Hull & East Riding Stroke Service 
Provider Report
ANNUAL REPORT
2008/09
ANNUAL REPORT
April 2008/09
TABLE OF CONTENTS
|
Executive Summary |
3 – 4 |
|
Acute Stroke Care |
5 – 10 |
|
Community Rehabilitation |
10 – 12 |
|
Community Stroke Nurse Co-ordinating Team |
12 – 15 |
|
User/Carer Support |
16 |
|
Stroke Support Groups |
16 |
|
Development of Stroke Services with HERYC voluntary services |
16 |
|
Patient experience and service evaluation |
17 |
|
Training & Education |
17 – 18 |
|
Stroke Networking |
18 |
|
Therapy Reports |
19 – 29 |
ANNUAL REPORT
2008/09
Executive Summary
2008 has been one of the highest profile years for stroke so far. A strong focus from the Department of Health through to Regions has seen stroke as a leading part of service development agendas across the country and likewise in
The challenges to meet all the quality markers for stroke (Stroke Strategy 2007) should be addressed over the next 2-3 years through local Commissioning Programmes. Clinicians continue to support Commissioners in identifying key gaps and making recommendations for service developments to meet the evidence based requirements for stroke services.
The North East Yorkshire and Northern Lincolnshire Cardiac and Stroke Network continue to be, extremely supportive in facilitating the local focus necessary to make the key recommendations to local Commissioners. They have also facilitated a focused Clinical Advisory Group for stroke care which comprises Clinicians across the North East Yorkshire and
Clinicians have worked hard locally to raise the profile of importance of treating stroke as an emergency and together with good support from the Yorkshire Ambulance Service, a greater number of patients are attending
Providers will be challenged over the next year to increase the number of patients who are able to access acute stroke services for 90% of their hospital stay. A significant amount of work also needs to be done to achieve a TIA service that provides assessment and investigations in one episode of care within 7 days of onset of symptoms or within 24 hours of onset of symptoms for patients with high risk of stroke within one week.
Clinical data collected by Clinicians in the service continues to highlight areas for focus including the fact that 25% of the stroke population going through the acute stroke care pathway at Hull & East Yorkshire Hospitals were of working age and under over the past year. This strongly supports the need for a focus to improve people’s awareness of the risk factors for stroke, lifestyle changes and vascular checks.
The need to support patients from diagnosis in acute treatment to rehabilitation and long term support remains crucial. There is still much work to be done to ensure that the infrastructure both in the acute hospitals and in the community are where they need to be to enable all stroke patients to have direct access to an Acute Stroke Unit at the time of onset of a stroke.
The Clinical team have worked hard to gather more views from patients and carers experiencing the service over this recent year. Key areas for further address include refinement of the way we give information at all stages through the pathway. This, together with ensuring there is right emotional support for patients and carers in the acute hospital setting as well as in the community is one of the most important areas of development from a patient and carer perspective. In addition to this, more information is required to support any changes to medication, treatments as well as ensuring there are better mechanisms to inform patient and carers about any benefits they may be entitled to. These views were also reflected in a consultation event held in March of this year in partnership with the Local Authority to gather the views of both Health and Social Care professionals, patients and long term service users, carers and volunteers.
ACUTE STROKE CARE
Acute Stroke Care in
There has been no further expansion to Acute Stroke Services at Hull Royal Infirmary. A limited Thrombolysis Service is available between the hours of 8am and 2pm during the working week only, the limitations to this have primarily been in relation to the availability of specialist stroke nursing staff both to co-ordinate the support of patients from admission to hospital and on the acute stroke ward. This is an area of short fall in the current nursing establishment. Expansion of the Stroke Nurse Co-ordinating team is also needed to ensure all stroke and TIA patients can be assessed and supported as soon as they are admitted to hospital.
The Acute Stroke Unit at Hull Royal Infirmary has again seen a high turnover of nursing staff leaving the ward in favour of less physically demanding work. Recommendations have been put forward by the Acute Trust to increase the existing establishment in order to reduce the likelihood of high turnover of nursing staff. This is paramount if the service is to maintain the level of expertise required for specialist stroke care.
The Acute Stroke Unit at Hull Royal Infirmary has also been challenged with a reduction in the number of available beds on the unit, primarily as a result of infection control requirements. There are plans to increase the equipment storage space on the ward which will hopefully enable bed capacity to increase back to 24 beds; however, supporting 24 stroke patients on the Acute Stroke Unit would not be safely sustainable without investment to increase the current nursing establishment.
The Service continues to struggle with ensuring all stroke patient investigations are carried out as inpatients and this is again mainly related to capacity for Carotid Doppler scanning, Echocardiogram and 24hour ECG recording.
The Stroke Team at
A limited number of patients living in the outskirts of the East Riding utilise
Scunthorpe and
Stroke Services at these hospitals are currently developing plans to offer a limited Thrombolysis service.
ACUTE STROKE CARE ACTIVITY IN
The Specialist stroke team based in
The number of patients admitted through the Acute Stroke pathway at the Hull Royal Infirmary between April 2008 and March 2009 was 648; 355 (55%) Hull residents and 264 (41%) East Riding with 29 (4%) accessing the service with postal addresses outside of Hull & East Riding.
Stroke post admission
A total of 17 patients had a stroke following hospital admission for surgery.
