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What has happened, where are we now – and where are we going? Stroke Services in Southend.

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Presentation on theme: "What has happened, where are we now – and where are we going? Stroke Services in Southend."— Presentation transcript:

1 What has happened, where are we now – and where are we going? Stroke Services in Southend

2 What is a Stroke?

3 In the beginning…..(pre-2004) 26 bed Stroke rehabilitation unit - 6 th floor! 16 consultants No protocols 40% Catheter, 40% mortality

4 …. Dr Tony OBrien 2004 : took over Stroke Rehabilitation

5 2005 Weekly TIA Clinic 2006 Move to Ground floor 14 bed ASU, Gym, new Consultant: £ 800,000 Strokebusters Charity appeal

6 Progress: date 2007 May - 2 Consultants 2007 July - ASU opened, Daily TIA clinic Monday-friday thrombolysis weekdays hr thrombolysis 7/7 (1:2 on call) stroke consultants (1:4 on call) day Patient-centred TIA service

7 What do you want if you have a stroke?

8 RAPID treatment by stroke Specialists: SAVE MY BRAIN!

9 Immediate pre-alert and stroke team review of all patients Consultant-delivered care 24/7 Rapid imaging directed for that patient Acute stroke nurses 24/7 Single point of contact for hospital/GP Integrated working: Individual patient goals Weekly multidisciplinary team meetings, family conferences Discharge planning begins on admission Its all about the patient: 2 million brain cells/second

10 The only hospital in Essex to have 24/7 BASP accredited stroke specialist consultant-led and delivered service including in hospital weekend working Patient-specific imaging decision 24/7: the only hospital to have stroke MRI availability 7 days a week Hyperacute service

11 Range – 1 to 15 minutes Median – 6 minutes IN hours – median 6 minutes OUT hours – median 5 minutes As soon as urgent imaging is requested Source: Request to scan time (Recurrent Door To Needle Audit 2012) The right scan at the right time

12 First in the region to implement the service Over 500 patients treated since 2007 with highest experience with proven safety in delivery (SITS database) One of the highest percentages of intravenous thrombolysis nationally (SINAP) 100% of eligible patients receive the treatment (SINAP) Intravenous thrombolysis

13 Stroke beds ring-fenced Consistently the highest performance for >90% stay on stroke unit across the East of England Bed occupancy year to date: o Acute stroke unit: 78% o Rehabilitation stroke unit: 88% First in the region for rehabilitation 7 day working Acute services

14 What do you want if you have a TIA?

15 Rapid investigation and treatment. Risk of Early Recurrent Stroke: 12% with 7 days (most within hours)

16 Innovation – systems built around the needs of patients 7 day clinic MRI service with walk-in protocol 3 doctors trained in carotid ultrasound which can take place on the stroke unit Single point of contact for telephone referral Electronic referral system / TIA HOT referral system Rapid Carotid surgery assessments Medication taken before leaving! TIA service

17 What do you want if you have a blocked artery?

18 SAFELY OPERATE to prevent a stroke ASAP!

19 Collaboration with vascular surgery Basildon (Oct 10-Oct 11) Mid Essex (Oct 10-Oct 11) Southend (Oct 10-Oct 11) Number of procedures Proportion in 14 days 43%5%88% Median days17489 National Carotid Audit Round 4 (June 2012)

20 Collaboration with vascular surgery Southend 7 days Basildon 13 days PAH 15 days Mid Essex 18 days Colchester 19 days National Carotid Audit Round 5 : formal public report will be October 2013 June Time from Initial symptoms to carotid surgery

21 7 original research articles and 38 posters since 2008 Collaborative research NIHR Portfolio research – 10 studies Only centre in Essex recruiting to commercial studies Monthly teleconference collaboration with all Essex trusts Consultant Interventional Radiologist for stroke / Research appointed Research

22 Patient Outcomes …what actually matters!

23 Dr Foster Stroke Mortality Aug-11 / Jul-12 National PAH BTUH 106 MEHT CHUFT 92.3 SUHFT 78.4

24 Peer (NATIONAL) SpellsSuperspells% of all deathsDeaths % of dea ths Expecte d deaths % RRLowHigh Kings College Hospital NHS Foundation Trust % % % Royal Free London NHS Foundation Trust % % % Lewisham Healthcare NHS Trust % % % University College London Hospitals NHS Foundation Trust % % % Croydon Health Services NHS Trust % % % Derby Hospitals NHS Foundation Trust % % % Shrewsbury and Telford Hospital NHS Trust % % % Southend University Hospital NHS Foundation Trust % % % Ealing Hospital NHS Trust % % % Guys and St Thomas NHS Foundation Trust % % % RISK OF DYING FROM STROKE BY TRUST IN ESSEX - DR FOSTER DATA; AUG 11 - JULY 12

25 Estimates done as part of the stroke review: If number of deaths from stroke cut by 30% in Essex: 422 deaths/year saved If more modest reduction to the 100 baseline (Relative risk of 1) 104 deaths/year saved Most London HASUs are below 80 (RR 0.8) – even greater benefit

26 Outcome for all stroke patients at Southend Average length of stay Pre days days days Home Independent Pre % % % Source: Southend stroke database

27 SUHFT 13 Days 1st April st March 2012 Source – Network Stroke Database

28 Stroke patient satisfaction survey 2013 What was your overall impression of your care and the support you received from the stroke multidisciplinary team?

