going up a gear: practical steps to improve stroke care

Stroke Improvement Programme

Going up a gear:practical steps to improve stroke care

NHSNHS Improvement

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Foreword

Introduction

Joining up prevention

Implementing best practice in acute care

Post hospital support and long term care

Sustainability

Measuring for improvement

Resources and contacts

Contents

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Going up a gear: practical steps to improve stroke care | 3

Foreword

We are at an important milestone inthe implementation of the NationalStroke Strategy.

This publication, Going up a gear, is achance for all of us to learn from theprojects which were launched inMarch 2009. It is a testament to thecontribution the teams have madelocally and the product of a lot ofhard work. You will no doubtrecognise many of the issues theyfaced, and we hope you will be ableto use their solutions as you arecontinuing to develop your ownservices.

All those involved in stroke serviceshave been making great strides toimprove care since the publication ofthe Strategy in 2007. Thiscontribution of many individuals andteams across the country is starting toshow results for people who have astroke in England, as the NationalAudit Office recognised in theirreport, Progress in improving strokecare, published earlier this year.

But they also reminded us that thereis much to do, particularly to supportpeople to live long term with theconsequences of their stroke. That iswhy earlier this year we launched theAccelerating Stroke Improvementprogramme, to go further, faster inimproving stroke services with theadditional support and toolsavailable, to sustain improvementinto the future.

We can all agree that excellent strokecare is our main goal. Going up agear, has been designed to help youin meeting that challenge.

Professor Roger Boyle CBENational Clinical Director for HeartDisease and StrokeDepartment of Health

Dr Damian JenkinsonNational Clinical LeadNHS Stroke Improvement Programme

www.improvement.nhs.uk/stroke

Professor Roger Boyle CBENational Director for Heart Diseaseand Stroke, Department of Health

Dr Damian JenkinsonNational Clinical Lead, NHS StrokeImprovement Programme

4 | Going up a gear: practical steps to improve stroke care

Introduction

The Stroke Improvement Programmeworked with 37 project sites in2009/10 on implementing theNational Stroke Strategy.1 Theprojects aimed to help clinical teamsimprove their service and to generatelearning to benefit others. Projectswere grouped into four areas, basedon sections of the strategy:

• Transient Ischaemic Attack (TIA)services

• Acute care• Transfer of care• Rehabilitation

Key themes and learning have beendrawn from the projects and othersites around the country. ‘Top tips’have emerged which will help othersas they also make improvements totheir stroke services.

More detail and contact informationis available in the accompanyingpublications, Case studies from theStroke Improvement Programmeprojects.

Additional learning has been drawnfrom the projects investigating thedetection and treatment of atrialfibrillation.

Accelerating Stroke ImprovementAccelerating Stroke Improvement is adrive to rapidly improve strokeservices in 2010/11. The systems andstructures are in place to provideleadership, guidance and support aprogramme of work to go further,faster in improving stroke services inthis year. The three main areas offocus are:

• Joining up prevention• Implementing best practice inacute care

• Improving post hospital and longterm care

The programme is aboutsystematically taking stock of whathas been achieved so far in improvingstroke services and assessing whatelse needs to be addressed, includinglong term care. This means buildingon existing plans, mapping out whatcan be achieved this year with theadditional support and tools availableand how this can be sustained andextended into the future so thateveryone gets the right treatment, inthe right place, at the right time

Learning from the projects has beenorganised to support this new focus.


How to use this documentThe suggestions, experiences andexamples provided in this documentare intended to generate ideas, toshow what is possible when teamswork constructively together and toguide planning for improvementactivities.

The Stroke Improvement Programmecontinuously publishes materials tohelp those striving to improve strokeand TIA services. Resources andmaterials will be made available thisyear to support the AcceleratingStroke Improvement programmework. New materials will beadvertised in the StrokeImprovement e-bulletin and will beavailable on the Stroke ImprovementProgramme website at:www.improvement.nhs.uk/stroke

1National Stroke Strategy, Department of Health, 2007.


Joining up prevention

Joining up prevention includesinformation on stroke preventionthrough better identification andtreatment of both atrial fibrillation(AF) and transient ischaemic attack(TIA).

Both these approaches are essentialto realise the ambitions of theNational Stroke Strategy under‘Managing Risk’ (quality marker 2)and ‘TIA and minor stroke’ (qualitymarkers 5 and 6). Chapter eight ofthe National Service Framework onCoronary Heart Disease also set outthe quality requirements for theprevention and treatment of patientswith cardiac arrhythmias.2

Atrial fibrillation: detectionand treatmentAtrial fibrillation (AF) is the mostcommon sustained dysrhythmia,affecting at least 600,000 (1.2%)people in England alone. It is also amajor cause of stroke with 16,000strokes annually in patients with AF,of which approximately 12,500 arethought to be directly attributable toAF. It is also an eminentlypreventable cause of stroke with asimple highly effective treatment;with warfarin known to reduce riskby 50-70%.

The first phase of 18 projects wereestablished in October 2007 andcompleted April 2009. Workingacross 15 networks, with PCTs,general practices, Practice BasedConsortia and acute trusts, theypiloted a range of approaches toimprove detection and optimaltreatment of patients with AF inprimary care, to reduce risk of stroke.


TOP TIPS

• Detect AF though opportunisticscreening e.g. at annual fluclinics

• Consider local enhanced serviceschemes for detection, screeningand review of AF

• Develop new models foranticoagulation services inprimary and community settings

• Develop tools to support thereview of patients with AF, to riskstratify for stroke and optimaltherapy

• Develop guidelines for primary tosecondary care referral

• Educate both professionals andpatients on:• pulse palpation• barriers to anti-coagulation inprimary care

• ECG training and interpretation• AF as a major risk factor forstroke.

The Stroke Improvement Programmepublications that provide a summaryand overview of the outcomes fromthis first phase are listed in theResources section.

Quality and productivity agendaThe opportunity to provide costeffective high quality care to preventavoidable mortality and morbidity hasbeen recognised as one of six keyrecommended interventions underthe national quality and productivityagenda, details of which can beaccessed at NHS Evidence.3

Driving forwardA further stage of this work began inOctober 2009 with nine healthcommunities, led by the Heart andStroke Improvement Programmes.Building on the evidenced basedlearning, resources and demonstrableoutcomes from the first phase, theyaim to embed the identification,diagnosis and optimal therapy forpatients with AF to significantlyreduce risk of stroke.

2National Framework for Coronary HeartDisease; Arrhythmias and Sudden CardiacDeath, Department of Health, March 2009.

3See: www.library.nhs.uk/qualityandproductivity

In pushing forward the challenge tojoin up prevention, some teams areworking across the whole primaryand secondary care pathway tounderstand the issues and improvethe management and outcomes forstroke and TIA patients with AF.

The learning, evidence and outcomesfrom this phase of work will bepublished later this year.

Timely and effectivetreatment of TIAThe Stroke Improvement Programmeworked with 10 sites from March2009 to test implementation ofquality markers 5 and 6 of theNational Stroke Strategy and tocontribute to national learning.

Key themes and learning have beendrawn from the projects and othersites around the country. Much ofthe work this year has concentratedon the ‘front end’ of the TIApathway, ensuring prompt access toeffective diagnosis and treatment.The following points aim to identifythe changes that will make thebiggest difference to services.

More detail is available in theaccompanying publication, Joining upprevention: case studies from theStroke Improvement Programmeprojects.

Clearly define a pathway for highand low risk patients, agreedacross primary and secondary careA clear pathway is essential to ensurepatients are referred and treated onthe right pathway from initial referral.The pathway will differ according tolocal catchment populations andgeography, staffing and access toimaging. Different models areemerging across the country.

NHS Doncaster: after reviewing,mapping and redesigning theirpathway, the team in Doncaster wereable to introduce a new service thatprovides:• rapid access next day clinic, fromreferral to being seen in clinic, forall patients

• same day carotid doppler, ECG andechocardiogram and brain imaging

• same day diagnosis• immediate preventive treatment• same day clinic vascular surgeryreview and listing for theatre

• rapid communication of results tothe patient and the GP

This has removed between 21 and 41days from the original pathway ofcare.

Streamline the referral route withsingle point of contact for highand low riskIt is crucial to streamline the referralprocess to ensure patients quickly geton the correct pathway. A singlecontact point for all TIA patientssimplifies the referral process and ismore efficient for co-ordinating theservice, enabling efficient use ofappointments and facilitating the 24hour requirement for high riskpatients. Data collection can alsobegin at one entry point.

It requires standardised referralproformas that are appropriate to thereferrer, highlight the pathway, givean aid to diagnosis (such as theABCD2 score) and include informationto be given to patients.

Some providers are operating oraiming for one queue for high andlow risk patients. Early results indicatethat once demand and capacity are inbalance, and a seven day service inplace, this is possible. This makes lifeeasier for everyone, especiallyreferrers, and protects lower riskpatients that turn out to be high risk.

Surrey and Sussex HealthcareNHS Trust created a single bleepholder to take all calls. GPs found itvery helpful, confirming that thisaccess is exactly what they want.Consultants were reassured that it didnot translate into an unmanageablenumber of calls.

North Bristol NHS Trust appointeda TIA co-ordinator as a single point ofreferral to ensure timely and efficientbooking of patients according toABCD2 prioritisation.



TOP TIPS• Clearly define a pathway forhigh and low risk patients,agreed across primary andsecondary care

• Streamline the referral route withsingle point of contact for highand low risk

• Employ a comprehensivecommunication strategy

• Establish a sustainable data andaudit system

• Tailor the weekend service tolocal needs and demand

• Think differently about how andwhere TIA clinics are provided

TOP TIPS



North West London Cardiac andStroke Network created newreferral forms outlining the approvedprotocols and out of hours service forTIA referral, having gained consensusfrom clinical teams in each hospital.Separate forms were made for A&Edepartments and GPs in every formatlikely to be used by GP databases(e.g. EMIS, Vision, Word etc. Bothforms included an aid to diagnosisincluding ABCD2 score) and contactdetails for TIA clinics for bothweekdays and out of hours.

Lancashire Teaching HospitalsNHS Foundation Trust established aunified single point of access, with aninitial telephone call to the acutestroke unit, for high and lower riskTIA patients. This was used fromOctober 2009 to improve GP accessand minimised the time from thepatient presenting to the GP to clinicreview.

Employ a comprehensivecommunication strategyAn explicit communication strategy,covering awareness, education andtraining, will provide benefits forthose experiencing TIA through:• supporting implementation on thepathway and ensuring patientsenter the right pathway of care assoon as possible

• raising awareness in primary care,the ambulance service, A&E andany other referral points in the TIApathway

• emphasising and reinforcing theimportance of early referral

• enabling education in the ABCD2

score ensuring appropriate referralsand effective triage

• highlighting the need for clearpatient information and supportingits provision

North West London Cardiac andStroke Network created acommunications plan to launch thenew referral forms to GPs, A&Edepartments and all interestedparties. It included comprehensiveinformation for services, clearlydefining what information wasneeded by whom, and givingpractical advice and examples of howto do this.

To ensure the new referral formsreached everyone and increase thelikelihood of their adoption:• the network sent emails to all GPsacross north west London,explaining the new referral forms.The clinical contracts lead for eachPCT forwarded emails to GPs andincluded a link to dedicated webpages on the network website

• dedicated web pages were created,including downloadable versions ofall forms and information regardingaids to diagnosis and use of referralforms

• printed copies of the forms weresent to every practice manager,including pens inscribed with theweb address of the dedicated TIAwebpage to further publicise thesite

• stroke consultants at each trusttrained their A&E departments onuse of forms

Data collection is under way but earlyindications show that the use of newreferral forms in A&E departments isnow in excess of 80% and the use ofnew referral forms by GPs, althoughvariable, is increasing month bymonth and has reached 60% in oneunit. Hits on the network’s websiteincreased by 20%.

