Together for Health. Stroke Delivery Plan, Annual Report 2014

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1 Together for Helth Stroke Delivery Pln, Annul Report 2014

2 Contents 1. Introduction 2 2. How well re we doing on stroke services in Wles? Overview Stroke incidence rtes Stroke mortlity rte dy hospitl survivl rtes 7 3. Stroke services in Wles Preventing stroke Detecting stroke quickly Stroke rehilittion Trgeting reserch Conclusion: looking hed to 2014/15 nd eyond 28 Annex 1 Helth ords performnce 30 1

3 1. Introduction The puliction of the second ll-wles nnul report for stroke is prt of the commitment of the Welsh Government to deliver more ccountle nd visile NHS for the people of Wles. This nnul report highlights the progress we hve mde in our stroke services over the pst 12 months nd identifies res for future improvement. Reports hve lredy een produced y helth ords, setting out locl progress ginst Together for Helth Stroke Delivery Pln. This report provides ntionl overview. Tken together, the reports demonstrte our commitment in Wles to the provision of stroke services nd reporting on progress. It presents n overview of how well the NHS cross Wles is performing in this re, nd identifies wht more NHS orgnistions need to do. Good progress is eing mde in implementing the ctions set out in our Stroke Delivery Pln: Deths from stroke (ge stndrdised mortlity rtes per people) hve fllen from 60 in to 38 in This is fll in over 1,000 deths per yer. 1 Overll etween nd there hs een n increse in stroke survivl numers of 552. Emergency dmissions for stroke hve fllen y over 1,000 since , 22% reduction. Survivl rtes, within 30 dys of hospitl dmission, for those ged 74 nd under re 91.3%. An improvement of 1.8% since There hs lso een modest improvement of 0.5% for those ged 75 nd over t 77.6%. Performnce with the pre-hospitl cre undles y the Welsh Amulnce Service Trust hs shown stedy improvement over the yer. Complince cross ll three undles hs improved from 77.5% in June 2013 to 94.7% in June The percentge of ptients eing thromolysed within one hour of rriving t the hospitl hs improved y over 50 ptients, from 17% in to 26% in The progress we hve seen is gret triute to the dedicted stff tht work tirelessly to support ptients nd crers through difficult times. There re however numer of res where progress hs een more chllenging nd requires further work to give sustinle progress: Direct ccess to stroke wrd within 24 hours of dmission hs fllen from over 80% in April 2013 to 65% in Mrch Just over 60% of stroke ptients spent over 90% of their time on n cute stroke wrd, this needs to improve to over 70% in the next 12 months. Performnce ginst the cute stroke undles hs een vrile throughout the yer. Complince ginst undle one (first hours undle) nd undle three (first three dys) hs shown improvements to 92.2% nd 89.2% in August 2014 ut still remin elow the 95% complince level required. Bundle 4 (seven dys undle) hs een consistent t round 78%. Performnce ginst undle two (first dys undle) however hs fllen from 58.5% in August 2013 to 48.2% in August Bsed on three-yer verge etween nd

4 Assessments on dischrged stroke ptients should tke plce within 6 months of the dischrge. However during the period April to June 2014 only 12% of these ssessments took plce within the six months cross Wles. Prince Philip ws the only site to complete 98% of its ssessment within six months. Prticiption in reserch continues to fll. We expect to see improvements in these res in We lso hope to see greter emphsis on the delivery of stroke services tht re cliniclly led nd put the ptient t the centre of cre. The Stroke Implementtion Group hs greed three ntionl priorities ginst which they expect cler progress to e mde. These re the identifiction nd mngement of tril firilltion, the reconfigurtion of stroke services in Wles including the development of hyper-cute services in Wles nd community rehilittion. In July 2013, helth ords in Wles strted to record performnce in line with requirements from the Royl College of Physicins in the sentinel stroke ntionl prticiption udit. This will result in enhnced understnding of the stroke journey for ll ptients nd ultimtely their outcomes. Through this nd future nnul reports, the Welsh Government ims to give cler ccount of its stroke services to the pulic nd indicte to the NHS where it is doing well nd where it needs to improve cre. Informtion like this is the est wy to support continuous improvement in services so tht we cn ensure tht people of ll ges, wherever they live nd whtever their circumstnces, hve ccess to excellent NHS stroke cre. Andrew Goodll Chief Executive, NHS Wles Adm Cirns Chir Stroke Implementtion Group 3

5 2. How well re we doing on stroke services in Wles? 2.1 Overview Stroke is disese tht hs mrked impct on the length nd qulity of mny people s lives. The outcome indictors mesured ntionlly to trck how well stroke services re doing over time include: how mny people hve stroke or suffer from symptoms of stroke ech yer; how mny people die from stroke ech yer; nd how mny people survive stroke. It is estimted tht ech yer cross Wles, pproximtely 6,000 people will hve stroke; of those round third my die. In ddition over 65,000 people re living with the effects of stroke 2. Stroke is leding cuse of dult disility 3. More thn hlf of ll stroke survivors re left dependent on others for everydy ctivities 4. Stroke cuses out 7% of deths in men nd 10% of deths in women 5. The percentge of those treted for stroke is much higher for those ged 65 nd over. In 2010 stroke ws mjor cuse of deth in Wles fter cncer, hert disese nd respirtory disese, cusing lmost 2,800 deths 6. However there hs een stedy decline in the numer of people dying from strokes since Stroke incidence rtes This tells us how mny people hve hd stroke or suffered symptoms of stroke. It provides feel for how well we re doing t preventing stroke in Wles. If we re chieving our ojectives, we would expect to see over time: A slower rise in the rte of increse. A reduced gp etween the most nd lest deprived res of Wles. Incidence rtes comprle with the est in Europe. The est mesure of incidence rtes in Wles is the numer of emergency dmissions to hospitl for stroke. Figure one shows tht the numer of emergency dmissions for stroke during hs fllen y 141 ptients to 3,974 when compred to the previous 12 months. This is fll of over 1,000 ptients, 22% since Stroke Assocition Aville t 3 Admson, J., Beswick, A. nd Erhim, S. Stroke nd Disility Journl of Stroke nd Cererovsculr Diseses 2004 vol 13, No P Royl College of Physicins Ntionl Sentinel Stroke Clinicl Audit 2010 Round 7 Pulic report for Englnd, Wles nd Northern Irelnd. Prepred on ehlf of the Intercollegite Stroke Working Prty My 2011 P43. 5 British Hert Foundtion Coronry hert disese sttistics 2012, pulished Oct British Hert Foundtion Coronry hert disese sttistics 2012, pulished Oct Dt suject to coding issues t C&V UHB. 4

