implementing best practice in acute care: case studies from the stroke improvement programme...

Stroke Improvement Programme

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Implementing best practice in acute care:case studies from the Stroke ImprovementProgramme projects

Introduction

Milton Keynes Hospital NHS Foundation Trust

Nottingham University Hospitals NHS Trust

Poole Hospitals NHS Foundation Trust

Queens Hospital NHS Foundation Trust

Royal United Hospital, Bath

Sandwell and West Birmingham Hospitals NHS Trust

Surrey and Sussex Healthcare NHS Trust

Worcestershire Acute Hospitals NHS Trust

Yeovil District Hospital NHS Foundation Trust

Resources

Further information

Contents

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Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 3

Introduction

Since March 2009, ten projectsworked with the Stoke ImprovementProgramme to explore how toimprove the care they provide fortheir patients. Their experience hasled to the identification of the somekey actions.

The suggestions, experiences andexamples provided in this documentare intended to generate ideas, toshow what is possible when teamswork constructively together and toguide planning for improvementactivities. Nine out of the 10 sitesare included in this publication.

The Stroke Improvement Programmecontinuously publishes materials tohelp those striving to improve strokeand TIA services. All materials areavailable on the Stroke ImprovementProgramme web site at:www.improvement.nhs.uk/stroke

Contacts for each of the projects areincluded. Full details of the serviceimprovement can be found at:www.improvement.nhs.uk/stroke

www.improvement.nhs.uk/stroke

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

4 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

Sustainable acute stroke and TIAmanagement programme


Milton Keynes Hospital NHS Foundation Trust

AimsThe project in Milton Keynes aimedto achieve a patient-centred pathwayfor stroke, and worked across severalareas of their stroke and TIA service.The main aims for the acute strokeportion of this work were to improveaccess and quality of care through:• ensuring all patients with acutestroke were admitted directly to anacute stroke unit equipped andstaffed to be able to deliver highquality care

• providing timely access todiagnostics both within and outof hours

• ensuring seamless transfer of carefrom acute stroke rehabilitation tothe community based rehabilitation

IssuesAt the start of the project, there wasa high proportion of stroke outlierson other medical wards. Theproportion of stroke patientsspending at least 90% of their stayon a stroke unit was, on average,45%, and 20% of patients were notreceiving brain imaging within 24hours.

ActionsThe need for ‘fast track’ bed wasagreed with acute stroke unitclinicians, the bed management teamand divisional manager. Use of thebed is monitored and reportedweekly, and it is kept solely for use bystroke patients to enable timelytransfer from A&E and the clinicaldecision unit.

To ensure stroke patients identified inA&E or clinical decision unit do nottransfer to another ward, a bedmanagement protocol was put inplace and shared around the trust toensure members of staff across alllevels identify the urgency oftransferring a patient to the acutestroke unit.

Multiple workshops were held withacute and community staff involvedin stroke patient care to map thepathway a patient has access to,identify current constraints in hospitaland the community, involve staff onthe ground in suggestingimprovements, and develop transferof information across teams. Thishelped healthcare professionals putinto perspective their role in the

wider patient journey, and increasedawareness of the importance ofstroke as a specialism.

A ‘productive board’ listing allpatients, and key information on theirstatus and care, was installed toimprove ward organisation. Thisenabled staff to better plan patientcare, enable safe discharge, andimprove communication amongst allthose involved in a patients care.

OutcomesBy the end of the project, all strokepatients received brain imagingwithin 24 hours of arrival at hospital.The proportion of stroke patientsspending at least 90% of their timein hospital on a stroke unit increasedfrom 50% to 70% and continues toimprove (see figure 1).



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Figure 1: Patients spending 90% of their time in anacute stroke unit in Milton Keynes

Communication around the hospitalhas been improved and there is muchgreater awareness and recognition ofstroke within the trust.

ContactNicola EvansProject ManagerMilton Keynes Hospital NHSFoundation [email protected]



Direct access into the strokehyper acute unit (DASH)Nottingham University Hospitals NHS Trust

AimsThe central aim of the Nottinghamproject was that individuals who hada stroke had rapid and equitableaccess to the stroke hyper-acuteservice. This would include admissiondirectly to the stroke unit whenarriving at the hospital, as opposed toadmission through A&E. Patientsshould be admitted, assessed and,where appropriate, treated withthrombolysis within three hours ofonset of symptoms.

