Consultant Stroke Physician Royal Bournemouth & Christchurch NHS Foundation Trust

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Accelerating Stroke Improvement? Progress to Date. Damian Jenkinson. Consultant Stroke Physician Royal Bournemouth & Christchurch NHS Foundation Trust. National Clinical Lead NHS Stroke Improvement Programme. Stroke Quality Standard. National advice and guidance. Vital Signs. - PowerPoint PPT Presentation


<ul><li><p>Consultant Stroke PhysicianRoyal Bournemouth &amp; Christchurch NHS Foundation TrustNational Clinical LeadNHS Stroke Improvement ProgrammeDamian JenkinsonAccelerating Stroke Improvement? Progress to Date</p></li><li><p>National advice and guidance20072010Vital SignsBest Practice TariffEleven processstandardsIndicators along the pathwayMore emphasis on prevention and on long term care</p></li><li><p>Accelerating Stroke Improvement</p><p>The Accelerating Stroke Improvement programme is a national initiative designed to ensure that maximum implementation of the Quality Markers in the National Stroke Strategy is achieved before the end of the financial year 2010/11. The programme does not redefine existing ambitions and goals, but does provide renewed emphasis and urgency, and values and spreads best practice accomplished to date.Accelerating Stroke Improvement will provide intensive whole-system support to services to accelerate implementation of the strategy during 2010/11, with the aim of achieving key milestones in care across the stroke pathway covering prevention, acute and long-term care and better joint working across the health and social care interface. The methods will combine the efforts and activities of Stroke Networks, the Stroke Improvement Programme (SIP) and the Department of Health (DH) to mobilise local improvement initiatives, supported by SHA, PCT and Trust senior management. The learning from the 5 programmes that SIP has run over the past year will be distilled and spread. Data will be reported on a regular basis, and this will be monitored at national, regional and Network level. Networks will work with local teams to support service improvement and data management in order to deliver the key measures and aims by April 2011. There is another one year with stroke as a national priority and dedicated DH programme funding available, and the Accelerating Stroke Improvement programme is designed to make the very best use of these opportunities. This will also provide a firmer grounding for work beyond 2010/11.</p></li><li><p>Implementing Best Practice in Acute CareImproving Post Hospital and Long Term CareJoining Up PreventionDomainsi) Presence of a stroke skilled Early Supported Discharge teamii) Proportion of patients supported by a stroke skilled Early Supported Discharge team (40% by April 2011) Proportion of patients and carers with joint care plans on discharge from hospital to final place of residence (85% by April 2011)Proportion of stroke patients that are reviewed at six months after leaving hospital (95% by April 2011) Proportion of patients who have received psychological support for mood, behaviour or cognitive disturbance by six months after stroke. (40 % by April 2011)Key measures (aim)Proportion of patients admitted directly to an acute stroke unit within 4 hours of hospital arrival (90% by April 2011) Proportion of patients spending 90% of their inpatient stay on a specialist stroke unit (80% by April 2011. Vital Sign)i) Proportion of stroke patients scanned within one hour of hospital arrival (50% by April 2011)ii) Proportion of stroke patients scanned within 24 hours of hospital arrival (100% by April 2011)Proportion of patients with AF presenting with stroke anti-coagulated on discharge (60% by April 2011)Proportion of people with high-risk TIA fully investigated and treated within 24 hours (60% by April 2011. Vital Sign)</p></li><li><p>Stroke and TIA Vital SignsTrajectory