Hull & East Riding Stroke Service 
ANNUAL REPORT
2007/08
ANNUAL
REPORT
April 2007/08
TABLE OF CONTENTS
|
Executive Summary |
3 |
|
Acute Stroke Care |
4-8 |
|
Audit of the flow
of patients through the Acute Stroke Care Pathway |
9 -12 |
|
Stroke Networking |
13 |
|
TIA/Minor Stroke |
14 |
|
Community
Rehabilitation |
14 |
|
Community Stroke
Care Pathway |
15 |
|
Community Stroke
Co-ordinating Activity |
16 |
|
Community
Occupational Therapy report |
17-18 |
|
Hull Acute Home
Therapy Service report |
19 |
|
Community Speech
& Language Therapy report |
19-20 |
|
Physiotherapy in |
20-22 |
|
Acute Occupational
Therapy Service |
23 |
|
Acute Physiotherapy
Service |
23 |
|
Service Evaluation |
24-27 |
|
Training &
Education |
27 |
|
Research |
27 |
|
Key Priorities for
2008/09 |
27-28 |
ANNUAL REPORT
2007/08
Executive Summary
The key drivers to improve stroke care standards have never been so strong. The publication of the National Stroke Strategy in 2007 provides a clear framework for raising standards across all aspects of stroke care. This strategy is also supported by the 2008/09 NHS Operating Framework which includes the requirement for Commissioners to focus on the improvement of stroke care in their local areas.
This focus is strengthened further by the development of a 10 year NHS Strategy which has been clinically driven via the NHS Next Stage Review which is due to be published in July 2008. There is an expectation that many specialist areas of Acute Care (including Stroke) will deliver these services via highly specialised teams within Hyper Acute Units.
In Acute Stroke Care in
There is local recognition that the Acute Stroke Unit at Hull Royal Infirmary requires an increase in the nursing staffing establishment in order to meet the high dependency workload, which is resulting in greater than average staff turnover and this must be addressed before any additional resources can be used to expand a Thrombolysis Service
Direct admission to the Acute Stroke Unit remains difficult and the service has recently audited the cause of delays in discharge which clearly identifies areas for focus and investment for 2008/09.
Work in on going particularly in the Hull PCT to increase screening opportunities for the prevention of Cardiovascular Disease including Stroke and TIA.
The Community Stroke Co-ordinating team is now well established and able to provide the crucial links required for well co-ordinated transfer of patient care from the Acute to Community Services and long term support for stroke survivors and their carers.
During 2007/08 the Hull &
East Riding Stroke Service has made links with the Regional Cardiac Network who
have facilitated a service mapping exercise for Acute Stroke Care. The lead Stroke Physician, Dr Abdul-Hamid has
also made links with lead Stroke Physicians in
This next year will require significant focus and additional resource to enable Hull & East Riding to meet the national targets and level of acute intervention for stroke patients in relation to the evidence base.
Dinah Fuller, Nurse Consultant in Stroke
Dr Abdul-Hamid, Lead Stroke Physician
ACUTE STROKE CARE
Recommendations from the National
Stroke Strategy together with the recently published NHS Review led by Dr Darzi
(Healthy Ambitions,
- Investigations of TIA should be within a maximum of 7 days and for TIA with high risk of imminent stroke, these should not be delayed more that 24 hours.
- Paramedics should use the F.A.S.T (Face, Arm, Speech Test) protocol for transfers of patients with suspected stroke to a hospital with an Acute Stroke Unit, meeting best practice standards.
- To meet best practice, all units dealing with acute stroke should have:
- Senior Clinical decision makers at the front door able to fully assess patients and ensure speedy to Thrombolysis and a full stroke pathway within 2 hours of onset of the stroke.
- Access to Neuro-radiology opinion (this could be via a telemedicine link).
- Organised acute stroke care and dedicated acute stroke units
- Where a local hospital cannot provide or access
these services either in or out of hours, patients may require redirection
to Hyper Acute stroke units in hospitals which are equipped in this way. Such patients should be repatriated to
post acute rehabilitation stroke units which should be available in every
Acute Stroke Activity 07/08.
636 patients were supported through the Acute Hull & East Riding Stroke Pathway and these are all patients who received their acute stroke care through Hull & East Yorkshire Hospitals Acute Trust.
|
GENDER |
AGE BAND |
TOTAL |
% |
|
16 - 45 46 - 65 66 – 74 75+ |
5 35 62 241 |
0.79% 5.50% 9.75% 37.89% |
|
|
Gender total |
|
343 |
53.93% |
|
|
|
|
|
|
Male |
16
- 45 46
- 65 66
– 74 75+ |
6 66 74 147 |
0.94% 10.38% 11.64% 23.11% |
|
Gender total |
|
293 |
46.07% |
18% of patients were of working age (under 65 years of age) and it can be noted that 2/3 of this working age group were men.
Locality of patients
|
East Riding of |
249 |
31% |
|
|
358 |
56% |
|
Other (transferred from out of
area) |
29 |
5% |
Length of Stay in the Acute Hospital
|
LENGTH OF
STAY |
AGE BAND |
TOTAL |
% |
|
0-14
days |
16
- 45 46
- 65 66
– 74 75+ |
4 73 89 229 |
0.63% 11.48% 13.99% 36.01% |
|
|
|
395 |
62.11% |
|
|
|
|
|
|
15+ |
16
- 45 46
- 65 66
– 74 75+ |
7 28 47 159 |
1.10% 4.40% 7.39% 25.00% |
|
|
|
241 |
37.89 |
62% of stroke patients were discharged from Acute hospital within 14 days or less of their stroke and a high percentage of these were supported in a Community Rehabilitation setting before returning home.
Out of the number of patients who stayed more than 15 days, approximately 60% were 75 years and older.
Access to the Stroke Unit
In Hull & East Riding Stroke Service, 69% of stroke patients accessed the Acute Stroke Unit during their hospital stay. 31% of patients did not access the Acute Stroke Unit and were supported by the Specialist Stroke Team as outlyers.