IssuesAt the start of the project there werepatients being admitted directly ontothe stroke unit, but lower in numberthan compared with those beingtransferred from the A&E situated ona campus five miles across the city,and from the emergency admissionsunit which was on the same site asthe stroke unit.

Patients began to arrive on the strokeunit from A&E without a call beingmade to the stroke unit to advisethem in advance. Telephone calls andtriage of the calls were not reliablyrecorded.

ActionsAs many stakeholders as possiblewere involved to gain commitment,including the support andsponsorship of the chief executive,along with clinical and medicaldirectors.

The existing pathway was ‘processmapped’ to identify what workedwell and the gaps in service.Communication and monitoring workwas systematically undertaken. Thisincluded contacting the ambulanceservice to ensure they had thepathway information and supportedthe project, and collectinginformation weekly on strokeadmissions to A&E to enablechallenge of the ambulance service toexplore why patients were notadmitted directly into the stroke unit.Common themes that arose werethat crews were unaware ofadmission protocol, unsure of timefor admission, and there wasconfusion around thrombolysis.

To ensure that the ambulance crewswere fully informed of changes whichwould affect the patients pathway,work was undertaken with EastMidlands Ambulance Service

management to produce bulletinscontaining the direct access policy,and more importantly, the directphone number for the telephone onthe stroke unit, known as ‘the batphone’.

To help distinguish the ‘bat phone’from the several other phones on theunit, a new ring tone and flashinglight was installed to alert the teamto the emergency response required.



This new phone and number alertsstaff on the ward immediately whena patient is going to be transferred,giving them the opportunity to triage,and then give advice to the crew onwhere to take the patient.

Information was sent to all GPsasking them to contact the strokeunit if they assessed a patient withstroke symptoms. A further requestwas sent with a reminder that the callto East Midlands Ambulance Serviceshould include the instructions for anemergency ambulance, and not aroutine admission. The vehicle to besent must also be a four wheelvehicle with a two manned crew.

‘Walking the patient pathway’ wascarried out by both clinical and non-clinical members of the team, andhighlighted a number of problemsthat could be easily and rapidlyaddressed, such as the A&E nothaving the ‘bat phone’ numberdisplayed, even though the ‘batphone’ number had been included onthe stroke emergency departmentpathway poster.

OutcomesThe project has successfully produceda direct access route into the hyper-acute stroke unit. All suspectedstroke patients are now referreddirectly to the stroke unit via the ‘batphone’.

The ‘bat phone’ changed thepathway for the patient almostimmediately, with everyoneconcerned fully aware of what washappening, where the patient was tobe sent and what would happennext. There was a reduction in delaysin transfer, and a decrease in thenumber of patients being admittedvia A&E. FAST-negative patients laterconfirmed as a stroke are then sentdirectly to the stroke unit from A&E.

All ambulance crews now assesspatients at site and report theirfindings to the triage nurse, whorecords all relevant information onnew documentation in readiness forthe arrival of the patient. The unitnow has new signs identifying wherethey are located, which helps withdirections for both ambulance crewsand relatives.

ContactHeather McCormackService Development ManagerEast Midlands Cardiacand Stroke [email protected]



Improving acute stroke care in PoolePoole Hospitals NHS Foundation Trust

AimsThe team from the Integrated StrokeUnit at Poole Hospital aimed toimprove direct admissions to the unit,and increase the percentage ofpatients spending more than 90% oftheir hospital stay there. As part ofthis they wanted to consolidate thehyper-acute service experience for allstroke admissions and improve theirthrombolysis service.

IssuesA lot of work had been done acrossthe stroke network to improve theurgent response by ambulance teamsto stroke in the area and developprovision of 24 hour thrombolysis,but the number of patientsthrombolysed at Poole remained low.The team had tried a number ofinitiatives over the years to improvethe quality of service, but were notachieving the standards aroundassessment and treatment of strokefor every patient, and only 37% ofstroke patients were admitted to theunit within four hours.

ActionsAfter raising stroke higher on thetrust agenda through widespreadcommunication and process mapping(including bed managers and highdependency unit staff). A new patientpathway was agreed, focusingspecifically on the part of thepathway from arrival at hospital tocompletion of the multi-disciplinaryteam assessment. This wouldminimise unnecessary delays forpatients being admitted and ensurea safe but speedy pathway forthrombolysis patients both in andout of hours.