to TargetNB A definition change in Q1 08/09 means that direct comparisons with previous quarters may not necessarily be valid DH analysis of vital sign data Stroke: Proportion of patients spending more than 90% inpatient stay on a stroke unitTIA: Proportion of high-risk TIA patients completely treated within 24h of referral</p><p>Chart1</p><p>0.390.36</p><p>0.40.4</p><p>0.450.44</p><p>0.470.47</p><p>0.520.49</p><p>0.580.46</p><p>0.580.51</p><p>0.610.56</p><p>0.680.56</p><p>0.730.584</p><p>0.750.64</p><p>Q4</p><p>Stroke desired position 90% stay on stroke unitFor 90% stay on stroke unit</p><p>TIA desired position High risk TIA treated </p></li><li><p>Proportion of patients with AF presenting with stroke anti-coagulated on discharge (60% by April 2011)13 networks reporting some data on anti-coagulation on dischargeMost networks performing above 60%Using this to quantify strokes prevented / lives savedASI 1: Preventable Stroke</p></li><li><p>18 networks reporting dataAverage 48%4862 strokes, 2358 admitted directly in under 4 hoursASI 2: Direct admission 4 hoursProportion of patients admitted directly to an acute stroke unit within 4 hours of hospital arrival (90% by April 2011) </p></li><li><p>*Performance data shows that London is performing better than all other SHAs in EnglandThrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world% of patients spending 90% of their time on a dedicated stroke unit % of TIA patients treatment initiated within 24 hours12%10%3.5%Feb Jul 2009Feb Jul 2010AIM</p><p>Chart1</p><p>6154.770</p><p>69.959.370</p><p>75.459.970</p><p>78.661.570</p><p>83.768.170</p><p>London</p><p>England</p><p>Target</p><p>% achievement</p><p>Sheet1</p><p>Stroke</p><p>2009/102010/11</p><p>Q1Q2Q3Q4Q1</p><p>London6169.975.478.683.7</p><p>England54.759.359.961.568.1</p><p>Target7070707070</p><p>TIA</p><p>2009/102010/11</p><p>Q1Q2Q3Q4Q1</p><p>London73.369.268.78484.9</p><p>England50.</p><p>Target6060606060</p><p>Sheet1</p><p>London</p><p>England</p><p>Target</p><p>% achievement</p><p>Sheet2</p><p>London</p><p>England</p><p>Target</p><p>% achievement</p><p>TIA patients treatment initiated within 24 hours</p><p>Sheet3</p><p>Chart13</p><p>0.01</p><p>0.02</p><p>0.03</p><p>0.04</p><p>0.05</p><p>0.07</p><p>0.08</p><p>0.09</p><p>0.1</p><p>0.11</p><p>0.12</p><p>0.13</p><p>0.14</p><p>0.15</p><p>Sheet1</p><p>HASU activitySU activity1%Feb - Jul 2009</p><p>10 patients6 patients2%</p><p>3%</p><p>4 go home4%</p><p>6 go to SU5%</p><p>ALOS - 3 daysALOS - 10 days6%</p><p>7%</p><p>8%AIM</p><p>HASU activity x ALOS309%Feb - July 2010</p><p>SU activity x ALOS6010%</p><p>TOTAL9011%</p><p>12%</p><p>Total activity1612313%789101112131415</p><p>14%</p><p>ALOS pathway5.62515%</p><p>1%2%3%4%5%7%8%9%10%11%12%13%14%15%</p><p>4 patients3 days12</p><p>6 patients13 days78</p><p>90</p><p>9 days ALOS</p><p>Thrombolysis</p><p>Before</p><p>Expected</p><p>After</p><p>Achieving 7 acute criteria</p><p>St George's Hospital100</p><p>UCLH100</p><p>Northwick Park Hospital100</p><p>Charing Cross Hospital100</p><p>Kings College Hospital100</p><p>St Thomas' Hospital100</p><p>The Royal London86</p><p>Queen's Hospital57</p><p>London75</p><p>Nationally7</p><p>Achieving all 7 criteria</p><p>Yes75</p><p>No25</p><p>Yes7</p><p>No93</p><p>National</p><p>London</p><p>Sheet1</p><p>0</p><p>0</p><p>0</p><p>0</p><p>0</p><p>0</p><p>0</p><p>0</p><p>0</p><p>0</p><p>Sheet2</p><p>75</p><p>25</p><p>Sheet3</p><p>7</p><p>93</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>Direct admission for pre-72 hour stroke care</p><p>St George's HospitalYes</p><p>UCLHYes</p><p>Northwick Park HospitalYes</p><p>Charing Cross HospitalYes</p><p>Kings College HospitalYes</p><p>St Thomas' HospitalYes</p><p>The Royal LondonNo</p><p>Queen's HospitalNo</p><p>London75</p><p>Nationally39</p><p>LondonNational</p><p>Yes75%Yes39%</p><p>No25%No61%</p><p>0</p><p>0</p><p>0</p><p>0</p><p>HASUNon-HASU</p><p>Oct-0945%55%</p><p>Nov-0944%56%</p><p>Dec-0950%50%</p><p>Jan-1052%48%</p><p>Feb-1063%37%</p><p>Mar-1066%34%</p><p>Apr-1068%32%</p><p>May-1069%31%</p><p>Jun-1068%32%</p><p>1st - 18th Jul68%32%</p><p>19th - 31st Jul88%12%</p><p>Aug 10 - indicative90%10%</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>HASU</p><p>Non-HASU</p></li><li><p>Supporting Life After Stroke</p></li><li><p>Overall results</p></li><li><p>What did the review find?Early supported discharge available across only 37% of areasIn 48% of areas average waits for community based speech and language therapy exceed two weeksOnly 37% of areas provide rehabilitation services to people based in their community, focusing on helping them return to work.In around a third of areas not all carers can access peer support, such as carer support groups or befriending schemes.Most people are given a pack of information when they leave hospital but only 40% of these packs contained good information on local services. While 68% of areas provided a named contact to help people plan and organise their care after transfer home, in only half of areas did these contacts look across health, social and community services</p></li><li><p>Aspiration 40% - evidence of depression, anxiety and poor cognition rates from South London Stroke Register dataPsychological therapy examples on SIP website</p><p>Proportion of patients who have received psychological support for mood, behaviour or cognitive disturbance by six months after stroke. (40 % by April 2011)ASI 6: Timely Access to Psychological Support</p></li><li><p>CQC Data Is there an agreed process for integrated reviews of health and social care needs for those living at home? Joint Care Planning Resource on SIP website; consensus statement and case examples</p><p>Proportion of patients and carers with joint care plans on discharge from hospital to final place of residence (85% by April 2011)ASI 7: Joint Health and Social Care Plans</p></li><li><p>Proportion of patients reviewed 6 months after leaving hospitalAspiration 95% of patients to be reviewedASI 8: Assessment and ReviewProportion of stroke patients that are reviewed at six months after leaving hospital (95% by April 2011) </p></li><li><p>Policies for reviews</p></li><li><p>Current models of stroke reviews use a standardised tool, which cover, at a minimum, five key areas Topic 1: Medical and secondary preventionTopic 2: AbilityTopic 3: Daily living Topic 4: Social life and supportFor examples of tools to use see the South Central Stroke Review Tool and the GM-SAT tool developed by Greater Manchester CLAHRCAlso consider how to: solve more complex issues arising from the review share information with relevant organisations signpost to other local services and organisationsinclude a named or single point of contact Topic 4: Psychological support</p></li><li><p>Aspiration 40%14 Networks with good data</p><p>i) Presence of a stroke skilled Early Supported Discharge teamii) Proportion of patients supported by a stroke skilled Early Supported Discharge team (40% by April 2011) ASI 9: Access and availability of ESD services</p></li><li><p>Early Supported Discharge Access to ESD in 37% PCTsOnly 18% PCTs report fully-specified ESD service</p></li><li><p>Driving further improvementacross whole pathwayLocal coordination and sustainability: PCT, GP consortia, Public Health &amp; CouncilBetter information to support person-centred care and accountabilityConsolidate national systems: Standards, data, outcome measures, tariff/Harness user voiceNational, local &amp; individual</p></li><li><p>Requirements of Stroke TariffHyper-acuteAcute care And early rehabPost-acute rehab In hospitalHome / communityStroke specialist rehabESDTransfer to communityNSS CompliantThrombolysisCommunity rehab tariff uplift for ESD </p></li><li><p>Clarify existing local patient pathways and associated financial flows</p><p>Focus on what is best for patients when redesigning services