North Bristol NHS Trust, with theUniversity of the West of England,developed an online training modulefor ABCD2 assessment for all GPsand Great Western AmbulanceService staff.

Establish a sustainable data andaudit systemAccurate data collection is vital tounderstanding the pathway andwhere improvement needs to beconcentrated. It enables:• an understanding of the currentposition and monitoring, on anongoing basis to create asustainable service

• an understanding of the service atall points along the pathway,identifying bottlenecks

• regular audit of referrals withfeedback to primary care A&E andambulance services

• ongoing review of demand andcapacity, which has been essentialfor these new services as projectsnoticed that demand changed asthe referral system and the use ofABCD2 was refined and thepathway embedded

Surrey and Sussex Healthcare NHSTrust created an electronic audit toolto standardise note-keeping, lettersto GPs and gather audit data thatwas reliable and easy to analyse.They have since achieved a figure of66% of high risk patients with TIAseen and treated in 24 hours.

North West London Cardiac andStroke Network created a datatemplate for use within TIA clinics tocollect baseline data, assess the useof referral forms, measure referringpatterns and report on the vital sign.Data was accepted in whateverformat was convenient, andassistance offered by the network tofacilitate collection.



Tailor the weekend service tolocal needs and demandWork to date indicates that it is likelythat only large centres will be able tosustain an independent weekendservice. Accurate demand for theweekend service will only beapparent once the pathway isestablished and all referrers are usingit. Many services are reporting lowernumbers than expected at weekends,and it is not yet clear whether this is atrue reflection or because referrersare unaware of the service available.Further work will be undertaken onthis over the coming year to try toestablish the optimal population basefor a viable weekend service.

Different approaches to weekendservices are developing, typicallybased on cooperation betweenservices within the same network.These include:• hyper-acute stroke centresproviding a weekend service basedon the agreements in place forthrombolysis cover

• rotating service provision atweekends within multi-site trusts

• partnering with neighbouring trustswhere one trust operates atweekends or the lead trust rotates

The University Hospitals ofLeicester NHS Trust has establisheda seven day service, agreed with thePCT with a locally negotiated tariff,using this structure:• consultant-led clinic• Saturday and Sunday: one Band 6nurse, one clinical aide or clinicclerk

• specialist registrars help whenavailable

• morning attendance• carotid ultrasound screening from10am to 12.30pm

• MRI available 11am to 2.30pm (fiveslots), CT at weekends (five slots)

• consultant review from1pmonwards

The service has moved from fullassessment of three to four patientsper week to up to seven per day, andare now assessing 66% of high riskTIA patients within the 24 hourwindow.

North West London Cardiac andStroke Network developed an outof hours, 24 hour TIA service for highrisk referrals. The Monday to FridayTIA service is based in six hospitals innorth west London; the weekendservice is based at the two hyper-acute units, making efficient use ofthe staff and facilities available.

Rather than replicate a traditionalface-to-face outpatient clinic serviceat weekends Royal Devon andExeter NHS Foundation Trustdecided to investigate using strokenurse practitioners to perform carotidultrasound screening, to address theissue of appropriate urgent imagingand screening during weekend andbank holiday periods. The strokenurse practitioners cover the hospitalseven days a week, 7.30am to 8pm,providing a potentially cost effectivesolution to providing a weekendservice.

Think differently about how andwhere TIA clinics are providedServices are acknowledging that ‘onesize doesn’t fit all’ necessarily, and aredeveloping more imaginative modelsthan standard out-patient clinics.These include:• basing TIA clinics in the acutestroke unit

• using medical assessment units orequivalent facilities open 24 hoursa day

• providing a mobile service in ruralareas where travelling is difficult orlengthy for patients

• developing paramedic assessmentand triage

In Surrey and Sussex HealthcareNHS Trust the Acute Medical Unitdeliver the TIA service, operating eachday Monday to Friday for all patientsreferred the previous day with TIA(including low and high risk patients).Using the acute medical unit hasensured that the acute medical teamshave an excellent operationalknowledge of TIA and stroke andtherefore manage the patients in amuch more effective way.

Cornwall and the Isles of ScillyPCT operated with a daily mobilemultidisciplinary team (whichincluded a stroke doctor, a vasculartechnician with portable doppler, thestroke co-ordinator, and a clinicnurse) running a clinic across fivesites. They moved from a 90 daywait to an average 24 hour wait formedium to high risk patients, and a48 hour wait for low risk patients.They have seen 35 patients weekly,from five to ten per week previously,and reduced the wait for carotidendarterectomy to seven days.

The Royal Bournemouth andChristchurch Hospital NHSFoundation Trust, with SouthWestern Ambulance Service, haveset up a referral pathway allowingopen-access for GPs, emergencydepartment staff and paramedics. Aneducation leaflet was developed forparamedics, so that they couldundertake the triage and refersuspected TIA patients to the clinic.



ImagingMeeting the imaging requirements ofthe National Stroke Strategy is asignificant challenge for manyorganisations. Key suggestions fromthe projects include:• review scanning capacity regularlyas it will change as the service ispublicised and referrals refined

• consider carotid imaging with MRAat weekends if an MR scanner isalready in operation

• consider nurse training in carotidultrasound screening

The NHS Improvement Diagnosticsteam have been working with sitesinvolved in projects to review theissues in imaging for TIA. Furtherinformation on the review by theDiagnostics Team is available onthe Stroke ImprovementProgramme web site at:www.improvement.nhs.uk/stroke

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Patient seeks aGP appointment Patient calls 999

Patient is seen and assessedas presumptive TIA/minor stroke

GP refers to outpatient clinic

Clinic receives referral and booksappointment for the patient

Clinic receives referral and contactspatient directly to make same/

next working day appointment

Tests are done Tests are done

Ambulance clinician, nurseor out-of-hours GP referrs

direct to TIA clinic

Patient is seen and assessedas presumptive TIA/minor stroke

HIGH RISKADMISSION

Figure 1: Before and after TIA referral pathways in Bournemouth



Quality markers 7, 8 and 9 in theNational Stroke Strategy define thekey components of effective acutestroke care. It is clear what needs tobe done for those experiencing stroketo guarantee best outcomes, andhow the health care system needs toorganise itself to provide the bestservice for patients.

Ten projects worked with the StokeImprovement Programme to explorehow to improve the care they providefor their patients. Together withlearning from three rehabilitationprojects, their experience has led tothe identification of the some keyactions.

More detail is available in theaccompanying publication,Implementing best practice in acutecare: case studies from the StrokeImprovement Programme projects.

Protect stroke unit bedsKey to achieving effective andprompt treatment of stroke isensuring that patients are cared for ina properly staffed and skilled strokeunit. When this happens, strokepatients receive optimal care,resulting in improved outcomes and ashorter length of stay in hospital.

Bed availability can be a barrier tothis, often due to the use of strokeunit beds for people who have nothad a stroke. Bed managementpolicies that ensure stroke patientscan be admitted straight onto theunit are essential. Successfullyprotecting stroke beds, through

various tactics and agreements, willensure that stroke patients are morelikely to get the necessary care. Oneapproach is to apply the modeldeveloped by cardiac services, whereheart attack treatment is accepted asa clinical priority and consequentlycardiac beds are protected.

Royal United Hospital, Bath initiallyundertook bed modelling work whichshowed a lack of beds, shared on anintegrated ward with neurology. Thestroke and neurology services wereseparated into two ward areas to giveeach specialty its own clear identity.Left with a 28 bed ward, the teamconverted one bed area (from sixbeds to four) into a hyper-acutestroke unit, ensuring the 26dedicated stroke beds needed.

The team got agreement for theacute stroke unit to have the samebed and site management principlesas the cardiac unit. Every day at thesite meeting, the availability of anacute stroke unit bed is checked inthe same way as for a cardiac bed,and as soon as a stroke patient isadmitted to the unit, bedmanagement prioritise clearinganother bed.

Implementing best practice in acute care

TOP TIPS

• Protect stroke unit beds• Actively cooperate with the restof the hospital

• Develop a flexible, stroke skilledworkforce

• Work with stroke survivors andcarers

• Build an active partnership withA&E

• Work with the ambulanceservice

• Move to six days a weekworking for therapy services



This has raised the stroke unit’sprofile within the trust, boostedmorale for staff working on the unit,and given a clear mandate to geareverything about the ward aroundproviding the best stroke care. By thethird week of direct admissions, thelength of stay had reduced from 18to 5.5 days.

Queens Hospital NHS FoundationTrust linked in with the hospitalemergency pathway redesign tomake sure the acute stroke unit wasincluded in daily operations meetingsand bed allocation ensured strokeunits beds were for people who havehad a stroke. A stroke unit admissionprotocol was written and agreed.

Patients are identified by bedmanagement earlier and are allocatedto the stroke unit quicker.Communication between cliniciansand capacity management is muchimproved. The percentage of patientsspending 90% of their stay in astroke unit is now 89% as of April2010 (up from 71%).

Milton Keynes Hospital NHSFoundation Trust agreed the needfor a fast track bed with the acutestroke unit clinicians, the bedmanagement team and the divisionalmanager to enable timely transferfrom A&E and the clinical decisionunit (CDU). The use of the bed ismonitored and reported weekly. Highbed pressures in the Trust remove theeffectiveness of the bed.

A bed management protocol forstroke patients was implemented toensure stroke patients identified inA&E or CDU do not transfer toanother ward. The protocol wasshared around the trust to ensuremembers of staff across all levelsidentify the urgency of transferring apatient to the acute stroke unit.

This was also communicated throughscreensavers and posters around thehospital to ensure stroke patients arereferred to the stroke unit.

The Trust met the SHA goal of 70%of stroke patients spending 90% oftheir time in hospital on a specialiststroke unit.

Poole Hospitals NHS FoundationTrust have developed an ‘assessmenttrolley’ on the acute stroke unit tospeed up assessment processes bythe stroke team for suspected strokepatients not likely to benefit fromthrombolysis, and assist admissiondirectly to the stroke unit for optimalcare.

This led to an increase in directadmissions to the stroke unit - up to63% from 54% at the start of theproject, and a dramatic increase inpatients reaching the stroke unitwithin four hours of arrival, up to76% from 54%. Patients who aremanaged via the assessment trolleyhave higher quality of care – they areassessed quicker, scanned quickerand treatment is started earlier thanthose not admitted via this route.

Similarly, the team in Sandwell andWest Birmingham Hospitals NHSTrust negotiated an agreement withmanagers, including bed managers,that there would always be a bedavailable on the stroke unit. Anydelays in A&E were escalated up tothe on call manager. To overcomedata collection problems in trackingthis, an audit clerk was employed tocollect times of admission to A&E andthe stroke unit and this data isreviewed weekly with seniormanagement.

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Figure 2: Patients spending 90% of their time inan acute stroke unit in Milton Keynes



Bed management was improved inSurrey and Sussex Healthcare NHSTrust through a fast-track bed policy,now in operation 24 hours a day,which uses a system of identifyingpatients that can be moved from theacute stroke unit to a ‘fast track’ bed.Additionally, a daily bed status formwas developed to identify delaysto discharge, patients awaitingrepatriation in and transfer out ofthe acute stroke unit for ongoingrehabilitation or care homeplacement. The form is presented atthe daily bed meeting, and copies ofthe forms are kept for audit purposesand have been used to monitor thenumber of stroke outliers. Throughthis and other measures, directadmissions to the acute stroke unithave gone from 7% at the start ofthe project to 60%, and 67% ofpatients are spending the majority oftheir time on the stroke unitcompared to a baseline of 33%.

