The Stroke Project has been underway since October 2000. This workshop represented the first mechanism where by issues surrounding the project have been addressed by the multi- disciplinary stroke team and the Darent Valley Hospital Staff. Approximately 35 members of staff attended the workshop, demonstrating the high level of interest and ownership. Currently, the hospital receives an average eight or nine new stroke admissions a week. The turnover is such that patients suffering from stroke account for around 22-23 occupied beds in the acute hospital at any point in time. In the past the Acute Trust had had a lead Stroke Physician responsible for 20 designated stroke beds within a stroke unit. In that system many (but not all) cases of acute stroke admitted under the General Physicians would have been referred to the stroke unit and had their acute care and acute rehabilitation provided on site in that unit. At that time the overall number of beds occupied by cases of stroke was around 28- 29

Meade, F.

O'Neill, Declan

Woodley, R.

English

Kent Academic Repository

    Report on the Integrated Stroke Care Workshop  Dr Declan O’Neill Miss Fiona Meade Ms Rosemary Woodley     December 2000 REPORT OF THE INTEGRATED STROKE CAREWORKSHOPMonday 13th November, 2.3Opm, Chief Executive Boardroom, Level 4,East Wing, Darent Valley Hospital, Dartford.Lead:Facilitator:Ms Rosemary Woodley, Rehabilitation Co-ordinator, Darent Valley HospitalDr Declan O'Neill, Senior Lecturer, CHSS at Tunbridge Wells, University ofKentBackgroundThe Stroke Project has been underway since October 2000. This workshop represented thefirst mechanism where by issues surrounding the project have been addressed by the multi-disciplinary stroke team and the Darent Valley Hospital Staff. Approximately 35 members ofstaff attended the workshop, demonstrating the high level of interest and ownership.Currently, the hospital receives an average eight or nine new stroke admissions a week. Theturnover is such that patients suffering from stroke account for around 22-23 occupied bedsin the acute hospital at any point in time. In the past the Acute Trust had had a lead StrokePhysician responsible for 20 designated stroke beds within a stroke unit. In that system many(but not all) cases of acute stroke admitted under the General Physicians would have beenreferred to the stroke unit and had their acute care and acute rehabilitation provided on site inthat unit. At that time the overall number of beds occupied by cases of stroke was around 28-29.Recently there has been a reconfiguration of services and the retirement of the former leadStroke Physician. The new system is such that cases of acute stroke admitted under theGeneral Physicians will generally remain within the ward where they are admitted untildischarge. A successor to the lead stroke physician takes up his appointment in January. Oncurrent strategy, the lead stroke physician is to provide a specialist consultation service toother clinicians, but is not expected to have a unit for taking over the care of such patients. Inplace of some of the elements of the former system there is a community based stroke teamand there are six new community based stroke care beds at the Livingstone. These areoverseen by a General Practitioner with an interest in stroke care. In fact the Acute hospitalhas seen a bed reduction of 20% (500 beds reduced to 400) and the proportion of occupiedbeds represented by stroke has seen a concomitant reduction of 20% (c.28.5% reduced to22.5%). At the same time the Livingstone, with 6 stroke care beds and c.l00% occupancy, inthe community, can be said to have accounted for the reduction in acute care provision.The Stroke team therefore is the subject of interest in that with its services in start-up modeand the establishment of PCT managed intermediate care services due in January. There is acertain expectation that these community focused services should be able to take more of thestroke burden out of the acute unit. This is especially hoped for in the face of evidence thatshows how a substantial proportion of acute unit occupied bed days identified as stroke casesare occupied by patients no longer in need of acute care. It is however also acknowledgedthat much of the 'bottle neck' relates to a relative shortage and perhaps contracting stock ofnursing home beds in the community. It is a legitimate fear, therefore, that the dis-investmentfrom acute care and reinvestment into community health care might be better spent byredirecting some of it to social care enhancing the provision of nursing home beds.IntroductionThe workshop consisted of two sessions. The first session involved dividing the attendeesinto six groups, namely: the stroke strategy, acute care management, rehabilitation, hospitalutilisation, discharge management and the stroke team. Within these divisions the attendeesconsidered aspects of the stroke project which they deemed to be 'excellent' (representingbest practice in action), 'satisfactory' (those things which appear to be going to plan, butwhich