Hull & East Riding Stroke Service

ANNUAL REPORT

April 2004/5

TABLE OF CONTENT

ANNUAL REPORT

April 2004/5

IN PATIENT ACTIVITY AND ACUTE CARE MANAGMENT

The activity experienced in 2004 replicates that of previous years in terms of the number of patients admitted to the Acute Hospital with diagnosis of stroke and those with a secondary diagnosis of stroke (post admission). Freeing up enough beds on the Acute Stroke Unit to enable all stroke patients to access this facility is proving to be a very difficult task.  On average there are approximately 8-10 patients distributed across the Hull Royal Infirmary in an outlying bed following stroke who cannot access this facility and further consideration to locate additional acute stroke beds in one defined area with therapy support may be needed.

The development of an Acute Stroke Unit has provided a focus for specialist care of stroke patients in the Acute Hospital but as a consequence of this, the ward experiences a mix of both high throughput of patients together with requirements for acute medical management and rehabilitation of patients and families with high dependency needs from a physical and psychological perspective.  This concern has been highlighted through the Stroke Working Group business planning process to support additional funding requirements for nursing care on both Ward 110, Hull Royal Infirmary and Ward 2, Castle Hill Hospital.

Information collated from the Stroke Register January 2004 – December 2004

Out of 737 stroke patients, 559 accessed and were treated on Ward 110 (76%)

Future information will be recorded and evaluated in the Trusts financial year (April 2005-March 2006)

DEVELOPING A THROMBOLYSIS SERVICE

Senior Clinicians within the Stroke Service are currently discussing the logistics of introducing a Thrombolysis service in the acute hospital for stroke patients.  Dr Abdul-Hamid, lead Stroke Physician and Neurology Consultants are facilitating a workshop in May (2005) to discuss and prepare recommendations for introduction of this service in the near future. 

The Stroke Service team will be putting a case of need together to identify the requirements for New Ways of Working and resource implications to introduce this service.

STROKE REGISTER

This year the stroke team have managed to set up a stroke register with a clinical database.  This register is live and therefore the Stroke Service is now aware of the majority of stroke patients admitted to the hospital and their whereabouts which enables continuing support of these patients and their clinical and psychological management if they are unable to access the Acute Stroke Unit. 

Clinical data recorded within the stroke register reflects the requirements of Clinicians and Service Commissioners and will enable us to identify, not only the number of patients admitted to the Acute Hospital, but also age ranges, geographical localities of patients, previously identified risk factors and newly identified risk factors and treatment changes.  This information will provide us with continuing clinical audit data with which to develop the service and local approaches to clinical management of stroke risk factors. The Stroke Service Facilitator will provide 6 monthly reports to the Stroke Working Group to reflect clinical activity. (please see template attached)

CO-ORDINATION AND CARE OF PATIENTS THROUGH THE STROKE CARE PATHWAY

The appointment of a Stroke Nurse Co-ordinator to support the Nurse Consultant in co-ordinating the Acute and Community patient care pathway has made a significant difference.  All stroke patients admitted to the Hull Royal Infirmary are now supported on a daily basis (Monday to Friday) and the Stroke Co-ordinator is able to prioritise patient transfers to the most appropriate place including the Acute Stroke Unit and Community Rehabilitation facilities.  The Stroke Co-ordinator also takes a lead responsibility for accurate stroke register compilation.  This service is dependent on recurrent funding from the Primary Care Trusts and would  not be possible without it. 

Plans are now underway to develop a strong team of Stroke Co-ordinators across the acute and community settings to support the clinical and psychological needs of stroke patients and their carers.  This will strengthen existing capacity to support early transfer of stroke patients from hospital to community rehabilitation; disseminate skills and support to carers in Nursing & Residential care settings.

CLINICAL PSYCHOLOGY

There is still no funding available to introduce much needed Psychology input to the Hull & East Riding Stroke Service.  The Psychology Service locally remains extremely keen to provide their support and expertise to the service which is much needed.

Currently there is no access to Clinical Psychology services for any stroke patients locally and this remains very concerning.

TIA

2004 remained a busy year for the TIA service with growth documented in all of the services provided.

·        652 patients seen by TIA Specialist Nurse

·        688 patients seen by Dr Abdul Hamid and Dr Hamdalla (who left in Dec of ’04)

·        223 patients had CT scan

·        488 patients had Carotid Doppler.

The most patients seen in a one-month period by the TIA specialist nurse was 83 in March 04 compared to 33 in October. A mean average of patients seen in one month is 54

The most patients seen in the Consultant led TIA clinics was 88 in September but this has a mean average of 42 patients per month

Several changes were made to the service in 2004: -

The number of dedicated CT scans was increased by 2 per week to 6.

The number of dedicated Carotid dopplers remained the same at 7 per week.

The number of nurse clinic slots was increased during busy periods with the support of Medical outpatients but the number of allocated slots remains as was at the end of 2003.

20 slots per week.

A proposal was put forward in September 04 to increase the service provision based on the demand trends of the last 3 years.

The proposal was to increase the number of CT slots and Carotid doppler slots as well as providing the TIA service with its own office, clerical staff and a second nurse.

Towards the end of 2004 an interest group was formed to make plans for Stroke Awareness week 2005 following a small pilot in October 04.

The First event was planned for April 2005 and was a great success.

Stroke Awareness through risk factor identification and subsequent management was offered and over 4 days approximately 160 staff attended.

The TIA service continues grow in number of referrals for the first few months of 2005 and we eagerly await the arrival on the new Consultant  (to replace Dr Hamdalla) in June 2005.

