TITLE OF REPORT: Improving Stroke Services Update December 2009

HEREFORD HOSPITALS NHS TRUST PUBLIC BOARD MEETING 25 TH JANUARY 2010 AUTHORS OF REPORT John Sharman Business Unit Manager, Medicine; Dr Rupert Ransford Business Unit Director, Medicine; Dr Colin Jenkins Consultant Physician, Clinical Lead for Stroke Services CONTACT EMAIL AND TELEPHONE NUMBER john.sharman@hhtr.nhs.uk ext 4008 TITLE OF REPORT: Improving Stroke Services Update December 2009 1.0 INTRODUCTION The purpose of this paper is to update the Board on progress made in implementing the NICE Clinical Guideline CG68 for Stroke (2008) and to review progress against the West Midlands Service Specification for the Management of Stroke Thrombolysis and Acute Care (2009). Details of the guidance are attached as Appendices 1 and 2. There will also be an assessment of what will need to be done to meet the draft NICE Quality Standard for Stroke. There will also be discussion of our performance in the National Sentinel Audit and what data is routinely collected for Stroke. 2.0 RECOMMENDATION The Board should note the progress made in implementing current guidelines and the likely future Quality Standard. As this is an area of interest with respect to Quality and Safety the Board may wish to indicate what information it would like to see regularly in the Quality Report. 3.0 MAIN BODY OF REPORT The National Stroke Strategy was launched in 2007. It has been followed by a series of guidelines. We are currently working to NICE CG68 and the West Midlands Service Specification for the Management of Stroke Thrombolysis and Acute Care. We are also considering the Draft Quality Standard for Stroke issued by NICE in November 2009 which is currently out for consultation; compliance with this is likely to become part of the regulatory framework as these Quality Standards have been commissioned by the Care quality Commission. Stroke Thrombolysis was introduced in HHT in May 2008. Additionally, for the year 2009/2010 we have had a Stroke CQUIN in our contract with Herefordshire PCT: achievement of the CQUIN will improve our income position. Performance against Stroke standards is monitored in a number of ways. Every 2 years there is a National Sentinel Stroke Audit which collects organisational data and clinical data over a 2 month period. We are also now collecting this data regularly in house. There are Stroke Vital Signs indicators which are collected monthly and submitted Improving Stroke Services January 2010 1

quarterly to the PCT; these are also being reviewed monthly in house. The CQUIN data is reviewed with the PCT in the Quality Forum. A number of changes have recently been introduced to facilitate compliance with these measures. West Midlands Service Specification for the Management of Stroke Thrombolysis and Acute Care (2009) Details of performance against the specification is shown in Appendix 2 Sentinel Audit The National Sentinel Stroke Audits have documented changes in secondary care stroke provision since 1998. In the last full report (2008), HHT submitted evidence from 60 patients during April and May 2008. The next Audit will be in 2010. HHT s scores for the 9 key standards was in the Upper Quartile. Our overall performance in the clinical section of the audit improved from lower quartile in 2006 to middle half. In the organisational section of the audit we remain middle half. Within the West Midlands our performance in the key indicators is better than a number of other Trusts. Details of performance in the 9 key indicators are shown in Appendix 3 Recent Changes to Acute Stroke Care It is widely recognised that patient outcomes are improved and length of stay reduced when patients receive a high level of care, supervision and therapy support during their stay in an acute stroke unit. The CEO has recently authorized additional resource (November 2009) to the Acute Stroke Unit (ASU) to further enhance patient care. The additional night nursing and therapy support will aid recovery during the acute phase. This enhanced support, together with changes to staff rotation across both the ASU and Frome ward ensures that patients will receive a high level of stroke care for their whole stay on the ward. Direct admission to the ASU is now possible for the majority of the time, as since 1 st November there is always a protected bed on the ASU for new admissions. Current Performance The Stroke currently regularly records data on the 9 key items for the Sentinel Audit and other key indicators. This data also reflects the key elements of NICE. Latest data reflects the following; Percentage of 90% stay on ASU 71.4% (November 2009) Average length of stay 9.8 days (October 2009) Percentage of direct stroke admissions 55.6% (November 2009) Percentage of patients with CT scan in <24 hrs 50% (November 2009) There has been a remarkable improvement in November in direct admissions to ASU (56%). The monthly average for the 4 months to October was 18%. In May Improving Stroke Services January 2010 2