Direct access to the Acute Stroke Unit on the day of admission remains difficult with only 23% of the total population of stroke patients accessing the Acute Stroke Unit on the day of the stroke. 15% directly accessed the Stroke Unit from the Assessment Unit within 1-2 days and a further 1.5% direct from the Acute Assessment Unit within 3-7 days. 31% of stroke patients were transferred to an outlying ward in the first instance, 12% of these patients accessed the Stroke Unit within 2 days, a further 14% in 3-7 days and 5% took longer than 7 days.
Discharges and transfers from Ward 110
52% of patients transferred
either to Ward 2,
Activity from Ward 2,
|
Destination |
Total Number of Patients Patients still in ward |
Transfer to own home |
Transfer to Nurse/Res Home |
Transferred
to inner city rehab unit |
Transferred
to |
Transferred
to other Acute |
RIP |
Length of
stay |
||
|
|
|
|
|
|
|
|
|
|
Ave num of days |
AveNum of weeks |
|
Ward 2 |
96 |
14 in |
32 |
13 |
16 |
8 |
1 |
12 |
56 |
8 |
|
|
|
|
39% |
16% |
19% |
10% |
1% |
15% |
|
|
RIP Patients
Out of the 636 stroke patients
who came through the
When broken down into PCTs, 62%
of deaths were patients from the Hull PCT and 26% from East Riding PCT (8% out
of area).
Stroke
Characteristics
|
Left Hemianopia |
83 |
13% |
|
Right Hemianopia |
77 |
12% |
|
Left Hemiplegia |
237 |
37% |
|
Right Hemiplegia |
253 |
40% |
|
Incontinence Urine |
166 |
26% |
|
Incontinence Stool |
26 |
4% |
|
Loss of Consciousness |
166 |
26% |
|
Seizures at time of stroke |
17 |
3% |
|
Sensory loss at time of stroke |
161 |
25% |
|
Visual inattention/neglect |
121 |
19% |
Type of Stroke
|
Age
Band |
Total /
% |
|
|
Haemorrhage |
16-45 |
2 (0.32%) |
|
|
46-65 |
17 (2.69%) |
|
|
66-74 |
17 (2.69%) |
|
|
75+ |
41 (6.48% |
|
TOTAL |
|
77 (12.16%) |
|
|
|
|
|
Infarct |
16-45 |
9 (1.42%) |
|
|
46-65 |
83 (13.11%) |
|
|
66-74 |
117 (18.48%) |
|
|
75+ |
348 (54.50%) |
|
TOTAL |
|
557 (87.52%) |
|
|
|
|
|
Stroke not specified as haemorrhage or infarct, cerebrovascular accident NOS |
66-74 75+ |
1 (0.16%) 1 (0.16%) |
|
TOTAL |
|
2 (0.32%) |
Risk Factors
Previous Stroke
20% of the stroke
population had recorded previous stroke as part of their medical history. 3%
less than 6 months previously and 17% more than 12 months previously.
Previous TIA
12% of stroke
patients had a previous history of TIA, 4.5% of which were in less than 6
months and 7.5% more than a year ago.
Hypertension
61% of the stroke
population group had hypertension as a risk factor. 11% of these required treatment to be
actioned following the stroke. Therefore,
a high percentage of patients with known hypertension are still presenting to
the service with stroke (it should be noted that hypertension may not have been
their primary risk factor).
Diabetes Type I & Type II
5% (28 patients) of
the stroke population were identified as type I diabetics, 4% (26 patients) of
whom were already on treatment.
12% (75 patients)
were identified with Type II diabetes and in 2% (9 patients) of that
population, treatment was actioned.
Smoking
14% (89 patients)
were identified as active smokers at time of stroke
|
Age Band |
Total |
% |
|
16-45 |
4 |
0.63% |
|
46-65% |
42 |
6.60% |
|
66-74 |
21 |
3.30% |
|
75+ |
22 |
3.46% |
|
|
89 |
14% |
Hypercholesteraemia
55% (350) of stroke
patients were identified as having high cholesterol and 20% (129) of those
patients were requiring treatment to be actioned at the time of the stroke.
Atrial Fibrillation (AF)
16% (100) of the
stroke population group were identified as having Atrial Fibrillation at the
time of stroke and 8.4% (54 patients) treatment was actioned at time of
stroke. Warfarin was contraindicated in
only 1.26% of cases (8 patients)
Antiplatelet Therapy
37% of the total
population group required antiplatelet therapy commencing or to be
reviewed. 33% of patients were already
identified as being on antiplatelet therapy before the stroke
Dependency of patients
The Stroke Service
uses the Barthel score bandings. This is a functional assessment of patients
physical ability to carry out all normal daily activities including getting
washed and dressed, eating and drinking, continence and mobility. The score ranges between 0-20. Patients
scoring 0-5 are in the most severely disable category; patients scoring between
16-20 are in the most independent category.
Pre-admission
scores
|
Physical dependency status
before admission not known |
123 |
19.34% |
|
6 - 10 |
5 |
0.79% |
|
11 - 15 |
8 |
1.26% |
|
16 - 20 |
500 |
78.62% |
|
TOTAL |
636 |
|
Admission
scores
|
0 - 5 |
245 |
38.52% |
|
6 - 10 |
128 |
20.13% |
|
11 - 15 |
147 |
23.11% |
|
16 - 20 |
116 |
18.24% |
|
TOTAL |
636 |
|
More that 78% of the
total population group were physically in the high independence category range
before their hospital admission with stroke.
On admission to hospital, 60% of patients were categorised as significantly
or severely dependent at the time of stroke
Further assessment of
functional ability following discharge has been carried out this year by the
Community Stroke Team. Data from 100
patients was captured and this suggests
an increase of disability amongst stroke survivors by as much as 20%, however
this figure could be much higher and full evaluation of functional ability of
the stroke population during 08/09 will give more accurate data in relation to
this.
Sample Group
First
Visit Scores
|
0 - 5 |
2 |
2% |
|
6 - 10 |
6 |
6% |
|
11 - 15 |
34 |
34% |
|
16 - 20 |
58 |
58% |
|
TOTAL |
100 |
|
Discharge Scores
|
0 - 5 |
0 |
0% |
|
6 - 10 |
1 |
1% |
|
11 - 15 |
10 |
10% |
|
16 - 20 |
89 |
89% |
|
TOTAL |
100 |
|
These results support
the requirements for improving long term care for stroke survivors particularly
in relation to severe disability and the psychological and social difficulties
that often accompany this.