The team put in place an ambulancepre-alert system to ensure A&E, thestroke team and other key staff wereaware of any potential thrombolysispatient en route to the hospital tospeed up the response time onarrival. They established training inthrombolysis and telemedicine for allrelevant staff, from ambulance crewsthrough to radiology. Additionalnursing staff for the acute stroke unitto support thrombolysed patientswere secured, protocols agreed forthe senior nurse practitioner torequest CT scans, and all registerednurses and medical staff undertooktraining in safe swallow screening.

A ‘Patient Group Directive’ wasestablished for aspirin to assistdelivery to appropriate patientswithin 24 hours of admission.Extending the developments to strokepatients who were not suitable forthrombolysis, they created an‘assessment trolley’ on the acutestroke unit to speed their assessmentand admission process. Localagreements with a neighbouringtrust enabled 24 hour thrombolysis tocommence in November 2009,supported by a range of publicity andvisits from the team to local GPs.

OutcomesStroke patients are now more likely tobe thrombolysed, to be admitteddirectly to acute stroke unit, to havetimely swallow screening and brainscanning and to be commenced onantiplatelet therapy within 24 hours.



Data shows that thrombolysis rateshave improved from 1.4% at thestart of the project to 5.6% by March2010, and mean door-to-needle timehad reduced steadily from 120minutes in January to 96 minutes byMarch 2010. The percentage ofpatients receiving aspirin within 24hours of admission has risen by 40%and brain scanning within 24 hoursby 16%. The percentage of patientsadmitted to the acute stroke unitwithin four hours of arrival has risenfrom 50% to 76%.

ContactDr Suzanne RagabStroke ConsultantPoole Hospitals NHS Foundation [email protected]



Improving access to the acute stroke unitQueens Hospital NHS Foundation Trust

AimsThe team from Queens Hospitalaimed to increase the numbers ofpatients that access the acute strokeunit) through direct admissionprotocols from A&E. They alsowanted to enhance the strokepathway from A&E to the acutestroke unit and include TIAadmissions, provide 24 houradmission to support strokethrombolysis and to develop theacute stroke unit staff to support A&Ein managing stroke patients andfacilitating transfer.

IssuesInitially, most stroke patients wereadmitted to the emergencyadmissions unit for at least 24 hoursand transferred to the stroke unitlater. No protection of stroke unitbeds meant the six beds in the strokeunit were often used for care of theelderly and medical admissions.

All high risk TIA patients wereadmitted and managed as inpatients,and the thrombolysis service only ran9am to 5pm on weekdays.

ActionsThe TIA service was completelyredesigned to include a five day aweek drop in clinic, with a singlepoint of referral and dedicatedcarotid ultrasound slots. All referralsand carotid requests were screenedby a stroke coordinator, and a directreferral pathway for those patientsneeding vascular surgery wasestablished.

The thrombolysis service wasextended to 9am to 8pm weekdaysusing on call registrars to managecalls and provision of an in-houseradiographer until 8pm. An out ofhours pathway was developed tosupport staff. Developments includeddaily provision of an admission bedon the stroke unit to supportthrombolysis.

An agreement was put in place withthe imaging department to routinelyscan all stroke patients overweekends and bank holidays. Thisincluded provision for tele-radiologyso radiologists could read scans athome.

A stroke unit admission protocolwas written and agreed and acompetency based in-house trainingprogramme put in place on the acutestroke unit. Developments on thestroke unit were linked in withhospital emergency pathway redesignto make sure acute stroke wasincluded in daily operations meetingsand bed allocation was usedappropriately.

OutcomesTIA patients are now managed on anoutpatient basis, avoiding admission,and most are now seen within 24hours.

The acute stroke unit now runs muchmore smoothly. Patients are identifiedby bed management earlier and areallocated to the stroke unit quicker.Communication between cliniciansand capacity management is muchimproved. The proportion of patientsspending 90% of their stay on thestroke unit has increased from 71%to 89%. Now 96% of strokepatients are scanned within 24 hours,compared to 70% at the start of theproject.