Length of stay
62% of stroke patients (404) stayed less than 14 days in the acute hospital
|
LENGTH OF STAY |
AGE BAND |
TOTAL |
% |
|
0-14 days |
16 - 45 46 - 65 66 – 74 75+ |
14 93 77 220 |
2.16% 14.35% 11.88% 33.95% |
|
|
|
404 |
62.35% |
|
|
|
|
|
|
15+ |
16 - 45 46 - 65 66 – 74 75+ |
11 58 47 128 |
1.54% 8.95% 7.25% 19.75% |
|
|
|
244 |
37.65% |
Age & Gender of Stroke Patients
|
GENDER |
AGE BAND |
TOTAL |
% |
|
16 - 45 46 - 65 66 – 74 75+ |
12 49 54 208 |
1.85% 7.56% 8.33% 32.10% | |
|
Gender total |
|
323 |
49.85% |
|
|
|
|
|
|
Male |
16 - 45 46 - 65 66 – 74 75+ |
13 102 70 140 |
2.01% 15.74% 10.80% 21.45% |
|
Gender total |
|
324 |
50.00% |
Number of deaths within 30 days of stroke
|
GENDER |
TOTAL |
% |
|
Female |
48 |
|
|
|
| |
|
|
| |
|
Male |
31 | |
|
Total |
79 |
12% of the total number of patients coming through acute stroke pathway. |
A National Key performance indicator is measuring the percentage of time patients spend in an Acute Stroke Unit. Locally, this is way below the national required target of 60% of patients spending 90% of their time in an acute stroke unit. Clinicians monitor the length of time patients take from admission to get the acute stroke unit at
Access to Ward 110 On day of admission 103 (16%)
(Acute Stroke Unit) 1-2 days delay 163 (25%)
3-7 days delay 92 (14%)
7+ delay 38 (6%)
Total number accessing Ward 110 499 (77%)
Total number of patient supported outside of ward 110 149 (23%)
All patients with acute stroke need to be admitted directly to an acute stroke unit to maximise their chances of reduced mortality and reduced severity of long term disability. The evidence base for this is overwhelming both nationally and internationally. The data here supports the current difficulties of being anywhere near that which is needed to meet these targets and ensure best possible outcome for stroke survivors in our area.
Improvement of this is dependent on a strengthened stroke co-ordinating team as well as strengthened infrastructures in community based services including an Early Supportive Discharge Specialist Stroke Team to ensure patients can be discharged straight home wherever possible and still receive specialist rehabilitation to maximise the outcome of their stroke.
There have been numerous, previous requests from clinicians in various meetings locally over the years to support commissioned step down beds for stroke survivors with massive disabling stroke who are waiting for community care assessments and long term solutions which allow for patients choice for those patients needing to go into long term Nursing and Residential care. Focused commissioning of 6 step down beds specifically for stroke patients with these needs would contribute considerably the freeing up of acute stroke beds both on the acute stroke unit and the neuro-rehabilitation ward at Castle Hill Hospital.
Type of stroke patients coming through the stroke pathway have had
|
Age Band |
Total / % |
|
|
Haemorrhage |
16-45 |
5 |
|
|
46-65 |
23 |
|
|
66-74 |
18 |
|
|
75+ |
41 |
|
TOTAL |
|
87(13%) |
|
|
|
|
|
Infarct |
16-45 |
21 |
|
|
46-65 |
128 |
|
|
66-74 |
107 |
|
|
75+ |
310 |
|
TOTAL |
|
560 (86%) |
|
|
|
|
|
Stroke not specified as haemorrhage or infarct, cerebrovascular accident NOS |
75+ |
1 |
|
TOTAL |
|
648 |
|
|
TOTAL |
% |
|
Partial Anterior Circulatory Stroke (PACI) |
440 |
68.5% |
|
Total Anterior Circulatory Stroke (TACI) |
90 |
14% |
|
Posterior Circulatory Stroke (POCI) |
72 |
11% |
|
Lacunar Anterior Circulatory Stroke (LACI) |
40 |
6% |
|
Multi Focal Infarction |
3 |
0.5% |
TIA/ Minor Stroke
The evidence base for patients with Transient Ischaemic Attack (mini stroke) according to the Royal College of Phsyicians guidelines 2008 and latest NICE guidance, requires that all patients with TIA should be seen and treated within 7 days of the onset of their symptoms. Patients with high risk TIA need to be seen and treated within 24hours of the onset of their symptoms. The service in Hull & East Riding is unable to meet these standards at this point in time.
There are additional concerns that the infrastructure to support the service is not sufficient to ensure there are no difficulties in running the service on a continuing basis throughout the year. Currently there is only one WTE TIA Nurse Specialist and no cover for annual leave or sickness. This causes significant disruption to the clinics and further delays in patients being seen are experienced year on year. An urgent solution to this needs to be addressed without delay.
741 patients were seen in the TIA/Minor stroke clinic this year with a waiting time of 5 – 7 days to see the TIA Nurse Specialist and 2-3 weeks to be seen by a Consultant.
This year, CT scanning has been more available and now patients requiring a scan are scanned on the day of clinic appointment.
Waiting time for Carotid Doppler scanning was from 5-6 weeks until half way through the year and is now averaging 2-3 weeks.
It is anticipated that this will decrease further due to the vascular laboratory ring fencing 10 slots per week (2 per day) for TIA patients from 11th May 2009.
There is a strong current Commissioning focus through Hull PCT to achieve a one stop TIA Service to include Carotid Doppler scanning, CT Head scanning and investigations in one consultation.
Investigations to look at the most efficient way to ensure a fail safe urgent referral mechanism are currently underway. TIA referrals are currently not compatible with electronic Choose and Book systems and the service needs to rise to the challenge of investigating patients with high risk TIA within 24hrs of symptom onset.
The other concern is reviewing patients who present to A&E and acute assessment unit. At the moment we have agreed on a referral system from A&E and all high risk patients are admitted to AAU. However, the way these high risk cases are then tackled by the relatively junior and inexperienced medical staff in AAU can be extremely varied. The ideal situation would be that all of these patients get reviewed by a stroke team member e.g. a doctor or a nurse {to ensure that the event of the current hospital admission is fully utilised and they don’t get seen 2 weeks down the line in TIA clinic, hence missing the window of opportunity for investigations e.g. Doppler and MRI}. One of the ways in providing reviews would be utilising the hyper-acute stroke physician for advice ( when the 24/7 or even limited availability thrombolysis service i.e. 8-5 service is in place) or maybe liaising with TIA nurse specialist.
