales Stroke Services Improvement Collaborative Admissions proforma

9. Slide 9 All Wales Stroke Services Improvement Collaborative ABDOMEN PR: NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONS OTHER RELEVANT FINDINGS (Oral, Hands, Breast etc) Admissions proforma 2005

10. Slide 10 All Wales Stroke Services Improvement Collaborative Remember, if it is an acute stroke (< 6 hours of symptoms) they may be eligible for thrombolysis NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONS Conscious level Eye opening Motor response Verbal response Mini-mental test score Coverings of the nervous system Head Neck Spine Posture Gait Romberg’s test Cranial Nerve II Acuity II, III Visual Fields Pupil responses Optic fundus III, IV, VI V Sensory Eye movements Motor VII VIII X Palatal movement XI XII Cough Swallowing Phonation Limbs Inspection Tone Strength Coordination Reflexes Sensation Admissions proforma 2007

11. Slide 11 All Wales Stroke Services Improvement Collaborative Why are people not being randomised into trials of thrombolysis ? IST 3 trial External validation Your centre is ok to be involved Audit done by someone else Plugged in to a research mentality Do the ethics application Sort out paperwork Organise visit by IST3 coordinator Satisfy research standards in UHW Start!

12. Slide 12 All Wales Stroke Services Improvement Collaborative Since October 2007; 9-5, Mon-Friday. 3 patients randomised into the trial 4 patients treated on licence Need to extend to out of hours Need to involve more people on the rota Needs to become part of the dumpety-dump of the acute medical take Education, education, education...

13. Slide 13 All Wales Stroke Services Improvement Collaborative Aspirin administration as identified in a previous audit All stroke patients to receive aspirin in a timely fashion unless clinically contra-indicated If patient was unable to swallow safely there was no consistency in considering PR or NG administration

14. Slide 14 All Wales Stroke Services Improvement Collaborative Where Acute admission areas EU and MAU on one hospital site

15. Slide 15 All Wales Stroke Services Improvement Collaborative Aspirin in the first 24 hours Pharmacist agreed to collect data prospectively Over two weeks five patients on the acute medical unit had aspirin prescribed on admission None had it written as po/pr/ng How could we raise the aspirin profile?

16. Slide 16 All Wales Stroke Services Improvement Collaborative Dear All, The recent RCP and NICE guidelines recommend that Aspirin 300mg daily be given to all patients presenting with acute stroke in whom intracerebral haemorrhage has been excluded by brain imaging. This should be continued for two weeks. This dose of Aspirin can be given by mouth, through an NG tube, or rectally. To ensure that Aspirin is given to this group of patients, many of whom have a swallowing problem, please prescribe Aspirin 300mgs daily PO/NG/PR. Thankyou, Tom Hughes Hamsaraj Shetty

17. Slide 17 All Wales Stroke Services Improvement Collaborative We fancied a logo!

18. Slide 18 All Wales Stroke Services Improvement Collaborative Dear All, The recent RCP and NICE guidelines recommend that Aspirin 300mg daily be given to all patients presenting with acute stroke in whom intracerebral haemorrhage has been excluded by brain imaging. This should be continued for two weeks. This dose of Aspirin can be given by mouth, through an NG tube, or rectally. To ensure that Aspirin is given to this group of patients, many of whom have a swallowing problem, please prescribe Aspirin 300mgs daily PO/NG/PR. Thankyou, Tom Hughes Hamsaraj Shetty Reliable comparable (before and after) data not available yet.

19. Slide 19 All Wales Stroke Services Improvement Collaborative Lessons learnt Meaningful data are difficult to obtain It is very time consuming Someone needs to have dedicated time to do it during the working week and it has to be part of the routine service It is possible to introduce change, particularly if you can become the change

20. Slide 20 All Wales Stroke Services Improvement Collaborative Physiotherapy

21. Slide 21 All Wales Stroke Services Improvement Collaborative Physiological monitoring

22. Slide 22 All Wales Stroke Services Improvement Collaborative OT assessment

23. Slide 23 All Wales Stroke Services Improvement Collaborative Aspirin

24. Slide 24 All Wales Stroke Services Improvement Collaborative CT within 24 hours

25. Slide 25 All Wales Stroke Services Improvement Collaborative Aspirin within 24 hours

26. Slide 26 All Wales Stroke Services Improvement Collaborative Manual handling assessment