1. Slide 1 All Wales Stroke Services Improvement Collaborative Stroke Services in Wales An Update Anne Freeman Consultant Physician Royal Gwent Hospital Clinical Lead AWSSIC

2. Slide 2 All Wales Stroke Services Improvement Collaborative RCP Audit 2008 Organisational Report August 2008 Stroke Unit provision in UK Hospitals % of sites with stroke unit 20062008 England 98%96% Wales 50%45% N Ireland 92%92% % of sites with stroke units who have all 5 SUTC characteristics England 73% Wales 80% N Ireland 64%

3. Slide 3 All Wales Stroke Services Improvement Collaborative Criteria for judging quality of acute and combined stroke units (SUTC characteristics)` These characteristics are not all evidence based but were developed using the consensus of an expert working group – the Intercollegiate Stroke Working Party: Continuous physiological monitoring (ECG, oximetry, blood pressure) Access to scanning within 3 hours of admission Policy for direct admission from A&E/front door Specialist ward rounds at least 5 times a week Acute stroke protocols/guidelines

4. Slide 4 All Wales Stroke Services Improvement Collaborative ORGANISATION OF STROKE CARE BY DOMAINS 8 areas assessed by the proforma 1. Acute Stroke Care 2. Organisation of Care 3. Consultant physician time (overall) 4. Inter disciplinary Services (for sites with a stroke unit) 5. TIA/neurovascular Services 6. Continuing Education in stroke 7. Team working –Team meetings 8. Communication with Patients and Carers

5. Slide 5 All Wales Stroke Services Improvement Collaborative Range of Scores for Wales Wales Range across 20 units: 23 -77 (evenly distribributed) England Median about 75 (50-90) Northern Ireland Range about 15 - 78

6. Slide 6 All Wales Stroke Services Improvement Collaborative Changes from 2006 in Wales 2008 13 sites in bottom range 6 sites in middle range 1 top range Change from 2006 1 site moved up to top 3 sites moved up to middle 1 site moved down to bottom All others stayed the same

7. Slide 7 All Wales Stroke Services Improvement Collaborative Top Ten Recommendations 1. All patients with acute stroke should be admitted directly to an acute stroke unit 2. Thrombolysis should only be provided when all the other components of acute stroke care are of high quality 3. Comply with the recommendations in the NICE guidelines for Acute Stroke and TIA 4. Development of seven day rehabilitation services should be made a priority 5. Stroke services should urgently review policies that exclude certain groups from admission to the stroke unit

8. Slide 8 All Wales Stroke Services Improvement Collaborative Recommendations continued 6. Patients without stroke should not occupy beds on the stroke unit while stroke patients are managed off the unit 7. Levels of nurse staffing on acute stroke units needs to be increased in many units 8. Social worker involvement as an integral part of the stroke team is essential and should be mandatory for every stroke service 9. Early supported discharge services should be made available for all patients 10. All services managing patients with TIA should have systems in place in line with the recommendations in the National Stroke Strategy and the NICE guidelines for Acute Stroke and TIA.

9. Slide 9 All Wales Stroke Services Improvement Collaborative Further details http://sentinelstrokeaudit.rcplondon.ac.uk

10. Slide 10 All Wales Stroke Services Improvement Collaborative RCP Process Audit 2008 Clinico-demographic results National England Wales N. Ireland Sites 216 184 18 11 (Patients) 11,369 10,007 863 355 % new institutionalised on D/C 11 12 7 11 % D/C Barthel of 20 39 39 45 41 % D/C Barthel of <10 17 17 12 19 Mean Age 76.5 75.6 74.7 73.6 Mean LOS to D/C or death 24 23 25 25

11. Slide 11 All Wales Stroke Services Improvement Collaborative RCP Process Audit 2008 Overall results for 9 key process indicators in 2008 NationalEnglandWalesN. Ireland Patients- 90% stay in a stroke unit58594159 Screened for swallow within 24 hrs adm72745270 Brain Scan < 24hrs59 5456 Aspirin < 24hrs85 82 PT Assessment <72 hours adm84857085 OT Assessment < 4 working days adm66684373 Weighed72735968 Mood Assessed by discharge65664680 Rehab Goals set by MDT86877483 Average for 9 indicators72735873