29 Awards for quality of stroke unit care Health and Social Care Awards(2009) WINNERS: East of England RUNNERS-UP: National finals Transforming Services Award: Strokebusting - a comprehensive neurovascular service, saving lives and preventing disability Health Service Journal Awards(2009) WINNERS: Delivering Quality and Value with NICE Guidance Research awards TSRN – Top Recruitment to RCTs TSRN – Top Recruitment to RCTs TSRN – For Essex and Herts Award for highest recruitment to RCTs by CLRN TSRN – Highest Recruitment to Commercial Studies UK Stroke Forum award (2009): Highest IST-3 trial recruitment 2009 in the UK Awards and recognition

30 Recommended clinical reconfiguration decision following the completion of the Essex stroke options appraisal: 3 HASUs: One for South Essex HASU - Southend; ASU - Basildon Its worked before and it will work again Hyperacute Stroke unit: what is it? HASU for South Essex ….Full circle

31 Before Basildon Hospital started thrombolysis - we delivered this service The EoE ambulance service has delivered patients from Basildon, Harlow, Chelmsford AND Colchester – all who received thrombolysis within 3 hours – before their services started Patients have been airlifted in to provide a thrombolysis Basildons CT scanner broke recently; we were able to accept patients both in and out of hours and some were repatriated We have never refused a patient from anywhere Service provision effectively manages population flows into and out of the area

32 Sustainability of outcomes as a HASU Mortality rate reduced over time

33 Scope for improving the door to needle time: SINAP data TrustApr-Jun11Jul - Sep11Oct-Dec11Jan-Mar12Apr-Jun12Jul-Sep12Oct-Dec12 Average Door To Needle Time in minutes BTUH Eligible but no records Insufficient records CHUFT MEHT Eligible but no records PAH7078 Insufficient records 14267NA Eligible but no records SUFHT

34 WHERE DO WE GO NEXT? WHAT DO WE NEED? A COMPLETE PATIENT-CENTERED SERVICE As easy as 1-2-3!

35 15 February 2013 Ms Jacqueline Totterdell Chief Executive Southend University Hospital NHS Foundation Trust Dear Ms Totterdell RE: MIDLANDS AND EAST REVIEW OF STROKE SERVICES: ESSEX HASU/ASU CLINICAL RECONFIGURATION DECISION I am writing to you following my letter dated 4 February On behalf of the Essex stroke commissioner group I am now able to share with you the recommended clinical reconfiguration decision following the completion of the Essex stroke options appraisal centre HASU model with HASUs at: Mid Essex Hospitals Colchester Hospital University NHS Foundation Trust Southend University Hospital NHS Foundation Trust There will be an ASU at all DGHs including Princess Alexandra Hospital and Basildon and Thurrock University Hospital.

36 I must emphasise that this recommendation is a clinical reconfiguration recommendation only. Before an ultimate decision can be made the following must be concluded: 1. A full financial sustainability evaluation of the whole stroke pathway, your finance leads are currently working with Stephanie Watson who has been seconded from the SHA to work with the Essex Stroke commissioners and Dawn Scrafield, finance lead for the Essex local area office to assess financial viability of the suggested reconfiguration. Further work is also required to assess ambulance interference costs and PTS transport costs. 2. CCG agreement to the proposed financial impact of the new service model for stroke services 3. Further patient flow analysis work taking into consideration suggested reconfigurations across the whole of Midlands and East. 4. Public consultation.

37 What do we need: 1. Firm decisions regarding the Stroke Hyperacute Stroke Units (HASUs) Since this letter: 7 months Unable to plan services & staffing until decisions made Similarly, a decision required regarding Vascular Surgery services In South Essex

38 Stroke rehabilitation Long-term rehabilitation after stroke Issued: June 2013 NICE clinical guideline 162 The core multidisciplinary stroke team A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation: consultant physicians nurses physiotherapists occupational therapists speech and language therapists clinical psychologists rehabilitation assistants social workers.