6 6,000 Figure 1 Emergency dmissions for stroke, ll persons, ll ges, Wles 2009/10 to 2012/13, y finncil yer 5,000 4,000 3,000 2,000 1, Source: Pulic Helth Wles Oservtory, using PEDW (NWIS), June Stroke mortlity rte This tells us how mny people die from stroke ech yer 8. If we re successful, over time we would expect to see: A continued fll in the rte of deths from stroke. A reduced gp etween the most nd lest deprived res of Wles. Mortlity rtes comprle with the est in Europe. Figure two shows tht there hs een stedy decline in the overll rte of people dying from stroke since 2002 indicting tht the outcomes from stroke cre in Wles re resulting in improvements in survivl cross Wles. 8 Expressed s n ge stndrdised rte to llow comprisons etween yers nd countries 5

7 Figure 2 Deths from stroke (ge stndrdised mortlity rtes per 100,000 people) Source: NWIS, My 2014 However s figure three highlights tht, despite the improvements in the mortlity rtes, s percentge of totl deths slightly higher percentge of people died from stroke in Wles thn the rest of the UK. Figure 3 Deths y stroke s % of ll deths in ll dults in UK, % 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Wles Englnd Scotlnd Northern Irelnd Source: Coronry hert disese sttistics 2012, British Hert Foundtion 6

8 dy hospitl survivl rtes This mesure shows us how mny people re live 30 dys fter they hve een dmitted to hospitl with stroke. It is n indictor of the overll effectiveness of tretment s well s the generl helth of the popultion. If successful, over time, we would expect to see: An increse in 30 dy hospitl survivl rtes. A reduced gp etween the most nd lest deprived res of Wles. Figure 4 Survivl within 30 dys of hospitl dmission for stoke % nd over 74 nd under Source: PEDW, August 2014 Figure four shows the generl trend of incresing survivl rtes. 91.3% of those ged 74 nd under; nd 77.6% of those ged 75 nd over now survive eyond 30 dys fter hospitl dmission for stroke. We re especilly interested in mesuring how well people survive following stroke following hospitl dischrge nd whether they cn return to their previous lives fully or prtilly. We hve not yet developed n pproch to mesure this yet, ut will seek to do so in future yers. 7

9 3. Stroke services in Wles A numer of NHS performnce mesures hve een developed to help us understnd how well we re preventing, detecting nd treting stroke in Wles. The seline for ech mesure ws pulished in the 2013 Stroke Annul Report. In this report we will look t the progress tht hs een mde ginst the performnce mesures. We lso review service improvements cross helth ords tht will drive up the qulity of stroke services in Wles. Implementtion of the Cwm Tf University Helth Bord s delivery pln is overseen y the Cwm Tf Stroke Delivery Group, chired y the Executive Led for Stroke. This Group received Cwm Tf Recognition Awrd for Sustinility nd Improvement in My 2014, in recognition of the vrious stroke service improvements it hs driven over recent yers. 3.1 Preventing stroke Our popultion is getting older nd overll helth is improving. But wide inequlities in helth etween socioeconomic groups nd geogrphic res persist, nd overll popultion helth sttus in Wles is fr from the est in Europe. Mny of the cuses of poor helth re difficult to tckle nd re relted to the wider socil determinnts of helth nd inequlities. Smoking, lcohol consumption, oesity, physicl inctivity nd n unlnced diet re ll mjor risk fctors for stroke nd re widespred cross Wles. Helthier lifestyles cn reduce the progression of therosclerotic disese nd therefore the risk of stroke. Chnge4Life The Welsh Government hs invested hevily in the Chnge4Life progrmme. This is imed t helping people to recognise the importnce of investing in their own future helth nd mke lifestyle choices tht will ring them long term enefits, reducing the need for mediction nd hospitl dmission. There is still gret del to e done s highlighted in figure five. Effective mngement of medicines plys key role in the prevention of strokes. As result of successful community phrmcy cmpign in 2013, which focussed on medicines use reviews (MURs), Welsh Government will e funding renewed collortion with Stroke Assocition nd Community Phrmcy Wles to deliver three-month long cmpign in This will continue to rise wreness of the importnce of medicines in the prevention of secondry strokes. The cmpign will lso cover dischrge medicines reviews (DMRs) y providing prcticl support for stroke ptients who come into phrmcies to mke sure they get their medicines reconciled following their dischrge from hospitl. 8