12. Slide 12 All Wales Stroke Services Improvement Collaborative Results in Wales since 2004 200420062008 Patients 667925863 1 Patients – 90% stay in a stroke unit N/A3941 2Swallow screen within 24 hrs of admission 515552 3Brain scan < 24 hours of strokenot comparable 3850 4Aspirin by 48 hours of stroke 737685 5PT assessment < 72 hrs of admission 495470 6OT assessment < 4 working days of admission N/A3043 7Weighed 515459 8Mood assessment by discharge 475346 9Rehab goals agreed by MDT 677074

13. Slide 13 All Wales Stroke Services Improvement Collaborative Site variation for the process domains in 2008

14. Slide 14 All Wales Stroke Services Improvement Collaborative How domain scores are obtained D1 Initial patient assessment Screen for swallowing 24 hours Visual Fields Sensory Testing Brain scan within 24 hours of stroke D2 Multi-disciplinary assessment Swallow assessment by SALT within 72 hours PT assessment within 72 hours Initial assessment of communication by 7 days OT assessment within 4 working days SW assessment within 7 days of referral

15. Slide 15 All Wales Stroke Services Improvement Collaborative How domain scores are obtained D3 Screening and functional assessment Patient weighed at least once Evidence of mood assessed Cognitive status assessed Screening for malnutrition D4 Care Planning Evidence of rehab goals Plan to promote urinary continence Receiving nutrition within 72 hours

16. Slide 16 All Wales Stroke Services Improvement Collaborative How domain scores are obtained D5 Communication with patients and carers Discussion with patient about diagnosis Carer needs for support assessed separately Skills taught to care for patient at home Follow up appointment at 6 weeks Driving advice D6 Acute Care Aspirin <48 hours of stroke 90% of care in a SU Admitted to an acute or combined SU < 4 hours Receiving fluids < 24 hours % of applicable patients thrombolysed

17. Slide 17 All Wales Stroke Services Improvement Collaborative 9 key indicators Comparing sites in Wales/regions

18. Slide 18 All Wales Stroke Services Improvement Collaborative Mid and West Wales 2008 score 2008 2006 * 75 Middle Upper * 35 Lower Lower * 59 Middle Middle * 42 Lower Lower * 53 Lower Lower * 36 Lower Middle * 31 Lower Lower * 64 Middle Middle

19. Slide 19 All Wales Stroke Services Improvement Collaborative North Wales 2006 2008 * 60 Middle Middle * 61 Middle Upper * 66 Middle N/A

20. Slide 20 All Wales Stroke Services Improvement Collaborative South East Wales

21. Slide 21 All Wales Stroke Services Improvement Collaborative Top Ten Areas with recommendations for change in Process of Care 1.Work with all agencies to raise the public awareness of stroke to speed up access to hospital following stroke 2. Organise hospital care so that patients are admitted directly to an acute stroke unit from A&E and all suitable patients can be treated with thrombolysis as quickly as possible 3. Improve the training and support given to junior doctors and staff from non stroke disciplines who undertake initial clerking of stroke patients 4. There should be regular quality control to ensure that documentation is complete 5. Brain scanning should be speeded up in many units

22. Slide 22 All Wales Stroke Services Improvement Collaborative 5. Ensure that all acute stroke units have effective multidisciplinary teams and working 6. Find the 25% of patients who do not currently get to a stroke unit and do something for them 7. Take urinary continence more seriously 8. Manage all patients so as to avoid chest infection and urinary tract infection and identify and treat infections early when they do occur 9. Communicate better with patients and relatives, particularly about the stroke diagnosis and prognosis and how to prevent further strokes 10. Give the correct advice is given to patients who drive

23. Slide 23 All Wales Stroke Services Improvement Collaborative Profession Specific Audit Autumn 2008 Second Pilot for RCP Tools provided by RCP but modified by the Rehab subgroup of WSA 20 sets of notes per discipline

24. Slide 24 All Wales Stroke Services Improvement Collaborative Involved…. Nursing PT OT SALT Dietetics Psychology Podiatry Social work