Through promoting stroke services tohave equal status with urgentspecialist services such as cardiology,the team inWorcestershire AcuteHospitals NHS Trust raised theprofile of stroke management andcare within the organisation. This ledto agreement to ring-fence beds onacute stroke units countywide, andthree additional acute stroke bedsopened on the site in August 2009.As a consequence, access to thestroke unit and the proportion oftime spent on the unit has beenincreasing month by month.

Actively cooperate with the restof the hospitalTo enable the stroke unit to functioneffectively, it must cooperate withother services in the hospital.Problems have arisen in the past dueto a lack of understanding of theimportance of the clinical functions ofthe stroke unit and the necessaryurgency of scanning and transfer ofpatients to the stroke unit. As aconsequence, stroke patients are nottreated appropriately and promptly,services such as scanning notperformed quickly enough, andpatient experience and outcomessuffer.

To combat this, many acute strokeunit teams have recognised thebenefit of actively buildingrelationships with other parts of thehospital, e.g. A&E, radiology andmedical admissions units, to promotethe effective pathway for strokepatients. Better cooperation leads tomore coordinated transfer of care foreach patient, and avoids mistakesand delays due to misunderstandingand poor communication. It providessubtle education for other clinical andmanagerial staff, and can have theadditional benefit of improving theability to care for stroke patients wellin non-specialist services whenattending for other clinical reasons –a frequent complaint from peoplewho have had a stroke and carers.

Royal United Hospital, Bathdeveloped strong links with A&E,radiology and the older people’s unitto expand thrombolysis to provide 24hour cover. Patients are nowadmitted directly from A&E to theacute stroke unit, bypassing themedical assessment unit and otherwards.

The Nottingham UniversityHospital NHS Trust project wascalled DASH – Direct Access to StrokeHyper-acute Unit. As the projectwould involve other hospitaldepartments, it was felt important toengage as many stakeholders aspossible in order to gain commitmentto progress. This ensured the projecthad the support and sponsorship ofthe trust chief executive, along withclinical and medical directors.

Poole Hospitals NHS FoundationTrust improved their links with otherservices through process mapping theacute stroke patient pathway withclinicians from all teams involved withthe patient, including ambulanceteams, A&E, radiography, radiology,stroke unit, bed management, andthe high dependency unit. This led toa new patient pathway being agreedby all teams, covering from hospitalarrival to completion ofmultidisciplinary assessments. Thishelped teams minimise unnecessarydelays for patients being admittedwith stroke and ensured a safe butspeedy pathway for thrombolysispatients (in and out of hours).

Process mapping helped the staffinvolved along the patient pathwaybetter understand the patient journeyand the impact of their performanceon overall patient outcomes andpatient and carer experiences. It alsohelped build relationships betweendifferent departments andorganisations which have beeninvaluable in making changeshappen.



Sandwell and West BirminghamHospitals NHS Trust has a monthlystroke action group withrepresentation from all departments.There is a weekly review of thepatient’s pathway and an ongoingmonitoring system that highlights thepatients that do not spend 90% oftheir time on a stroke unit, whichallows the pathway to be monitoredand data to be validated easily.

Develop a flexible, strokeskilled workforceA key principle of the National StrokeStrategy is to ensure that there is anappropriately stroke skilled workforceto meet the needs of patients. Strokeservices generally function inmultidisciplinary teams and this is animportant factor in tackling problemsand bottlenecks than can arisethrough shortages of staff in keyareas.

Providing stroke team staff withnecessary skills and competencies,even if outside of traditional roles(e.g. speech and language therapystaff training non-speech andlanguage therapy colleagues inswallowing screening) can provide amuch needed additional flexibility tothe team.

When done well, this approach canimprove staff satisfaction throughdevelopment of roles. The StrokeSpecific Educational Framework isdesigned to help this process byproviding a clear and structureddescription of patient need andassociated clinical skills.4

Milton Keynes Hospital NHSFoundation Trust developed anintegrated multidisciplinary team carerecord, a collaborative record of eachprofession’s contribution to apatient’s care throughout their stayon the acute stroke unit. It sets outguidelines for good practice based onthe National Stroke Strategy or NICEguidelines and is used to set goals forthe patients to aid care planning ofthe patient during the weeklymultidisciplinary meetings.

The team from Poole Hospitals NHSFoundation Trust undertook severaltraining and staff developmentinitiatives to improve care, including:• agreeing a protocol for the seniornurse practitioner to request a brainscan (CT), speeding up scanrequests so that now 78% ofeligible patients receive a brain scanwithin 24 hours of arrival athospital compared to 65% at thestart of the project

• training acute stroke unit staffnurses and stroke medical staff togain competency in swallow screenafter stroke, resulting in 89% ofpatients now receiving a swallowassessment within 24 hours ofadmission compared to 50% at thestart of the project

• establishing a Patient GroupDirective for aspirin to assistdelivery to appropriate patientswithin 24 hours of admission.Consequently, the percentage ofpatients receiving aspirin within24 hours of admission has gonefrom 23% to 63%

In Yeovil District Hospital NHSFoundation Trust, recent changes tothe thrombolysis service, extended to8am to 11pm Monday to Friday, hasresulted in all medical registrars beingtrained in the NIHSS and acutemanagement of stroke. As a direct

consequence, all stroke patients havebenefited from greater stroke-specificknowledge by the staff caring forthem. All qualified nursing staff alsohave received individual teachingfrom the stroke lead for thedepartment which has also impactedon clinical care.

The Aintree University HospitalsNHS Foundation Trust teamundertook a mapping exercise,involving representatives from all keystaff impacting on the unit and,combined with the views of patientsand carers, identified issues forimprovement. This process in itselfhas meant the team have developeda mutual understanding and respect,good foundations for developing realmultidisciplinary team working.Communication within the team hasimproved, the occupational therapistsattend the daily nursing handoverand occupational therapy andphysiotherapy staff actively use andupdate the nursing electronichandover. The team is working onhow nurses can support thetherapists work through teaching andeducation within the multidisciplinaryteam.

Six day working in York HospitalsNHS Foundation Trust and NHSMedway has led to a different workenvironment. During the pilot,feedback indicated that therapists aremore accessible to relatives and carersas they tend to be more able to visitat weekends and consequently, ableto attend therapy sessions. Nursingstaff are often more available atweekends to observe or support thetherapy sessions, providing a usefuleducation opportunity, assisted withtransfer of information across themultidisciplinary team and supportedcarry over of therapeutic treatments.

4Stroke-specific education framework,Department of Health, April 2009.



Work with stroke survivors andcarersClinical teams working with those forwhom their service is provided, toproperly understand patient needsand how best to meet them, is afundamental principle of effectiveimprovement work.

Through systematic and effectivegathering and analysis of patientviews and experiences, teams can:• ensure that they are providing thekey aspects of care that patientsand carers require

• develop insight into the patient andcarer perspective to guidedevelopment and planning

• improve outcomes through givingpatients and carers a sense ofinvolvement and partnership inmanagement of the service and oftheir own care

• enhance staff satisfaction• create more responsive and patientcentred services

The cognitive and communicationimpairments that can result fromstroke make the gathering of patientviewpoints more complex than insome other areas, but can beaddressed.

Royal United Hospital, Bathundertook patient focus groups withthe help of The Stroke Association,and the main theme to emerge waspoor patient experiences on themedical assessment unit, onoccasions when this took several daysfor them to be transferred to thestroke unit. This both informed andstrengthened the case for directadmission to the acute stroke unit.

In Nottingham University HospitalNHS Trust, both clinical and nonclinical members of the stroke teamengaged in ‘walking the patientpathway’. A number of problems

were highlighted, which could beeasily and rapidly addressed. Forexample, in A&E, staff had only thegeneral ward phone numberdisplayed, not the emergencynumber, despite it being included onthe A&E stroke pathway poster.

Aintree University Hospitals NHSFoundation Trust undertook a seriesof questionnaires and consultationswith staff, patients and carers,including a patient observation study.This enabled the team to have a verydifferent perspective on ‘life inrehabilitation.’ Feedback frompatients showed that there wereperiods of boredom, particularly inthe afternoons, and that mostpatients did not even know that aday room existed. From a staffperspective, much of the day isplanned around getting patients upand dressed, accessing medical tests,or being ready for therapy,medication and mealtimes, with littletime for considering much else.

Staff are now more confident aroundthe process of patient and carerengagement. The team have agreedon a plan to improve the access to,and use of, the day room and areconsidering the reintroduction ofcommunal eating on the wards, toreduce isolation and boredom and toprovide therapeutic opportunities.Plans are also in progress for thedevelopment of information forpatients and carers, a stroke staffnewsletter and focus groups to lookat the other issues flagged up fromthe project work around dischargeplanning and the admission processto the unit.

When the NHS Medway projectteam were planning the move to aweekend rehabilitation service, theyreceived the overwhelming messageof support from patients on the acute

ward, as most expressed a wish formore therapy. Carers also felt itwould give them more opportunity tomeet with therapy staff. This is incontrast to views of patients usingthe community service, who by thenfelt weekend therapy would beintrusive to family time.

Build an active partnershipwith A&EAn effective and cooperativerelationship with A&E services iscentral to acute stroke care, andfundamental to two main areas ofessential clinical care - prompt arrivalon a stroke unit and spending themajority of time under its care.

Acute stroke services that havedeveloped and formalised workingpractices with A&E colleagues haveseen their patients benefit fromearlier diagnosis and prompttreatment, and enhanced the abilityof A&E services to manage strokepatients.

This has included:• discussing, mapping andredesigning the pathway of carebetween A&E and the acute strokeunit

• procedures for ‘alert calls’ to thestroke unit when a suspectedstroke patient is due to arrive

• developing the skills of nominatedindividuals within the A&E team asa stroke liaison post

• clear protocols to avoid strokepatients being admitted to medicaladmission units or clinical decisionservices

Royal United Hospital, Bath hascontinued to develop strong links toA&E, to support the delivery ofthrombolysis, but also so thatpatients are now admitted directlyfrom A&E to the acute stroke unit.



In Queens Hospital NHSFoundation Trust, the project hasraised the profile of the stroke servicewithin the hospital. Where once moststroke patients were admitted to theemergency admissions unit for atleast 24 hours and transferred to thestroke unit later, staff now recognisethe importance of the stroke pathwayand the benefits of thrombolysis.More patients are being assessed forsuitability for thrombolysis and thestroke service has joined the IST-3research trial.5

In Sandwell and West BirminghamHospitals NHS Trust stroke unit staffworked with the A&E generalmanager and the stroke co-ordinatorto reinforce new pathways with thestaff in A&E and the on call team.There was confusion, so a pathwaywas developed on an A4 sheet for allsuspected stroke patients to bedirectly transferred to the stroke unit.This was circulated to all A&Edoctors, nurses and the radiologydepartment and laminated anddisplayed in all departments. Thispathway clarified who wasresponsible and what to do when asuspected stroke came to A&E.Scanning times were reduced to fourhours.