10 As concerted response to the inquiry into the Stroke Risk Reduction pln, the Welsh Government will e funding the Stroke Assocition to deliver its stroke prevention cmpign. This will highlight the three stroke risk fctors specific to stroke: Hypertension, TIA nd, s stted erlier, AF. This cmpign will enle the implementtion of the priorities identified y the ntionl Stroke Implementtion Group nd, to hve mximum rech, it will e delivered in collortion with Pulic Helth Wles nd the helth ords cross Wles. Assurnce mesure one: Percentge of popultion with crdiovsculr risk conditions mnged ppropritely The risk of stroke cn e voided y preventtive work on lifestyle choices, including the reduction of lcohol nd smoking rtes, incresing exercise levels nd helthy eting. The Welsh Helth Survey undertken in 2013 gives n overview of the helth nd lifestyle reported mongst Welsh dults s cn e seen from figure five. More thn hlf (58 per cent) of dults re clssified s overweight or oese, including under qurter (22 per cent) s eing oese. Excessive lcohol intke is widespred; 42 per cent of dults reporting tht they drnk ove the recommended guidelines on t lest one dy in the previous week, including 26 per cent reporting inge drinking (more thn twice the dily guidelines). Under qurter 9 (21 per cent) of dults reported smoking (dily or occsionlly). Smoking levels in Wles hve fllen y five percentge points etween nd A recent nlysis of Welsh Helth Survey dt hs shown tht within Aneurin Bevn University Helth Bord there is significnt vrition risk fctor prevlence for dult smoking nd the percentge of dults with BMI clssified s oese. Similr ptterns cn e oserved with other risk fctors such s hrmful drinking nd physicl inctivity. In April 2014 the helth ord implemented n integrted dult weight mngement service, the first in Wles to e fully ligned to the Wles oesity pthwy. This is multidisciplinry service tht provides rnge of tretment nd support options for oese individuls. The helth ord is lso implementing n enhnced smoking cesstion service through the development of new level 3 community phrmcy smoking cesstion progrmme, new hospitl service nd service for pregnnt women in ddition to the Stop Smoking Wles Service. 9 Welsh Helth Survey

11 Figure 5 Percentge of dults who Smoke dily or occsionlly Are oese Reported drinking ove guidelines on t lest 1 dy in the previous week Reported eing physiclly ctive on 5 or more dys in the pst week Reported fruit nd vegetle consumption of 5 or more portions the previous dy Source: SDR 77/2014 Welsh Helth Survey 2013: initil hedline results, 21 My 2014 Add to Your Life or Add To Your Life helth nd welleing self-ssessment for people over 50 hs een developed to ssist people to puse nd think out wide rnge of spects of their own helth nd welleing, helping them to: Access gret del of relile, qulity ssured informtion in one plce Discover simple steps they cn tke to improve their helth nd the wy they feel Avoid some of the helth prolems tht hve ecome more prevlent Mke informed decisions out the wy they live Lern out services nd support ville to them Dt from the Qulity nd Outcomes Frmework Dtse (June 2014) highlights tht over 80% of those dignosed with hypertension were given lifestyle dvice from their GP. There hs een 0.8 percentge point increse in Wles etween 2012 nd 2013 compred to 1.6 percentge point increse cross the UK. We would expect this figure to continue to rise in the coming yers. Powys teching Helth Bord is developing community helth chmpion pproch through identifiction of community connectors. The purpose of this pproch is to use the ssets within the locl communities to help tckle pulic helth issues. The helth ord hs developed n pproch where ehviours re seen s clusters e.g. smoking nd lcohol consumption re tckled together. 10

12 Assurnce mesure two: Reducing high lood pressure High lood pressure is n importnt risk fctor for stroke, contriuting to out 50% of ll strokes nd it hs een estimted tht 53% of men nd 41% of women with high lood pressure re not receiving tretment. Of those who re eing treted, round hlf still hve high lood pressure. 10 Dt from the Qulity nd Outcomes Frmework Dtse (June 2014) highlights tht there re round 8% of ptients with hypertension, who hve not hd recent lood pressure check. This hs incresed slightly over recent yers. We would expect this figure to fll over the next 12 months. Assurnce mesure three: Atril firilltion Dmge to the hert cn cuse the formtion of clots. If these form in the left side of the hert they cn esily pss through rteries to the rin nd cuse stroke. Atril firilltion (AF) ( rpid nd irregulr hert et) increses the risk of clot formtion ecuse it cuses the hert to pump lood inefficiently. In Wles AF ffects out 58,000 people 11. People who hve AF re more likely to hve stroke thn those who do not nd those strokes re more likely to led to deth or to leve the sufferer with high levels of disility. People with AF who develop stroke hve greter mortlity, more disility, more severe strokes, longer hospitl sty nd lower rte of dischrge to their own homes compred with people without AF who develop stroke. AF-relted strokes cn not only hve potentilly devstting impct on people nd their fmilies, ut they cn lso present significnt cost urden for the NHS in Wles to mnge. Figure six indictes tht over 95% of those people dignosed with AF in , re hving pproprite tretment. 10 Coronry hert disese sttistics 2010 edition. British Hert Foundtion. 11 Stroke Implementtion Group Stroke Priorities Septemer 2014 sed on dt from the Qulity nd Outcomes Frmework 11

13 100 Figure 6: % of people with tril firilltion who re currently treted with nti-cog drug therpy or nti-pltelet therpy % Wles UK Crdiff nd Vle University Helth Bord hs een working with their primry cre tems to fcilitte the recognition nd prompt mngement of AF for stroke prevention. They hve collected dt on nerly 800 ptients with AF in primry cre nd re in the process of nlysing the dt. The introduction of the revised generl medicl services qulity nd outcomes frmework is likely to fcilitte the identifiction of AF ptients who re on spirin y 31 Mrch The new generl medicl services contrct will lso enle GPs to dignose nd mnge AF more efficiently. Erly identifiction nd tretment of AF hs een set s priority for the Stroke Implementtion Group. It is felt tht the prevention of AF-relted stroke services in Wles could e improved to ensure more ptients receive pproprite tretment, which is not only vitl to improving ptient outcomes, delivering high-qulity cre nd enhncing ptient experience, ut is lso cost-effective use of the Welsh NHS resources. Bsed on dt from the Qulity nd Outcomes Frmework 12, it is estimted tht in Wles, there re pproximtely 58,800 ptients dignosed with AF. Of these 33,500 ptients need to e nti-cogulted, 18,329 re on nticogultion, 12,100 re on spirin nd just over 3,000 ptients hve no tretment. 12 Stroke Implementtion Group estimted for Wles sed on English dt 12

