COMMUNITY STROKE SERVICES

Transcription

1 Members Event COMMUNITY STROKE SERVICES Sue Baker Matron/Specialist Nurse Practitioner Worcestershire Health & Care Trust Caroline Lister Worcestershire Acute Hospitals Trust September 2013

2 Aims: To gain an understanding of what a stroke is. To be able to recognise signs and symptoms of stroke To have knowledge of Strokes services in Worcestershire.

3 Stroke is not just an inevitability of old age.

4 But can happen to anyone at any age

5 Statistics Approximately 152,000 strokes in the UK every year. That is more than one every 5 minutes. Approximately 1.1 million stroke survivors living in the UK. Stroke is a leading cause of adult disability. West Midlands Strokes per year - 11,600 People living with stroke - 125,452 Stroke Association January 2013

6 Drivers for change National Service Framework for the Older Person (2001) National Stroke Strategy (2007) Royal College of Physicians Stroke Guidelines 4th edition (2012) SINAP- SSNAP- Sentinel Stroke National Audit Programme (2012) NHS Midlands & East Stroke Review (2012) NICE Clinical guideline 162 Stroke rehabilitation. Longterm rehabilitation after Stroke (June 2013)

7 What is a Stroke? A stroke is caused by the interruption of the blood supply to the brain. A stroke is sudden and the effects on the body are immediate. There are two main types of stroke: Ischaemic: the most common form of stroke, caused by a clot narrowing or blocking blood vessels so that blood cannot reach the brain, which leads to the death of brain cells due to lack of oxygen. 85% of strokes are caused by a blockage

8 Causes of Ischaemic Strokes Smoking High blood pressure (hypertension) Obesity High cholesterol levels Excessive alcohol intake Diabetes (particularly if poorly controlled) Irregular heart beat Heart disease Family history of stroke, heart disease and/or diabetes

9 What is a Stroke? II Haemorrhagic: caused by a bursting of blood vessels producing bleeding into the brain, which causes damage. 15% of strokes are caused by bleeding in the brain.

10 Causes of Haemorrhagic Strokes High Blood pressure being overweight or obese drinking excessive amounts of alcohol smoking a lack of exercise stress, which may cause a temporary rise in blood pressure Treatment with medicines given to prevent blood clots, such as warfarin. Rupture of a balloon-like expansion of a blood vessel (aneurysm) and badly-formed blood vessels in the brain. A traumatic head injury

11 Transient Ischaemic Attacks T.I.A also known, by some, as minor strokes, occur when stroke symptoms resolve themselves within 24 hours..

12 Meet Bill

13 One Morning in May Feeling unwell unspecific Slurring speech Difficulties with Balance Dizziness Weakness down right side ( arm and leg) Difficulty in understanding speech

14 Signs & Symptoms The FAST test FACE, ARMS, SPEECH, TIME identifies the most common symptoms of a stroke in three easy to recognise categories. FACIAL WEAKNESS: Can the person smile? Has their mouth or eye drooped? ARM WEAKNESS: Can the person raise both arms? SPEECH PROBLEMS: Can the person speak clearly and understand what you say? TIME : If you see any one of these three signs, it s TIME to call 999. Stroke is always a medical emergency.

15 Frontal Lobe Premotor Storage of motor patterns Prefrontal area Concentration Elaboration of thought Judgement Inhibition Personality Emotional traits Broca s Area Language production Temporal lobe Auditory reception area Expressed behaviour Receptive Speech Memory/information retrieval Motor cortex Voluntary motor activity Parietal Lobe Processing sensory input Sensory discrimination Body orientation Brain Stem Breathing Digestion Heart control Blood vessel control Alertness Wernicke Area Language and Speech Occipital Lobe Visual reception area Visual interpretation Cerebellum Coordination and control of voluntary movement

16 Any questions, thoughts or discussions points??

17 Acute Services

18 Centralisation of Stroke Services Caroline Lister Interim Manager for Stroke Services

19 Introduction to the story so far.. In 2011, NHS Worcestershire undertook an option appraisal for Acute stroke services in order to inform its future commissioning strategy, with 3 options being considered: Worcester Royal Hospital (WRH) and Alexandra Hospital (AH) WRH AH The option appraisal looked at the care of Acute Hospital patients only, and included the impact on the Ambulance services, and the assessment of patients with suspected stroke. A conclusion was reached that the option to centralise the services at WRH only had the potential to give the highest quality of care for Worcestershire but further evaluation was requested May 2012 further evaluation again identified the centralisation of Acute Stroke Services at WRH was the preferred option.