Risk Factors
Previous Stroke
19% of the stroke population had recorded previous stroke as part of their medical history. 4% less than 6 months previously and 13% more than 12 months previously.
Previous TIA
10% of stroke patients had a previous history of TIA, 4% of which were in less than 6 months and 5% more than a year ago.
Hypertension
58% of patients had hypertension as one of their risk factors. Again, as in previous years, statistics demonstrate a high number of patients already identified with hypertension and on treatment at the time of stroke.
Smoking
18% of the stroke population were actively smoking at the time of stroke.
Diabetes
2% of the stroke population were found to have Type I Diabetes and already on treatment and 11% had Type II Diabetes with 9% already on treatment and 2% had treatment actioned during admission
Hypercholesteraemia
58% of the this years stroke population had high cholesterol levels with 33% already on treatment pre admission and 25% needing to commence treatment.
Atrial Fibrillation
118 (18%) patients admitted with stroke had Atrial Fibrillation. 40 of those patients were already on anticoagulation therapy, 53 had treatment actioned and 25 showed treatment was contraindicated.
Transfer of stroke patients to the Neuro-rehabilitation ward
(Ward 2,
As part of the Stroke Pathway in
|
Destination |
Total Number of Patients |
Discharged 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 |
95 |
20 |
9 |
32 |
14 |
2 |
7 |
42 |
6 |
| ||||||||
|
|
|
24% |
11% |
38% |
17% |
2% |
8% |
|
| |||||||||
COMMUNITY REHABILITATION
The total number of patients who received rehabilitation in the Inner City Rehabilitation Units was 175 during this financial year.
|
Destination |
Number of Patients |
Transfer to own home |
Transfer to Nurse/Res Home |
Return to Acute/transferred |
RIP |
Length of stay | ||
|
|
|
Still in rehab units at time of analysis |
|
|
|
|
Average number of days |
Average Number of weeks |
|
Alderson |
59 |
8 |
43 |
5 |
1 |
0 |
48 |
7 |
|
St Marys |
56 |
7 |
27 |
15 |
3 |
3 |
43 |
6 |
|
Rossmore |
60 |
|
|
9 |
6 |
0 |
49 |
7 |
|
|
|
|
|
|
|
|
|
|
|
Total |
175 |
22 |
108 (62%) |
29 (16.5%) |
10 (6%) |
3 (1.7%) |
44.9 |
7 |
Patients in the inner city rehabilitation units are supported by the Stroke Nurse Co-ordinating team on a daily basis throughout the working week. The aveage length of stay remains consistent a 7 weeks.
Breakdown of occupancy for Hull & East Riding patients
|
BED OCCUPANCY RATES FOR STROKE REHABILITATION IN THE INNER CITY COMMUNITY BASED UNITS IN | |||
|
|
| ||
|
|
|
|
|
|
|
FOR THE PERIOD - |
01.04.08 |
31.03.09 |
|
|
|
|
|
|
|
ALDERSON STROKE UNIT (9 BEDS) |
Bed Days |
% |
|
|
Hull PCT |
2031 |
71.3% |
|
|
East Riding of |
818 |
28.7% |
|
|
|
|
|
|
|
|
|
|
|
|
Total number of bed days occupied |
2849 |
100% |
|
|
|
|
|
|
|
ROSSMORE STROKE UNIT (8 BEDS) |
Bed Days |
% |
|
|
Hull PCT |
2167 |
60.1% |
|
|
East Riding of |
1436 |
39.9% |
|
|
|
|
|
|
|
|
|
|
|
|
Total number of bed days occupied |
3603 |
100% |
|
|
|
|
|
|
|
ST MARYS STROKE UNIT (8 BEDS) |
Bed Days |
% |
|
|
Hull PCT |
1982 |
83.0% |
|
|
East Riding of |
405 |
17.0% |
|
|
|
|
|
|
|
|
|
|
|
|
Total number of bed days occupied |
2387 |
100% |
|
|
|
|
|
|
|
TOTAL ALL STROKE UNITS |
Bed Days |
% |
|
|
Hull PCT |
6180 |
69.9% |
|
|
East Riding of |
2659 |
30.1% |
|
|
|
|
|
|
|
|
|
|
|
|
Total number of bed days occupied |
8839 |
100% |
|
|
|
|
|
The usage of available bed days within the three rehabilitation units is 97%
Discharge to Long term Nursing/Residential Care
The number of patients discharged to long term care straight from the Acute hospital setting was 57, 9% of the total stroke population for 2008/09.
The number of patients discharged to long term care from the Community Rehabilitation Units was 29, 4.5% of the total stroke population.
Therefore, in total, 86 (13%) stroke patients were discharged to long term Nursing or Residential home care.
Stroke rehabilitation in the East Riding
Access to Stroke rehabilitation beds across the East Riding remains limited. Closure of hospital beds to meet infection control requirements has resulted in an increased percentage of usage in Inner City Rehabilitation beds over the past year.
|
Destination |
Number of Patients |
Transfer to own home |
Transfer to Nurse/Res Home |
Return to Acute/transferred |
RIP |
Length of stay | ||
|
|
|
Still in ward at time of analysis |
|
|
|
|
Average number of days |
Average Number of weeks |
|
Beverley |
26 |
4 carr’d |
19(86%) |
2(9%) |
1(4.5%) |
0 |
39 |
5.6 |
|
Alfred Bean |
7 |
0 carr’d |
6(86%) |
0 |
0 |
0 |
61 |
9 |
|
Hornsea |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
Withernsea |
12 |
1 carr’d |
7(64%) |
1(9%) |
2 (18%) |
1(9%) |
28 |
4 |
|
|
|
|
|
|
|
|
|
|
|
Total |
45 |
5 |
32(80%) |
3(7.5%) |
3 (7.5%) |
1(2.5%) |
18.2 |
3 |
Community Stroke Nurse Co-ordinating Team
The Community Stroke Nurse Co-ordinating team are a small team of Nurse and Support workers who ensure a seamless transfer of care and continued clinical and psychological support to all stroke survivors and their carers in Hull & East Riding.