14 Atril firilltion nd high lood pressure The Welsh Amulnce Service Trust hs developed ptient informtion leflet (PIL), which focuses on tril firilltion, nd high lood pressure. The PIL received significnt input from ptients, users nd other stkeholders through the Trust s reder s pnel, which ssisted in its development. The min purpose of the PIL is to llow mulnce clinicins to highlight nd record potentilly new onset or previously undetected AF/high lood pressure, nd to ring this to the ttention of their ptients. The Stroke Implementtion Group hve proposed tht ll those ged over 65 with pre existing vsculr disese (such s hypertension nd dietes) re reviewed on n nnul sis nd tht pulse check forms prt of this review. Those identified with irregulr pulse rtes will e investigted to determine whether AF is the cuse. Those identified with AF will then follow the pproprite pthwy of cre. This will require the development of rpid-ccess AF clinics with n AF nurse, nd ll helth ords will need to hve this service, unless they hve the cpility to do this in more generic stroke prevention service. The Stroke Implementtion Group expects to see n increse in the routine ssessment of individuls for AF through screening in the community either through phrmcies or GPs s well s converting the current cohort of ptients with known AF on spirin to wrfrin or NOAC if eligile. Although there re over 58,000 ptients dignosed with AF, it is estimted tht there re lrge numer of individuls with undetected AF. It is importnt tht these re identified nd treted. Therefore the Stroke Assocition nd the Welsh Government will e running pulic wreness cmpign in 2015 to rise wreness of the AF nd the ction tht person needs to tke should they hve symptoms. 3.2 Detecting stroke quickly Rpid dignosis nd tretment not only improves survivl ut lso the qulity of life of survivors. Our priority is to ensure tht wherever possile the erly signs of stroke re detected nd cted upon without dely. Trnsient ischemic ttck (TIA) TIAs (or mini strokes) serve s n erly wrning sign of stroke nd require immedite medicl ttention. The window of opportunity to do this effectively is smll nd requires such ptients to hve specilist ssessment s erly s possile following the event. Aout 46,000 people in the UK 13 ech yer hve first TIA. The Stroke Assocition estimte tht in 2012, one in 20 TIAs led to stroke within week. Treting TIAs urgently reduces the risk of stroke. 13 Stroke Sttistics 2009 Edition 13

15 Aneurin Bevn University Helth Bord hs seven-dy urgent high risk TIA ssessment service which is provided t the Royl Gwent Hospitl nd the Nevill Hll Hospitl etween Mondy nd Fridy nd vi the medicl ssessment units t the weekend. There re clinics for low risk ptients held throughout the week. Vsculr support is provided with two hot slots five dys per week t the Nevill Hll Hospitl nd five slots per dy t the Royl Gwent Hospitl nd work is on going to extend this service to seven dys on oth sites. Crotid endrterectomy (CEA) As people ge, they cn suffer from the nrrowing of the crotid rteries. These re the mjor rteries which supply lood to the rin, hed nd neck. This nrrowing of the rteries is cused y uild-up of plque. This plque my cuse turulent lood flow nd mteril reking off cn lodge in the rin cusing either trnsient symptoms or stroke. Those with trnsient symptoms hve the highest risk of stroke in the period immeditely following the onset of symptoms. The risk of stroke cn e reduced if surgery is performed quickly following onset of symptoms. For ptients with nrrowing of n rtery etween 50% nd 99%, it is recommended tht surgery to remove the plque, crotid endrterectomy, is performed within two weeks. The Ntionl Institute for Clinicl Excellence hs set trgets for the time from symptoms to intervention. For the symptom to surgery pthwy to work well, it requires mny stkeholders to co-ordinte cre delivery. The generl pulic nd helthcre professionls need to e wre of the symptoms of stroke nd TIA; nd wht to do when they recognise these symptoms. Generl prctitioners need to refer promptly nd NHS trusts need to hve orgnised stroke services with rpid ccess to specilist clinicins, imging nd surgery. The need for CEA ptients to undergo surgery is clerly outlined in NICE clinicl guidnce. This requires urgent cses to e operted on within two dys nd other cses within 14 dys of symptom onset. Unfortuntely the ltest CEA clinicl udit pulished on 25 Octoer 2013 does not demonstrte effective improvement in Wles since the 2011 report. Cse scertinment cross Wles is poor t 69% in comprison with other prts of the UK (Englnd 95%, Northern Irelnd 100% nd Scotlnd with 78%). The time etween referrl nd tretment hs continued to fll nd indictes commitment to improving the qulity of service within the NHS. However, s highlighted in figure seven, there is considerle room for improvement. In Wles 39% of ptients received surgery within seven dys of referrl (urgent cses) nd 44% within 14 dys of symptoms. There ws considerle vrition in the time to intervention etween hospitls. No helth ord in Wles treted ptients within the NICE trget of 14 dys from the onset of symptoms nd there were significnt vritions etween helth ords, with less thn 20% of ptients eing operted on within these time frmes in some res. The est performnce in Wles ws 53%. Overll, the figures for Wles re similr to Scotlnd, ut worse thn Englnd nd Northern Irelnd. 14

