stroke pathway redesign project governing body

www.enhertsccg.nhs.uk .

Stroke pathway redesign project Governing Body Presentation November 2017 update An update on the outcomes of the stroke pathway redesign.

Lead Director: Sharn Elton Director of Operations

Gillian Catchpole, Project Manager, East & North Hertfordshire Clinical Commissioning Group (ENHCCG ) Jennifer Kearney, General Manager, East and North Hertfordshire Trust (ENHT) Charlotte Reynolds, Service Manager Neurological Services, Hertfordshire Community Trust (HCT)

www.enhertsccg.nhs.uk

Purpose

To provide information to organisational Governing Bodies on the full year effect of stroke pathway changes.

To provide feedback to ENHCCG on actions from previous presentations.

Approval for stroke pathway changes to move to business as usual.


Project summary

Project summary:

Implementation of evidence based pathway redesign to include Centralised hyper-acute stroke unit

Early supported discharge (ESD)

Community stroke rehabilitation beds

Primary Prevention

Pre-hospital

Acute Phase

Community Rehab

Long Term Care

Secondary Prevention

End of Life


Discussion points from January 2017 Governing Body Presentation

Confirm delivery of business case objectives based on full year effect.

Investigate potential to deliver out-reach stroke out-patient follow-up and Transient Ischaemic Attack (TIA) clinics at PAH.

Investigate the potential to benchmark TIA performance.


Summary of changes

Unplanned:

No Acute stroke unit, TIA or out patient clinics at Princess Alexandra Hospital (PAH).

Bedford Hospital changes in stroke service pathway.

Phased plan:

Centralised hyper-acute and acute stroke unit.

24/7 TIA service at East and North Hertfordshire Hospital Trust (ENHT).

7 day ESD.

Support to provide stroke rehabilitation standards to up to 4 beds at Herts and Essex Hospital.

Establish 6 month reviews.

Other:

Updated Royal College of Physician Guidance for Stroke Care V5 October 2016.

Pathways for thrombectomy (mechanical clot removal).


ENHCCG: Confirmed inpatient stroke activity flows 2016-17

Provider

Predicted Inpatient Flows*

Actual No. of Inpatients

Spells

Variance Spells

%Variance

(Under - / + Over)

(Under - / + Over)

East & North Hertfordshire 605 630 25 4.1% Mid Essex Hospitals 44 5 -39 -6.4% Queens Hospital 8 25 17 2.8% Cambridge University Hospitals 18 18 0 0.0% University College Hospital 15 15 0 0.0% Luton & Dunstable Hospital 0 7 7 1.2% Imperial College 5 5 0 0.0%

Royal Free 3 3 0 0.0%

West Hertfordshire Hospitals 2 2 0 0.0%

North Middlesex Hospital 2 1 -1 -0.2%

Other 22 9 -1 -0.2%

Total 712 720 8 1.3% Notes:

1) * Predicted confirmed inpatient flows as per the business case

2) Actual number of patients spells is as per the SSNAP Annual Report


ENHT: Confirmed inpatient stroke Activity by CCG 2016-17

CCG Name (where ENHT first admitting hospital)

Predicted Inpatient Flows*

Actual No. of Inpatients

Variance (Under - /

Over +)

% Variance (Under - / Over

+)

East and North Hertfordshire CCG 605 630 25 4.1%

Other CCG 156 201 45 28.8%

Total 761 831 70 9.2%

Notes:

1) * Predicated patient flows as per the business case

2) Actual number of patients is as per the SSNAP Annual Report 3) Number of patients admitted increases to 846 when transfers & in-patient stroke included

The increased activity against plan attributed to • Additional ENHCCG activity • Changes in the Bedford stroke pathway


Improved performance on stroke metrics: Sentinel Stroke National Audit Programme (SSNAP) clinical audit

Other providers April-July 2017: 4 or more admissions

Apr-Jun 2015

July-Sep 2015

Oct-Dec 2015

Jan-Mar 2016

Apr-Jul 2016

Aug-Nov 2016

Dec-Mar 2017

Apr-Jul 2017

ENHCCG D D D C A B A A

ENHT D C C C A B A A

Queens HASU D

University College Hospital HASU A

Addenbrooke’s Hospital B

Charing Cross HASU B


Rapid access to specialist services EEAST data

0%

10%

20%

30%

40%

50%

60%

70%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Pe

rce

nta

ge A

ttai

nm

en

t

EEAST Stroke Contract LQR3 Stroke FAST 60 Activity vs Target 2016/2017

2016/17 Target

Professor Tony Rudd, National Clinical Director of Stroke said in the initial ENHCCG stakeholder engagement “…in some cases an ambulance may drive a patient further, but we know that in other parts of the country where this already happens, it has saved lives.”

ENHT performance (SSNAP Patient centred 72hrs) 2015/16 2016/17

Median time from clock start to scan at ENHT hours: minutes 1:06 0:58

Assessed by a stroke consultant within 24 hours of clock start 68% 83.6%


ENHCCG performance against key targets


Outcomes data: Mortality CCG stroke mortality data

Year

Standardised mortality ratio

Crude

14/15 1.0 13%

15/16 0.94 12%

Data source: SSNAP clinical audit


Outcomes data: Mortality ENHT Stroke Mortality

SSNAP April 2015 – March 2016 April 2016-March 2017

Patients with fully record National Institute of Health Stroke Scale

89.3% 97.6%

Standardised mortality ratio 1.00 (not an outlier)

0.95 (not an outlier)

Crude Mortality 13% 12%


Outcomes: ENHT Key comparators

Reduction in mean length of stay.

Shift in percentage of patients being discharged with no or slight disability in relation to the percentage with severe disability.