25. Slide 25 All Wales Stroke Services Improvement Collaborative Progress Results not ready yet To be presented to RCP later this year Will become part of the National Sentinel Audit as from 2010

26. Slide 26 All Wales Stroke Services Improvement Collaborative Proposed RCP acute audit First 3 days On line audit Prospective Detailed audit of process in first 72 hours Pilot still to be done to assess tool Unlikely to be UK wide until later this year RCP have reassured us that we can defer until at least after September

27. Slide 27 All Wales Stroke Services Improvement Collaborative AOF Target- April 2009 AOF Target for Stroke Services WAG has set the following target in the Annual Operating Framework for stroke services. By March 2009, each patient suspected of or confirmed as having had a stroke must be admitted to dedicated and co-located acute stroke beds staffed by a specialist multi- disciplinary medical and acute rehabilitation stroke team.

28. Slide 28 All Wales Stroke Services Improvement Collaborative Detailed Definition dedicated and co-located acute stroke beds These are hospital beds in a ward or part of a ward that are located very near one another (subject to issues of dignity and gender) and are guaranteed for admitting stroke patients who should have access to high quality specialist acute medical and rehabilitation stroke care.

29. Slide 29 All Wales Stroke Services Improvement Collaborative Such a service must satisfy the following quality indicators; * Access to continuous physiology monitoring * Access to brain imaging within 24 hours; * A policy in place and adhered to for direct admission from A & E; * Access to specialist ward rounds at least 5 times a week; * Consultant physician with responsibility for stroke; * Formal links with patient and carer organisations; * Multi-disciplinary meetings, at least weekly, to plan patient care; * Provision of information to patients, about stroke; * Continuing education programmes for staff.

30. Slide 30 All Wales Stroke Services Improvement Collaborative AOF Monitoring Tool Developed by Sarah Jones on behalf of SSIP Based on the elements of the AOF Reviewed by the team at NHH Will be on the nww.stroke.wales.nhs.uk website To be completed by end of April Letter to service will be coming out very soon Letter from Minister regarding assurance of AOF target by 13 th March Informal visits in March/early April Formal visits in May/June to verify compliance with AOF and to assess any shortfall Report to WAG by Mid June??

31. Slide 31 All Wales Stroke Services Improvement Collaborative Interim Organisational Audit RCP 2009 Same format as 2008 Just the organisational element No clinical audit on process of care Agreed to participate Timescale much the same as AOF monitoring – end of April 2009 Hopefully will see improvement following HM resources allocated to fund additional staff, etc

32. Slide 32 All Wales Stroke Services Improvement Collaborative Intelligent Targets Organisational Process Outcome

33. Slide 33 All Wales Stroke Services Improvement Collaborative Organisational- Uptake Indicators Use of Monitoring Tool Identified Clinical Champion and Specialist Stroke Team Evidence of progress on all intelligent targets

34. Slide 34 All Wales Stroke Services Improvement Collaborative Process Measures- Intelligent Targets Demonstrate an ongoing improvement in compliance rate with 10 stroke care bundles 4 TIA 4 Acute Stroke 2 Early Recovery and Rehabilitation

35. Slide 35 All Wales Stroke Services Improvement Collaborative Outcome Measures Percentage of people with suspected TIA who go on to have a full stroke within 7 days Mortality Rates Change in Functional Outcome Average Length of Stay in hospital on stroke unit within stroke service Percentage of people who return to their usual place of residence Percentage of people who are re-admitted within 28 days

36. Slide 36 All Wales Stroke Services Improvement Collaborative Acute Phase Driver Diagram

37. Slide 37 All Wales Stroke Services Improvement Collaborative TIA

38. Slide 38 All Wales Stroke Services Improvement Collaborative Early Recovery and Rehabilitation

39. Slide 39 All Wales Stroke Services Improvement Collaborative

40. Slide 40 All Wales Stroke Services Improvement Collaborative Managing a complex system

41. Slide 41 All Wales Stroke Services Improvement Collaborative

42. Slide 42 All Wales Stroke Services Improvement Collaborative Count the black dots !! Any questions??