16 80 Figure 7 CEA 2012 Time from symptom to tretment 70 % c d e c d e c d e Cses referred within 7 dys of symptoms Cses receiving surgery within 7 dys of referrl Cses receiving surgery within 14 dys of the symptom tht triggered referrl Ntionl Englnd c Northern Irelnd d Scotlnd e Wles Source: UK Crotid Endrterectomy Clinicl Audit Round 5 Report Welsh Amulnce Service NHS Trust The Welsh Amulnce Service NHS Trust (WAST) trets cute stroke s medicl emergency. Any stroke relted cll with symptom onset of five-hours or less is ctegorized s RED cll, which will e llocted n immedite response. When cller rings 999, the mulnce cll-tker uses system clled medicl priority disptch system (MPDS) which is used to identify the chief complint or min reson for the cll. MPDS ssists in determining the cuity, or life-thretening priority of the 999 cll. If the cll-tker in mulnce control identifies the cll to e stroke relted, the system directs them to more specific, stroke relted questions, which includes telephone use of the Fce, Arm, Speech Test (FAST). On rrivl t scene, the ptient will e ssessed y the mulnce clinicin (prmedic/ emergency medicl technicin). The ssessment will include use of FAST. Every stroke ptient tht is ttended y WAST clinicins should receive the sme stndrd of ssessment nd cre, which is referred to s the pre-hospitl stroke undle. This undle of cre includes n ssessment the ptient s lood pressure, lood glucose, s well s FAST ssessment. Blood glucose mesurement is n importnt spect of ssessment ecuse low lood sugr (hypoglycemi) is common stroke mimic nd needs to e excluded. 15

17 Through the introduction of the ASHICE pre-lert system, hndover times of stroke ptients from prmedics to A&E hve reduced from 45 minutes in Prince Chrles Hospitl nd 21 minutes in Royl Glmorgn Hospitl in 2012, to under 10 minutes on oth sites during 2013, nd 8.5 minutes or under in Over the lst 18 months, WAST hve undertken numer of stepwise interventions imed t improving its complince ginst the pre-hospitl stroke undle. In Mrch 2014, WAST introduced new ptient clinicl record which includes specific FAST ssessment section. The impct of this ltest intervention cn e clerly oserved in figure eight. % Figure 8 WAST complince with pre hospitl cre undles Apr-13 My-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jn-14 Fe-14 Mr-14 Apr-14 My-14 My-14 FAST BM BP Cre undle (FAST+BM+BP) Source: Welsh Amulnce Service NHS Trust Septemer 2014 Once ptient is identified s FAST positive nd hypoglycemi hs een excluded, the mulnce clinicin will contct the nerest district generl hospitl, to pre-lert them to the impending rrivl of the ptient. The purpose of the pre-lert, is to ensure tht the hospitl mke the necessry rrngements to prepre for the ptient, so tht they re quickly ssessed nd directed to CT scn, if pproprite. This yer the Welsh Amulnce Service hs worked collortively with the Stroke Assocition to develop FAST pulicity mterils. The eye-ctching posters hve een designed to rise pulic wreness of FAST nd stroke nd will e prominently displyed on its emergency vehicles. 16

18 Prticiption in clinicl udits Clinicl udit nd outcome review is criticl to continuous service improvement. All helth ords prticipte in ll relevnt ntionl clinicl udits nd clinicl outcome reviews s set out in the Welsh Government s ntionl nnul udit progrmme. They re then expected to ct upon the outcomes. Welsh stroke services prticipte on regulr sis in the Royl College of Physicins (RCP): Sentinel Stroke Ntionl Audit Progrmme s (SSNAP) udit. Results re presented in 10 domins, covering 44 key indictors. Outputs from the SSNAP udit progrmme re pulished on qurterly sis. The most recent findings (Octoer 2014, covering the period April June 2014) indicted tht: Overll Welsh hospitls re performing etter thn previous udits. This is reflected in the verge score ttriuted to ech helth ord. Overll in Wles the verge score rose from 34.7 to 42.0 The increse in the verge score hs resulted in Wles moving up slightly in the regionl rnkings Four Welsh hospitls noted n improvement in terms of their overll grdes s they moved from n E grde to D grde. In Wles there re now nine sites rnked s D, the remining sites remin s n E. Idelly we wnt ll sites to improve up the rnkings nd to chieve, in time the A grde. The RCP qurterly udit hs identified tht there is still considerle scope for improvement cross ll sites in Wles. Ares highlighted y the RCP include need to: increse the numers of ptients directly dmitted to stroke unit within four hours of clock strt; nd increse the numers of ptients treted y stroke skilled erly supported dischrge tem. The results of the next RCP SSNAP orgnistionl udit re expected in Decemer Assurnce mesure four: Stroke thromolysis Thromolysis, the use of drugs tht reks up clots in the lood, is n effective tretment for ptients suffering n ischemic stroke providing it is given soon fter the onset of symptoms nd within mximum of 4 hours following stroke. Evidence shows tht the fster the drug is given to ptient the etter their outcome will e. Improving thromolysis rtes nd the speed in which ptients re thromolysed is priority re for Wles. A complete review of the thromolysis pthwy is currently tking plce t Aneurin Bevn University Helth Bord with view to significntly reduce the door to needle time from 90 minutes to 45 minutes or etter. This will require pre-dmission hnd over from the mulnce crew, with fully prepped stroke tem redy in ttendnce. When fully functionl, n increse in eligile stroke ptients eing thromolysed s result of the improved pthwy should e noted s will n improvement in door to needle times. 17

19 Across Wles, in the finncil yer ending Mrch 2014, 96% of ll those eligile for thromolysis received the drug. Of those thromolysed 26% were thromolysed within one hour of rrivl t hospitl. This mens tht n dditionl 90 ptients were thromolysed in thn the previous yer nd 115 ptients were thromolysed within one hour, n increse of over 50 ptients thn the previous yer. Although this is lower thn we would like, it highlights 9% increse over the previous period s cn e seen from figure nine. We would expect this figure to continue to increse over the next 12 months Figure 9 % of eligile ptients thromolysed within nd fter 1hour of rrivl t hospitl % Ptients thromolysed within 1 hour of rrivl t hospitl Ptients thromolysed fter 1 hour of rrivl t hospitl Source: Delivery Unit 18