bear scrutiny to assess that they are optimal) and those 'needing attention'. Theseaspects were recorded and presented by an elected raconteur from each group. A definitivelist was then constructed from all the groups responses with any repetitions omitted.The second session involved the six groups pairing up and discussing the issues raised insession one under the headings of: action (what action is to be taken), responsibility (whoshould be responsible to take the action) and time frame (when should the action be taken).Session OneThe IssuesThere was good positive discussion in all groups and a number of issues were examined. Thepresentations allowed for further debate between all the attendees. Various issues werereplicated, but there were differing opinions surrounding some issues as to what wascurrently in place, and what was believed to be working at various points on the carecontinuum for stroke patients.Aspects of Excellence:The Stroke Team - who are dedicated, multi-disciplined, enthusiastic, approachable peopleoffering specialist advice and expertise. The team was also thought to be easily contactablebetween the hours of 9-5, however this lead to discussions over the out-of-hours access andthe location of various members of the team (on/off site ego OTlPhysio).The Concept - the idea of the stroke team was believed to be an excellent concept by onegroup and representative of a very positive initiative. Concerns were expressed over whetherthe delivery of this concept was quite as effective as desired, although it was acknowledgedthat the stroke project had good potential.Quick Response - Some groups expressed this as an excellent feature, but not all attendeeswere in agreement as discrepancies were highlighted between the referral, assessment, CTscans and admission times. Although it was suggested that once all the tests etc had beencompleted then the stroke cases were dealt with quickly. One group identified the fast2response of being able to assess new CVA's within 24 hours. Again this lead to discussionover the whether the time frame of 24 hours included admitting the patient or not.Liaison - this was deemed to be an excellent aspect by a number of groups. In particularthose involved with dietetics and speech and language believed that having the sameemployer and coverage of the acute and community sectors lead to excellent liaisons. Closeliaisons and communication was emphasised between members of the stroke team and GP's,DN's, community multi-disciplinary services and the discharge co-ordinator. One groupidentified that a key worker for each patient with which they could liaise was a positiveaspect.The Referral Process - a small clarification appeared to be required on this area as to whethera completed form was required or just a phone call was needed for referral. Variousattendees mentioned that they were unsure whether a form had to be filled in as they had notcompleted one to date and if not then would this be detrimental for auditing purposes.Within this issue area it was deemed that the appropriateness of GP referrals was excellent, aswas the referral from physiotherapists.Fast Track Rehabilitation - factors such as immediate acceptance of CVA patients by theLivingstone was emphasised as being a very positive issue. The good rehab in DVH wasalso emphasised as a positive issue. The policy of being able to look after stroke patients athome by having the total involvement of the family was categorised as an 'excellent' aspect.Other issues - three aspects which were identified under the heading of'excellent' includedthe prevention of hospital admissions, the evaluation of patient progress including goalcentred care and valid outcome measures and outpatient accessible CT scans taking placewithin the 48 hours. Again there was a question over the amount of time between referral,the CT scan taking place and actual diagnosis for admission.Aspects which are satisfactoryThis appeared to be a difficult category to slot issues in to as they either appeared to work inwhich case they were categorised in to the 'excellent' list or they failed to deliver what wasexpected in which case they were in the 'needing attention' list. However a number of issueswere stated by some of the groups.One issue which appeared to be defined as satisfactory was the speed in which cases are dealtwith, however one group specified that although the patients were accepted quickly there isstill a delay in the discharges and a large number remaining in DGH.Other satisfactory aspects include improving links with physiotherapy staff and supportiveward staff. The final aspect which was highlighted was that the criteria was agreed andworking, but members with in the group stated that the criteria may need re-visiting at certainpoints in time.3Aspects which need attentionA large number of issues were highlighted in this particular section and which produced agreat deal of discussion. The issues detailed are as follows:CT Scans - the main concern under this issue appeared to be the delay in getting the CT scanperformed. Over