A&E now recognise the importanceof the stroke pathway and thebenefits of thrombolysis. Morepatients are being assessed forsuitability and the stroke service hasjoined the IST-3 research trial.1

Two members of the stroke teamreceived the trusts serviceimprovement award this year.

ContactPeter TariStroke Co-ordinatorQueens Hospital NHSFoundation [email protected]

1The 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



Royal United Hospital, Bath, Stroke 2010Royal United Hospital, Bath

AimsThe team from the acute stroke unitat Royal United Hospital, Bath aimedto improve access to the unit anddevelop the services provided there.The existing stroke services would beexpanded to include a hyper-acuteunit and to provide thrombolysis 24hours a day. These improvementswould be evident through measureson speed of access to the unit, timespent on the unit and scanningpromptness.

IssuesThe biggest problem was getting allstroke patients in the trust onto theacute stroke unit. Despite proactivelytracking stroke patients within thehospital and managing beds closely,in the 2008 National Sentinel Audit,only 36% of patients spent 90% oftheir stay on a stroke unit. Inaddition, only 2% were admitted toa stroke unit within four hours ofadmission to hospital.

Patient focus groups, run with thehelp of The Stroke Association,highlighted how bad acute strokepatients’ experiences were when onthe medical assessment unit forseveral days.

ActionsSystematic modelling showed thatbed numbers were inadequate fordemand on the unit. In addition,existing beds were integrated on a28 bed ward shared with neurology,which resulted in a lack of clearidentify for the acute stroke unit.Calculations showed that 26 acutestroke unit beds were needed toensure all stroke patients could bedirectly admitted from A&E, even attimes of peak stroke admissions.

Board level sign up to improving strokeservices was obtained to make this apriority within the trust. Stroke andneurology services were separated intotwo ward areas to give each specialtyits own clear identity. This left a 28 bedward, including one six bed area thatwas converted into a hyper-acutestroke unit and reduced to four beds.

Support for bed availability wasprovided by agreeing equity of theacute stroke unit with the coronarycare unit within the trust in terms ofbed and site management. Every dayat the site meeting, the availability ofa stroke bed is checked in the sameway as a cardiac bed. As soon as astroke patient is admitted to acutestroke unit, bed managementprioritise clearing another bed.

OutcomesAs there is now, for the first time, anentire ward clearly signposted ‘AcuteStroke Unit’, the service’s profilewithin the trust has been raised,morale for staff much improved anda clear mandate given to gear theward around providing the beststroke care.

Patients are now admitted directlyfrom A&E to the acute stroke unit,bypassing the medical admissionsunit and other wards. By the thirdweek of direct admissions, length ofstay had reduced from 18 to 5.5days. Staff throughout the hospital,from infection control to bedmanagement, commented on thedramatic change in the unit.

Twenty eight patients have alreadybeen thrombolysed in the last yearcompared to 12 the year before.The service has been significantlyimproved with no extra money, andthe reduced length of stay hasresulted in cost savings to the trust.

ContactDr Louise ShawConsultant Stroke PhysicianRoyal United Hospital, [email protected]



Fast access to stroke care pathwaySandwell and West Birmingham Hospitals NHS Trust

AimsThe core aim of the team in Sandwellwas to develop a direct admissionpathway and protocol for all strokepatients. This would improve careand result in patients beingtransferred directly to an acute strokeunit from A&E within four hours,spending at least 90% of theirhospital stay on a stroke unit, andreceiving timely swallow assessmentand brain scanning.

IssuesAt the start of the project, the strokepathway meant patients wentthrough the emergency assessmentunit before going to the stroke unit.There could be a delay of a day ormore before the patients wereadmitted to the stroke unit; thosewho had minor strokes could bedischarged home without reachingthe stroke unit at all.

Although there was a clear pathwayestablished, the thrombolysis servicewas from 9am to 5pm weekdaysonly.

ActionsTwo initial consultation exercises wereheld with all staff and also patientsand carers. This lead to a plan ofareas to be reviewed and developedand had management support andengagement. An initial review of thepathway confirmed that there wereoften long delays in admission to thestroke unit.

A process of meetings anddiscussions were held over a periodof time with the acute on-call teams,A&E, the stroke unit and radiologyteams. The agreed path was toadmit patients directly from A&E,following a medical review there withthe co-operation of the on call teams,and patients should receive their CThead scans before transfer to thestroke unit, all within 24 hours.