20 Assurnce mesure five: Access to n cute stroke wrd Evidence indictes tht if ptient is directly dmitted to stroke wrd on rrivl t the hospitl nd spends more thn 90% of their time on stroke wrd then their chnces of recovery will e improved. Across Wles, helth ords re struggling to ensure tht ptients re dmitted to dedicted stroke wrd within 24 hours. Figure ten shows tht cross Wles the percentge of ptients eing dmitted directly to stroke wrd hs fllen from just over 80% in April 2013 to round 65% y Mrch Access to stoke wrd is directly influenced y unscheduled cre pressures nd helth ords re under considerle pressure to improve performnce in this re. Mny helth ords re responding to this through the cretion of dedicted stroke eds nd we expect to see n improvement in this mesure in the coming months. 19

21 % Figure 10 Direct ccess to stroke wrd within 24 hours of dmission Apr-12 My-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jn-13 Fe-13 Mr-13 Apr-13 My-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jn-14 Fe-14 Mr-14 On verge, just over 60% of stroke ptients spent over 90% of their time on n cute stroke wrd (figure 11). This represents grdul improvement in performnce over the pst 24 months. It is disppointing to note tht performnce in this re dropped towrds the end of the finncil yer. Helth ords recognise the importnce of ensuring direct ccess to stroke wrd nd re in the process of reorgnising stroke provision cross their sites to ensure good service delivery. As helth ords improve their generl performnce, we would expect this to increse to t lest 70% in the next 12 months, with further improvement the following yer. 90 Figure 11 % of stroke ptients who spend up to 90% of their time on n cute stroke wrd % Apr-12 My-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jn-13 Fe-13 Mr-13 Apr-13 My-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jn-14 Fe-14 Mr Source: Acute Stroke Dt, Delivery Unit, My 2014

22 Assurnce mesure six: Mortlity within 30 dys of hospitl dmission for stroke Figure 12 shows the percentge of ptients who re dmitted into Welsh hospitls with stroke nd die within 30 dys of dmission. This trend line indictes n improvement in such outcomes since Septemer However, there is considerle vrition on monthly sis, in prticulr during winter months. Our priority is to reduce this vrition in the coming yers nd ctivities such s ensuring tht ptients ccess stroke wrd quicker nd spend longer on tht wrd will help improve this mesure. % Figure 12 Mortlity within 30 dys of hospitl dmission for stroke Sep-10 Nov-10 Jn-11 Mr-11 My-11 Jul-11 Sep-11 Nov-11 Jn-12 Mr-12 My-12 Jul-12 Sep-12 Nov-12 Jn-13 Mr-13 My-13 Jul-13 Sep-13 Nov-13 Jn-14 Mr-14 Source: APC (PEDW), August 2014 Assurnce mesure seven: Complince with the cute stroke undles The NHS hs developed four undles of cre which re sets of ctions tht re known to e likely to improve ptients outcomes if done together in time-limited wy, rther thn seprtely. The undles of cre re: Bundle 1 First hours undle rpid recognition of symptoms nd dignosis within 3 hours. Bundle 2 First dy undles emergency tretment for people with stroke within 24 hours. Bundle 3 First 3 dys undle erly moilistion following stroke within 3 dys. Bundle 4 7 dys undle ptient centred nd gol-orientted specilised cre following stroke within 7 dys. Their use in stroke cre during recent yers hs een vrile nd ll helth ords hve struggled to chieve the 95% trget for ll of the undles (figure 13). Performnce ginst the second undle hs een prticulr chllenge for ll helth ords. As mentioned, timely ccess to cute stroke units (ASUs) remins the lrgest chllenge for NHS Wles. This hs een ffected y generl ed pressures cused y unscheduled cre, mening tht stroke eds hve to e used y ptients other thn those with stroke. 21

23 Helth ords re expected to estlish correctly resourced ASUs in line with clinicl guidelines nd stndrds, nd tret stroke s medicl emergency. The NHS hs een set trget of 95% for complince with the stroke undles. All helth ords hve stroke recovery plns in plce nd through implementtion of these plns they re working towrds chieving 95% complince. Figure 13 Complince with cute stroke undles % Bundle 1 Bundle 2 Bundle 3 Bundle Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Fe-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Fe-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Fe-14 Apr-14 Jun-14 Aug-14 Source: Welsh Government, Septemer Stroke rehilittion The disility cused y stroke cn ffect mny prts of the ody nd e long-lsting. Mny people need to hve n extended period of rehilittion efore they cn chieve mximum independence. The process of rehilittion is specific to ech ptient, depending on symptoms nd severity. There is sustntil evidence tht mortlity nd moridity outcomes re significntly improved for stroke survivors who receive rehilittion in specilist stroke rehilittion unit. 100% of ll strokes will enefit from stroke rehilittion. The evidence out exctly wht stroke rehilittion interventions hve the gretest impct is still limited, ut there is evidence tht the intensity of rehilittion is importnt. This is underpinned y the evidence for the neuroplsticity the nervous systems ility to remodel fter dmge in order to regin function. 22