AUDIT OF THE FLOW OF
PATIENTS THROUGH THE HULL & EAST RIDING
ACUTE STROKE CARE
PATHWAY
November 2007 – March 2008
BACKGROUND
The National Guidance for Acute Stroke Care is for direct
admission to an Acute Stroke Unit.
The purpose of this audit was to
identify the current pathway and flow of patients through the Acute Stroke Care
Pathway at Hull Royal Infirmary site.
- Identify the key factors causing a delay in moving
patients through the Stroke Care Pathway
- Make the necessary recommendations to improve
access to the Acute Stroke Unit.
AUDIT PROCESS
The audit took place between
November 2007 and March 2008. The data
was collected via the Acute Stroke Nurse Co-ordinator as patients were admitted
to the Acute Stroke Unit and then on Ward 110 at Hull Royal Infirmary.
Data from 147 patients in total
was used in the audit.
Length of delay to the acute stroke unit for those patients who got to the acute stroke unit was analysed together with any reasons for delay. Further data was collected in relation to the discharge of those patients from ward 110. Data from 129 patients of the original 147 was analysed in relation to their discharge from the ward including cause of delay.
A decision was made by the
auditors not to include every patient who transferred or discharged to and from
ward 110 because of the potential for skewed data during ward closure (the ward
was closed on 2 occasions during the audit due to infection control reasons).
Data was also collected during
this time tin order to identify the average number of patients who were being
supported by the Acute Stroke Team as outlyers (on another ward other than the
Acute Stroke Unit).
RESULTS
Admissions to Ward
110 – Total number of patients included in the audit = 147
Noted reasons for delay to Ward 110
Delayed discharges
FROM ward 110
Total number of
patients included in the audit = 129
Delay was defined as from the time the patient was deemed
medically fit for transfer or discharge.
Planned transfers or discharges that required one or two days to ensure
all elements were in place were not identified as delays
Ranges of delayed
discharges
Noted reasons for
delay in discharge FROM ward 110
- 8
(31%) Awaiting transfer to
R/H or N/H
- 7
(27%)
- 6
(23) Bed on Ward 2 CHH
not available
- 3
(11%) Community Stroke Bed
not available
- 2
(8%) Intermediate Care
not available
PATIENT OUTLYERS
DURING THE AUDIT
During the 5 months when the
audit took place, a record was kept of all patients who were being managed
outside of the Stroke Unit on a daily basis.
Reasons for not moving to the Acute Stroke Unit included patients who
were too unwell to move and put onto the Care of the Dying Pathway, patients
who’s primary clinical need was deemed greater than their stroke (i.e patients
in the high dependency units, coronary care unit and post surgical intervention
requiring specialist support).
Patients with less complicated
stroke who were medically stable were also reviewed during this time and
actions planned accordingly to transfer these people either straight home with
the appropriate support or to a community based stroke rehabilitation service.
Numbers of outlyers ranged on a
daily basis from 15 to 5 (other than when Ward 110 was closed to admissions and
these statistics were not included in the audit as they did not reflect a true
picture of the normal situation). The
average number of outlyers equated to 8 patients per day at any one time.
GENERAL COMMENTS
This audit reflects an accurate
picture in relation to current service provision with 31% of stroke patients
admitted directly to the Acute Stroke Unit and 39% within 24 hours. Of the remaining 30%, 27% (40 patients) got
to the Stroke Unit between 2 – 6 days.
The remaining 3% ranged from between 7 and 19 days.
One of the most significant
reasons for delay to the Acute Stroke Unit was identified as delay of referral
to the Acute Stroke Team (54%). There
was also 9 patients (13%) whose delay to the Stroke Unit was directly related
to a delayed diagnosis.
This audit also demonstrated 80%
success in no delay of discharge. No
delay was regarded as from the time the Consultant Physician recommended
discharge. Planned discharges to a
Approximately 15% of patient’s
discharges were delayed by up to 8 days with a maximum delay of 19 days. The greatest reason for delay was for those
patients who were waiting to transfer to long term Nursing or Residential home
facilities (31%). The other two most significant delays were
related to patients waiting for
RECOMMENDATIONS
- The Acute Stroke Unit is operating at a high
standard to ensure access and speedy transfer out of the unit and the team
feel that these statistics could not have been any better in relation to
current existing resources. However, we are unable to meet the standard of
direct access to the Stroke Unit for 69% of patients.
- Delays to the Acute Stroke Unit may result in
increased mortality and reduced morbidity for our stroke population and
further work is needed to reduce current delays. The current infrastructure for the Acute
Co-ordinating Stroke team is limited to a week day service and may
contribute to delayed referral to the Stroke team which the audit
demonstrated was of significant concern.
- The most significant reason for delay from the
Stroke Unit was for those patients waiting for long term Residential and
Nursing home care. The Acute Stroke
Unit does not have dedicated Social Worker support and for a population of
patients with high social care need, this continues to be a concern. Step down beds for patients on ward 110
and ward 2, CHH who are waiting for long term care.
- Access to Ward 2,
- A significant number of patients also waited for a
- The Stroke team will also be making recommendations
to the Commissioners for the development of an Early Supportive Discharge
Team which would increase the options for direct discharge from the stroke
unit to patients own homes. This
could free up Acute beds and community rehabilitation beds more readily
Auditors
Dinah Fuller, Nurse Consultant in Stroke
Tony Stonehouse, Acute Stroke Nurse
Co-ordinator
Jo McNeil, Acute Stroke Ward Manager
Dr Abdul-Hamid, Lead Stroke Physician.
May 2008
STROKE NETWORKING
The Yorkshire & Humber Cardiac Network is currently supporting the Hull & East Riding Stroke Service through a process mapping exercise for both the Acute and Community Stroke Care Pathways. This will help provide the PCT’s with the necessary assurance that all currently funded elements of the service are working as effectively as possible when looking at Commissioning additional infrastructure into Stroke Services locally.