20 Case for change. Key Elements: Poor health outcomes compared with other areas of the country Failure to meet performance targets Failure to achieve BPT (best practice tariff) Key benefits: Improved patient outcomes: reduced length of stay, reduced mortality Achieving stroke performance targets: direct admission to a stroke unit within 4 hours, spend at least 90% of your time on a stroke unit, have urgent scans within an hour, all within 24 hours, provide investigations for 60% patients presenting as a High Risk TIA within 24 hours Development of a 7/7 fit for purpose multidisciplinary service

21 Drivers for change. To provide a fully integrated end to end stroke service working with our partners To implement the recommendations of the national stroke strategy To meet the service standards and specification set by the RCP and NICE guidelines Ensure delivery of improved outcomes, quality and patient / carer experience Ensure equity of service provision, outcomes and experience To provide a countywide service benchmark able against peer services

22 Transforming stroke services Put users and carers at the heart of the service Empower local services to focus on all levels of the stroke pathway Maximise the skills of professionally qualified staff

23 How are we doing prior to centralisation. Yearly performance : Length of stay: 79.1% (80%) Direct Admission: 76.67% (70%) High risk TIA: 61.5% (60%) July performance (month of centralisation): Length of stay: 90.4% (80%) Direct Admission: 92.7% (70%) High risk TIA: 68.4% (60%)

24 Centralised unit: HASU Unit (Hyper Acute) 6-8 beds, high/low to allow for nursing at risk patients Monitored beds, with a central console to allow level 2 care 2:1 qualified nursing ratio Specialist training and signed off competency documents Access to 3x CNS in stroke, meeting patients / relatives in A&E where possible 7/7 consultant ward rounds 7/7 access to diagnostics OT,PT, SLT, dietetics and Social work staffing, dedicated to the stroke unit Pathway work will continue to ensure step down as appropriate after 72 hours to ASU (Acute stroke unit)

25 Centralised unit: ASU (Acute stroke unit) step down beds within the same template, sharing expertise 5/7 consultant ward rounds, with future aspirations to weekend cover 5/7 therapy and social work input with phased plans to move towards 6/7 day services Pathways: we are working on our pathways for on-going transfer either to step down beds or home with ESD (early supported discharge) teams Intend to provide palliation as deemed appropriate within the unit Core competency training and sign off booklet for all staff involved in stroke care

26 Phased approach In July 2013 the stroke service was centralised as is on the Worcester Royal Hospital Site Fully functioning, flexible HASU beds High risk TIA delivered as ambulatory care Gap analysis: movement towards a 7/7 service

27 High risk TIA: ambulatory care High risk TIA have an 8% risk of a stroke in 24 hours, and a 12% risk in 7 days. Within the centralised stroke unit is space for provision of ambulatory care patient s referred as having had a High Risk TIA These patient s may have been referred /presented to their GP, or have come into A&E, and will be sent to the unit to allow assessment, appropriate diagnostics and treatment to be provided Working in partnership with the CCG s, the Trust will enhance patient education and the success of the preventative pathway

28 New stroke pathway Pathway work has been carried out to ensure the safe and effective flow of patients who present with stroke symptoms The pathway flow includes what the expected journey would be for: Patients suitable for thrombolysis Stroke mimics In-Hospital strokes Patients who walk in to the Alex site not knowing they are having a stroke

29 No decision about me without me The MDT are setting up admission meetings: an opportunity to discuss a patients stroke admission with the patient and family/ carers, and discuss progress and answer questions These meetings will be held as soon as possible post admission, and will include goal setting as appropriate Where possible the MDT members that attend will be those representative of that patients main issues, e.g PT, OT, SLT.

30 Discharge Planning and stroke recovery The Acute hospital is only one part of the stroke care pathway When a patient is medically stable their discharge or transfer to another unit will be facilitated so their recovery can continue The acute length of stay can vary dependent on need, but will average at 7 days (or less)

31 Driving Quality. The centralised unit will be using a new computer based data capture system that will alert, monitor and report on the performance of the ward and the care delivered to individual patients The system is based on the best practice for stroke care as laid down by the Royal College of Physicians Working with our colleagues from critical care staff are having bespoke stroke training delivered to ensure the competency of staff, both nursing and therapy staff senior MDT staff have taken the opportunity to train in the delivery of swallow assessments to assist with effective and timely delivery of nutrition

32 Partnership working. Worcestershire CCG s: Working with GP s Pathway modelling Community step down beds ESD/CSS Stroke network / Local Area Team: Wider agenda s and quality initiatives WMAS: Emergency pathway Shared learning Alert systems

33 Stroke Care Pathway All stroke patients enter via Emergency Department Bill Hyper Acute Stroke Unit Acute Stroke Unit Home Inpatient Stroke Specialist Rehabilitation WW Community Hospital/Resource Centre Nursing Home/ Step-down Beds Community Stroke Service (ESD) Community Stroke Service (Specialist assessment and advice) PATIENTS NO LONGER REQUIRING SPECIALIST SERVICES FROM CSS ABI Promoting Independence Provided by Social Care x 4 teams (x1 Physio, x1 OT, x 11 CSWs, x1 SW) Community Services DNs, Physio, OT, SLT Follow Up