24 Constrint induced movement therpy (CIMT) Stroke therpists in Cwm Tf hve successfully triled n innovtive new tretment clled CIMT, wherey stroke ptients re encourged to use their stroke ffected lim therey incresing its functionlity. This hs improved prticipnts independence in eing le to undertke ctivities of dily living, nd hs oosted their motivtion nd confidence levels. Further group sessions re now eing held enling other stroke ptients to enefit from this innovtive therpy. Stroke survivors with mild to moderte impirment who receive high intensity rehilittion in their own homes from stroke skilled stff hve etter outcomes thn those who receive rehilittion in hospitl. It is however recognised tht this my not e the most cost effective model for some rurl res. Ech stroke unit t Betsi Cdwldr University Helth Bord hs weekly multi professionl/multigency meeting which includes representtion from socil services nd the Stroke Assocition. This meeting fcilittes dilogue etween professionls regrding the short nd long term requirements of the stroke survivor. Ongoing cre nd support is tilored to ssist the person to meet their short nd longer term gols y utilising the most pproprite service/s ville such s erly supported stroke dischrge, relement nd community rehilittion tems. A stroke journl (sometimes clled pssport) hs een introduced cross North Wles for ll stroke survivors on dischrge from hospitl. There hs een limited focus on stroke rehilittion over the pst seven yers in Wles. Rehilittion services hve t times een dversely ffected with the focus on cute stroke services s stff from the rehilittion setting hve een moved into cute services. The Stroke Implementtion Group hs greed tht ntionl priority will e plced on developing stroke rehilittion in the community. Rehilittion will e delivered y stroke skilled therpists nd support workers t the pproprite level of intensity required to optimise recovery from stroke. This will: Improve functionl outcomes for stroke survivors, reducing the long term demnd on helth nd socil cre services Reduce length of sty in cute nd rehilittion units, therey incresing flow into hyper-cute stroke services 23

25 Assurnce mesure eight: Six month ssessment Figure 14: Six month ssessment Routinely dmitting tems Six month ssessment Trust Aertwe Bro Morgnnwg University Helth Bord Aneurin Bevn University Helth Bord Betsi Cdwldr University Helth Bord Crdiff nd Vle University Helth Bord Cwm Tf University Helth Bord Hywel Dd Helth Bord Tem nme Morriston Hospitl Princess of Wles Hospitl Nevill Hll Hospitl Royl Gwent Hospitl Gln Clwyd District Generl Hospitl Melor Hospitl Ysyty Gwynedd University Hospitl of Wles Prince Chrles Hospitl Royl Glmorgn Bronglis Hospitl Prince Philip Hospitl West Wles Generl Withyush Generl Hospitl Numer pplicle % pplicle Numer ssessed % ssessed % 17 10% 77 99% 12 16% 79 98% 3 4% % 0 0% % 0 0% % 0 0% % 0 0% % 0 0% % 0 0% % 1 1% % 0 0% 50 86% 49 98% 74 97% 27 36% % 38 45% Source SSNAP Qurterly Reports Octoer 2014, covering April June

26 A six month follow up following dischrge is good indictor tht n effective rehilittion progrmme is in plce. Dt on six monthly follow ups hs een mde ville for the first time nd s highlighted in figure 14 clerly shows tht there is room for improvement cross ll sites, with the exception of Prince Philip Hospitl who ssessed 98% of stroke ptients fter six months. Stroke eds were moved from the Bronllys hospitl to Brecon hospitl t Powys teching Helth Bord in Ferury 2014 fter long consulttion nd plnning period. Extensive stff trining ws crried out prior to the move to minimise disruption nd ensure continuity nd high qulity rehilittion. One of the min chnges tht hs occurred s result of the move is review of the process for mnging people who re unle to swllow sfely s result of stroke: Additionl trining hs een done for nursing stff: new protocol hs een developed for replcement of misplced nsogstric tues, which includes eing le to ccess x-ry fcilities in Brecon hospitl t the weekend if required: new threshold hs een set for which types of swllowing prolems cn e mnged sfely in Brecon, nd which ones re est mnged in n cute stroke unit. It is felt tht is positive step towrds improving ptient sfety nd qulity of cre. 3.4 Trgeting Reserch Assurnce mesure nine: Recruitment to stroke NISCHR CRP studies Advnces in stroke reserch cn improve qulity of life, influence ptient cre, nd sve resources. Reserch hs the ultimte im of mking stroke preventle nd tretle disese, nd improving the qulity of life for people ffected y stroke. According to The Older People nd Ageing Reserch nd Development Network (OPAN Wles) stroke reserch in Wles is under-funded compred to other specilisms in Wles nd in comprison with investment in stroke reserch in other countries of the United Kingdom. As cn e seen from figure 15, the numer of ptients prticipting in stroke relted reserch hs fllen y 79 since

27 350 Figure 15 All Wles recruitment to stroke NISCHR CRP trils Source: Ntionl Institute for Socil Cre nd Helth Reserch 2014 It is well reported tht individul outcomes improve when ptients re entered into clinicl trils. In ddition, cdemic excellence drives up stndrds of cre to ensure tht outcomes for the popultion re ettered, contriutions re mde to glol reserch knowledge, locl clinicl crediility is strengthened nd recruitment to clinicl posts improves. Wles now hs the opportunity to join the world scene in stroke reserch ut must develop roust cdemic se s the pltform for reserch success y ensuring cdemic sustinility nd ility to grow reserch cpcity through scientific nd clinicl reserch progrms. Ultimtely, the development of network of stroke reserch in Wles cross ll the Universities nd cross ll disciplines (medicl, nursing nd llied helth professionls) will ensure Wles chieves its plce in the igger picture. As prt of its UK Lectureship progrmme the Stroke Assocition, in collortion with Welsh Government nd NISCHR, lunched full-time lectureship opportunity specific for Wles to uild long term stroke reserch cpcity nd expertise. 26

28 The Stroke tem t Cwm Tf University Helth Bord re currently prticipting in two reserch trils: RESTART Restrt or stop nti-thromotics reserch tril for stroke ptients with cererl hemorrhge who were on nti-thromotic drugs t the time of their stroke. The im is to determine whether the eneficil effects of ntipltetet drugs on the risk of clotting outweigh ny risks of repet cererl hemorrhge. FOCUS Fluoxetene or control under supervision to consider the effect(s) of routine dministrtion of fluoxetine in ptients with recent stroke. The study hypothesis is tht routine dministrtion of fluoxetine (20mg dily) for 6 months fter n cute stroke will improve ptients functionl outcome. The occuptionl therpy service in the helth ord hs lso registered nd een ccepted for the study of prisms nd therpy in ttention loss fter stroke tril with Mnchester University. 27