In Yeovil District Hospital NHSFoundation Trust a key limitation inenabling patients to be accuratelyassessed and admitted to the strokeunit was poor early assessment withinA&E. This was solved througheducation of medical and nursingstaff and ensuring an accuratepathway. Redeployment of resourceswithin the stroke team also enabledthe appointment of a Band 6 strokeand neuro lead junior sister within

A&E. With a respected member ofthe existing nursing team to act as anadvocate for stroke, address thetraining needs and support thedevelopment of protocols to embedthe change in practice, there hasbeen a dramatic improvement in theperception of the stroke patientwithin the department and theprocesses required for quick triagingafter arrival in A&E.

Work with the ambulance serviceAmbulance services are the first lineof effective stroke care. It is crucialwhere a network approach to thedelivery of thrombolysis is in place sothat patients travel to the righthospital, quickly. They have excellentknowledge of the issues in movingpatients round the local patch. Closerworking can help tackle problems,such as ensuring the right type ofvehicle, i.e. one which is able tosafely transport the patient, is sent tosuspected stroke cases.

In Nottingham University HospitalNHS Trust a communication wassent to all GPs informing them tocontact the stroke unit directly if theyassessed a patient with strokesymptoms, and asked that the call tothe East Midlands Ambulance Serviceshould include the instructions for anemergency ambulance, a four wheelvehicle with a two manned crew, andnot a routine admission.

To ensure that ambulance crews werefully informed of changes whichwould affect the stroke pathway,work was undertaken with themanagers of the ambulance serviceto produce bulletins containing thedirect access policy, but moreimportantly, the direct phone numberfor the telephone on the stroke unit,known by all as ‘the Bat Phone’.

A new ring tone and flashing lightwas installed to alert the stroke unitteam to the emergency responserequired. This new phone andnumber would alert staff on the wardimmediately that a patient was goingto be transferred, giving them theopportunity to triage, and then giveadvice to the crew on where to takethe patient. This action changed thepathway for the patient almostimmediately, with everyoneconcerned fully aware of where thepatient was to be sent and whatwould happen next. There was areduction in delays in transfer, and adecrease in the number of patientsbeing admitted via A&E.

Poole Hospitals NHS FoundationTrust set up an ambulance pre-alertsystem to ensure A&E, the stroketeam and other key staff were awareof potential thrombolysis patients enroute, assisting speed of response onarrival.

Move to six day a week workingfor therapy servicesTwo project sites in Medway and Yorktested the provision of a six daytherapy service and evaluated itseffect on patient experience, accessto services and flow.

Often services experience abottleneck every Monday whentherapy staff have a backlog ofassessments accrued over theweekend. For new patients it meanssome may have waited for 48 hoursto be assessed and commencetreatment, for others skills gainedduring the previous week may nothave been practiced over theweekend, and for staff, theirtreatment time is reduced, as priorityhas to be given to new assessments.

5The Third International Stroke Trial (IST-3) of thrombolysis for acute ischaemic stroke: aninternational multi-centre, randomised, controlled trial to investigate the safety and efficacy oftreatment with intravenous recombinant tissue plasminogen activator (rt-PA) within six hours ofonset of acute ischaemic stroke. For further information, see www.controlled-trials.com



When the project teams analysed thedata after the pilot services andcompared it with the routine services,they were able to determine variousfactors, including how provision of aSaturday service impacted on thenumber of new patients to assess ona Monday, admission to referral time,and access to therapy time forpatients.

NHS Medway evaluated the effectof a six day service on the number ofpatients who needed to be seen on aMonday. They found that movingtowards providing rehabilitation on aSaturday had a limited effect onreducing the bottleneck of newpatients, as in practice this capturedonly those new patients admitted onFriday afternoon or evening. If thesixth day of therapy had beenSunday, patients on Saturday couldalso be assessed, therefore havinggreater impact on the work Mondaymorning.

The project team did however reduceadmission to assessment time from42 hours to 35 hours by moving tosix days a week. There was littledifference between the time toassessment for physiotherapy withthe addition of a Saturday service asthey already met the recognised 72hour standard. However, inoccupational therapy where theywere not delivering the desiredstandard of assessment within fourdays, a one day reduction in accesstime was achieved. There was also animprovement in the time betweenadmission and first contact by aspeech and language therapist.

The team found that six day therapydoes not significantly impact onweekend discharges without otherchanges. However, the data showedthat the six day service did bringforward the date of discharge to anearlier point within the workingweek. On the rehabilitation unit,

there was a 100% increase in thenumber of Friday discharges duringsix day working compared with fivedays.

During the six day working period,bed occupancy rose from 69% to79%. The effect of the additionaltherapy staff on the ward atweekends may impact on decisionmaking by the ward staff and bedmanagers. For example, guiding bedmanagers’ decisions around selectionof patients to move off the ward,

facilitating an unanticipated but safeweekend discharge, preventinginappropriate transfers off the ward,identifying an appropriate strokepatient located elsewhere in thehospital. This also had a beneficialeffect on the trust’s vital sign data.

There was a positive effect with theacute unit length of stay, reducingfrom 8.2 to 5.1 days. On therehabilitation unit, the impact wassignificant, reducing from 33.5 to 22,a reduction of 8.5 days.

100

80

60

40

20

0

Valu

e

Patient1

Patient2

Patient3

Patient4

Patient5

Patient6

Patient7

Patient8

Patient9

Patient10

Patient11

Patient12

Patient13

Patient14

Interval

92 90

19

128

4656

28

1115

47

31

12

Target 56

Mean 33.5

LCL 2

4b

Length of Stay, SRU, 5 Day TherapyUndertaken using less than 25 points

Figure 3: Impact on length of stay in NHS Medway

80

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0

Valu

e

Patient1

Patient2

Patient3

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Interval

65

34

19

1218

57

27

15

510

20 21

9

Target 56

UCL 73.48

Mean 22.06

LCL 0

Value Mean UCL LCL Target

4b

Length of Stay, SRU, 6 Day TherapyUndertaken using less than 25 points

15

3



In York Hospitals NHS FoundationTrust the project team found that50% of their patients accessedphysiotherapy within 48 hours duringthe five day service but when theyprovided a six day service this rose to64%, averaging ½ day reduction inreferral to treatment time forphysiotherapy.

The project team examined the effectof a six day service on access totherapy time. Their baseline dataindicated that on average patientswere seen four times a week forphysiotherapy and occupationaltherapy. Only 63% of patients forwhom it was appropriate received 45minutes or more of either therapy.When a six day service was providedtheir patients were then able toreceive physiotherapy five days aweek, and 90% of them could access45 minutes of occupational therapy.

The baseline length of stay for allstroke patients averaged 47 days,when a six day service was availablethis reduced to 21 days. TheMedway team also found thatalthough the numbers of patientsreturning home did not change, thereis likely to be a link to the reductionin the number of patients requiringcare packages.

Many of the project teams across allof the workstreams refer to theimpact of noro-virus or other hospitalacquired infections on their work.This not only complicated theirimprovement work, but lentadditional importance to their effortsto effectively manage beds for strokepatients.

Table 1: Care package of patients going home from the Medway rehabilitation unit

Audit Period Total numberof carersneeded

Number of patientsneeding carepackage

Number ofpatientsdischarged home

Five day therapy

Average numberof carers perpatient

Percentage ofpatients needingcare package

7 6 20 3.6 85

Six day therapy 8 3 5 1.3 37.5



Since March 2009, the StrokeImprovement Programme has beenrunning projects looking at the keyareas of transfer of care andrehabilitation. This chapter focuses onthe learning to date in those areas.

More detail is available in theaccompanying publication, Posthospital support and long term care:case studies from the StrokeImprovement Programme projects.

Transfer of careThe National Stroke Strategy set aclear standard that individuals shouldhave a discharge plan, covering alltheir needs, both health and socialcare. Nine sites across Englandanalysed their systems for transfer ofcare for people with stroke andfocused their improvements onprocesses influencing this stage ofthe pathway.

Getting transfer of care right has animpact on the whole stroke pathway.The project teams have demonstratedthat improvements to transfer of careprocesses enable more patients toaccess the stroke ward more rapidlyand for longer by creating capacityand improving flow through theward, as well as reducing waitingtimes for community rehabilitationand improving patient and carersatisfaction.

Manage the health and socialcare interfaceAll national project teams whetherled by health or social care expressedconcerns about how to enablemeaningful joint working acrossorganisations. The teams establishedthe key differences in ways ofworking and developed methods toimprove joint working andcommunication:

Understanding national driversfor health and social careSocial care priorities are focused onlong term conditions, personalisedcare, partnership working and carersupport. Key drivers for strokeservices in health are the NationalStroke Strategy and NICE and RCPclinical guidance. Analysis of nationaldrivers helped to establish commonthemes and objectives to align bothwith national and organisationalagendas.

Nottinghamshire County Counciland Nottinghamshire CommunityHealth established a team whichincluded a social care commissionerfrom Nottinghamshire CountyCouncil, a community stroke teamleader from Nottinghamshire NHScommunity health team and TheStroke Association.

Post hospital support and long term care

TOP TIPS

• Manage the health and socialcare interface

• Involve patients in improvingtransfer of care

• Provide emotional support forstroke survivors and carers

• Ensure access to appropriateservices, including rehabilitation,social care and communityopportunities



The project leads from each of theorganisations met regularly anddeveloped shared objectives whichagreed with their organisation’sstrategic objectives. The successfulimplementation and effectiveness ofthis improvement post has supportedthe plan to commission twoadditional family and carer supportservices in the county.

Understanding nationalmeasures of progressStandards in local authorities aremeasured using national indicatorsrather than the activity data andoutcome measures used in health.Investigation of the social carenational indicators demonstrates linkswith the stroke strategy qualitymarkers, e.g. National indicator 131is about delayed transfers of care,132 records timeliness of social careassessment and 133 is abouttimeliness of packages of care, all ofwhich relate well to quality marker 12of the National Stroke Strategy.6 Thisawareness of the potential for sharednational measures can also enablealignment of objectives.

Dudley PCT, key staff from DudleySocial Services, Dudley Groupof Hospitals and The StrokeAssociation improvedcommunication through regular shortmeetings and task groups to tacklespecific problems. The team madean impact on delayed discharges,reducing length of stay to 18.5 daysin 2008/9 and to 15.7 days in2009/10, saving £750 per patient.

Use of the stroke social care grantenabled a protected resource forstroke specific posts and services inlocal authorities. The operationalfocus in social care is on the needs ofthe individual rather than the

condition or disease of the individual,so there may not be a stroke specificfocus in social care for services or fordata collection. Funding has beenused with good effect, often forstroke specific social care posts, manyof which have demonstrated valuefor money and will be continued afterthe life of the social care grant.

Stoke on Trent City Council usedtheir grant funding to enable a dailyward visit by social care workers tothe stroke rehabilitation ward andfacilitate earlier referral to social careservices. A single point of contact forpatients and carers on discharge andpolicies for discharge and for rapidassessment were implemented. Bothsocial care and the early supporteddischarge teams adopted the newname of ‘Community StrokeDischarge Team’ so that patients andcarers were aware of the closeworking relationship to provide aseamless service.

The Royal Bournemouth andChristchurch Hospitals NHSFoundation Trust focused theirattention on improvements whichcould be made in transfer of careprocesses in hospital. The teamsupported closer working of healthand social care teams by co-locationof the social workers, informationsupport officer and StrokeAssociation support staff in thehospital, near to the stroke ward,rather than at the local authority.Measurable improvements made bythis team include significantlyimproved patient satisfaction scoresfor involvement in the transfer of careprocess, reduced waiting times forcommunity therapy and improvedquality of handover informationbetween hospital and communityteams.