However, everyday pressures meantthat the new pathway requiredcontinuously reinforcing, monitoringand reviewing. There was agreementfrom management, bed managementand the stroke unit that there wouldalways be a bed available on thestroke unit. Any delays in A&E wereescalated up to the on call manager.

An audit clerk has been recruited andthe information department havedeveloped a monitoring system thathighlights patients that do not spend90% of their time on a stroke unit.This allows the pathway to becontinuously checked and data to bevalidated easily. There is a weeklyreview of the patient’s pathway and amonthly stroke action group(including representation from alldepartments) which provides supportfor development of the wider strokeservice.

OutcomesA staff and patient and carerengagement process, called ‘listeningin action’, was successful in raisingawareness of stroke and engaging allkey stakeholders.

Stroke has become recognised as anemergency and it is acknowledgedwidely that ‘time is brain’. Scans aredone faster and suspected strokepatients are transferred directly fromA&E to the stroke unit. There hasbeen a significant increase in patientsbeing scanned in a timely manner,and there is always a bed available onthe stroke unit.



The most significant change is therecognition of stroke and teamdevelopment across a wide range ofdepartments from the ambulanceservice, A&E, bed management,radiology, the acute stroke unit andgeneral management.

There is now a 24 hour thrombolysisservice including a comprehensivepathway and a structured educationprogramme for both doctors andnurses.

ContactJackie WilkinsonStroke Co-ordinatorSandwell and West BirminghamHospitals NHS [email protected]



Acute stroke care: ‘building teams,building stroke services’Surrey and Sussex Healthcare NHS Trust

AimsThe project aimed to develop aneffective stroke team, which woulddrive their stroke service forward andto develop comprehensiveinterdisciplinary working. This wouldsupport wider aspirations aroundimproving the acute stroke service,including establishing an acutepathway for direct access to specialiststroke services, introducing athrombolysis service, improved accessto brain imaging and patientsspending more of their stay on thestroke unit.

IssuesThe acute stroke unit comprised 21beds, but lacked a formal bed policyor stroke pathway. The service hadbeen led by successive locumconsultants for two years, andselection of patients for the acutestroke unit was made by on callmedical staff, resulting in an ad hocapproach. CT was accessed via the‘next day early bird slot’ system. Thetrust did not have a thrombolysisservice for eligible patients and soFAST positive patients were divertedto other trusts. Only 7% of patientswere directly admitted from the A&Eand 56% of stroke patients did notspend any time on acute stroke unit.

Having had a long period of timewith different clinical leadership andstyles, morale on the ward was low.

ActionsTwo key actions have facilitatedimproved bed management and flow:1. the introduction of a fast-track

bed for patients who can bemoved off the acute stroke unit,and a daily bed status form tohighlight delays to discharge ispresented at the daily 9am bedmeeting

2. a 24 hour stroke outreach teamnow identifies and tracks strokepatients within the hospital, with asupernumery bleep holder duringthe day, a senior acute stroke unitnurse at night and other outreachnurses who proactively seek strokepatients from the wards

Through engagement with radiology,a dedicated bleep is held by a dutyradiographer for 24 hours and acutestroke patients are automaticallyadded to the urgent protocol for nextCT scan slot.

Many initial difficulties within theservice stemmed from the lack of aunified vision of its future amongstthe team. The project was used to setobjectives with timeframes in whichto map the changes, and establishworking groups to achieve them.

Senior team members organisedtraining for junior members as well asensuring core competencies weremet, and specific training on goalplanning was given to therapy andnursing staff. As a result, workingpractices have gradually developed,delivering a more cohesive approach.This includes interprofessionalsupport for the daily ward rounds toenable status updates, effectivedischarge planning and a predicteddate of discharge for each patient.

A new whiteboard has become thecentre of the teams’ activities,allowing rapid knowledge of thecurrent status of each patient,including their predicted dischargedate and destination. This allows theweekly interdisciplinary teammeetings to focus on patient centred,specific goals and trialling differentoutcome tools.



Two experienced stroke consultantphysicians have been in post sinceJanuary 2010, bringing newleadership and direction to theservice, with new ideas fordevelopment and productivity. Thenew stroke pathway commenced inJanuary 2010, and an 8am to 10pmthrombolysis service was launchedwith four consultant physiciansworking the rota, supported by off-site CT viewing.