2008 it was 7%. Percentage of 90% stay on ASU has improved from an average of 38% in the preceding 6 months to 71% in November which exceeds the 2008 NICE guideline. Length of stay on ASU continues to fall gradually. There is room for improvement in timely CT scans. The figure from November (50%) was lower than the previous average of 62%. Patients suitable for thrombolysis remain in the minority. Patients must be under 80 years of age and receive therapy within 3 hours of stroke. Because of recent changes to the configuration of the stroke unit the Vital Signs indicators which are extracted from the PAS system have to be reconciled with the directly collected data. The future NICE has recently produced a draft Quality Standard for Stroke ( Appendix 4); work on development of the service should take this in to account as it is likely to form part of the regulatory framework against which we are assesses.. The major implications for the current level of service provision include a requirement for more rapid CT scans, plus the provision of a geographically identified specialist stroke rehabilitation unit for those patients who require ongoing hospital care after completion of their acute diagnosis and treatment. The provision of suitable rehabilitation facilities is currently part of the Care Pathway Work for Stroke. Stroke was selected as one of the first pathways to be considered in detail across the health economy as part of the Provider Services Integration Project as it is of such importance to the public and our patients. The intention will be to deliver a more integrated service. This work is building on the work which had already occurred in developing Stroke services. 4.0 POLICY AND BUSINESS PLAN CONSIDERATIONS Stoke Services are driven by the National Stroke Strategy (2007) and by a series of nationally produced or recognised guidelines. Increasingly compliance with these is likely to be a requirement from Commissioners of Stroke services. Improvements to Stroke services link to the delivery of Trust Objectives: 1, 2, 3, 5, 7 and 8. 5.0 IMPLICATIONS Healthcare /National Policy Continued improvements to the Stroke service will ensure compliance with NICE Clinical Guidance for Stroke (2008), provides progress towards compliance with West Midlands Service Specification for the Management of Stroke Thrombolysis and Acute Care (2009), Improving Stroke Services January 2010 3

delivers local CQUINN targets and will maintain a high standard of quality as measured by the National Sentinel Stroke Audits. 6.0 CONCLUSIONS Our performance against National and Regional Guidelines continues to improve. The re-designation of Frome Ward as a stroke ward has improved the percentage stay. This has been supported by flexible staff working arrangements across the ward to deliver improved care. The additional nursing and therapy support recently agreed by the CEO will continue to enhance the care across the ward. There must be consideration given to the numbers of CT scans performed within 24 hours where this is clinically indicated. The CT service is available 24/7 in emergency, but in general scans could be performed the next day if requested. A review of current clinical practice and decision making will ensure CT scans are performed in an appropriate timeframe. Thrombolysis will always be limited at HHT due to travel time and age of patients. Consideration is being given to increasing the number of clinicians available to deliver thrombolysis which at present is limited to 1. Across the region it is noted that no acute trusts meet the national target for percentage of patients receiving timely thrombolysis. Improving decision making for CT will also improve thrombolysis access. Although our standardised mortality for stroke is above 100 it does not show as an outlier in the West Midlands Provider Mortality Protocol. Within the stroke unit, the 7 day mortality rate for stroke patients is 8% against 11% nationally. Future planning will need to take into account all current and proposed standards Improving Stroke Services January 2010 4

Appendix 1 Summary of 2008 NICE guidelines for the management of stroke patients people with suspected stroke should be admitted directly into an Acute Stroke Unit (CQUINN) 80% of patients will spend 90% of their inpatient stay in an Acute Stroke Unit (2010/11 measures CQUINN) Brain imaging should be performed within 1 hr for patients who: o Have indications for thrombolysis or anti-coagulant therapy o Are pre-disposed to bleeding o Have a Glasgow Coma score below 13 o Unexplained progressive or fluctuating symptoms o On anticoagulation o Papilloedema, neck stiffness or fever o Severe headache at onset of stroke symptoms On admission patients with acute stroke should have their swallowing screened by appropriately trained individuals. Patients who have had a suspected TIA who are at high risk of stroke should be assessed by a specialist within 24 hours Stroke Thrombolysis should be available for those patients who meet the criteria including; o Within 1 hour of symptoms o Under 80 years of age Improving Stroke Services January 2010 5

! " STANDARD CURRENT MEASURE RESULTS ACTIONS REQUIRED Al Proportion of patients with suspected stroke admitted to stroke unit directly from A+E within 4 hours Aim statement - 80% 54.55% Bed available at all times on ASU from 1st November 2009. Timely patient referral to ASU needs to be put in place. Admission to ASU still dependant on level and mix of staffing Proportion of patients receiving swallow screen within 4 hours of admission Aim statement 80% of cases 77.27% On course to meet target Proportion of patients identified as having swallowing difficulties, and who are NBM having a naso gastric tube inserted Aim statement 60% of cases 3 patients were NBM and all had NG tubes inserted 100% compliance Proportion of urgent cases that receive a CT scan within 24 hours of onset of symptoms Aim statement 80% 50% Action required to improve decision to scan at point of diagnosis. Providers will have systems in place to enable the collection of patient/relative satisfaction of service YES 100% compliance The number of patients requiring urgent referral for neuro-surgery assessment/treatment 0 No patients identified Improving Stroke Services January 2010 6