Dr Abdul-Hamid has made links
with the local Stroke Physicians in
HULL & EAST RIDING STROKE SERVICE APPROACH TO IMPLEMENTATION OF THE
STROKE STRATEGY
The Stroke Working Group has agreed four main working groups to focus on all elements of the stroke strategy. These include:
Group Lead
Stroke Prevention Phil Davis,
AD Service planning & Improvement, Hull PCT
Emergency Response Dr Abdul-Hamid, Consultant Stroke Physician
Dinah Fuller,Nurse Consultant in Stroke
Phil Davis, AD Service planning & Improvement,
Hull PCT
Education & Training Dinah Fuller, Nurse Consultant in stroke
Jeanette Hyam & Nikki Longbottom
Community Stroke Nurse Specialists
Long term support & rehabilitation Alison Forrester
Clinical Lead, Occupational Therapy
An Acute Stroke Commissioning Group has been established in order to identify
on the programme management required for assessing all elements of Acute
Stroke Care in order to make the Commissioning recommendations by
September 2008 for implementing a 24hr, 7 day week Acute Stroke Service in
the area. Group members include:
Dr Abdul-Hamid
Phil Davis
Dinah Fuller
Karen Ellis, Commissioning, ERYPCT
Tim Fowler, Commissioning,
Alan Harper, Hull & East Yorkshire Hospitals Trust
Kerry Gardiner, Hull & East Yorkshire Hospitals Trust
TIA/MINOR STROKE SERVICE
The average number of referrals to the TIA clinic remains constant at between 650 – 700 patients per annum.
The Service has remained under
pressure particularly in relation to access to carotid Doppler scanning with
patient waiting times ranging from
Dr Abdul-Hamid the Lead Stroke Physician, plans to develop a direct access clinic in conjunction with a telephone triage service whereby GPs can speak to the Stroke Physician directly. This should help to reduce the current number of inappropriate referrals to the service as well as reduce current waiting times to see the Consultant. The appointment of a second Stroke Physician in September 2008 will enable these plans to be taken forward.
Recommendations have been put forward to address the current waiting times for carotid Doppler and these include access to portable Doppler scanning equipment and a whole time Senographer to the Stroke Service. This would enable TIA and stroke patients to be screened either in the clinic or on the ward and reduce the number of patients requiring full carotid Doppler scanning.
COMMUNITY REHABILITATION UNITS
Statistics from April 2007 – April 2008
|
Destination |
Number of Patients |
Transfer to own home |
Transfer to Nurse/Res Home |
Return to Acute/transferred |
RIP |
Length of stay |
||
|
|
|
|
|
|
|
|
Average number of days |
Average Number of weeks |
|
Alderson |
59 |
9 carr’d |
39(78%) |
5(10%) |
6(12%) |
0 |
46 |
6.5 |
|
St Marys |
62 |
7 carr’d |
38(69%) |
14(25%) |
2(3.5%) |
1(2%) |
42 |
6 |
|
Rossmore |
50 |
7 carr’d |
26(60.5%) |
13(30%) |
3(7%) |
1(2%) |
49 |
7 |
|
Beverley |
22 |
4 carr’d |
8(44%) |
7(39%) |
3(17%) |
0 |
37.5 |
5 |
|
Alfred Bean |
5 |
2 carr’d |
5(100%) |
0 |
0 |
0 |
73 |
10 |
|
Hornsea |
4 |
0 |
4(100%) |
0 |
0 |
0 |
29 |
4 |
|
Withernsea |
10 |
1 carr’d |
6(66%) |
1(11%) |
0 |
2(22%) |
38 |
5 |
|
|
|
|
|
|
|
|
|
|
|
Total |
212 |
30 |
126(69%) |
40(22%) |
14(8%) |
4(2%) |
44.9 |
6 |
Year on year activity remains fairly constant with 70% of this population returning to their own homes often despite severe disability
Total number of patients transferring to Long Term Care across the
Acute and Community pathway
|
Ward 110 |
61 |
10% |
|
Ward 2 |
13 |
2% |
|
Community Rehabilitation
facility |
40 |
6% |
|
TOTAL |
114 |
18% |
COMMUNITY STROKE CARE
PATHWAY
The Hull & East Riding
Stroke Service has a Community Stroke Co-ordinating Team who are based in the
Community. Their remit includes:
- To provide a smooth
transition of care between Primary and Secondary Care for Stroke patients
as well as a support and advice mechanism for carers
- To follow up all
stroke patients who have been discharged from Acute Stroke Care or
Community Rehabilitation settings in the Hull & East Riding area and
report back to the patients own GP (and Stroke Consultant if
requested) and relevant Health and
Social Care professionals.
- To support GPs,
Nurse Consultant in Stroke and Community Neurotherapy teams with ongoing
clinical and psychological support for stroke patients receiving
rehabilitation in community settings including Hull City Centre Stroke
Rehabilitation Units at Rossmore, Alderson and St Marys and the local
Community Hospitals including Beverley Westwood, Driffield and
Bridlington, Hornsea and Withernsea and patients in their own homes
- To develop strong
links with Chronic Disease Management teams including GPs, PN, DN and
Community Matrons. Ensuring good
handover to these teams and to provide specialist input to them as and
when required.
- To work in close
liaison with Social Services and Voluntary agencies and to help develop
the local stroke User/Carer groups and to work with therapists to develop
additional supportive services including day rehabilitation services and
support groups.
- To work closely with
and support Community Therapy teams
in the long term management of stroke patients including reinforcing
rehabilitation goals and plans with
patients and carers
- To provide a problem
solving service for stroke patients at any point in time after their
stroke and direct links with access back to any part of the service as
required/appropriate
- To visit all
patients discharged to long term care settings, Residential and Nursing
Homes to provide support and practical advice to Nursing and Care Teams
linking back to members of the MDT as required.
- To work in close
liaison with Social Services and Voluntary agencies and to help develop
the local stroke User/Carer groups and to work with therapists to develop
additional supportive services including day rehabilitation services and
support groups.
- To provide stroke
outreach support to patients at Castle Hill and Bridlington hospital sites
- To follow patients
with long term disability and or significant post stroke complications
life long if needed.
- Once patients have been discharged from the active caseload of the
Community Stroke Team, the patients own GP and Practice Nurse will be
updated as regards to their recovery and progress to date in writing. The team will be happy to support with
any enquiries related to the patients stroke in the future.
Patients and
carers will also be given the direct contact numbers back to the Community Stroke
Team for additional support and advice as and when they need it.