OutcomesSignificant improvements have beenmade to access to the acute strokeservices and compliance with vitalsigns targets is better. Directadmissions peaked at 60% inFebruary 2010, with 67% of patientsachieving 90% stays on the acutestroke unit, and 86% of patientsspending some of their hospital stayon the acute stroke unit. By March2010, 66% of patients had CT scanswithin three hours.

The team feels that muchimprovement is due to thedevelopment of the outreach service,crucially incorporating a dedicatedbleep holder, presence in A&E andproactive approach. This has beenfurther enhanced by staffenthusiasm, positive PR for the strokeservice and improved relations withradiology.

The bed status sheet has beeninvaluable in highlighting whereproblems are encountered on a dailybasis and has given the teampermission to actively manage theirown beds. Documentation of theinterdisciplinary team has improved

and become clearer, encapsulatingstatus and goals, and a simplesummary sheet for bettercommunication with patients andrelatives. Average length of stay hassteadily reduced from 20.4 to 13.7days.

A recent staff feedback exerciseshowed positive attitudes andexamples of considerably improvedmutual professional regard andunderstanding. A key learning pointhas been that the team is morepowerful as a whole than the sum ofits parts, and that forwardprogression need not rely on any oneindividual. With mutual respect andan understanding of each others rolesa team can work effectively without asingle leader. When a team ismotivated and empowered, it hasdirect effects on patient care andoutcome measurements.

ContactDr Natalie PowellSpecialist Registrar in StrokeSurrey and Sussex HealthcareNHS TrustEast Surrey [email protected]



AimsThe team aimed to improve patientaccess to the acute stroke unit, andensure those transferred to otherwards are identified and moved toacute stroke unit promptly. This wascoupled with specific aims to speedup physiotherapy assessment,improve discharge processes anddevelop staff education and training.

IssuesInitially, only 20% of patients weredirectly transferred to the acutestroke unit from A&E and/or themedical admissions unit. There weredaily issues with patients with strokeon other wards and stroke beds filledwith non-stroke patients.

Process mapping showed thepathway for stroke patients wascomplicated and confused (see figure2). There was no formal programmeof education for staff, rehabilitationwas bed-based and only oneconsultant physician was undertakingthrombolysis.

ActionsThe service improvement lead for thetrust ran a pathway exercise with agroup from the trust and the PCT toplot the current pathway and designa better one.

A key step in the project was topromote the stroke service status asan urgent specialist service, similar tocardiology. This raised the profile ofimproving the quality of strokemanagement and care within thetrust by prioritising stroke patients,and ensured stroke was considered atbed meetings three times a day.

A capacity mapping exercise wasundertaken to look at the number ofacute stroke beds and the numberneeded. An agreement was made toring-fence beds on the acute strokeunits countywide, and threeadditional acute stroke beds openedin August 2009. Two newappointments of stroke specialist

EASY (early admission to strokeunit your brain heals quicker)Worcestershire Acute Hospitals NHS Trust

Figure 2: Worcestershire Acute Hospitals NHS Trust process map



nurses enabled an overview of whereall patients are, and helped to workclosely with the bed manager totransfer patients appropriately.

The team set up a formal programmeof education and training for staffworking in stroke units, includingthrombolysis training days, andundertook a workforce mappingexercise. There was increasedawareness of how fundamental it isto manage the ‘back door’, i.e.improving rehabilitation and speedingup discharge. Although delays stilloccur with social services dischargingpatients, close liaison with thecommunity stroke team has enabledimproved patients flows.

OutcomesAccess to the stroke unit and theproportion of time spent on the unithas been increasing month by month,with an increase in direct admissionsfrom A&E or the medical admissionunit. Physiotherapy assessment hasimproved, and the Commissioning forQuality and Innovation (CQUIN) forthe service achieved.2

There are now daily multidisciplinaryteam meetings on the acute strokeunit and all stroke patients arediscussed at all bed meetings threetimes a day. The acute stroke unit onthe Worcester site has beenreconfigured to have its own staff(who are not rotated), and the

appointment of a family and carersupport worker from The StrokeAssociation offers inpatient and post-discharge follow up. The strokerehabilitation ward has beenupgraded in line with privacy anddignity guidelines and further clinicslots opened for high-risk TIA patientsto avoid admission.