Reduction in percentage of patients discharged to a care home where not previously resident.

SSNAP 2015/16 2016/17

Mean length of stay on a stroke unit

16.9 days 12.5 days

SSNAP post 72hr team centred


ENHT: Outcomes against business case

Position at service launch Business case prediction Status

5 days consultant led ward rounds 7 day consultant led ward round Achieved

5 day consultant TIA clinics 7 day consultant TIA clinics Achieved

Telemedicine supported out of hours stroke service

24/7 consultant led service Achieved. In house service planned Q4

Nursing levels to support current bed model

Nursing levels numbers meet national guidance

Achieved improved staffing ratios*

5 day therapy services 7 day therapy services Achieved

7 day stroke specialist nurses 24/7 stroke specialist nurses Achieved

No ward based psychology Ward based psychology Achieved

42 stroke beds 44 stroke beds Achieved 48 beds

* See slide 21 – workforce for further detail


Outcomes: Patient feedback

“Within a short time the ambulance crew arrived , attended to me at home & decided to take me to A&E Lister. I was seen afterwards by a steady stream of professionals. Throughout the episode I was treated well and as speedily as can be expected & I am pleased to report that I am progressing from the low point I was at when I was taken ill.”

98.5% Average Friends &

Family score at ENHT on stroke

wards

“…. was rushed to A&E with symptoms of a stroke. In the A&E Department he was treated by two amazing stroke doctors from Pirton ward where he was eventually transferred to. His entire stay was for 12 days where I believe he received a truly brilliant service.”


Outputs & outcomes: ESD 2016/17

45% of patients discharged with

ESD

7.1% increase in the number of

patients seen by ESD

92.6%

of goals met on transfer/discharge

87% of patients started a

treatment programme within one working day of

discharge from hospital

68% of patients assessed and

discharged from an inpatient setting within 1

working day of referral

Source HCT contract monitoring data 2016/17

71%

of patients admitted to ESD are from ENHT


Outcome: ESD – Patient Story

62 year old male previously fit and well discharged from an out of area hospital, with three times a day care following diagnosis of multiple cerebellar infarcts.

Carers telephoned ESD the morning after discharge highlighting concerns about mobility.

Urgent physiotherapy assessment completed within 1 hour of the call and ensured a safe method of transferring.

An exercise programme completed with support from Rehabilitation Assistants.

Occupational Therapist assessments encouraged independence with functional tasks and provided necessary equipment.

Successful MDT working with the patient gradually reduced the number of care calls required.

After 4 weeks the patient was discharged with no requirements for ongoing care and independently walking his dogs.

No onward referrals were made.


Outputs and outcomes: Stroke rehabilitation Community Beds

Business case: ESD to support a maximum of 4 beds (2 beds to be ring fenced for stroke for first 4 months). Average 2-3.

Community bed based stroke activity 2016/17

Name of Unit Number of Admissions Average Rehab Length of Stay

Danesbury 120 (81%) 37 Days

Herts and Essex 27 (19%) 27 Days

A SSNAP


Low take-up but above national average.

Offered face to face and phone consultation.

Positive feedback from those in receipt of a 6 month review.

Plan: Questionnaire to identify reasons for decline, pilot evening sessions, collect data to inform future planning.

Outputs & outcomes - 6 month reviews

Local Stroke Association

ESD


Hertfordshire County Council: Outcomes of integration of social care into stroke teams

Better multidisciplinary working.

Increased involvement of Adult Social Care in Joint Care Planning.

Positive outcomes enabling long term recovery and support.

Greater recognition of the carer role - carers assessment and contingency planning.

A fully integrated pathway

Small dedicated team of care workers - specialist training in stroke care.

Effective communication & partnership working.

Review of 60 people accessing ESD - only 4 needed on going care.

Adult Social Care Specialist care packages in ESD


Outputs: Workforce changes

6 Consultants

24/7

Clinical Stroke Nurse

Specialists

Nursing vacancy on

stroke wards

3.8 Band 5

2.51 Band 2

7 day therapies for

in-patient beds and

ESD

Psychology in both

acute and community

Dedicated Social Care

and specialist

care workers


Outcome: Staff feedback

“More of a complete team than before.”

A service to be proud of.”

“We get recognised by the trust management and given good feedback to the team now.”

“It feels good when patients and their families say they’ve had a good service”


Background to TIA

Updated RCP guidelines Patients whose symptoms within last 7 days to be seen within 24 hours.

Patients whose symptoms not within last 7 days to be seen within 7 days.

ENHT operating a 7day TIA service.

Reviewed potential to provide TIA and outpatient clinics at PAH or Hertford County – not viable.

Commenced implementation of new guidance at ENHT Currently baselining performance

Setting up STP benchmarking

Challenges around patient recognition of urgency to attend Currently developing a ‘2ww’ type leaflet


LEADERSHIP, COMMUNICATION,

TRUST &

TRANSPARENCY

PARTNERSHIP &

COLLABORATION

Organisational and clinical engagement

SOLUTION FOCUSSED

& CAN DO

ATTITUDE

System integration based on an evidence based framework of care

GIVE TIME &

PERSEVERE

SHARED VALUES & COMMON AIMS

VISION

PROACTIVE

INNOVATE

ENGAGE VISABILE


Continued challenges

24/7 thrombolysis

Thrombectomy

Improving uptake of 6 month reviews

Final recruitment push

Embedded culture

Changing landscapes


Next steps

Continuation of Stroke Programme Board – horizon scan

Pathway outcomes measured through contract and quality meetings

Communications campaigns particularly in Bishops Stortford area

Link into social prescribing project and other relevant prevention initiatives

Interventional pathways (thrombectomy)

TIA leaflet

stroke pathway redesign project governing body

Documents