Involve patients and carers inimproving transfer of careThe National Stroke Strategy makes itclear that stroke survivors should beinvolved strategically in stroke serviceimprovement, as well as in decisionsabout their own care. The challengefor services is to obtain real andmeaningful involvement of strokesurvivors rather than token gestures.The project teams were able toestablish the patients’ and carers’perspectives of stroke services and touse these views to significantlychange the service.

Poole Hospital NHS FoundationTrust and NHS Bournemouth andPoole, with Dorset Stroke Networkused a patient and carer feedbackforum to establish the shortfalls inthe transfer of care pathway andsuggest a vision for how they wouldlike services to be, which was used bystaff from social care, health and thevoluntary sector to develop anaspirational pathway for the service.The team established a ‘meet theteam’ meeting early in the first weekof the hospital stay to discussprognosis and plans for rehabilitationand discharge with the patient andfamily.

The Royal Bournemouth andChristchurch Hospitals NHSFoundation Trust team obtainedpatient and carer feedback usingquestionnaires after hospitaldischarge. The feedback becameintegral to the project, informing theteam at many levels as to theeffectiveness of their improvements.Formalised care reviews with patientsand carers for enhancedcommunication and dischargeplanning were implemented early inthe hospital stay. Care reviewdocumentation given to the patient

6For further information on similarities between National Indicators and Quality Markers,see Stroke Improvement Programme website social care resourceswww.improvement.nhs.uk/stroke/SocialCareforStroke/SocialCareforStrokeResources.aspx

reinforced information given duringthe meeting. Patient satisfactionabout information given hasimproved.

Provide emotional support forstroke survivors and carersThe National Stroke Strategy, RCPclinical guidance and Department ofHealth guidance7 recommend theemotional needs of people who havehad a stroke are met and carers aresupported to have their needsassessed. The challenge is inidentifying individuals in need ofthese services and in providing askilled service to meet the need.Several of the project teams foundways around these challenges todemonstrate positive outcomes forpatient and carer satisfaction, carerstrain and the economic benefits ofgood emotional support.

Nottinghamshire County Counciland Nottinghamshire CommunityHealth’s improvement was focusedon access to emotional support forcarers by funding and defining a rolefor a family and carer support workerpost on the stroke ward. Key learningpoints were that:• the timing of interventions andsupport for carers is critical. Carersare in crisis themselves at the acutestage of the pathway so supportmay be best received at the postacute stage

• carers also wanted to talk afterusual office hours when they feltthey had more capacity after workfor visiting

• specific carers support is valuedenormously and warrants particularattention by the stroke service

The South West London Cardiacand Stroke Network projectimplemented a self managementprogramme in Croydon. 72% of staffparticipants changed their practicetowards a more patient centred, goalorientated approach, whichpromoted patients’ self efficacy.Improvements in patient self efficacyscores were shown in eight of the 12patients and two others had scoreswhich remained high throughout.Improvements were also made inpatients perceptions of the impact ofthe stroke, measured using the StrokeImpact Scale.

In Dudley PCT, patients and familieswere given a contact number for thefamily support worker to use for anyquestions and concerns, instead ofseeking help from the GP or going toA&E when they were anxious orworried. The team demonstrated thepost saved the PCT around £94,500in its first year on crisis admissionsand emergency room visits bypatients recently discharged fromhospital.

Ensure access to appropriateservices, including rehabilitation,social care and communityopportunitiesImproving transfer of care isfundamentally about getting theprocess right and ensuring peoplewho have had a stroke access servicesthey need when they need them.Several of the national project teamsobtained investment for majorpathway redesign and were able toimplement improvements in thetransition from hospital and toaccessing community therapy, socialcare support and beyond.

The joint commissioner-provider ledteam from NHS Milton Keynes andMilton Keynes Council planned aservice redesign to establish a newearly supported discharge service.There were no stroke specialistrehabilitation staff in the communityand poor follow up when theystarted. Implementation of the newservice was less than straightforward,but in its first month saw a dramaticimprovement in length of stay frommore than 23 days to less than 10days and an improvement in thestroke vital sign from an average of50% to 70% of stroke patientsspending 90% of their time on thestroke unit.

The team from LincolnshireCommunity Health Services set outto establish a cost effective assisteddischarge stroke service in a healthcommunity, from no stroke specificcommunity rehabilitation and verylimited generic communityrehabilitation. The team set up anassessment process, in-reaching toward team meetings at referringstroke units, and, in some areas,attending daily handover sessionswith stroke unit staff. Recruitment tothe new service was highly successfuland access to a seven day communityservice was established across thecounty. Average Barthel scoringimproved, and waiting times forcommunity therapy reduced fromthree weeks to two to four days.Patient satisfaction with the newservice is high.



7Putting People First, Department of Health, 2007

NHS Lewisham, with South EastLondon Cardiac and StrokeNetwork and social care colleaguesredesigned the post acute strokephase to create an integratedpathway between acute andcommunity stroke services. Ward levelprocess changes, improvements inlinks with social care and investmentin social care posts as well as a neuro-rehabilitation team pilot wereimplemented, which has a significantmeasurable impact on the wholestroke service.

In summary to improve the transferof care, consider the followingactions:• nominate a champion to driveimprovement in each organisation

• co-locate the stroke health andsocial care team in the samebuilding, preferably in the sameroom

• use a variety of tools to involvepatients and carers to see wherethe service is and what needs tochange

• actively include the patient andfamily in decisions about leavinghospital at the earliest appropriateopportunity

• nominate a single point of contactas a resource for people who havehad a stroke after hospitaldischarge

Developing communityservicesStroke Improvement Programmeproject teams in Norfolk,Northampton, Portsmouth,Hampshire, West Sussex andBournemouth and Poole aimed tobuild an evidence base for theimplementation of quality marker 10,covering high-quality specialistrehabilitation. In this section,examples have also been drawn fromsuccessful established communitystroke teams in WandsworthCommunity Neurological Team, NHSBlackburn with Darwen TeachingCare Trust Plus and NHS NorthLincolnshire (Scunthorpe).

Proactively recruit patients to thecommunity serviceCommunity teams found benefit inproactively seeking patients suitablefor either community rehabilitation orearly support discharge whilst theywere still in hospital (in-reach). Insummary, teams managed toeliminate waiting lists, smoothed thetransfer of care, made the servicemore efficient and better for patients,shortened length of stay, andspeeded up access for all those whohave had a stroke at the optimumpoint in their recovery process.



Table 2: Lewisham PCT waiting times

Stroke vital signProportion of patients spending90% of time on a stroke unit

Average length of stay (days)

Waiting time for communitytherapy

Number of new patients per month

Duration of therapy

<40%

22.5

Intermediate careteam 4-6 weeks

Adult therapiesteam 12 weeks

LINC 1-2

LINC 35 days

>80%

18

SALT - 48 days

OT - 65 days

Physio - 96 days

-

-

>80%

19 (Oct-Dec swine flu and norovirus)

SALT - 38 days

OT - 44 days

Physio - 74 days

New pilot LINC team 5-6 days

New pilot LINC team 28 days

Jan 2009 Apr-Jun 2009 Oct 2009 - Mar 2010

TOP TIPS

• Proactively recruit patients to thecommunity service

• Develop a flexible, stroke skilledworkforce

• Develop a team commitment tomeasuring progress

• Identify and use all services anddelivery partners

• Support effective leadership

The Norfolk and NorwichUniversity Hospitals NHSFoundation Trust and NHS Norfolkproject team developed an earlysupported discharge service thatprovided a proactive in-reachingassessment service from the hospitalbased rehabilitation services. As aresult the waiting list was eliminated,with no patients waiting more than24 hours from referral.

In Portsmouth Hospitals NHSTrust, the team demonstrated thatin-reach could lead to a moreefficient and better service forpatients, by combining in reach withhome visits (including a ‘welcomehome’ visit on the first day home) toensure that the right equipment isprovided to fit the individual’s needsand home environment. Assessmentby all professionals continues withinthe first three days, with ongoingactivity and goal planning and familymeetings.

NHS Blackburn with DarwenTeaching Care Trust Plus achieved apositive impact on acute services witha reduction in the need for homevisits by hospital based occupationaltherapists. The team’s assistance withdischarge management has shown areduction in the length of acute stayand faster bed turnover with morepatients returning home andimproved performance for the vitalsigns.

Portsmouth Hospitals NHS Trustdemonstrated in the first year of dataa reduction in acute length of stay ofan average of 16 bed days, with nocompromise of patient outcomes.NHS Blackburn with DarwenTeaching Care Trust Plus have seenthere has been a steady reduction inthe acute length of stay to less than21 days (see figure 4).

Develop a flexible, stroke skilledworkforceSpecialist teams may be moreimportant in the early stages ofrehabilitation, while generic teamscan be appropriate for the laterstages. However, the configuration ofcommunity teams is less importantthan ensuring that these teams aremultidisciplinary and all staff have theright specialist skills to helprehabilitate people who have had astroke. This development of thetraditional multidisciplinary teammodel delivered better patientoutcomes and satisfaction andshorter length of stay.

The Portsmouth Hospitals NHSTrust Community StrokeRehabilitation Team established theskills and competence levels for itsentire staff by reviewing existing skillsand then developing a Core StrokeSkills Framework as the basis of skilldevelopment. A staff skills survey wasrepeated in April 2010 and resultsdemonstrate that each member ofstaff increased their learning over theyear; 15 out of 20 staff perceive theyhave made “good progress” indeveloping their skills and knowledgeand have confidence in working instroke rehabilitation.



Figure 4: Length of stay in Blackburn

35

30

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15

10

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0

Day

s

Year

Stroke patients hospital length of stay: death or discharge

2005 2006 2007 2008 2009

Average length of stay31.06

27.6825.98

28.19

21.55

In Norfolk and Norwich UniversityHospitals NHS Foundation Trustand NHS Norfolk, difficulty inrecruiting Band 3 and 4 staff withstroke specialist skills led to a need todevelop core competencies for thesestaff, based upon all professionsrepresented in the team. Ongoingtraining and competency packs havepromoted greater independence, andthe new staff have been invaluable tothe success of the service.Multidisciplinary team working hasenabled good goal setting practice tobe applied to the rehabilitation ofpeople who have had a stroke. Theyfound working from a central basewhere the team meets regularly todiscuss patient progress and planfuture visits supported this.

InWandsworth CommunityNeurological Team, the teamwanted to develop stroke specificearly supported discharge. To free upskilled staff time, administrativesupport was recruited, and adatabase improved case and workload planning. There is now a higheremphasis on the patient pathway andgoal plans in weekly team meetings,informed by accurate data. Throughthe use of Outlook diaries on thecomputer, it is easier to set up jointvisits and meetings, administrativestaff can book in patients for staffand it is much easier to tell where theinefficiencies are.

Develop a team commitment tomeasuring progressIf the team is committed tomeasuring progress across a range ofmetrics, including qualitative andquantitative measures, this can bettersupport service development.

NHS Blackburn with DarwenTeaching Care Trust Plus createdtheir own specific database, enablingthe team to further analyse theimpact of their interventions. Thedata results for occupational therapistcontacts demonstrated thatsignificantly more patients wererequiring intervention than had beenanticipated. This led to a review ofthe initial skill mix of equal workingtime equivalents for physiotherapyand occupational therapy. Furtheranalysis of the teams’ activityrevealed a significant number ofcontacts around management ofcognitive issues and an analysis of theoutcomes by strokeclassification/severity, ensuring thatan effective business case foradditional occupational therapystaffing could be prepared, andfunding was secured.