A successful ‘stroke school’ has beenestablished, and further sessions arebeing delivered, giving staff greaterinsight into their work and the workof other members of the team. Acardiovascular disease degree moduleat Worcester University has also beenset up.

ContactElaine StratfordStroke Specialist NurseWorcestershire AcuteHospitals NHS [email protected]

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Figure 3: Percentage of stroke patients spendingat least 90% of their time on a stroke ward

2Further information on CQUIN can be found on theDepartment of Health website at: www.dh.gov.uk



AimsThe team wanted to improve theprocess for all acute stroke patientsbeing admitted and make the serviceless dependent on individual staff. Itwas envisaged that this wouldincrease the likelihood of success ofexpanding the thrombolysis serviceinto evenings and the weekend.

IssuesThere was agreement within theteam on perceived key issues, but anabsence of readily available data tosupport this. Firstly, challengesaround early assessment for strokepatients in A&E, and secondly,insufficient capacity on the strokeunit because of difficulties with timelytransfer to the community.

ActionsThe team held monthly meetingswith time divided between the twokey issues to help them remain clearand progress with both aspects.Money released by a reduction ofclinical hours of the consultant nursewas transferred into two posts forstroke within A&E, therebysmoothing the process of trainingand developing protocols in strokeamongst A&E staff.

The issue of outlying stroke patientswas highlighted to senior staff bycreating a daily list. This meant thatthe process of transfer onto thestroke unit became less dependanton the knowledge of any oneprofessional and reduced the numberof duplicate phone calls.

To tackle challenges around transferout of the unit, work with communityteams reduced the paperwork trailand streamlined the process wherepossible. As there were three PCTs,each with different referral processes,this was a complex task. To resolvethis, at each multidisciplinary teammeeting, the stroke unit team wouldcode each patient red (medicallyunfit) amber (ready for transfer within72 hours) or green (fit for transfer),and then share this with theappropriate PCT link team. Thecommunity team now anticipatepatients that will be ready fordischarge in the next few weeks, andtake the necessary actions locally.

All the newly developeddocumentation, protocols, andtraining information for stroke wastransferred onto the trust intranet,for use as the key resource and forthe stroke team collectively to keep itup to date.

OutcomesStroke patients are being triagedmore quickly in A&E. Initially, datacollection showed no significantimprovement in either initialdiagnosis or direct admissions, butthis may been due to the recentextension of the thrombolysis serviceto 8am to 11pm Monday to Friday,which had meant additional trainingof medical and nursing staff. Aswith other teams, local factors, suchas ward closures and peaks inadmissions, may have skewed thepicture for direct admissions,although there is now a confidencethat a change in thinking has beenembedded, and that all staff areworking collectively to ensure accessto the stroke unit from A&E.

One call does all: smoothing the transfer fromthe emergency room to the acute stroke unitYeovil District Hospital NHS Foundation Trust



Despite problems created by wardclosures for infection control creating‘bumps in the road’, progresscontinues towards the aspiration for‘90% stay on a stroke unit’.

The length of stay for Somersetpatients in the last three months hasreduced from 18 days to 13 days;whilst the only change in practice hasbeen the smooth, consistent, transferof information from the acute trust tothe PCT on a weekly basis.

The team feel that the appointmentof a stroke link within A&E hasresulted in a greater than expectedimprovement in knowledge andstroke care, which is evidenced byincreased attendance of A&E staff atstroke study days. Data collection willcontinue, as it has helped quantify‘gut feelings’ and demonstrateimprovements, however small. Theservice is now viewed less as aMonday to Friday service across allparts of the organisation, with morerecognition being given to theimportance of timely intervention,particularly in relation to brainscanning and direct admissions.

ContactCaroline LawsonConsultant Nurse – StrokeYeovil District Hospital NHSFoundation [email protected]

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Figure 4: 90% stay on a stroke unit



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.

Stroke Resources

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



Stroke Improvement ProgrammeNational TeamNHS Improvement - StrokeImprovement Programme3rd Floor, St John's House,East Street, Leicester LE1 6NB

Tel: 0116 222 5184Fax: 0116 222 5101www.improvement.nhs.uk/strokeEmail: [email protected]

Further information

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

Telephone: 0116 222 5184 | Fax: 0116 222 5101


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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