Patient caseloads are picked up through the Acute Stroke Services via
East Riding 289
All patients are followed up post acute care. Support, information and intervention is assessed and implemented on an individual needs basis.
No of patients supported by the team in Nursing /Residential Homes: 162
The team play a vital role in supporting patients with complex, severe disability in long term care. Providing advice to Nursing and Care staff and all Community based disciplines.
Development of Community Based Stroke Support Clinics
From April 2009 the Community Stroke Co-ordinating team are setting up clinics across
Patients with severe disability and complex needs for ongoing specialist support will continue to be supported in their own homes or in long term care establishments. The team would like to see the Community Clinic Service expanded to a multi disciplinary review once they are more established.
Patients with severe disability who would have been reviewed on an ongoing basis through the Department of Rehabilitation Medicine at Castle Hill Hospital are discharged to ongoing review by the Community Stroke Nurse Co-ordinating team wherever possible and it is hoped that this approach will continue to reduce the number of follow up appointments for stroke patients in the acute hospital setting. Direct access back to Acute Stroke Physicians support, advice and review remains in place as required.
DATA COLLECTION – 8 MONTHS
(April 2008 – November 2008)
````````````````````
|
Number of referrals received through the H & ER Stroke pathway |
449 |
|
Number of referrals made outside the H & ER Stroke pathway |
58 |
|
Number of discharges made |
321 |
|
|
Home Visits |
Phone contact |
|
Nurse Specialist |
1300 |
594 |
|
Support workers |
1240 |
721 |
|
Total |
2,540 |
1,236 |
In addition to the above home visits, the team also support patients in community based clinic reviews, community based rehabilitation settings, in-reach support to Hull Royal Infirmary,
Outcome of some home visits and some actions taken
|
Swallowing problems identified on visit |
8 |
|
Existing swallowing problems with concerns |
13 |
|
On anti-depressants & managing psychologically |
72 |
|
On anti-depressants & NOT managing psychologically |
17 |
|
NOT on anti-depressants and NOT managing psychologically |
35 |
|
Self medication concerns identified needing further action |
18 |
|
Activated additional blood pressure management |
148 |
|
Activated investigation treatment for AF |
34 |
|
Activated support for other post stroke complications (ie spasticity, pain, social probs) |
9 |
|
Concerns raised and advice given re driving |
73 |
|
Prevent admission |
6 |
|
Carer assessed due to levels of carer stress and strain |
25 |
Transfer of the community stroke database to system one has resulted in difficulties extracting a full years data collection.
Community Stroke team supporting Stroke Awareness
The team have been actively involved in promoting stroke awareness by attending various venues with information about risk factors, offering to take blood pressures and generally advising the public on health lifestyle and living. These have always been well received and statistics below demonstrate their usefulness.
In conjunction with the Rotary Club
Asda,
26.04.2008
Number of people seen: 196
Number referred to GP for high BP: 32 (16%)
Number referred to GP for low BP: 5 (2.5%)
Number already on Meds for BP: 26 (13%)
Irregular pulse detected: 7 (3.5%)
Already on meds for irregular pulse 3 (1.5%)
On medication for high cholesterol: 12 (12%)
Reported to have diabetes: 5 (2.5%)
Smoker: 39 (20%)
Total number advised to visit GP: 43 (22%)
Hornsea Carers Support Meeting
12.06.2008
Number of people seen: 41
Number referred to GP for high BP: 1 (2.4%)
Number referred to GP for low BP: 2 (5%)
Number already on Meds for BP: 8 (19.5%)
Irregular pulse detected: 0
Already on meds for irregular pulse 3 (7%)
On medication for high cholesterol: 10 (24%)
Reported to have diabetes: 2 (5%)
Smoker: 5 (2.5%)
Total number advised to visit GP: 3 (7%)
Driffield Show
16.07.2008
Number of people seen: 104
Number referred to GP for high BP: 19 (18%)
Number referred to GP for low BP: 0
Number already on Meds for BP: 24 (23%)
Irregular pulse detected: 6 (6%)
Already on meds for irregular pulse 2 (3%)
On medication for high cholesterol: 24 (23%)
Reported to have diabetes: 6 (6%)
Smoker: 5 (5%)
Total number advised to visit GP: 25 (24%)
Tesco Superstore, Beverley
04.09.2008
Total number of people seen: 130
High blood pressure discovered: 34 (26%)
Number referred to GP for high BP: 18 (14%)
Number referred to GP for low BP: 0
Number already on Meds for BP: 29 (22%)
Irregular pulse detected: 8 (6%)
Already on meds for irregular pulse 3 (2%)
On medication for high cholesterol: 20 (15%)
Reported to have diabetes: 2 (1.5%)
Smoker: 11(8%)
Total number advised to visit GP: 23 (18%)
In conjunction with the Rotary Club
Asda,
24.04.2009
Number of people seen: 298
High blood pressure detected: 31(10%)
Irregular pulse detected: 4 (1.3%)
Advised to see GP: 12 (4%)
User/Carer Support
The
- Providing national input from a User/Carer perspective at the Department of Health
- Contribution to Hull Stroke Commissioning Group and various sub groups
- Supporting the further development of patient support groups across
- One to one support to individual stroke survivors as requested and further support through the Internet and Stroke websites.
Stroke Support Groups
There are a significant number of stroke support groups across
- OK Stroke Group,
- Masterstrokes,
- Strokes-r-us,
- Stroke Club Juniors,
- Willerby Stroke Club
- Beverley Stroke Club
- Bridlington Stroke Club
- Driffield Stroke Club
- Goole Stroke Club
- Market Weighton Stroke Club
- Pocklington Stroke club
- Holderness Stroke club, Withernsea
Developing Comprehensive Stroke Services in partnership with Hull & East Riding Councils and Voluntary Organisations.