COMMUNITY STROKE
CO-ORDINATING ACTIVITY
DATA COLLECTION – 9 MONTHS
(JULY 2007 – MARCH 2008)
|
Number of referrals received through the H & ER Stroke pathway |
463 |
|
Number of referrals made outside the H & ER Stroke pathway |
57 |
|
Number of re-referrals (pts & carers who have contacted the service for additional support) |
8 |
|
Number of discharges made |
258 |
|
|
Home Visits |
Phone contact |
|
Nurse Specialist |
957 |
481 |
|
Support workers |
969 |
755 |
|
Total |
1,926 |
1,236 |
Outcome of Visits
|
Swallowing problems identified on visit |
10 |
|
Existing swallowing problems with concerns |
70 |
|
On anti-depressants & managing psychologically |
126 |
|
On anti-depressants & NOT managing psychologically |
49 |
|
NOT on anti-depressants and NOT managing psychologically |
47 |
|
Self medication concerns identified needing further action |
40 |
|
Activated additional blood pressure management |
103 |
|
Activated investigation treatment for AF |
27 |
|
Activated support for other post stroke complications (ie
spasticity, pain, social probs) |
42 |
|
Activated support for other medical problems |
47 |
|
Concerns raised and advice given re driving |
80 |
|
Prevent admission |
2 |
|
Support and advice to Residential/Nursing home staff |
79 |
|
Support and advice given to other professionals |
48 |
|
Carer assessed due to levels of carer stress and strain |
33 |
Additional Responsibilities
|
·
Nurse Consultant & Specialist Nurses visit
Stroke Rehabilitation units daily |
|
· Nurse Consultant & Specialist Nurses visit Community Hospitals as required |
|
· Specialist Nurses support in the acute outreach service weekly · Nurse Consultant and Specialist Nurses visit Ward 2 & Bridlington Hospital weekly and support outreach for
Stroke patients at |
|
·
Visits to stroke units made by a member of the
team twice monthly |
THERAPY REPORTS
COMMUNITY OCCUPATIONAL THERAPY REPORT
East Riding of
Since the set up of the Stroke
Service no further funding for Stroke Rehabilitation has been made available in
the East Riding of Yorkshire.
The original funding purchased
1.33 WTE Senior Occupational Therapists and 1.00 WTE Technical Instructors.
This currently funds 1.00 WTE
Senior Occupational Therapist (Band 6 Rotation) based at Westwood Hospital
Beverley and two Occupational Therapy Assistant posts 0.50 WTE (Band 3
Technical Instructors) to support the Senior Occupational Therapists working in
Holderness based at Hornsea and
Stroke Rehabilitation continues
to be provided as an integral part of the existing Community Rehabilitation
Service for both In-patients and services provided to people in their own
homes.
In-patient Beds
Patients continue to be seen by the Occupational Therapists
working in the Community Hospitals in Hornsea, Withernsea, Driffield and
Beverley. The service aims to see all
in-patients within the standard of three working days following receipt of
referral to Occupational Therapy.
Workshop
The Workshop at
Gaps
Shortfalls in providing the service continue resulting from
a lack of services commissioned for Stroke Rehabilitation. These shortfalls
will continue to be raised in business planning.
City of
In
Funded establishment:
2.00 WTE Senior
Occupational Therapist
1.00 WTE Senior
occupational Therapist (rotation)
1.00 WTE Technical
Instructor.
Step-down Stroke
Rehabilitation Beds
In
Occupational Therapy continues to
be developed with the provision of Domestic ADL, and Gardening to enhance a
return to pre-stroke occupations for the patients.
Community Rehabilitation
Referrals continue to be received
for ongoing Occupational Therapy in patients own homes following their time
with Intermediate Care or HAHTS. Referrals are also received for patients whose
stroke is long standing but require another episode of therapy.
Gaps
Rehabilitation in the community
continues to be under funded There is minimum provision for these patients from
the staff providing a service to the Step-down stroke rehabilitation beds in
Hull, resulting in a long wait for Occupational Therapy and to some patients
falling through the net and not receiving the input required to maintain their
functional ability. Monitoring of the shortfall continues and will continue to
be raised in business planning.
Clinical Governance in The East Riding
and
The
Occupational Therapy Stroke Clinical Specialist 1.00 WTE contributes to the
clinical governance of the service in the East Riding of Yorkshire and
The
Clinical Specialist is also involved in the Stroke Foundation Course and
delivery of in-service training to Occupational Therapists. The Stroke service
has recently been audited against national standards and changes are being made
with support from the Clinical Specialist to allow improvements to be made in
the Occupational Therapy Service provided to stroke patients across
Alison Forrester,
Head Occupational Therapist,
Clinical Specialist Stroke,
Community Rehabilitation,
Rossmore Stroke Unit
Sunny Bank
HULL ACUTE HOME
THERAPY SERVICE---STROKE REPORT 2007/8.
The team had 85 Stroke patients referred ( approximately 12% of the total 700 referrals received from all areas.) These were from the following areas;
33 Ward. 110.
33 Community stroke beds.
5 Ward 2 Castle Hill.
2 Ward 12 HRI.
8 Other Wards HRI.
2 G.P.
1 A & E.
1 From out of the area.
1 patients were referred to the community team for physiotherapy and 2 for occupational therapy on discharge from HAHTS.
Val Masterman Band 7 O.T. in the team is a member of the Stroke Working Group looking at long term rehabilitation, as part of the Integrated Service Improvement Programme.
Linda McFadden Team Leader.
SPEECH & LANGUAGE THERAPY - Therapy Services Partnership
Overview
The East Riding of Yorkshire Speech and Language Therapy (SLT) Service (part of the Therapy Services Partnership) provides input to the stroke service on the rehabilitation ward (ward 2) at Castle Hill Hospital, outpatient services to East Yorkshire Community (excluding Hull and Holderness) and to the Hull Stroke Rehabilitation Units (at St Mary’s, Rossmore and Alderson).
Ward 2 (Stroke Rehabilitation)
Over the past year, ward 2 has continued to receive a maximum of 5 (1/2 day) sessions a week of Speech and Language Therapy input, with a few additional hours of support from a generic therapy assistant. Neurology patients are also seen within these sessions, which further reduces the time available for stroke rehabilitation.