Further work by this team across arange of measures has enabled themto build a business case forpsychology support. They have alsomore fully examined the impact ofthe different components ofrehabilitation in relation to thedifferent complexities of patientneed, to help with further workforceredesign and skill mix planning, anddemonstrate the efficacy of theirservice model for all stroke survivorslocally.

Their data for 2010 for clinicaloutcomes, looking at the averagechange following team interventionacross four clinical outcome measuresdemonstrates good results. Thereduction in dependency post teamintervention reduces the help needed,measured as a saving of 12,480 carehours (provided by the family or ascare package provision), equating to£93,600 per year saved.

Wandsworth CommunityNeurological Team used theirdatabase to establish the currentactivity level for all staff, and then aproject manager created newindividual targets based on professionand grade. This was informed by atwo week audit of travel time andcaseload management. Accurate andrelevant information was used as afoundation for the evidence base fora business case to increase thestaffing sufficiently to enable earlysupported discharge provision.

The team established a database thatenables them to maintaintransparency and ensure effectiveaudit and target monitoring, run anefficient booking/scheduling system,better monitor patient input andproduce monthly summaries that canbe given to the team.



Identify and use all services anddelivery partnersMapping and engaging those whoprovide existing services, acrossprimary and secondary care, socialcare and other local authorityservices, and the voluntary sector, toensure they are accessible to strokesurvivors saves time and resources. Itcan also uncover untapped existingopportunities for people who havehad a stroke and their carers, and canlead to efficiency gains.

As part of their work to develop abusiness case for a comprehensivecommunity stroke team theNorthampton General Hospital,Kettering General Hospital andNHS Northamptonshire projectteam undertook an extensivemapping exercise, including 40different representatives from health,social care, voluntary sector andpatient and carer representatives (seefigure 5).

In NHS Blackburn with DarwenTeaching Care Trust Plus goodrelationships and understanding ofother local services enabled theservice to offer a richer range ofopportunities, to enable individuals tolead a more socially integratedlifestyle (see figure 6). For example,work with local transportorganisations meant that once anindividual had been taught by thecommunity team how to transfer onand off a bus, the local ‘dial a bus’service will collect them for a smallfee and transport them to a localexercise class.



Figure 5: Northampton Pathway

NHS Bournemouth and Poole havedeveloped a 12 week exerciseprogramme for people who have hada stroke, including an exercise diary, afitness information pack and selfrecorded exercise. The team workedwith local leisure centres so thatwhen the formal programme ends,individuals can benefit from reducedfees, a suitable exercise package andsupport from stroke educated leisurecentre staff. The team saw an impactin reduced inappropriate referralsback into the service, unnecessarydeterioration in physical well beingand more confidence and ownershipof their physical well being byindividuals.

NHS Hampshire developed acommissioning specification for earlystroke rehabilitation, with wideengagement in its development.

The team took time to scope therequirements and stakeholders. Acore team of stakeholders wasestablished to steer the project fromacross the commissioningcollaborative and adult services.

Regular communication between theproject team and all stakeholders wasconducted via a project website. Asignificant stakeholder event washeld in November 2009, chaired byNHS Hampshire’s Chief Executive andinvolving around 100 staff, includingclinicians and managers from healthand adult services, andrepresentatives from voluntaryorganisations. The feedback wasanalysed, alongside patient andcarer feedback from surveys, toinform the content of thespecification and considerationsfor the implementation stage.

The specification is now being takento each of the organisations fordecision on commissioning plans.Relationships have been developedwith the local authorities, and there iscommitment to work together infuture to address pathway issues as awhole system.

In Norfolk and Norwich UniversityHospitals NHS Foundation Trustand NHS Norfolk patients beingadmitted to early supporteddischarge from hospital are notreferred to social services until theyhave met their rehabilitation goals.As a result of their clinical outcomes,the team are able to demonstrate apositive effect on the overall demandfor packages of care for strokepatients locally both in number andintensity. Using the Bartel score, asignificant improvement in the levelof independence of patients atdischarge from the service wasshown. Their throughput costs havealso reduced steadily, as the teamsettles and improves its efficiency.

The NHS West Sussex, WestSussex Health and West SussexCounty Council project teamincludes a manager on a three yearsecondment from social services. Therole is to understand the linksbetween services, identify gaps andimprove transfers of care. Thecommunity stroke team have formallinks with Crawley Stroke Unit andSussex Rehabilitation Service. Weeklymultidisciplinary planning meetingsenable a prompt effective transfer ofcare. A dedicated social workerwithin each locality will in-reach theward to provide prompt effectivedischarge planning, liaise closely withthe North Area Stroke Team, and tolink into the social care provision byexisting locality teams.



Figure 6: NHS Blackburn with Darwen approach to services

Stroke specificexercise class

Stroke specificgardeninggroup

Stroke specificcommunitywalks

Secondaryprevention andeducation

Links to leisureactivities

Communitystroke exerciseand prevention

class

Support effective leadershipWhere comprehensive communityservices are developed in the contextof a whole pathway process, theopportunities and patient experiencecan be maximised. This requiresstrong and effective leadership, frompeople who can work at strategiclevels, local levels and acrossboundaries. It is also essential forbuilding teams and deciding uponservice models, which in turn hasrequired effective business casesbased on good, relevant and timelydata and sustained communication.

In NHS Blackburn with DarwenTeaching Care Trust Plus thecreation of a database enabled theservice to effectively evaluate anddemonstrate its achievements. Thisenabled the team leader to giveweight to her arguments, and she isnow included on all the key groups tobe able to influence stroke services ata strategic level.

The success of the early supporteddischarge service and the new strokerehabilitation unit in Norfolk andNorwich University Hospitals NHSFoundation Trust and NHS Norfolkhas resulted in significantimprovement for people who havehad a stroke locally and significantreductions in length of stay. The teamleader is now in the process ofdeveloping the business case to rollthe service out across the county.

In Northampton General Hospital,Kettering General Hospital andNHS Northamptonshire, the initialplans for a local community servicefor Northampton grew, through thenational project work andinvolvement of the stroke network,into plans for a county widecommunity stroke team and equityacross the patch. This tookperseverance by the team, inparticular the lead consultant, toensure the need for the improvementwas widely understood. Establishing agood working relationship with thelead commissioner and findingcommon ground was key. The teamalso understood the need to geteveryone who has a part to play inthe service involved in itsdevelopment including, mostimportantly, patients and serviceusers.

The health and social care partnershipin NHS West Sussex, West SussexHealth andWest Sussex CountyCouncil used their combinedknowledge and experience to steertheir project through challengingtimes locally, to the point ofdelivering from June, a new,equitable, and comprehensivecommunity stroke service.

Accessing psychological supportwithin community teamsThe knowledge and skills of a clinicalpsychologist are of most benefitwhen they are integrated with thoseof other team members as part of apatient focused, goal drivenrehabilitation approach.8 Experienceto date is that these posts are oftenhard to secure funding for, or evenwhere funds have been madeavailable recruitment is problematic.However, there are examples of somecreative solutions:

In NHS North Lincolnshire(Scunthorpe), the stroke leadidentified appropriate additionaltraining in counselling for Band 2and 3 staff to improve the skill poolwithin the team and support forpatients.

In Northampton General Hospital,Kettering General Hospital andNHS Northamptonshire, the plan isto create a pathway that enablesstroke patients to access existingpsychology services and support thiswith additional appropriate trainingfor the stroke team staff.

In NHS Blackburn with DarwenTeaching Care Trust Plus funds havebeen made available for scoping theservice needs, and a plan is in placefor training all staff within thecommunity team. Working with thelocal authority staff led to thefunding of a psychologist to thecommunity stroke team.

The Norfolk and NorwichUniversity Hospitals NHSFoundation Trust and NHSNorfolk, team did not have formalpsychology support, but linked to thesix monthly review by the stroke carecoordinator who has the capacity toaccess a clinical psychologist, ifappropriate.



8Wilson, Evans and Keohane 2002;Wilson et al 2009

With a continued focus on quality,innovation, productivity andprevention, it is important thatorganisations show that they cantransform, deliver and, mostimportantly, sustain improvements incare. Sustainability can be defined aswhen new ways of working andimproved outcomes become thenorm. The Stroke ImprovementProgramme projects have beenencouraged to ensure there was acommitment to sustainability of theproject and the improvements fromthe beginning, and in this section wewill look at how the projects areplanning to sustain the changes theyhave made.

The Stroke Improvement Programmeprojects have identified a number oftactics to ensure that theirimprovements are sustainable. Fromthese plans, we have identified thefollowing top tips for sustainability.

Prioritise staff communication,training and moralePortsmouth Hospitals NHS TrustCommunity Stroke RehabilitationTeam’s project aimed to ensure theyare a team fit to deliver qualitymarkers 10 and 18 of the NationalStroke Strategy. The Portsmouth teamidentified that providing an openculture of learning is vital to supporta growing expertise in communitystroke rehabilitation. Staffdevelopment, supported by the CoreStroke Skills and ExpectationsFrameworks9, will continue.

Surrey and Sussex Healthcare NHSTrust have implemented a rollingeducational programme to keep themomentum and enthusiasm oflearning. They are developinginduction packs aimed at all membersof the interdisciplinary team so thatnew staff can quickly familiarisethemselves with common practicesand feel engaged in the team. Theteam also aim to have trulyinterdisciplinary notes where alldisciplines document in the sameplace and for key workers to developfor each patient.

Following NHS Medway’s project todevelop and agree a six day therapymodel, staff were more open toworking weekends, as theyrecognised the benefits to patientcare and that it may provide staffwith a less stressful and moreeffective work environment, forexample providing opportunities formore flexible working practices.



Sustainability

TOP TIPS

• Prioritise staff communication,training and morale

• Communicate within thedepartment and with otherspecialties, patients and carers

• Secure support and endorsementfrom senior staff

• Ensure continuous monitoringand review of practices and data

• Embed system changes toprevent the service returning toold ways of working

9The Core Stroke Skills and Expectations Frameworks will be presented on the Southern StrokeForum website: www.southernstrokeforum.org

Patient and carer satisfaction surveyshave not only been useful in helpingto shape the changes, but the RoyalBournemouth and ChristchurchHospitals NHS Foundation Trustfound they helped to improve staffmorale in the team, making staffmore likely to support continuing thenew measures introduced.

Milton Keynes Hospital NHSFoundation Trust identified risks ofdiscontinuity of time limited projectdedicated staff. However,achievements will be embedded ineveryday practice of staff so that themain force of change can besustained.

Communicate within thedepartment and with otherspecialties, patients and carersQueens Hospital NHS FoundationTrust’s project on improving accessto the acute stroke unit, led to amonthly multidisciplinary strokedevelopment group which links withcommunity teams. The group reviewservice provision and implement plansfor development and change. Theongoing communication continues todrive improvement. WorcestershireAcute Hospitals NHS Trust alsohold monthly stroke strategy andoperational group meetings involvingall key stakeholders to continue todrive forward the agenda.

Surrey and Sussex HealthcareNHS Trust highlighted theimportance of maintainingcommunication outside the stroketeam. Personal relationships betweenthe outreach nurses and A&E andradiology staff have ensured that theyare immediately notified when newpatients present. LancashireTeaching Hospitals NHSFoundation Trust also recognisedthat sustaining improvements willdepend on continued effectiveinteraction between all the relevantspecialties.

