Learning from the Stroke

PathwayPrinciples for Success

Damian Jenkinson

30 Day Stroke Mortality Over Time

SINAP = Stroke Improvement National Audit ProgrammeSSNAP = Sentinel Stroke National Audit Programme

2006 2008 2010 20130

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100 % newly admitted to institution

% newly admit-ted to institution

Newly Institutionalised Rate Over Time

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% admitted SUSU within 4h90% on SUBrain scan <24h

Stroke Care Over a Decade

2004 2006 2008 2010 2013 20140

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Swallow screen <4h

SLT assess swallow <72h

PT assess <72h

OT assess <4d

SLT assess communication <7d

Stroke Care Over a Decade

National Audit Office 2005Value for Money of the Nation’s Stroke Services

A Comprehensive Stroke Service

C) Includes:i. Hyper-acute servicesii. Acute services (including in-

hospital rehabilitation)iii. TIA servicesiv. Tertiary care services e.g.

Vascular and neuro-surgery

D) Includes:i. Early Supported

Discharge (ESD)ii. Stroke specialist

community rehabilitation

E) Includes:i. Follow up

i. 6 weeksii. 6 monthsiii. Annually

ii. Integrated health and social care team plan

Research

Information

Patient, public and carer involvement

The Recent Journey

2007

Accelerating Stroke Improvement

Stroke QualityStandard

Vital Signs

Best Practice Tariff

Eleven processstandards

Indicators along the pathway

More emphasis on prevention and on long term care

2010 20142012

CCGs accountable for OIS

NHSOutcomes Framework 2011/12

TheMandate

CCG Outcomes Indicator Set

CCG Outcome Indicators 2014/15

Knowing Where You AreSSNAP

Case ascertainment Audit compliance

In first year• 9864 more people reached hospital faster• 642 had reduced disability through thrombolysis• Payback of £3.16 for each £1 spent

FAST Public Awareness Campaign

Significant increase in those intending to call 999:• 87% seeing weak face• 46% seeing weak arm• 74% hearing abnormal speech

Thrombolysis Provision

Bold Solutions to Large Scale ProblemsLondon Stroke Service

30-Minute Blue Light Ambulance Travel Time from the Hyper-Acute Stroke Units

• Population >8million• 11,500 strokes a year in London – 2,000 deaths• Commitment to whole system redesign

London Stroke Survival is Higher Than Rest of England

Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001

Reconfiguring Acute Care

Financial viability

Travel timesVolumes

• 600-1500 stroke admissions per year

• 45 minute travel time• 6 - 7 consultants with stroke

expertise on rota• Daily specialist ward rounds• HASU-grade staffing levels• 100% patients continuous

physiological monitoring• 95% patients admitted directly to

HASU from A&E• 100% urgent patients scanned

next slot and all within 24 hours• 50% appropriate patients

thrombolysed within 30 mins; 90% within 45 mins of arrival

Early Supported Discharge (ESD) and Community Stroke Teams (CST)

CQC 2011: ‘overall picture of inconsistency, waits between transfer home and commencing community rehabilitation and lack of specialists’

SSNAP 2014•ESD: 25% transferred to ESD•CST: 21% transferred to CST

•Only 14% patients with post acute rehabilitation registered on SSNAP

• Fear of costs of ‘double running’

• Many staff in traditional unidisciplinary roles

• No nationally-recognised stroke-specialist courses or competences for nurses or Allied Health Professionals

• Quality-assured framework for staff education based on the needs of patients at all stages of care pathway

• Endorsement process to assure trainees and employers

Shaping the Workforce

Stroke Research Network Patient Recruitment

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Non-randomisedRandomised

RCT Target

Target

Building Stroke Research Capacity

Making It Happen

• CCGs• Health and

Wellbeing Boards• Strategic Clinical

Networks• Area Teams• Clinical Senates• NHS IQ• Academic Health

Science Networks

1. Political priority2. Co-produced National Policy3. Raised Awareness4. Leadership5. National Audit6. Whole-System Engagement7. Networks8. Metrics

Learning from the Stroke PathwayPrinciples for Success