The service continues to manage its limited resources by prioritising swallowing assessments however the Speech and Language Therapists aim to assess, advise and provide therapy activities for patients with communication difficulties as soon as possible. When caseloads are high, the amount of regular direct therapy sessions is limited and it is not possible to provide intensive therapy. Similarly, the limited SLT service provision does not enable the Speech and Language Therapists to work fully as part of the multi-disciplinary team, such as in joint working with other therapists and attending case conferences and goal setting meetings.
Community Stroke Rehabilitation Units – Hull
Due to continued staffing pressures within the Therapy Services Partnership SLT Service, the service to the community stroke rehabilitation units has continued with a reduced number of sessions over the last year. This looks to be improved on in the near future to normal staffing levels of 1 WTE for the three units. 77 clients with communication and/or swallowing difficulties were referred to the service. Of these 86% of clients were seen within the standard of 5 working days from referral. The Speech and Language Therapist’s role within the units involves the assessment, management and treatment of clients with communication and swallowing difficulties. In addition the therapist has a key role in enabling clients to understand their treatment and make informed decisions regarding their care and future.
Community Outpatient Service
Throughout the past year, we have been able to provide a service to clients referred to the department for swallowing and / or communication assessment, however due to reduced staffing we have been unable to respond to referrals within our professional standard times. With the return of one member of staff from maternity leave and recruitment of a Band 5 therapist to the service, we are confident that we will be able to improve on our referral response times over the coming year.
Community Speech & Language Therapy Team
PHYSIOTHERAPY
The Physiotherapy Team in the Community Rehabilitation Units have seen a number of changes over the past year due to retirement and career changes of staff members.
Currently there are 2 WTE Band 7 Therapists supported by 3 WTE Band 4 Technical Instructors and 0.5 WTE Band 5 Therapist.
This team are not currently supporting stroke rehabilitation
at the
This arrangement is due for further review
Therapy Treatments
and New Patients April 2007 to March 2008
Rossmore Stroke Unit 2007-2008
Alderson Stroke Unit 2007-2008
St Mary’s Stroke Unit 2007-2008
Referral Sources
We continue to take referrals directly from ward 110, ward 2, and patients from outlying wards within the Acute Trust.
On rare occasions we admit patients from the community via the community teams.
The referrals from the community can be for a number of reasons; new problems have arisen that cannot be supported in their own home; further potential has been identified and some patients come to the units via the Community Team who come across patients that have not been through the stroke pathway.
These patients are discharged to either their own home, alternative home (single floor access, warden controlled); to live with relatives; nursing/ residential care or respite care. We can support these discharges for ongoing physiotherapy from the following services; I.C.T, E.R.I.C, H.A.H.T.S, Community Physiotherapy and neurology outpatients at Beverley Westwood Hospitals.
The future
It is hoped that a new Community Stroke Team and Early Discharge Team will be set up within the next 12months. This will provide support for patients on discharge from in-patient stroke care back into the community.
The configuration of these services is yet to be determined
and physiotherapy staff are actively involved in the planning stage. We are positive that this will contribute to
an improved therapy service for patients in
Community Physiotherapy Team
ACUTE OCCUPATIONAL THERAPY SERVICE
2007-08 has seen a period of
transition for the OT service with the internal reconfiguration of team
structure bringing ward 110 under the neurosciences team on the Hull Royal
site, and ward 2 amalgamation of staff with neuro rehabilitation and amputee
staff thereby providing greater equity for the shortfall in establishment to
the previous 16:2 wte ratio for stroke beds to 12:2.
The team has continued to have
regular training sessions with OT’s based on ward 2 Castle Hill site and cross
site training for Therapy assistant grades has been maintained.
Staffing
Ward 110
2wte OTs, we have now successfully recruited to the
permanent Band 6 position, having had temporary locum cover for and extended
period or more recently cover from the Clinical Specialist Neurosciences, the
band 5 rotation continues to be a
popular rotation choice and an attractive addition for recruitment of
new graduates.
Ward 2
4 wte equivalent OTs.
The 2 x Band 5 rotational posts remain popular choices within the cross site
rotation and a good way of skill development in new graduates.
Training and Development – 2 OT’s have undertaken evidence
based reviews of elements of practice whilst undertaking post graduate training
at York St John.
Ward 110 have provided practice placements for 3
undergraduates OT students, and with the accreditation of 2 staff members as
practice educators undergraduates placement on ward 2 from the autumn.
Team lead for neurosciences and team lead from ward 2 have been actively involved in the review of stroke guidelines relating to upper limb care, rehabilitation and moving and handling along with colleagues from therapies across the pathway. The introduction of a stroke wide therapy meeting is welcomed and staff welcome the opportunity to progress the work so far undertaken.
Debbie Parker
Clinical Specialist Occupational Therapist Neurosciences
HRI
PHYSIOTHERAPY REPORT WARD 110,
Productivity
|
Year |
New patients assessed by physio (includ
medical outliers) |
Follow up treatments |
Total |
Plus On Call Treatments |
|
2005 |
630 |
3812 |
4442 |
110 |
|
2006 |
647 |
3570 |
4217 |
133 |
|
2007 |
611 |
4026 |
4637 |
unknown |
Staffing
During 2007 we recruited to a
vacant therapy assistant post. We had 1 or 2 students for 30 weeks of the
year. These have helped to increase
productivity and usually meet patients’ expectations; however therapists are
aware that evidence points to greater frequency and intensity of therapy
resulting in improved patient outcomes.
Current staffing is one band 7
WTE, one band 5 WTE and three assistants who are shared between all the
therapies, this is below the national average and below that recommended by the
C.S.P. in response to the National Stroke strategy. A business case has been submitted
to support staffing appropriate for a 5 day service able to provide the
intensity of therapy recommended in the RCP Guidelines for Stroke, and also to
develop the 7 day service recommended
in the National Stroke Strategy.
Achievements
We have developed a trust
approved MDT information leaflet about the therapy services on ward 110 and
have started to gather formal patient feedback by a questionnaire that patients
receive while on the ward. Preliminary results from the questionnaire show that
patients are generally satisfied with the therapy service they receive,
however, some patients want more therapy than we are currently able to provide.
More responses are needed and as the audit continues will assist us in
accessing our services.