Yeovil District Hospital NHSFoundation Trust identified aproblem that services can becomereliant on individuals which, whilstpositive in the short-term, is notsustainable. The team made sureinformation on the stroke service wasavailable on the trust intranetproviding all the latest protocols andguidelines required for thrombolysis,acute management andrehabilitation. The stroke team thenkeep one site up-to-date, avoidingconcerns of having out of dateguidelines on the ward.

North West London Cardiac andStroke Network also have dedicatedweb pages on their website as asustainable information resource. It iseasily updated and provides aconstant point for downloading keyforms and protocols. RoyalBournemouth and ChristchurchHospitals NHS Foundation Trust,Poole Hospital NHS FoundationTrust and NHS Bournemouth andPoole use the trust website and haveput in place a system for regularreview of information. In Poole, thestroke services directories across thenetwork area are being adapted intoa web based directory to improveaccess for patients, carers andprofessionals and help maintain up todate information.

Aintree University Hospitals NHSFoundation Trust have streamlinedtheir communication services forimproved efficiency andcommunication with a regular strokenewsletter, Aintree News, and opendays. Surrey and SussexHealthcare NHS Trust’s promotionalactivities to improve communicationinclude TIA and stroke seminars andthe ‘Know your Blood Pressure’campaign.

Secure support and endorsementfrom senior staffStoke on Trent City Council’sAdult Social Services project toredesign the stroke care pathwayfrom rehabilitation into thecommunity have linked the projectinto the recovery model that thesocial strategic care manager ispreparing in order for the changes tobe sustained to ensure that stroke iskept high on the agenda of relevantmeetings for social care.

In order to keep stroke as a priority inthe organisation, Yeovil DistrictHospital NHS Foundation Trust arealso keeping key themes as rollingagenda items within the organisationso that they remain on the radar.

InWorcestershire Acute HospitalsNHS Trust, the trust’s executive teamhave stated that delivery of thenational, regional and local strokestandards is one of the trust’s highestpriorities in 2010/11, supporting theimprovements that are taking place.

Ensure continuous monitoringand review of practices and dataRoyal United Hospital, Bath andDudley PCT have committed toongoing performance monitoring toensure that any problems will beaddressed. Dudley PCT will becarrying out regular analysis of theservice at commissioner level. Surreyand Sussex Healthcare NHS Trust’sperformance data is monitored by thetrust on a monthly basis, againallowing any change to performanceto be noticed and acted upon.

In York Hospitals NHS FoundationTrust, the project group willcontinue as a forum for measuringprogress, auditing achievement ofstandards and identifying futuredevelopments. This team will alsofeed into the newly set up strokeworking party.



Embed system changes to preventthe service returning to old waysof workingSurrey and Sussex HealthcareNHS Trust now have threeconsultants with a clear clinical leadand up to five junior doctors,providing a strong core of servicepersonnel to ensure efficiency ismaintained.

Aintree University HospitalsHospitals NHS Foundation Trusthave reviewed roles of the core teamand re-evaluated staff induction. Theteam are developing systems so thatstaff are confident and trained inthe new way of working. Jobdescriptions, policies and proceduresreflect the new process. Facilities andequipment are all appropriate tosustain the new process.



Establishing systems for measuringthe effectiveness of a service, andthen analysing the information sothat you understand the impact ofchanges made, can be challenging ina busy clinical environment.

All the teams involved in the projectsrealised the importance of measuringtheir improvements, and to do so notonly made changes in data collectionsystems, but also culturally, to collectaccurate information about theirstroke services and the impact oftheir improvements. This has beenmost effective when teams have beenable to clearly and objectivelydemonstrate the benefits of theirimprovements to commissioners andchief executives, and to themselvesand their patients.

Why measure?To understand the currentstate of the serviceEstablishing a true baseline of currentservice delivery is a major part ofservice improvement. Unless it isknown what the position was, it willbe difficult to know if a change is animprovement and has had any impacton the process or outcomes forpatients. Once baseline data isobtained, analysis will enable fullunderstanding of the pathway andmay influence the direction of therequired change.



Measuring for improvement

The establishment of aclear service specificationand realistic andmeasurable keyperformance indicatorsgives focus to the teamand drives the service”Lincolnshire Community HealthServices project team

TOP TIPS

• Establish a clear objective for the improvement and communicate this to theteam involved

• Make sure the objective is ‘smart’ - i.e. specific, measurable, achievable,realistic and time-limited

• Establish a baseline to understand exactly how effectively the pathway isworking at the start

• Understand what data is available, where it is held within the organisationand how it relates to a pathway of care

• Be clear on data requirements at the outset and involve all those involved indelivering care to contribute to a data collection plan

• Where necessary, formulate a cross organisational data sharing agreementand system for measuring improvement across health and social care

• Find a unique patient identifier to link multi-organisational data and aim forthe inclusion of the patients NHS number

“

The baseline is a measure of how wellthe pathway is performing, in termsof efficiency, effectiveness andpatient and carer experience.

To understand the direction oftravelRegular monitoring and analysis ofinformation will inform the impact ofthe changes, and can give an earlyindication of whether the change ishaving the desired effect or if thereare unexpected consequences. Thisinformation can inform decisionsabout whether further adjustment isneeded to ensure the improvementachieves the planned benefits.

To determine progressWhen data is used as continuousfeedback about the effectiveness ofthe improvement, decisions can bemade about the likelihood ofachieving the objective, within thetimeframe. Using the data objectivelydemonstrates progress made,avoiding the need for assumptionsabout how well a change appears tobe working.

To determine achievement ofthe objectiveProvided the correct information hasbeen collected and analysedappropriately, data collected duringthe improvement will demonstratethe overall effectiveness of theimprovement in achieving the initialobjective.

To demonstrate effectiveness ofthe improvementUsing data to record the changesmade, makes the case clearly andobjectively for the effectiveness (orotherwise) of the change. This cancontribute to sustainability of thechange and focus attention on areasfor further improvement.

What should be measured?Measurements should tell youwhether your objective has beenachieved. The objective needs to bespecific, measurable, achievable,realistic and time limited (SMART).Thinking through the following stepscan help to define the key objectiveof the proposed change:• what do you aspire to achieve withthis piece of work?e.g. All stroke patients will bebetter informed about their transferof care from hospital

• define the main project aime.g. All stroke patients will receivecomprehensive dischargeinformation prior to transfer of carefrom hospital

• break the project aim into smaller,defined SMART objectivese.g. All patients and families will begiven a discharge information packon day one of admission by theadmitting nurse; all patients andtheir families will have a casemeeting with their key workerwithin four days of admission

• consider how each objective willbe measurede.g. Count numbers of packsissued against number of patientsadmitted to the ward; notes auditto check record and date of casemeeting in relation to date ofadmission; patient interviews aboutdischarge information received

Having defined objectives, andcommunicating them clearly, enableseveryone to know the purpose of thechange and to work towards thesame goal. Clear specific objectivesalso prevent the project growing outof control and therefore likely to fail.

What measurementsshould be used?Consider the different types ofmeasurement to use:• outcome measures are directmeasures of an intervention andare commonly used to assesstherapeutic effectiveness, andmeasure the endpoint of thechange or intervention

• process measures provideinformation to guide and manage achange as it is being made

Process measures can be used to testa specific hypothesis, for example,earlier social work assessmentshortens length of hospital stay. Theprocess measures are the date ofhospital admission, the date of thesocial work assessment, and the dateof discharge. The related outcomemeasure is the length of stay.Together, these data establish the linkbetween timing of the assessmentand the length of stay. Understandingthis connection will inform furtheradjustments to the process.

Measurements of process across apathway will provide informationabout the impact of the change inone part of the pathway on another.For example, the transfer of careprojects looked at the impact ofchanges made on the transfer of carepathway made on the proportion ofstroke patients spending 90% oftheir time on a stroke unit (the vitalsign). Although improvements werenot directly targeted at improvingadmission to the stroke ward, animpact could be demonstrated.



Table 3: Lewisham and the South London Cardiac and Stroke Network data

Stroke vital signProportion of patients spending90% of time on a stroke unit

Average length of stay (days)

<40%

22.5

>80%

18

>80%

19 (Oct-Dec swine flu and norovirus)

Jan 2009 Apr-Jun 2009 Oct 2009 - Mar 2010



A wealth of data are collected byhealth and social care services. Earlyinvolvement of trust or local authorityinformation departments andinformation analysts can improveunderstanding of what data is alreadyavailable, where this data is held andin what format. Being specific andasking the right questions in terms ofdata requirements will informdevelopment of a data collectionplan, make best use of data whichmay already be available and avoidthe need for the collection of newinformation.

Measuring across organisationsWhen linking data together fromdifferent sources, a commonidentifier is needed to ensure theaccuracy and consistency of theinformation. The most widely usedidentifier is the NHS number, which isusually sufficient for measuring apathway within one hospital, butproblems arise when measuringacross multi-organisational pathwaysof care. Early discussion withchampions for the improvement ineach organisation can address theissues of data sharing betweenorganisations and use of a singleidentifier.

The project team from Stoke onTrent City Council’s Adult SocialServices made changes to the wayinformation was recorded betweenhealth and social care to accuratelyreflect the work being done by thesocial worker on the ward and tounderstand the referral rate for socialwork assessment for stroke patientson the rehabilitation ward.



Accelerating Stroke ImprovementmeasuresMeasures and operational definitionshave been developed for theAccelerating Stroke Improvementinitiative. The measures chosendirectly reflect the observations madein the National Audit Office report inits assessment of stroke services inEngland.10 The three main areas offocus are joining up prevention,implementing best practice in acutecare and improving post hospital andlong term care.

10The Department of Health: Progress in improving stroke care,National Audit Office, 3 February 2010.

Improving Post Hospitaland Long Term Care

• i) Proportion of patientssupported by a stroke skilledEarly Supported Discharge team(40% by April 2011)ii) Presence of a stroke skilledEarly Supported Discharge team

• Proportion of patients andcarers with joint care plans ondischarge from hospital to finalplace of residence(85% by April 2011)

• Proportion of stroke patientsthat are reviewed at six monthsafter leaving hospital (95% byApril 2011)

• Proportion of patients whohave received psychologicalsupport for mood, behaviour orcognitive disturbance by sixmonths after stroke. (40 % byApril 2011)

Table 4: Summary of Accelerating Stroke Improvement measures

Implementing Best Practicein Acute Care

• Proportion of patients admitteddirectly to an acute stroke unitwithin 4 hours of hospital arrival(90% by April 2011)

• Proportion of patients spending90% of their inpatient stay on aspecialist stroke unit (80% byApril 2011. Vital Sign)

• i) Proportion of stroke patientsscanned within one hour ofhospital arrival (50% by April2011)ii) Proportion of stroke patientsscanned within 24 hours ofhospital arrival (100% by April2011)

Joining Up Prevention

• Proportion of patients withAF presenting with strokeanti-coagulated ondischarge (60% by April2011)

• Proportion of people withhigh-risk TIA fullyinvestigated and treatedwithin 24 hours (60% byApril 2011. Vital Sign)

KEY

MEASURES

(AIMS)

Further information about the detailof these measures, their operationaldefinitions and answers to somefurther questions about the measurescan be found on the StrokeImprovement Programme website at:www.improvement.nhs.uk/stroke



Resources

Stroke Improvement Programme websiteThe Stroke Improvement Programme website offersinformation and resources on improving stroke and TIAservices, including:• information on topical issues affecting stroke andTIA services

• presentations from events and meetings• examples of successful redesign and strokeimprovement in stroke and TIA services

• information on measureswww.improvement.nhs.uk/stroke

Sustainability Checklist, NHS CancerImprovement ProgrammeA checklist containing key questions to ask about yourproject or service to ensure plans are in place to sustainthe improvement.www.improvement.nhs.uk/cancer/documents/inpatients/Sustainability_Checklist.pdf

The Sustainability Toolkit, NHS HeartImprovement ProgrammeAlthough focused on improving cardiac pathways, TheSustainability Toolkit provides useful information andexamples on how to sustain improvements. It alsocontains resources on capturing data, measurementand analysis.www.improvement.nhs.uk/heart/sustainability

Trainer’s Resource Pack – An Introduction to ServiceImprovement, NHS ImprovementThe Trainer's Resource Pack - An Introduction to ServiceImprovement, is a collection of tried and tested trainingmodules for service redesign tools and techniques, andchange management skills.www.heart.nhs.uk/trainers_resource_pack.htm

Guidance on Risk Assessment and Stroke Preventionfor Atrial Fibrillation (GRASP-AF) ToolThis tool should be used as part of a systematic approachto the identification, diagnosis and optimal managementof patients with AF to reduce their risk of stroke.Developed collaboratively and piloted by the WestYorkshire Cardiovascular Network, the Leeds Arrhythmiateam and PRIMIS+, as part of the AF in primary careprojects, made available nationally through NHSImprovement.www.improvement.nhs.uk/graspaf

Atrial Fibrillation documents, NHS ImprovementThe following documents are available to download fromthe Stroke Improvement websitewww.improvement.nhs.uk/stroke

Atrial fibrillation in primary care: making an impacton stroke prevention, October 2009This document aims to capture the final summary of theirindividual approach, lessons learned, improvements topractice and quality outcomes, also sharing tools andresources developed to enable other health communitiesto drive this agenda forward.