This year the Department of Health has provided stroke services Nationally with an opportunity to focus on improving the long term co-ordination of care and experience of stroke survivors and their carers through a programme of funding allocated to all Council to the tune of £98,000 per year. Professionals in health care together with support from user and carer representation have been working closely with Hull & East Riding Councils to decide the best use of this addition resource locally to enhance the patient and carer experience.
Recommendations put forward to date include:
- Development of joint patients/carer information from both Health and Social care perspectives
- Plans to expand current training to focus on additional training and support for formal and informal carers.
- Development of Health and Social care plans for Stroke patients
Patient Experience and Service Evaluation
The Community Stroke Nurse Co-ordinating team continue to encourage Patient and Carer evaluation on an ongoing basis as patients come through the pathway.
Patients who are discharged following their support through the acute and community stroke pathway are sent and invited to fill in a feedback form.
Areas for feedback include the patient’s experience in the acute hospital setting, during rehabilitation either in hospital or community based units and support in the community. There is also opportunity for User and Carers to expand on any personal points, whether positive or areas that need further address.
Between April 2008 and March 2009, 63 patients and carers returned feedback to highlight their experiences of the service. Questions asked include:
- Whether people feel informed about their treatment plans
- Satisfaction levels with nursing and medical care
- Satisfaction levels with amount of therapy input received
- Whether they felt informed about medications prescribed
- Whether we met expectations to support emotional needs
- Whether peoples experience included having adequate verbal and written information.
Points that were highlighted where the service can be improved include the following:
- A significant number of patients felt that they did not have enough information about their medications (25%)
- General comments about needing more information (27%)
- Improving support to meet emotional needs of patients and carers. This was indicated by 17% of people
- Needing more information about benefits and entitlements (16%)
Comments were also made in relation to patient experiences where they felt that there were not enough Nurses on the Ward, Speech & Language Therapists and Physiotherapists.
There were also 5 (8%) patients who did not feel adequately supported with community dietetics services.
Plans are in place to review and renew current Patient Information as a direct result of these comments. Individuals for personal comments or concerns have been fed back to the appropriate hospitals wards and community teams.
A workshop including local stroke survivors, carers and professionals took place in the East Riding on 4th March 2009 to get an up to date view of patient experience and recommendations for service improvement.
Training & Education
Stroke Specialist within the Hull & East Riding Stroke Service continue to support annual training of a range of professionals and carers across all Health, Social Care and Private sector boundaries through the well established and highly regarded stroke foundation course.
Elements of Training include:
- Anatomy and functions of the brain
- Causes and effects of stroke
- Classification of stroke
- Surgical intervention of stroke
- Management of stroke patients in the acute phase
- The role of the Acute Stroke Co-ordinator
- Thrombolysis
- PEG and nasogastric feeding
- Neurological assessment
- TIA – clinical indicators and rapid assessment
- Management of secondary stroke risk factors
- Psychological adjustment to stroke and mood changes following stroke
- The role of the Occupational Therapist
- Perceptual and Cognitive problems related to stroke
- Discharge planning
- Understanding the role of the Physiotherapist
- Therapeutic Moving and Handling
- Feeding/Nutritional assessment/support for a stroke patient
- Swallowing assessment and management of stroke patients with swallowing difficulties
- Communication with dysphasic patients
- The history and role of the Communication Support Group (Stroke Association)
- The role Community Stroke Nurse Co-ordinating team
- Information about the Hull & East Riding Stroke Service
- User/Carer perspective of stroke
This is delivered over one day per week over a three week period.
The programme ran twice in 2008 (March & October) resulting in 53 people attending and again in April 2009 resulting in 32 attendees. The next course is planned for October 2009.
Stroke Networking
Clinicians across Hull & East Riding have, and continue to support the high profile that Stroke Services are now receiving locally, regionally and nationally. Senior Clinicians are supporting Commissioning Forums led by Hull PCT and the Cardiac and Stroke Network. There are plans for the commissioning focus to be set up in the East Riding imminently.
Senior clinicians are supporting the development of Stroke Services from the all important clinical recommendations via a Clinical Advisory Group which is providing clinical advice in relation to commissioning of Stroke Services for the North East Cardiac and Stroke Network.
THERAPY REPORTS
SPEECH & LANGUAGE THERAPY DEPARTMENTS
Combined Stroke Report 2008/09
The
In the 11 months from April 2008 to February 2009 inclusive, the SLT team at Hull Royal Infirmary (HRI) treated 233 new patients with the primary diagnosis of stroke. They were assessed and given therapy for a range of communication and swallowing disorders, with the type and amount of input varying according to clinical complexity and need. This service was delivered from the pool of SLT that covers the HRI site, as SLT resources specifically funded for stroke have never been identified. This is an area requiring development in the future.
One positive change in the past year has been the reintroduction of level one swallow screen training. This is delivered by the SLT team and allows qualified nursing staff to develop their skills in screening swallowing function and make a judgement as to whether swallowing has been impaired by the stroke. Nurses can then either refer to SLT if impairment is identified or introduce oral diet and fluids if no impairment is shown. As of February 2009 all qualified nursing staff on ward 110 had completed this training, as had others elsewhere in the trust.
Another positive change has been the reorganisation of SLT services across hospital sites and in the community. HEYHT will continue to deliver Speech and Language Therapy input at Hull Royal Infirmary but is now also providing the SLT service at the
The HEYHT SLT team no longer provide outpatient services to adults with acquired neurological communication or swallowing disorders and so on discharge from hospital, all clients who have had a stroke are now transferred to the community SLT teams provided by the Therapy Services Partnership.