Joint working with the Therapy
and Nursing teams, which is absolutely essential because of the challenges of
understaffing across all disciplines, is very well supported by the charge
nurse and OT Lead. MDT environmental risk assessments ward meetings,
fundraising, audits and in-service training all contribute to a more unified
approach and effective team working which improves the patient experience.
Formal and informal feedback from
physiotherapy students and visiting tutors indicate that ward 110 provides an
exceptionally supportive learning environment for students to develop their
knowledge and treatment skills around acute stroke management.
The Therapy assistant
competencies were reviewed and linked with KSF dimensions. In 2008 these will
need to be updated with respect to the new profile and incorporate the
competencies that are being developed for stroke nationally.
Limitations
Lack of time for research/audit
and service development because of clinical caseload has meant that many of the
ideas for future developments identified last year have remained as only ideas.
Without additional time only the clinical work and modest service development
can take place.
Rebecca
Canet-Baldwin
Senior
Physiotherapist, Ward 110
SERVICE EVALUATION
Hull & East Riding Stroke Service User experience of the Service
07/08
Patient feedback/questionnaire
evaluation
During 2007/08 the Stroke team have made efforts to invite feedback from patients and their carers following their experience through the stroke pathway in both the Acute & Community Service.
Questions asked related to the patient and carer experience in Acute Care then during rehabilitation in the Community and following discharge once the patient had got home.
17 patients responded with regards to their experience which demonstrated significantly positive experiences but with additional comments that will help focus Service Developments, particularly in relation to the staffing levels in the Acute Stroke Unit.
|
QUESTION |
YES |
NO |
Not indicated |
|
Did
you understand your treatment plans? |
13 (76%) |
3 (18%) |
1 (6%) |
|
Were
you satisfied with your nursing care? |
15 (88%) |
1 (6%) |
1 (6%) |
|
Were
you satisfied with your medical care? |
15 (88%) |
1 (6%) |
1 (6%) |
|
Were
you satisfied with the therapy input from
|
6 (35%) 8 (47%) 6 (35%) 2 (12%) |
1 (6%) 1 (6%) |
11 (65%) 9 (53%) 15 (88%) 14 (82%) |
|
Were
you given information about the medicines you were taking? |
13 (76%) |
2 (12%) |
2 (12%) |
|
Did
you feel that your emotional needs were met? |
13 (76%) |
3 (18%) |
1 (6%) |
|
Were
you given any verbal information about your stroke? |
13 (76%) |
2 (12%) |
2 (12%) |
|
Were
you given any written information about your stroke? |
14 (82%) |
1 (6%) |
2 (12%) |
Similarly, there was a high level
of satisfaction from patients receiving rehabilitation in a Community setting
either in the Rehabilitation Unit or
|
QUESTION |
YES |
NO |
Not indi- cated |
|
Did
you understand your treatment plans? |
10 (100%) |
|
|
|
Were
you satisfied with your nursing care? |
10 (100%) |
|
|
|
Were
you satisfied with your medical care? |
9 (90%) |
1 (10%) |
|
|
Were
you satisfied with the therapy input from
|
5 (50%) 5 (50%) 4 (40%) |
1 (10%) 1 (10%) 1 (10%) |
4 (40%) 5 (50%) 5 (50%) 9 (90%) |
|
Were
you given information about the medicines you were taking? |
5 (50%) |
|
5 (50%) |
|
Did
you feel that your emotional needs were met? |
4 (40%) |
1 (10%) |
5 (50%) |
|
Were
you given any verbal information about your stroke? |
3 (30%) |
2 (20%) |
5 (50%) |
|
Were
you given any written information about your stroke? |
5 (50%) |
|
5 (50%) |
|
Were
you given information about any benefits you may have been entitled to? |
5 (50%) |
|
5 (50%) |
High levels of satisfaction were also received as feedback from patients experience with the community base support they received once being discharged home. The most significant factor was information with regards to benefits and additional entitlements that some patients felt they did not receive as promptly as they would wish and again this is something for the team to work on in 08/09.
|
QUESTION |
YES |
NO |
Not indicated or applicable |
|
Did
you feel you were well supported by the Community Stroke Team? |
15 (88%) |
|
2 (12%) |
|
Did you receive supportive information about the
your stroke |
14 (82%) |
1 (6%) |
2 (12%) |
|
Did
you receive information about (if appropriate)
|
8 (47%) 10 (59%) 5 (29%) |
4 (24%) 2 (12%) 1 (6%) |
5 (29%) 5 (29%) 11 (65%) |
|
Were
you satisfied with the therapy input your relative received from
|
5 (29%) 7 (41%) 5 (29%) 6 (35%) |
1 (6%) 1 (6%) 1 (6%) |
11 (65%) 10 (59%) 11 (65%) 10 (59%) |
|
Have
you made any lifestyle changes since your stroke? |
9 (53%) |
1 (6%) |
7 (41%) |
|
If
Yes, what changes have you made?
|
2 (12%) 5 (29%) 8 (47%) 7 (41%) |
|
|
Patients would also appreciate more information with regards to User/Carer Stroke Groups in the long term.
|
QUESTION |
YES |
NO |
Not indicated or applicable |
|
Were
you given information about our User/Carer members |
8 (47%) |
5 (29%) |
4 (24%) |
|
Did you make contact or were you contacted by a
member of a group? |
5 (29%) |
5 (29%) |
7 (42%) |
Relative/Carer feedback/questionnaire evaluation
14 forms were received in
all. The most significant concerns for
carers and relatives were in relation to the giving of information before
discharge with back up explanation particularly in relation to stroke risk factors
and medication management. This supports
the view of the Specialist Stroke Team that additional stroke co-ordinating
time is needed to provide adequate information and explanation to all carers
and relatives pre discharge from the
|
QUESTION |
YES |
NO |
Not indicated |
|
Did
you understand the patients treatment plans? |
10 (71%) |
2 (14%) |
2 (14%) |
|
Were
you satisfied with the patients nursing care? |
12 (86%) |
2 (14%) |
0 |
|
Were
you satisfied with the patients medical care? |
13 (93%) |
1 (7%) |
0 |
|
Were
you satisfied with the therapy input from
|
9 (64%) 6 (43%) 9 (64%) 6 (43%) |
0 0 0 2 (14%) |
5 (36%) 8 (57%) 5 (36%) 6 (43%) |
|
Were
you given information about the medicines the pt was taking? |
7 (50%) |
6 (43%) |
1 (7%) |
|
Did
you feel that your emotional needs were met? |
11 (79%) |
2 (14%) |
1 (7%) |
|
Were
you given any verbal information about the pts stroke? |
11 (79%) |
3 (21%) |
0 |
|
Were
you given any written information about the pts stroke? |
5 (36%) |
8 (57%) |
1 (7%) |
High levels of satisfaction were again reiterated in terms of experiences in community rehabilitation placements and likewise with the Community stroke support following discharge home with again the exception of giving early information about benefit entitlements being a key concern.