39 Stroke Association: Feeling overwhelmed 2012 :UK survey to understand the emotional impact of stroke on survivors, carers and their families. Aimed at stroke survivors and their carers The total sample size is 2,711

40 My emotional needs are not looked after as much as my physical needs (62.8%) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 3.8% 9.6% 23.7% 41.4% 21.4% Health and social care services provide good emotional support (18.0%) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 20.0% 30.9% 31.2% 13.7% 4.3% Survey responses from stroke survivors Survey responses from carers My emotional needs were not supported (66.7%) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 6.6% 8.8% 18.9% 37.4% 28.3%

41 What do we need: 2. Work quickly to ensure that Stroke Psychology services continue after January 2014.

42 Andrew Marr's wife hits out at stroke care THE WIFE OF THE BBC JOURNALIST ANDREW MARR HAS CRITICISED THE LEVEL OF CARE AVAILABLE TO PEOPLE WHO HAVE HAD A STROKE, ONCE THEY LEAVE HOSPITAL SHE SAID THE INTENSIVE DAILY CARE IN HOSPITAL WAS REPLACED BY - AT BEST - WEEKLY APPOINTMENTS. CAMPAIGNERS SAID MANY SURVIVORS FELT "ABANDONED" WHEN THEY RETURNED HOME. SHE SAID THE NHS HAD BEEN "WONDERFUL, WONDERFUL, WONDERFUL". SHE ADDED: "THE INFLEXIBILITY OF THE SYSTEM IS STAGGERING. "I'VE BEEN CONTACTED BY MANY, MANY STROKE VICTIMS AND THE GENERAL VIEW IS THAT HOSPITAL CARE IS EXCELLENT, BUT THERE'S VERY LITTLE SUPPORT AFTER THAT.

43 Flexible Working between hospital and community …. For the Patient, not the system Within the hospital Stroke support worker – works with patients and carers Multidisciplinary: including vascular, radiology and cardiology teams End of life Information sharing Seamless transfer of care of every stroke patient into the community……

44 Community stroke ……seamless transfer of care of every stroke patient into the community Stroke support worker – works with patients and carers Community stroke team Early supported discharge Psychology End of life Patient and carer groups: local stroke clubs, Carers Association Flexible Working between hospital and community …. For the Patient, not the system

45 What do we need: 3. A complete patient-centred single streamlined service from admission to discharge – across primary care and the community flex services across hospital and community: will need a change in the way we work The teams we have do a great job – but the system is inflexible: need to put the patient first Cant plan properly until HASU decision: depends on beds and staffing

46 We are a centre of excellence which delivers excellence and continually strives to deliver quality

47 Scope for improving the door to needle time: SINAP data TrustApr-Jun11Jul - Sep11Oct-Dec11Jan-Mar12Apr-Jun12Jul-Sep12Oct-Dec12 Average Door To Needle Time in minutes BTUH Eligible but no records Insufficient records CHUFT MEHT Eligible but no records PAH7078 Insufficient records 14267NA Eligible but no records SUFHT

48 Staffing levels Site Name 2012 Qualified Nurses - WTEs per 10 SU beds Physiotherapy - WTEs per 10 beds Occupatio nal Therapy - WTEs per 10 beds Speech and Language Therapy - WTEs per 10 beds 6 or 7 day workin g for at least 2 of PT, OT and SALT Number of programm ed activities for stroke consultant physicians Junior doctor time per week for all SU beds Access to clinical psychologis t(s) NATIONAL %202652% BTUHBelow median Above median No Above median No CHUFTAbove medianBelow median Above median No Above median Yes MEHTBelow medianAbove median No Below median Above median No PAHAbove median No Below median No SUHFTBelow medianAbove median Below median Above median Yes Above median Pilot

49 Staffing levels Site Name 2012 Qualified Nurses - WTEs per 10 SU beds Physiotherapy - WTEs per 10 beds Occupatio nal Therapy - WTEs per 10 beds Speech and Language Therapy - WTEs per 10 beds 6 or 7 day workin g for at least 2 of PT, OT and SALT Number of programm ed activities for stroke consultant physicians Junior doctor time per week for all SU beds Access to clinical psychologis t(s) NATIONAL %202652% BTUHBelow median Above median No Above median No CHUFTAbove medianBelow median Above median No Above median Yes MEHTBelow medianAbove median No Below median Above median No PAHAbove median No Below median No SUHFTBelow medianAbove median Below median Above median Yes Above median Pilot

50 From: Jeffries Candy (NHS ENGLAND) Sent: 14 August :46 To: Guyler, Subject: RE: psychology Dear Paul, There is no doubt that psychology provision at all levels and at all stages of the pathway, is valuable to patients and carers, shortens length of stay and improves goal attainment and outcomes. The network supports having psychology available and it is in the service specification. It is certainly best practice, but many acute trusts and CCGs are treating it as a luxury item rather than a core part of the service and, as such, it is not commissioned in all parts of the pathway, and in some areas, not commissioned anywhere at all. I am happy to try and support your fight for continued funding, but, as I don't have any budget to support services, all we can do to support you is to lend our weight behind your request for ongoing funding. Do let me know if that would be any help, BW Candy Jeffries Cardiovascular SCN Manager (East of England) NHS England CPC1 | Capital Business Park | Fulbourn | Cambridge | CB21 5XE


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