and above the difficulties in organising for CT scans to be conducted out-of-hours or over a weekend (due to no service being available during these times), a numberof groups also mentioned the difficulties in obtaining the doctor's signature for the CT scan.This results in delays in acceptance by the stroke team and blocking of beds by those patientswho are then diagnosed as not having had a stroke. Some staff were under the impressionthat CT scan was essential for diagnosis of stroke and that this was a cause of delayedreferral. This lead to some debate whether or not those patients who had clearly suffered astroke should need to wait for a CT scan or whether they could be referred directly.Presumably they don't but this is a communication block.Acute Beds - There are six Livingstone acute beds available for stroke care under the leadstroke G.P. There are c.8-9 new cases of stroke admitted to the acute hospital each week.Each stroke case is admitted under the on-call physician of the day. Subsets of these will beonwardly referred to the lead stroke physician and to the rehabilitation service. Alladmissions diagnosed as stroke should be referred to the stroke team. Currently there aresome noticeable variations between physicians both in the actual uptake of the referralservice and in the lead time from diagnosis to referral.(Action opportunity ~ investigate the variations in physician use of the services and optionsfor increasing uptake where appropriate.)Rehabilitation Beds and Community Beds. - The numbers of both rehabilitation beds andcommunity beds are perceived to be lower than desirable. Some observers at the workshophave suggested that a lack of access ( or perceived lack of access)to beds in the communityfor people no longer needing acute medical care is still a significant cause of delayeddischarge. Some observers reported that the number of available nursing home beds in thecommunity, to which rehabilitated stroke patients can be discharged, is contracting. Thisproblem is thought to be more critical for the patients requiring slow stream rehabilitationrather than the fast stream ones.(Action opportunity - A short term alternative in the form offurther provision ofintermediatecare facilities should be considered. Various opportunities under joint investment planningpresent themselves. It may be that the volume of slow stream rehabilitation patients warrantsfurther development of specific facilities. It may be appropriate to review the available'hotel' function beds if there is truth in the suggestion that patients' no longer requiringacute medical care. There is a possibility to consider a model( used elsewhere) whichinvolves clinicians certifying continuing need for medical care after a certain length ofstayin hospital, (case mix adjusted). If, after the time in question, the doctor certifies that there isno longer a need for acute medical care, the onus for the patient's care is transferredelsewhere. This might require the availability ofnon-NHS residential beds on site or a jointinvestment agreement with the local authorities concerned)Criteria and Referral Process - a number of issues arose under this heading, some of whichrevolved around the inappropriateness of referrals, especially to the Livingston and the4amount of time wasted on non-CVA referrals. Delays in referring patients were thought to bedue to uncertainty over the initial diagnosis. It was acknowledged that few referrals camedirectly from GP's and that many GP's were still referring directly to physiotherapists andoccupational therapists. One group identified that the patients being admitted directly to thewards from MAU and A&E needs attention.(Action opportunities - A public relations exercise into Primary Care which is aimedspecifically at developing ownership of the concept by GPs. The decision to refer lies withthe GP and the principles for initiating changing practice need to be addressed along withthe PR exercise. Audit of A&E & MAU referrals to provide evidence to support or refuteperceptions ofdelays.)Therapist referrals - Concern over the progress in following up referral to physiotherapistsand OT's for out-patient treatment was expressed. There was some discussion over the issueof patients remaining in hospital simply because they did not have access to physiotherapistsand OT's every day if they were out in the community, although they were deemed wellenough to be discharged.(Action opportunity - a small audit ofdischarge delayed patients using an AEP instrument*or similar should reveal if this is actually taking place.)The Livingstone - Questions over the doctor's understanding of the referral criteria andprocess at the Livingstone was expressed, with concerns about the rigid nature of the criteriafor referral, the criteria by which the patients severity of CVA is measured and the unrealisticnature of the goals to be achieved within 3 weeks to fulfil the criteria (eg. Sitting balance).The timing of the initial assessment and what is meant by being 'medically stable' were alsoraised as issues which need to be addressed.