Performance in 2008 National Sentinel Audit 9 Key Clinical Criteria Appendix 3 Criterion sites HHTR Screening for swallowing disorders <24 hrs after admission 72% 92% Brain scan within 24 hrs of stroke 59% 50% Physiotherapist assessment within 24hrs of admission 84% 95% Occupational therapy assessment within 4 working days of admission 66% 91% Patient weighed during admission 72% 100% Patient s mood assessed by discharge 65% 94% Rehabilitation goals agreed by the multidisciplinary team 86% 100% Aspirin or clopidogrel by 48hrs after stroke 85% 67% Patients spent at least 90% of stay on stroke unit 58% 54% Percentage of eligible patients receiving all 9 indicators ( bundle of care) 17% 19% NICE Stroke Draft Quality Standard: No. Quality Statement Appendix 4 Improving Stroke Services January 2010 7

1 Patients with stroke receive care from commissioned services that encompass the whole stroke pathway from prevention through to acute care, early rehabilitation and initiation of secondary prevention, and on to palliation, later rehabilitation in the community and longterm support. 2 Patients with stroke are seen by at least one member of the specialist rehabilitation team within 24 hours for assessment and by all relevant members of the specialist rehabilitation team within 5 days of admission. 3 Patients seen within 3 hours of an acute neurological syndrome suspected to be a stroke will be transferred directly to the specialised hyperacute stroke unit to assess for thrombolysis and receive it if clinically indicated. 4 Patients requiring ongoing hospital care after completion of their acute diagnosis and treatment are treated in a geographically identified specialist stroke rehabilitation unit. 5 patients discharged home directly after acute treatment who have residual problems are followed up within 24 hours by specialist stroke rehabilitation services in order to assess the need for further interventions. 6 Patients with stroke who cannot be admitted to hospital, and who are not receiving palliative care, are seen by a specialist team at home or on an outpatient basis as soon as possible. 7 Patients with stroke will be discharged according to a locally negotiated policy. 8 Patients with stroke are offered a minimum of 45 minutes of each therapy that is required for a minimum of 5 days a week for as long as they are continuing to benefit from it. 9 (a) People with sudden onset of neurological symptoms outside hospital are screened by ambulance personnel using a validated tool to determine a diagnosis of stroke or transient ischaemic attack. (b) People with sudden onset of neurological symptoms who screen positive using a validated tool, in whom hypoglycaemia has been excluded and who meet the requirements for thrombolysis, are transferred to an acute stroke care facility within 60 minutes. 10 Patients with acute stroke receive brain imaging within 1 hour of admission if they meet any of the indications for immediate imaging. 11 Patients with acute stroke who meet the criteria for treatment with alteplase are treated in accordance with NICE technology appraisal guidance 122 (2007) and NICE clinical guideline CG68 (2008). 12 Patients admitted with acute stroke have their swallowing screened within 4 hours of admission by an appropriately trained healthcare professional, before being given any oral food, fluid or medication. 13 Patients with stroke who have any impairment at 24 hours receive a full multidisciplinary assessment using an agreed procedure or protocol for goal setting within 5 days, documented in the patient records. 14 Patients with stroke entering rehabilitation are screened for depression using a validated screening tool (for example, the GHQ-12 or PHQ-9 questionnaire). 15 Patients with stroke entering rehabilitation are screened to identify the range of cognitive impairments that may occur after a stroke using a validated screening tool (for example, mini-mental state examination or short orientation-memory-concentration test). Improving Stroke Services January 2010 8

16 Patients with stroke who have aphasia that persists for more than 2 weeks receive appropriate speech and language therapy. This includes being given treatment aimed at reducing identified specific language impairments while continuing to progress towards goals, being considered for early intensive (2-8 hours/week) speech and language therapy, if they can tolerate it, and being assessed for alternate means of communication (for example, gesture, drawing, writing, use of communication aids) and taught how to use any that are effective. 17 Patients with stroke who have loss of control of the bladder at 2 weeks are reassessed for other causes of incontinence which should be treated if identified. This treatment should include having an active plan of management documented, offering simple treatments first, Improving Stroke Services January 2010 9