Royal College of Physicians of Edinburgh

Scottish Stroke Collaboration Meeting

22nd September 2010

Queen Mother Conference Centre

The Hyperacute Stroke Unit Model NHS Ayrshire & Arran

BACKGROUND 2008

• NHS Ayrshire & Arran offers a comprehensive stroke care service.

• In Ayr hospital - 15 acute stroke beds in 30 bedded acute geriatric assessment unit. 20 rehabilitation beds at different site.

• In Crosshouse hospital – 21 acute stroke beds in acute geriatric assessment unit. 20 rehabilitation beds at different site.

QIS Standards 2008

• 70% of stroke patients are admitted within 1 day of admission.

• Swallowing assessment 100% on day of admission.

• CT scan 80% within 2 days of admission.

• Aspirin – 100% of definite ischaemic events within 2 days of admission.

Ayr Hospital 2008 figures

• 71% entered stroke unit within 1 day.

• Swallowing assessment 64%.

• 74% of patients scanned within 2 days of admission.

• Aspirin 49% within 1 day.

Background of Hyperacute stroke unit (HASU)

• Agreed all possible stroke patients should be admitted to a designated area with specialised medical & nursing input.

• It would enhance implementation of QIS standards.

• Facilitate monitoring of patients with a proposed limited thrombolysis service.

Design of HASU

• 6 bedded mixed sex area in 30 bedded acute geriatric assessment unit.

• Changed 15 stroke beds to 6 HASU beds & 9 acute stroke beds.

• 1 registered nurse & 1 NA allocated 24/ 7 plus an additional registered nurse Mon - Fri 0830 -1630.

• Daily medical review followed by brief review of investigation on same day.

Design of HASU

• Close monitoring of occupancy with agreed protocol of transferring patients out of HASU.

• Priority of at least 1 HASU bed 24/7 for proposed thrombolysis.

• Continuous monitoring of all patients including thrombolysis patients.

• Additional training for nurses.

Patients journey

Patients with possible TIA / Stroke

Admission to HASU immediate HASU nurse review including NIHSS medical review non-stroke diagnosed - moved out of HASU Stroke diagnosed – stroke protocol initiated.

Period review

• 01-04-08 – 31-03-09 pre- HASU

• 01-04-09 – 31-03-10 post- HASU

Number of patients

Pre - HASU419

Post HASU527

Number of admissions

Pre HASU

419

Number of stroke patients

377

Post HASU

527

Number of stroke patients

403

Comparison of QIS data pre & post HASUQIS Standard PRE POST

2008 - 70% enter stroke unit within 1 day. 2009 - 90% by 1 day

71% 92%

Swallowing 100% on day of admission 64% 82%

2008 - 80% scanned within 2 days of admission. 2009- 80% on day of admission

26%-74%

37% -82%

Aspirin 2008 – within 2 days of admission. 2009-100% on day of admission

49% 72%

Length of stay (days) 12.5 8

Number of deaths 27pts 23 pts

Number of patients discharged from ASU 24% 31%

Benefits

• Allows comprehensive assessment of patients presenting with possible diagnosis of stroke/ TIA.

• Facilitates implementation of QIS Standards.• Earlier detection of complications.• Reduces length of stay in hospital.• Safer environment for monitoring stroke patients

including those receiving thrombolysis.• Increased motivation of staff in area.• All new stroke patients clearly identified in HASU.

Challenges

• Increasing turn over of patients through a very specialised area.

• Allows many non-stroke patients to be admitted to HASU.

• Requires constant vigilance on bed management. • Requires dedicated nurses with specialist knowledge in

stroke.• Requires protected job plan for regular medical

supervision at a senior level.• May have impact on AHP workload.

Royal College of Physicians of Edinburgh

Scottish Stroke Collaboration Meeting

22nd September 2010

Queen Mother Conference Centre