The Therapy Services Partnership SLT team continued to provide input for stroke patients who experienced swallowing and communication difficulties on ward 2 over the past year. The level of service has continued to be restricted by limited staffing levels but prioritisation systems have allowed for patients with the greatest clinical need to be seen most intensively. Staffing levels have not allowed for SLTs to routinely attend multi-disciplinary case conferences and goal setting meetings but despite this, we have endeavoured to share goals and liaise closely with the rest of the team.
As explained above, at the end of March 2009 the HEYHT took over the service delivery of SLT to Ward 2.
Community Stroke Rehabilitation Units
Over the past year, SLT staffing has improved at the units and from October 2008 was back to normal staffing levels of 1 WTE for the three units. During the period February 2008 to February 2009, 81 clients with communication and/or swallowing difficulties were referred to the service. Of these 89% were seen within the standard of 5 working days from referral. The reason for clients not being seen within this time was either due to the SLT being on sick leave or annual leave.
Speech and Language Therapy have continued to develop the service by providing training to the multidisciplinary team on supporting conversation and decision making with clients with communication difficulties. Resources have also been developed and distributed to the units with the aim of further improving communication between staff and clients. The Band 7 SLT covering the units went on maternity leave from 19th February 2009. Since this time, Speech and Language Therapy has continued to cover the needs of clients with both swallowing and communication difficulties, albeit on a reduced staffing level. With continued use of prioritisation systems and individually tailored therapy programmes, clients at the units will continue to receive the best level of care that SLT staffing can provide.
Community Speech and Language Therapy
The Speech and Language Therapy team from the Therapy Services Partnership have continued to provide a service to stroke survivors in the East Riding Community over the past year. Despite the ongoing challenges of delivering a service over a wide geographical area with limited staffing, the team has continued to provide assessment and therapy for people with swallowing and communication difficulties within, or close to their own homes.
From the end of this financial year, all stroke survivors who have ongoing communication and swallowing difficulties in both Hull and East Riding (now including the Holderness area) are under the care of the community SLT team from the Therapy Service Partnership, hosted by East Riding of Yorkshire PCT. Clients who have a Hull GP are seen by the part of SLT team that are based at Highlands Health Centre in Bransholme and those who have an East Riding GP will continue to be seen by the SLT team based at Hessle Primary Care Centre.
New
New funding for the Hull Community Stroke Service has resulted in there being a much needed increase in funding for SLT service provision for clients who have a Hull GP. This funding is for 2.5 Speech and Language Therapists, dedicated to providing care for stroke survivors in their own homes and local community clinics. Unfortunately 1.5 of these posts are currently still vacant but the posts are to be re-advertised again soon and we hope to be able to attract suitable individuals to fill these roles.
When these posts are filled we are looking forward to working with the rest of the new multidisciplinary community team to continue developing the service, following direction from the National Stroke Strategy and RCP Guidelines for Stroke. Priority targets include providing more intensive therapy blocks for clients according to clinical need, establishing group therapy and closer working with the rest of the multidisciplinary team in the form of goal setting meetings and joint visits. As a team we are keen to involve service users and carers at all stages of developing the new service provided by the Hull Community Stroke Team.
Mary Harrington Kathryn Connolly
Head of SLT SLT Team Leader
NUTRITION AND DIETETICS SERVICES
Staffing
- Acute
The current funding for Dietetics within the acute stroke service is 0.5WTE Dietitian. This partly funds both a Neurosciences Specialist Band 6 Dietitian on ward 110 and a rotational Band 5 Dietitian on ward 2. A fortnightly specialist outpatient clinic based at Hull Royal Infirmary is available for Consultant referrals for secondary prevention of stroke including management of co-morbidities such as dyslipidaemia and/or hypertension and weight reduction advice.
In 2008, on Ward 110, 81 new patients were assessed and followed up by 748 reviews. On Ward 2 an additional 81 new rehab patients were assessed followed by 752 reviews. The focus of Dietetic input were patients requiring enteral tube feeding and those at high risk of malnutrition (as indicated by a high nutrition risk score) in order to prevent malnutrition and maximise rehabilitation potential.
- Community
Nutrition and Dietetics provide a service in Primary Care and Stroke Rehabilitation Units across the East Riding of Yorkshire PCT and Hull PCT and can attend MDT/Care review meetings in the Stroke Rehabilitation Units as required.
Patients are seen in mainstream dietetic clinics, Residential/Nursing Home care and in their own homes (if indicated as housebound)
Referral guidelines are available to enable appropriate dietetic care and optimise nutritional outcomes for these patients.
INDICATORS FOR REFERRAL TO NUTRITION & DIETETICS SERVICE
Patients presenting with :-
· Uncontrolled Diabetes - see departmental Professional Consensus Statement for Diabetes Mellitus
· Dyslipidaemias - see departmental Professional Consensus Statement for Hyperlipidaemia
· Hypertension - see departmental Professional Consensus Statement for Hypertension
· Dysphagia - Assessment and Treatment with Modified Texture Diet while maintaining adequate nutrition
· High/Very High Risk Nutritional Risk Assessment Score (MUST)
· Prescribed Nutritional Sip Feeds – monitoring of adequacy and appropriateness of prescription
· Enteral Tube Feeding
· Body Mass Index Over 30 with identified patient benefit for weight reduction
· Other concerns raised by patient/carer/health professional
Achievements
- Acute
Participation in the Stroke Foundation Course has continued and sessions on nutrition support within the acute stroke service have been provided. The Texture Modified Diet group with representatives from Dietetics, Speech & Language Therapists and the Catering Services have continued to monitor and improve the quality and range of the soft/puree diets. The Dietetic service has also updated the puree diet sheet. This year the Dietetic team has provided education on nutritional screening both Trustwide and also as part of the induction of the new nursing staff on ward 110.