(Action Opportunity - Education strategy for Doctors in question. Review of goals andcriteria where there appears to be a mismatch) Other issues raised in regard to this facilitywere the lack of a gym, the inappropriate environment and lack of space and the poor accessto equipment at the Livingstone. There were also a human resource needs specified. Theseare a specialist medical carer / stroke consultant, a counsellor, a psychologist, and a familysupport worker. It is considered that these are needed to provide quality care in thisenvironment.Communications and Management - One aspect of the programme which was considered torequire attention was the lack of co-ordinated information on patient care, diagnosis andmedical and nursing management. Improved communication between teams was emphasisedand in particular those communications between CST and acute workers. It was alsospecified that there was a need for the medical and nursing management to be consistentbetween the wards and that the national guidelines should be adhered to.(Action Opportunity - Consideration of a guideline implementation programme anddeveloping concensus towards the adoption of a common evidence based Stroke clinicalpathway, which in particular has medical clinician and GP ownership.)Stroke Team - Some of the attendees felt that a lack of knowledge and awareness exists aboutthe Stroke Team and one group were unaware of the results that the Stroke Team'sjudgement had been based on. The Stroke Team assessment report was not widely5disseminated and copies were requested by some of the attendees. Additionally variousattendees at the workshop felt the criteria of the stroke team was not being utilised and thestroke project group negotiations/agreement were being completely ignored.Resources - Concern was expressed that the resources specifically directed at themanagement of Transient Ischaemia attacks were inadequate and that more could be done inthis area in terms of improving patient care, preventing severe illness and improving theefficiency of this aspect of health care expenditure.(Action opportunity - A rapid appraisal of the evidence for Stroke prevention through TIAmanagement and economic evaluation ofspecific strategic options.)Session TwoThe issues derived from the 6 groups of altendees at the workshop were combined to form 3separate lists under the original headings of 'excellent', 'satisfactory' and 'needing attention'.The groups of attendees paired up to consider the list of issues needing attention. The issueswere examined and then suggestions made as to the action that needs to be taken, who is totake the responsibility and the time frame in which the action is to take place.6Group oneISSUE ACTION RESPONSIBILITY TIME FRAMEReferral mechanism Point of ref. Should be A&E, Directorate, nurse managers ImmediatelyMAU, NIC, surgeryCommunication breakdown Increase awareness CST Immediately.CST. ICP • DVH, CST • 6monthsCT Access Increased reporting faster CT Department (Radiologist) ImmediatelyLivingstone More beds, Slow stream beds PCT Now immediatelyOut of Area Liaise with Bexley teams PCT,CST 3 monthsMedical staff knowledge Stroke consultant. DVH In process Jan 200 ICST Presentation CST Rotation - 6 monthlyOut of hours access On call team CST 3 monthsAccess equipment, OT bureau More accessible PCT,OT,CST 3 monthsLack ofTIA resources Refer to intermediate care team DVH By Jan 2001Review criteria Audit Quality and audit dept 6 months - I yearDelayed discharge Increased community resources £ Health Authority OngoingWorking together as one health Social Servicesteam. GovernmentDevelop current nursing homes CST, PCT7Group twoISSUE ACTION RESPONSIBILITY TIME FRAMEReferral Mechanism ICP Audit Long termNominated person on each wards Acute sectorCOE meetingsDoctors inductionsCommunication Inform ward of allocated key Stroke team ImmediatelyworkerPhysio's and OT's to document Acute sectorprogress and named therapistList of therapist bleeps Acute sectorLivingstone (medical cover) Physician PCT ?GymSlow Stream Rehabilitation Slow stream facility PCT and acute sector ?More stroke beds at Livingstone HAMore N. H. beds HAAccess to equipment/adaptations Fast track access to technician PCT, SS, KCC ?Team technician8Group threeISSUE ACTION RESPONSIBILITY TIME FRAMEReferral Mechanism Co-ordinated referral from each Pam and A&E/MAU ?wardCommunication Develop integrated notes Sarah (Audit) CLINKS ASAPWard named/primary nurse PamCT Scan Increase capacity review criteria CLINKS (Ann) ?for management and reportingLivingstone Training Programme for nursing ChrisIDebbie ?staffPR work with GP's DebbieSlow stream rehabilitation Research alternatives provision MonicalDebbie OngoingBid for funding intermediate beds MonicalDebbieGood knowledge of the system Review/evaluation from key staff RosielDebbie 3 monthsDevelop link nurse role AnnBexley patients Liaise with PCG's / RN Social Monica/Bill/John ?Services (400 bed meeting)9

Report of the Integrated Stroke Care Workshop

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