Resources and contacts



Commissioning for Stroke Prevention in PrimaryCare - The Role of Atrial Fibrillation, June 2009Developed following a national consensus meeting ofopinion leaders in the field, this document is to developa concerted strategy towards the management of AF inprimary care, in particular anticoagulant managementand its significance in relation to reduction in the risk ofstroke.

Atrial Fibrillation in Primary Care National PriorityProject, April 2008A summary document produced in April 2008 includingdescriptions, supporting information and key learningfrom the local projects that were part of the AtrialFibrillation in Primary Care national priority project.

Atrial Fibrillation in Primary Care Resources andLearning, April 2008This online resource is a tool produced in April 2008 thatcaptured the learning from the local project sites thatworked on the Atrial Fibrillation in Primary Care nationalpriority project. The resource provides documents,guidelines, presentations, proformas and algorithmsdeveloped and used by the local priority projects.

Stroke Improvement Programme e-bulletinContaining updates, news and information for anyoneinterested in developing stroke services, the StrokeImprovement Programme e-bulletin is essential foranyone working in stroke and TIA services.

The Stroke Improvement Programme e-bulletin ispublished every two weeks and the latest edition isavailable on the Stroke Improvement websitewww.improvement.nhs.uk/stroke. If you would like tosubscribe to the Stroke Improvement e-bulletin, pleaseemail [email protected].

NHS Improvement SystemThe NHS Improvement System is a free, comprehensiveonline resource supporting quality improvement in NHSservices, offering a range of service improvement tools,case studies and resources.

The Improvement System gives NHS staff the capability torecord, track and report on projects, share improvementstories and documents, access Statistical Process Control(SPC) software, Demand and Capacity tools and a PatientPathway Analyser, all within a secure environment.www.improvement.nhs.uk/improvementsystemEmail: [email protected]

Sustainability Model, NHS Institute of Innovationand ImprovementThe Sustainability Model is a diagnostic tool that is usedto predict the likelihood of sustainability for yourimprovement project and provides practical advice onhow you might increase the likelihood of sustainability foryour improvement initiative.www.institute.nhs.uk/sustainability_model/general/welcome_to_sustainability.html

Improvement Leaders’ Guides, NHS Institute forInnovation and ImprovementA series of service improvement guides, including a guideto sustainability and how it can be used in improvementwork. The NHS Institute for Innovation and Improvementwebsite also contains worksheets for measuringimprovement.www.institute.nhs.uk/index.php?option=com_content&task=view&id=134&Itemid=351

StrokEngine-AssessThis website provides evidence to support strokerehabilitation assessment tools.www.medicine.mcgill.ca/strokengine-assess

Spreading good practice documents andinformation, Sarah Fraser & Associates LtdSarah Fraser is an independent consultant who workswith NHS organisations on how good practice spreadsand how improvements can be made. The websitecontains a number of free resources on spreading goodpractice and improvements.www.sfassociates.biz/sitebody/MultiMedia/Documents.php



Contacts

Stroke Improvement Programme National TeamNHS Improvement - Stroke Improvement Programme3rd Floor, St John's House, East Street, Leicester LE1 6NBTel: 0116 222 5184Fax: 0116 222 5101Email: [email protected]

For full contact details for the team seewww.improvement.nhs.uk/stroke

National Project Teams

TIA

Buckinghamshire Hospitals NHS TrustDr Matthew BurnConsultant Stroke Physician,Buckinghamshire Hospitals NHS [email protected]

Epsom General HospitalJanet PutterillConsultant Stroke Physician,Epsom General [email protected]

Lancashire Teaching Hospitals NHS Foundation TrustDr Hedley EmsleyConsultant Neurologist,Lancashire Teaching Hospitals NHS Foundation [email protected]

Milton Keynes Hospital NHS Foundation TrustNicola EvansProject Manager, Milton Keynes HospitalNHS Foundation [email protected]

North Bristol NHS TrustDr Neil BaldwinConsultant Stroke Physician, North Bristol NHS [email protected]

North West London Cardiac and Stroke NetworkMarcia ReidInterim Senior Project Manager, North West LondonCardiac and Stroke [email protected]

Royal Devon and Exeter NHS Foundation TrustCarol MasseyService Improvement Manager,Peninsula Heart and Stroke [email protected]

Royal United Hospital, BathDr Louise ShawConsultant Stroke Physician, Royal United Hospital, [email protected]

Surrey and Sussex Healthcare NHS TrustDr Ben MearnsConsultant Physician, Surrey and SussexHealthcare NHS [email protected]

United Lincolnshire Hospitals NHS TrustLouise PearsonClinical Services Manager – Stroke and TIA, UnitedLincolnshire Hospitals NHS [email protected]

Acute

Milton Keynes Hospital NHS Foundation TrustNicola EvansProject Manager, Milton Keynes HospitalNHS Foundation [email protected]

North West London NHS TrustLisanne BoumaSenior Project Manager, North West LondonCardiac and Stroke [email protected]

Nottingham University Hospital NHS TrustHeather McCormackService Development Manager, East MidlandsCardiac and Stroke [email protected]

Poole Hospitals NHS Foundation TrustDr Suzanne RagabStroke Consultant, Poole Hospitals NHS Foundation [email protected]

Queens Hospital NHS Foundation TrustPeter TariStroke Co-ordinator, Queens HospitalNHS Foundation [email protected]



Royal United Hospital, BathDr Louise ShawConsultant Stroke Physician, Royal United Hospital, [email protected]

Sandwell and West Birmingham Hospitals NHS TrustJackie WilkinsonStroke Co-ordinator, Sandwell and West BirminghamHospitals NHS [email protected]

Surrey and Sussex Healthcare NHS TrustDr Natalie PowellSpecialist Registrar in Stroke, Surrey and Sussex NHSHealthcare Trust, East Surrey [email protected]

Worcestershire Acute Hospitals NHS TrustElaine StratfordStroke Specialist Nurse, Worcestershire Acute HospitalsNHS [email protected]

Yeovil District Hospital NHS Foundation TrustCaroline LawsonConsultant Nurse – Stroke, Yeovil District Hospital NHSFoundation [email protected]

Transfer of Care

Dudley PCTDr Liz PopeGP, Dudley [email protected]

Derek HunterCommissioning Lead – Urgent Care, Dudley [email protected]

Lincolnshire Community Health ServicesJoan LawtonClinical team Lead AHP/Implementation lead ADSS,Lincolnshire Community Health [email protected]

NHS LewishamSara NelsonAssociate Director and Interim Project lead, South EastLondon Cardiac and Stroke Network and NHS [email protected]

NHS Milton Keynes and Milton Keynes CouncilDr Marianne VinsonConsultant in Public Health, NHS Milton [email protected]

Nottinghamshire County Council andNottinghamshire Community HealthChristopher GreensmithTeam Leader – Community Stroke Team,Nottinghamshire Community [email protected]

Poole Hospital NHS Foundation Trust and NHSBournemouth and PooleDr Tracey VillarStroke Consultant, Poole Hospital NHS Foundation [email protected]

Naomi GibsonSenior Physiotherapist, NHS Bournemouth and [email protected]

South West London Cardiac and Stroke NetworkElaine HaywardSenior Project Manager, South London Cardiacand Stroke [email protected]

Stoke on Trent City Council’s Adult Social ServicesLorraine CobbSocial Care Team Manager and Project Lead, Stokeon Trent Social [email protected]

The Royal Bournemouth and Christchurch HospitalsNHS Foundation TrustClare GordonConsultant Stroke Nurse, The Royal Bournemouthand Christchurch Hospitals NHS Foundation [email protected]

Rehabilitation

Aintree University Hospitals NHS Foundation TrustHelen EvansPhysiotherapy Manager, Aintree University HospitalsNHS Foundation [email protected]

NHS HampshirePhilippa DarntonProgramme Manager, NHS [email protected]



NHS MedwayFiona JenkinsStroke Services Manager, Medway Community [email protected]

NHS West Sussex, West Sussex Health and WestSussex County CouncilJane RalphStroke Services Development Manager, West SussexCounty Council and NHS West [email protected]

Norfolk and Norwich University Hospitals NHSFoundation Trust and NHS NorfolkJohn MallettStroke Care Team Leader, Community Rehabilitation –Inpatients, Norwich Community [email protected]

Northampton General Hospital, Kettering GeneralHospital and NHS NorthamptonshireJan MatthewClinical Specialist Physiotherapist,Northants Provider [email protected]

Melanie BlakeConsultant Stroke Physician, Northampton [email protected]

Portsmouth Hospitals NHS TrustSarah EastonCSRT Leader, Portsmouth Hospitals NHS [email protected]

York Hospitals NHS Foundation TrustIna JamesStroke Project Lead/Team Leader Stroke Physiotherapist,York Hospitals NHS Foundation [email protected]

Other organisations

Cornwall and the Isles of Scilly PCTMaggie ScottStroke Nurse Consultant,Cornwall and the Isles of Scilly [email protected]

NHS Blackburn with DarwenTeaching Care Trust PlusTracy WalkerTeam Leader, Community Stroke [email protected]

NHS DoncasterHelen TuckService Improvement Manager, NHS [email protected]

NHS North Lincolnshire (Scunthorpe)David BroomheadPhysiotherapy Service Manager, North Lincolnshire andGoole NHS Foundation [email protected]

Wandsworth Community Neurological TeamRachel SibsonClinical Team Leader, Community Neurological TeamCommunity Services Wandsworth, working withNHS [email protected]

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.ukstroke

NHS Improvement

With over ten years practical service improvement experience in cancer,diagnostics and heart, NHS Improvement aims to achieve sustainableeffective pathways and systems, share improvement resources andlearning, increase impact and ensure value for money to improve theefficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England,NHS Improvement helps to transform, deliver and build sustainableimprovements across the entire pathway of care in cancer, diagnostics,heart, lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

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