and a new local tariff structure</p><p>Agree the principles of new local stroke tariff structure</p><p>Create and implement the new local tariff structure</p><p>Ensure data systems are in place to monitor patient and financial flows after changes are made</p><p>Framework for Unbundling the Stroke Tariff</p></li><li><p>Unbundling the Block ContractAnglia Stroke &amp; Heart Network</p></li><li><p>Unbundling the Tariff to Fund ESDEast Midlands Cardiac &amp; Stroke Network</p></li><li><p>Threat of failure to receive HASU accreditation from South Central Stroke Services reviewLowest stroke unit access Vital Sign in SHA and no returns for TIA Vital Sign2 structured visit with 2 SIP Associates: Paul Guyler and Claire Moloney. Documentation submitted.Assisted with review of coding, on-call rota for acute stroke90% stay on SU risen from 34 to 83%24/7 acute rota live 2/12Best performance in CQC report</p><p>Accelerating Stroke Improvement On The Ground: Queen Alexandra Hospital Portsmouth</p><p>Chart1</p><p>0.350.31</p><p>0.40.41</p><p>0.450.35</p><p>0.50.41</p><p>0.550.5</p><p>0.70.58</p><p>0.750.68</p><p>0.80.63</p><p>0.820.64</p><p>0.840.83</p><p>0.85Mar</p><p>Trajectory</p><p>Actual</p><p>Sheet1</p><p>MayJunJulAugSepOctNovDecJanFebMar</p><p>Trajectory35%40%45%50%55%70%75%80%82%84%85%</p><p>Actual31%41%35%41%50%58%68%63%64%83%</p><p>Sheet1</p><p>Trajectory</p><p>Actual</p><p>Sheet2</p><p>Sheet3</p></li><li><p>TIAWeekend servicesOne month follow-upPsychological supportCare homesReviewsCarer support7/7 and 45 minutetherapyJoint Care PlanningCurrent SIP Project-Based WorkAccess to carotid interventionPatient</p></li><li><p>Community Stroke resource 11 different sections aligned with QM10 and includes Meeting needs of BME population, joint commissioning, using ASSET, tariff, stroke skilled workforce, developing community based activitiesExamples of services long term support, building independence, targeted interventions, new technologies, peer support activities, continence, relationships19 different models of ESD/Community services, with information about staffing, models, outcomes, and populations covered Linked with QM19 Workforce, QM3 Information advice and support,QM4 Involving individuals in developing services, QM12 seamless TOC, QM13 long term support, QM15 participation in community life, QM20 research and audit</p></li><li><p>Working with in 2011/12</p><p>*LWP = Less Well Performing</p><p>This review looks at the 'pathway' of care experienced by people who have had a stroke (or a 'mini-stroke', called a transient ischemic attack) and their carers. It starts from the point people prepare to leave hospital to the long-term care and support people may need to cope with stroke-related disabilities. It looks at both health and adult social care, as well as links to other relevant services, such as local support groups and services to help people participate in community life. The review aims to promote improvement by assessing local services, publishing data, and highlighting key national issues.</p><p>Data and provisional local assessment results were sent to lead contacts for checking (ratification) on 15 October 2010, and CQC has been assessing issues which have been raised. Lead contacts will be notified during week commencing 29 November 2010 of any changes to results arising from ratification.</p><p>Final local assessment scores, data and a national report will be published on the CQC website on 12 January 2011. CQC are discussing with the Stroke Improvement Programme how to ensure that action is taken locally to address issues identified by the review.Overall found a lot of variation patchy picture across Englandmany good services, where most elements set out in the (10 year) National Stroke Strategy are already in placebut many other areas where there has been limited progress in community based stroke care and with a lot to learn</p><p>***</p></li></ul>