- Community
Dietetic support to the Nurse led TIA Clinic has been provided twice a month
Local community clinic support for patients referred with hyperlipidaemia or for weight management (or as
Reviews of nutritional status are undertaken with changes to enteral tube feeding regimens as required as oral intake improves or weight loss occurs.
MUST Training continues to be delivered to care homes and Community Nursing Services with an aim to identify poor nutritional status and optimise care planning.
Menus in community hospitals have been revised to meet nutritional standards in conjunction with the Catering Service, Humber Mental Health NHS Trust and the new menus have been piloted in
Limitations/Shortfalls
- Acute
Shortfalls in funding the Dietetic service have prevented representation in the MDT meetings and the Stroke Working Group. The Dietitians have potential to be more involved in the care of patients with dysphagia, those at moderate risk of malnutrition and initiating secondary prevention dietary advice prior to discharge home. It is hoped that the recent proposal for increasing funding for the Therapies might result in increased Dietetic funding to provide a more comprehensive service and allow participation within the multidisciplinary team.
- Community
A budget overspend is predicted again for enteral tube feeding equipment due to the increase in cases since the introduction of the Stroke Service. The service wishes to provide routine replacement of enteral feeding tubes rather than the current emergency replacement service offered. This would require funding of equipment and additional training for dietitians.
The service is not accessible to all. Goole and Howdenshire have no home service in place and no support to the neighbourhood team and community matron. The service is very limited in Holderness with longer waits for home visits and ward assessments and reviews.
The new Stroke Rehabilitation team in
The service does not meet the needs as defined by the standards from the Royal College of Speech Therapy to accept referrals for all patients with dysphagia.
Helen Williams Sandra Gorman
PHYSIOTHERAPY
Acute Stroke Unit (Ward 110 HRI) and Acute Rehabilitation (Ward 2 CHH)
Staffing
On ward 2, physiotherapy provides a high intensity of specialist input to the 22 neuro rehab beds. (Diagnosis includes stroke as well as head injury and other conditions requiring rehabilitation.) We have two part time band 7 team clinical leaders, two band 6 senior physiotherapists on 6 monthly neurological rotations and two band 5 junior physiotherapists on 4 monthly rotations, plus two part time band 3 assistant grades. Additional assistant input is provided through part time multi disciplinary Therapy Assistant posts shared across Therapies. This reflects the complex nature of these patients and during the week allows us to provide daily therapy to patients who need it. This approximates to the 2008 Royal College of Physicians recommendations of 45 per minutes of therapy per day. We are not however staffed to provide therapy at the weekend and case mix also impacts on the daily treatment time available.
Ward 110 bed capacity varies between 20 and 24 acute stroke beds and is staffed by one band 7 clinical lead therapist, one rotational band 5 physiotherapist and three part time band 3 multi-disciplinary assistants who carry out treatment programmes for physio, occupational therapy and speech and language therapy, and who provide limited weekend input. In 2008 we conducted 483 new patient assessments, average of 9 per week, plus 3823 therapy treatments, average of 72 per week. We are unable to provide daily therapy to all patients; this is a weakness which continues to be monitored and we have worked closely with trust planners to submit a business case for increased staffing.
Clinical Governance
Ward 2 has benefited form major investment in the Installation of an over head tracking hoist system with walking jackets which has enabled us to safely attempt mobilisation of patients who are functionally unpredictable. We have also obtained a stand easy turn-table which aids patients to weight bear during supported transfers and is especially useful in confined spaces.
Closer liaison with the community stroke team through weekly MDT stroke review meetings has developed communication and aided in identifying appropriate patients for transfer to community stroke units. Patients have an opportunity to set patient centred goals and communication with family and carers has improved.
On ward 110 therapy and nursing teams work closely together, an audit of patient and staff incidents/injuries conducted jointly with nursing resulted in us obtaining the sensor care bed/chair alarm system which notifies staff by pager and alarm when a patient at risk of falls begins to try and get up without help. Joint environmental risk assessments led to recommendations which are currently being implemented to improve the physical environment on ward 110.
Acute and community therapists together updated and added to the local therapy guidelines. We are in the process of developing a stroke intranet site where stroke service information and guidelines will be available to professionals across
Both sites conduct departmental documentation audits based on Chartered Society of Physiotherapist Standards.
Education
Clinical lead therapist on ward 110 in 2008 attended external courses given by advanced Bobath tutors covering the Recovery of Function in the Upper Limb and Neurophysiology for Neurotherapists.
Weekly in-service training for rotational physiotherapists runs on both sites. Ward 2 also operates a monthly journal club.
Both sites take physiotherapy students from
Achievements
In 2008 physiotherapy was involved in fund raising for Ward 2 through running the
Ward 110 and ward 2 MDT teams jointly organised our third Stroke Unit Ball which was held this year at Lazaat and raised over £4000 for equipment to be purchased by therapy and nursing teams.
Rebecca Canet-Baldwin
Andrea Murphy
Annette Dennis
With effect from January 2009 a Specialist Physiotherapist (Anna Marritt) and a Physiotherapy Technical Instructor (Helen Davy) have been recruited to Hull Community Stroke Service. This is a dedicated stroke service offering physiotherapy to patients with a clear rehabilitation goal and a Hull Gp.
Currently, the physiotherapy staff have an office base at Rossmore Stroke Unit, however, it is envisaged that there will be a change of office base when the remainder of the team are in post.
Whilst it is likely that the majority of the caseload will come from the Stroke units (Rossmore, Alderson and St Mary’s) and the Hospital wards, (HRI 110 and CHH 2) referrals are already coming from a wide variety of sources, for patients with diverse issues.
At this stage it would be misleading to provide any figures, however, the rate of referrals has increased steadily since January, as the existence of the team becomes more widely known.
We look forward to an exciting year with much ongoing development in order to deliver an effective community based physiotherapy service.