|
QUESTION |
YES |
NO |
Not indicated or applicable |
|
Did
you understand the patients treatment plans? |
7 (50%) |
|
7 (50%) |
|
Were
you satisfied with the patients nursing care? |
7 (50%) |
|
7 (50%) |
|
Were
you satisfied with the patients medical care? |
6 (43%) |
1 (7%) |
7 (50%) |
|
Were
you satisfied with the therapy input from
|
7 (50%) 4 (29%) 4 (29%) 3 (21%) |
1 (7%) 1 (7%) |
7 (50%) 9 (64%) 10 (71%) 10 (71%) |
|
Were
you given information about the medicines the pt was taking? |
3 (21%) |
2 (14%) |
9 (64%) |
|
Did
you feel that your emotional needs were met? |
4 (29%) |
|
10 (71%) |
|
Were
you given any verbal information about the pts stroke? |
4 (29%) |
1 (7%) |
9 (64%) |
|
Were
you given any written information about the pts stroke? |
2 (14%) |
2 (14%) |
10 (71%) |
|
QUESTION |
YES |
NO |
Not indicated or applicable |
|
Did
you feel you were well supported by the Community Stroke Team? |
11 (79%) |
|
3 (21%) |
|
Did you receive supportive information about the
patients stroke |
10 (71%) |
|
4 (29%) |
|
Did
you receive information about (if appropriate)
|
6 (43%) 10 (71%) 7 (50%) |
3 (21%) 2 (14%) 2 (14%) |
5 (36%) 2 (14%) 5 (36%) |
|
Were
you satisfied with the therapy input your relative received from
|
3 (21%) 6 (43%) 6 (43%) 4 (29%) |
1 (7%) 1 (7%) |
10 (71%) 7 (50%) 8 (57%) 10 (71%) |
|
QUESTION |
YES |
NO |
Not indicated or applicable |
|
Were
you given information about our User/Carer members |
7 (50%) |
5 (14%) |
2 (14%) |
|
Did you make contact or were you contacted by a
member of a group? |
6 (43%) |
4 (29%) |
4 (29%) |
User/Carers involvement
- Regular meetings with the stroke team
- Representatives attend the Stroke Working Group
- National representation on the NICE Guidelines committee
- Working with NHS Research Network to explore patient experience in Hull & East Riding
- Supporting and facilitating stroke clubs in Hull & East Riding
- Supporting individuals referred by the stroke team
- Presenting on the local stroke foundation course
held twice yearly.
TRAINING AND EDUCATION
Stroke Foundation Course
This three day course, held twice yearly (March & October) has become well established over the past 6 years.
Attendance over 2007/08 includes:
- October 2007 – 28 attendees (18 Health &
Therapy professionals;
10 from Private Sector)
- March 2008 – 24 attendees (10 Health & Therapy
professionals;
14 from Private Sector)
Community Matron/Practice Nurse Training
November 2007
RESEARCH
The Service is currently participating in the National Sentinel Audit.
Dr Abdul-Hamid has secured funding support for a full time research nurse – this is supported by the Yorkshire Stroke Research Network. The post is currently
out to advertisement and once recruited to will enable the Service to participate in a range of National Clinical Trials.
KEY PRIORITIES FOR 2008/09
Priority 1 - Carotid Doppler Scanning
The current waiting time for carotid Doppler scanning is approximately 16 weeks locally and requires urgent attention to ensure patients receive their investigations within the national guidance which is within 7 days presentation of TIA or more urgently for those patients at high risk of full blown stroke. In addition to this, stroke patients locally, go through the care pathway without this fundamental investigation even in situations where it may have been the cause of their stroke.
Locally, access to Carotid Doppler scanning is the most concerning area of weakness within the service. As a bare minimum the service requires one WTE Senographer (£25,000) and portable senographer machine (£25,000)
Priority 2 - Staffing on the Acute Stroke Unit
The impact of 24 acute stroke patients on one ward together with the need for fast flow of patients through the acute stroke unit has put considerable strain on the ward. Staffing compliments on the Acute stroke unit is not sufficient to provide basic patient care including ensuring full nutritional requirements are met and reducing the incidents of pressure sores and this is a major concern. Additional staffing requirements at present are 3.78 WTE Qualified nurse and 1.54 Auxilliary Nurse.
Priority 3 - Thrombolysis Service
Hull Acute Hospitals cannot provide a 24/7 stroke thrombolysis service at this point in time. The service requires additional Senior Nursing to support the specialist out of hours service including evening and weekends, 3 x WTE Band 6 nurses.
Priority 4 - Step Down facilities
The acute stroke service sees approximately 700 patients per year coming through the pathway and in order to maximise the use of stroke unit beds, additional step down facilities are required for the early transfer of patients who require long term care solutions to community based step down facilities.
8 step down beds for patients in
this category who are not well enough to participate in active rehabilitation
programmes would enable direct transfer to the acute stroke unit for 90% of
stroke patients at a cost of £208,000 (each step down bed costing £500; £500 x
8 = £4,000 x 52 days of the year). These beds would also enable beds to be freed
up more easily on Ward 2 at
The Community stroke team would be well place to support the ongoing clinical needs of these patients during the multidisciplinary and family discussions to secure their long term care requirements.
The above identified areas are of
crucial importance to our local stroke service at this point in time and should
be prioritised amongst all the other areas of stroke service development for
2008/09.
Hull Acute Hospital Trust will be identifying this within their business plans this year.
These priorities in no way
underestimate the resources required for additional therapy both in the acute
and community settings or the longer term care infrastructures required in the
Hull & East Riding for our Stroke Service