29 4. Conclusion: looking hed to nd eyond There hs een progress in stroke cre in Wles over the pst 12 months. This is triute to ll those involved in the plnning nd delivery of this importnt re. This includes stff in the NHS nd those in other prts of the pulic sector. We must lso cknowledge the invlule work of the community nd voluntry sector. We must now uild upon these firm foundtions for further positive development. In severl res, we hve performed well nd seen some progress in mny of our performnce mesures. We will continue to trck our progress in future yers to ensure tht we re in sustinle position to chieve our vision y There is still tremendous mount to e done in Wles nd the Stroke Implementtion Group in order to support focused improvement hs produced the following elements of stroke cre tht they expect helth ords to deliver: Thromolysis ll (ischemic) stroke ptients in Wles cn ccess thromolysis s soon s possile. We would expect ll eligile ptients to e thromolysed within 180 minutes of stroke onset. Hyper-cute stroke units provide the immedite response to stroke, where the ptient is stilised nd receives primry intervention. The ptient s length of sty is typiclly no longer thn 72 hours. Acute stroke unit provide multi-therpy rehilittion nd ongoing medicl supervision following ptient s hyper-cute stilistion. Length of sty vries nd will lst until the ptient is well enough for dischrge from n cute inptient setting. Trnsient ischemic ttck ssessment service provide rpid dignostic ssessment nd ccess to specilist within 24-hours for high risk ptients nd within seven dys for low-risk ptients. Rehilittion in-ptient rehilittion should e ville for ll stroke ptients, community rehilittion nd erly supported dischrge services (include stff with specilist stroke skills) should e ville nd strt s soon s possile nd continue for s long s required. The chrcteristics of the service should e tht: All FAST positive ptients in whom hypoglycemi hs een excluded will e pre-lerted to the most pproprite district generl hospitl nd trnsferred to hospitl nd thromolysed if pproprite within the timescles outlined y the Royl College. On rrivl t hospitl, ptient must e ssessed y specilist, hve ccess to rin (CT) scn nd receive clot usting drugs (if pproprite), within the timescles outlined y the Royl College. Ptients re trnsferred to HASU ed where they receive high dependency cre for the first 72 hours following dmission. Once stilised, the ptient is trnsferred to n ASU, either in the sme hospitl or closer to their home. Ptients will e rehilitted in the ASU nd dischrged to the pproprite cre in the community. All ptients, nd their crers, should hve key support worker nd key contct from helth or socil cre whilst receiving cre in ech setting. For the first 12 months following stroke, ll individuls nd their crers should hve regulr ssessment of ongoing medicl, socil nd emotionl needs. 28

30 To support this, the Stroke Implementtion Group hs greed the following four priorities: The identifiction of individuls with tril firilltion. Awreness cmpign for tril firilltion. Reconfigurtion of stroke services in Wles including the development of hyper-cute services in Wles. Community rehilittion. In next yer s nnul report we will look t how we hve progressed during the yer. 29

31 Annex 1 Helth ords performnce 100 Figure 16 % of stroke ptients who re documented s receiving n pproprite pre-hospitl stroke cre undle % Apr-2013 My-2013 Jun-2013 Jul-2013 Aug-2013 Sep-2013 Oct-2013 Nov-2013 Dec-2013 Jn-2014 Fe-2014 Mr-2014 Apr Figure 17 % of ptients thromolysed Ptients potentilly eligile for thromolysis, ut did not receive tretment Ptients thromolysed % Wles Aertwe Bro Morgnnwg University Helth Bord Aneurin Bevn University Helth Bord Betsi Cdwldr University Helth Bord Crdiff & Vle University Helth Bord Cwm Tf University Helth Bord Hywel Dd University Helth Bord 30

32 Figure 18: % of ptients thromolysed % Ptients thromolysed within 1 hour of rrivl t hospitl Ptients thromolysed fter 1 hour of rrivl t hospitl Wles Aertwe Bro Morgnnwg University Helth Bord Aneurin Bevn University Helth Bord Betsi Cdwldr University Helth Bord Crdiff & Vle University Helth Bord Cwm Tf University Helth Bord Hywel Dd University Helth Bord Performnce for the following indictors ws vrile during The tles elow highlight the end of yer performnce position for Wles nd ech helth ord. Figure 19: Direct ccess to stroke wrd within 24 hours of dmission Mrch 2014 Aertwe Bro Morgnnwg University Helth Bord 76.50% Aneurin Bevn University Helth Bord 67.80% Betsi Cdwldr University Helth Bord 62.70% Crdiff nd Vle University Helth Bord 45.50% Cwm Tf University Helth Bord 91.70% Hywel Dd University Helth Bord 58.60% Figure 20: % of stroke ptients who spend up to 90% of their time on n cute stroke wrd Mrch 2014 Aertwe Bro Morgnnwg University Helth Bord 66 Aneurin Bevn University Helth Bord 39 Betsi Cdwldr University Helth Bord 58 Crdiff nd Vle University Helth Bord 37 Cwm Tf University Helth Bord 87 Hywel Dd University Helth Bord 46 Wles 55 31

33 Figure 21: Complince with cute stroke undles t Mrch 2014 Aertwe Bro Morgnnwg University Helth Bord Bundle 1 Bundle 2 Bundle 3 Bundle % 69.1% 91.2% 97.1% Aneurin Bevn University Helth Bord 97.7% 60.9% 83.9% 88.5% Betsi Cdwldr University Helth Bord 96.4% 51.8% 96.4% 92.8% Crdiff nd Vle University Helth Bord 95.6% 45.5% 77.3% 90.9% Cwm Tf University Helth Bord 95.8% 83.3% 95.8% 100.0% Hywel Dd University Helth Bord 96.6% 53.4% 94.8% 94.8% Wles 95.9% 58.8% 89.8% 93.1% 32 WG23624 Crown Copyright 2014 Digitl ISBN

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