Anna Marritt MCSP
Specialist Physiotherapist
COMMUNITY STROKE REHABILIATION UNIT – HULL
The three Hull Community Stroke Rehabilitation Units continue to be staffed by 2 WTE Band 7 Physiotherapists, 3 WTE Band 4 Technical Instructors and a 0.4 WTE Band 5 Physiotherapist. The Band 5 is on a shared rotation with the Hull Community Rehabilitation Team based at Highlands Health Centre in Bransholme. The team continues to be based at Rossmore Nursing Home where we are supported by a full time admin and clerical support worker.
The other two units within
The T.I’s rotate between the three units on a two monthly basis which allows for a T’I to be in each of the units on a full time basis when fully staffed. The two Band 7’s have a unit each and share the third. The Band 7’s rotate on a six monthly basis.
The physiotherapy service has once again been affected by long term staff illness over the last twelve months which has impacted greatly on the number of treatments provided within the units. This has also impacted on service development as patient treatments have taken priority.
Education:
We continue to support physiotherapy students from Bradford, Huddersfield,
The two band 7’s attended the 2 day National Stroke Conference in
The Future:
In the next twelve months it is hoped that we introduce our patient satisfaction questionnaire and update our information leaflets for Ward 110 and Ward 2 informing patients and relatives about the three units.
We are currently collecting data which will enable us to plan future resources for the Early Supported Stroke Discharge Team which will hopefully be se up in 2010.
Helen Rymchuck & Carol Bramley
Physiotherapy
Community Stroke Units
HAHTS had 63 stroke referrals this year, broken down as follows:
- 29 from Community Stroke beds
- 19 from Ward 110
- 6 from ward 12
- 3 from ward 2, CHH
- 6 from AAU / other wards at Hull Royal Infirmary
Referral Criteria
- 28 were referred for Occupational Therapy input only
- 21 were referred for both Occupational Therapy and Physiotherapy
- 14 were referred for Physiotherapy input only
Outcome
- 8 patients were referred onto other services on discharge from the team
- 5 were referred to community physiotherapy on discharge from the team
- 1 was referred to Clinical Psychology
- 1 was referred to Community Occupational Therapy
- 1 was referred to Neurological Physiotherapist at HRI
Linda McFadden
Team Leader
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.
In 2008 funding for a 1.00 WTE specialist Band 6 post was secured. The Senior Occupational Therapist was based at the
The 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 Withernsea Hospitals remain in post. The remaining funding of 0.33 WTE was integrated to fund the Senior Occupational Therapist based at
Stroke Rehabilitation continues to be provided as an integral part of the existing Community Rehabilitation Service and the new Neighbourhood Health Teams 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.
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:
3.00 WTE Senior Occupational Therapist
1.00 WTE Senior occupational Therapist (rotation)
2.00 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
With the funding of the new Community Stroke Rehabilitation Team Occupational Therapy have two new posts with which to provide ongoing rehabilitation for patients in their own homes. The Band 7 post has been recruited to and will be filled from the 8th June 2009. The Band 4 assistant Practitioner post is currently going through the Band process before being advertised. It is planned that these post holders will work closely with the new physiotherapy and Speech and Language therapy staff with a central referral point and team approach.
In the meantime referrals have continued 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. The current rate of referrals shows that there is more work than one wte qualified staff member can process. Monitoring of the shortfall continues and continues to be raised in business planning for the proposed Early Supported Discharge/ Community Rehabilitation Team.
There is also a need for additional Occupational Therapy TI time in the step down units. This would allow an increase in rehabilitation activities available to patients and improve the patient outcomes.
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 Clinical Specialist has also contributed recently to the Hull World Class Commissioning Group representing Therapy Services Partnership and also to the Stroke Network Group.
Alison Forrester,
Head Occupational Therapist,
Clinical Specialist Stroke,
Community Rehabilitation,
Rossmore Stroke Unit
Sunny Bank
OCCUPATIONAL THERAPY ACUTE STROKE SERVICE
This year has continued to see change within the Acute Trust Stroke Service; with the move of Ward 110 and Ward 2 into the Neurosciences Business Unit, we are beginning to see the benefits of consolidation of our service to mirror this model. The previous amalgamation of OT staff on ward 2 from stroke and neuro-rehabilitation in 2006/07 has provided some flexibility in working patterns and sharing of skill sets, and with the appointment of Selna Mathews to the senior OT position on ward 110 in August 08 we are beginning to reap the benefits of having stability of staffing, the Occupational Therapy been represented at business and service meetings by the Principal lead OT for Neurosciences. The restructuring has enabled us to re-focus on patient services and development of staff to meet agreed competencies.
The structure is supporting the development of Band 5 rotations by enabling staff to work across two areas during an eight month period. This has resulted in the consolidation of baseline skills which can be used in other areas of the Trust where stroke patients may be treated.
Training and Development – senior clinicians have continued to support and input to the Stroke Foundation course.
Four Band 5 OT - attended the Northern and Yorkshire Special Section for Neurology Event – Starting Out in Stroke – aimed at meeting requirements of the National Stroke Strategy staffing competencies.
Selna Mathews has undertaken MSc Module - The Management of Stroke at
Successful completion of training to support undergraduates OT’s on fieldwork placement has enabled both ward 2 and ward 110 to continue with cross service exchange of student visits with our colleagues in the Therapy Partnership.
Audit and Development of Stroke Service – OT staff have taken an active part in three strategic events held by the Cardiac and Stroke Network, and the Life After Stroke Event held by East Riding County Council, and where part of the multidisciplinary team who submitted information for the National Sentinel Audit for Stroke.
The service has carried out a cross site review of documentation in light of the updated RCP guideline 2008. Ward 110 are currently auditing treatment time spent with patients to assess level against the National Stroke Strategy and Ward 2 are auditing moving and handling requirements of patients within therapy – both audits will influence the services review of skill mix and be used to inform the business planning proposals for continuing development of service.
Debbie Parker
Principal Lead OT Neurosciences on behalf HEY OT Service.