34 Thank You Any questions.

35 Community Stroke Services

36 Community Stroke Service Structure

37 Roles of the Community Stroke Service To provide Early Supported Discharge (ESD) To prevent re-admission to hospital To provide Education, Training and Information for patients, their carers and families Needs led assessment and management in order to maximise stroke recipients potential Provide Interdisciplinary reviews at 3,6 & 12 months post stroke Research, Audit and Development in practice and service delivery

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39 Stroke Care Pathway All stroke patients enter via Emergency Department Hyper Acute Stroke Unit Acute Stroke Unit Home Inpatient Stroke Specialist Rehabilitation Community Hospital/Resource Centre Nursing Home/ Step-down Beds Community Stroke Service (ESD) Community Stroke Service (Specialist assessment and advice) PATIENTS NO LONGER REQUIRING SPECIALIST SERVICES FROM CSS ABI Promoting Independence Provided by Social Care x 4 teams (x1 Physio, x1 OT, x 11 CSWs, x1 SW) Community Services DNs, Physio, OT, SLT Follow Up

40 Bills post stroke recovery

41 Minimum Guidelines for admission to the Community Stroke Service Patient is medically stable Patient is physically safe to be left alone or with a carer/family member that is capable/trained to provide support Patient is cognitively safe to be left alone or with a carer/family member that is capable/trained to provide support Continence can be managed throughout the day and night Medication can be managed Essential equipment is in place. Reasonable steps taken to ensure property can be safely accessed and is safe for both patients and staff.

42 Patient Categories Early Supported Discharge (ESD) Specialist Advice & Support Categories Category A Category B Category C Category D Definitions Requires Specialist assessment rehabilitation advice and support with regular reviews and input to maintain safety and activities of daily living with Trained and Rehabilitation Assistant input Requires Specialist assessment, rehabilitation, support and advice with regular reviews and to maintain safety and activities of daily living with Trained and Rehabilitation Assistant input Requires Specialist rehabilitation in order to be able to undertake activities of daily living building through quality to optimum potential. Advice and Support in self management Patients who have been transferred from hospital to a Care Home or home with a Package of Care with post stroke and multi-pathology/social issues

43 Referral REFERRAL STROKE SERVICES Supported Discharge Name; Address; DOB; NHS No: Patient s Phone No... Note: all referrals MUST be faxed, no abbreviations please Lives with: Alone Spouse Other Lives in: House Bungalow Flat Other Toilet: Upstairs Downstairs Bathroom: Upstairs Downstairs Bedroom: Upstairs Downstairs Access into property: Patient Consent for information sharing gained - Date:.... GP:. GP Surgery:. GP phone no:. Ethnicity: Religion:.. Name of next of kin/carer & contact details: Relationship to patient Telephone No. Social/Carer Issues Social Worker (referring on) Social Worker (receiving) Date of stroke: Thrombolysed? Yes/ No Investigations still required: Result of CT scan: Medical History: Medically stable: Yes No Resuscitation Status: To be discharged Estimated Discharge/Transfer from (Ward, Unit, Date: service etc.) OBSERVATIONS date. B/P Temp Pulse Resps Urinalysis Bowels (date last opened) Pain: Does the patient have any pain? If yes site: Before Stroke- Y/N If yes site: Post Stroke - Y/N Is the patient s pain controlled? Y/N If yes how? If yes how?

44 Bill s return home Initial Interdisciplinary Assessment Planned visits Washing & dressing practice Supervision up and down stairs Exercise call Meal preparation Return upstairs in the evening

45 Post Stroke Challenges Cognitive problems - problem solving, organising, Communication problems expressive, receptive Low mood Depression Emotional - tearful, inappropriate laughter Fatigue Physical problems weakness Altered Sensation Visual problems Other problems may include physical pain, incontinence and balance problems

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47 On-going Support for Bill and Brenda

48 How do we know if we make a difference Goal attainment Patient & Carers Satisfaction Questionnaires Review clinics Outcome measures COPM, Barthel, TOMS

49 Discharge Acquired Brain Injury (ABI) Service Promoting Independence ABI college Headway Stroke Association Services Uni-disciplinary community services CSS Multidisciplinary Outpatient Review clinics 3,6 & 12 months post stroke.

50 Since discharge 6 month review Planning holidays Returned to work in part-time Brenda is also now working part time

51 Number of Referrals To date Forecast

52 The Future Category D patients Review Clinic management Continued development of communications across the whole pathway. Continued development of patient, carer and family support strategies Continued use of patient, carer and public feedback to improve and further develop service delivery. Put Worcestershire Stroke Services On the Map

53 Thank you for listening Worcestershire Health & Care NHS Trust Community Stroke Rehabilitation Service Matron/Specialist Nurse Practitioner Sue Baker