Dyson Stubbins, TIA Nurse Specialist

April 2005

AUDIT

The National Stroke Sentinel Audit, which was carried out earlier this year, demonstrated significant improvements within the Stroke Service and high levels of clinical management according to national guidance and was rated in  the top 25 out of 246 Trusts.  The Stroke Service was well above the national average for the 12 key indicators of clinical care with a score of 78%. 

RESEARCH

The stroke team are keen to look towards contributing to National Clinical Trials in stroke care.  This year it has proved very difficult as there has been no access to funding to support recruiting patients to such trials.  Support in this way will be a key area for focus in the forth coming year. 

A research proposal is currently being compiled to look at the incidence, risk factors and long term social effects of working age stroke sufferers and their carers locally.

THERAPY REPORTS

Speech & Language Therapy – Acute

For the past year the Speech and Language Therapy Department (at Hull & East Yorkshire Hospitals Trust) have provided 0.7wte time to ward 110, for assessment and treatment of swallowing and communication disorders after stroke. This has been well received and I am pleased that the National Sentinel Audit of Stroke 2004 has reflected the responsiveness of the SLT service. However, pressure across the whole SLT service has increased significantly and, given that the acute SLT service for stroke patients is from the general pool (not specifically funded for stroke), resources may need to be reallocated in the near future. The team have also done their best to meet the needs of outpatients discharged from hospital or rehab facilities. However, increased caseload numbers and already limited resources have led to a reduced outpatient capacity and we are currently unable to meet the demand. It is hoped that funding may be identified to continue the current level of service to ward 110 (and ideally increase it) and to establish an outpatient service.

                                                                                     Mary Campbell, Senior SLT, Acute

Speech & Language Therapy – Community

February 2004 – January 2005

The Speech & Language therapy service provides a service to clients with communication and /or swallowing difficulties who are receiving rehabilitation at three community stroke units (Rossmore Nursing Home, Alderson Resource Centre and St Marys Nursing Home).  There is a total of 24 beds (previously 25 until October 2004) across the three units.

Team members comprise of:

0.8 WTE of Senior Speech & Language Therapist (spine points 29-31)

0.2 WTE of Rotation Speech & Language Therapist (spine points 19-24)

The service provides assessment, management and treatment for communication and swallowing difficulties for clients while they are resident at the units.  Referrals are  usually made as transfers from the acute stroke unit at Hull Royal Infirmary and Castle Hill Hospital although direct referrals from staff at the units are also accepted.  Clients tend to stay on average between 6-8 weeks however, this varies according to individual client’s needs.  Speech & Language Therapy work closely with all members of the multi-disciplinary team (MDT), attending weekly MDT meetings and client reviews.  Depending on caseload and individual client need, SLT can provide up to 3 sessions of therapy a week.  Client’s families are actively encouraged to be involved in rehabilitation.

Caseload information

The table below give a breakdown of referrals made to Speech & Language Therapy during the period of February 2004, when the service started, to January 2005, prior to the senior therapist going on maternity leave.

The following code is used to indicate whether referrals were for communication ( C ), swallowing, ( S) or both (CS).

Total number of clients with communication difficulties:   74

Total number of clients with swallowing difficulties:         78

Average monthly referral rate                                                    9

The standard for initial assessment wainting time is 5 working days.  The average wait was 3 working days.  There were only 8 clients who were not seen within the standard.

Service Developments

New Service

Setting up the service

Training – texture modification

Computer therapy

(Stroke Foundation training)

Exploring prioritisation for therapy

Plans

Maternity leave

Computer therapy

Training in communication difficulties

Exploring increasing amount of therapy

                                                                       Anna Ray, Senior Therapist, Community SLT

Occupational Therapy – Acute

The Occupational Therapy Service within the acute Trust continues to offer a high level of support to the Hull and East Riding Stroke Service.

This report is a resume of some of the development features.

Cross site working

Occupational therapy is unique in the acute Trust for its integrated management style in effecting cross site working. This applies to both qualified and support staff. Qualified staff members, particularly, are known to the multi-disciplinary teams on both sites and can work equally effectively. Support staff have benefited from short secondments.

Charitable donations

Occupational therapy has been instrumental in working with several individuals to identify and acquire much-needed postural equipment to benefit patients on ward 110 and on ward 2.A particular benefit has been the standardisation of equipment on the two sites. A Tilt-in-Space reclined wheelchair and versatile adjunctive seating is now available to provide a wide range of seating choice for patients on both wards

This has been made possible by the generosity of the Catholic Women’s League in Cottingham (identified by Dr John Knox); charge nurse Pat Whitfield (ward 2); and Eileen Henderson (head of therapies.

Training has been given to the multi-disciplinary team on these products, and interest has been shown by the wider stroke service regarding information and training.

Charitable funds have also enabled the acquisition of additional cognitive resources.

Promotional opportunities

Opportunities have continued to arise which have enabled us to further our work on hand swelling. The stroke forum provided the opportunity to introduce a training document with the aim of raising interest from the wider stroke service. The intention is to roll out this good practice in a multi-disciplinary format.

Education

We have continued to support the stroke foundation course and would like to be further involved in this initiative.

New starters to the service have found the course to be particularly beneficial, especially if they have been able to attend near the beginning of their rotation. Rachel Pymer has fitted new starters in mid course, and reports suggest this has not been detrimental. The important factor is to gain an overview of the service as soon as possible.

Links with community OT service

Qualified staff are meeting regularly to promote practice development, sharing skills and identifying service update issues. These meetings take place over lunchtime.

Long term development plans

The outcome of last September’s time-out day is still not known. Bids were put forward on that occasion, which were subsequently reviewed by Eileen Henderson and Joanne Evans. It would be helpful to have a positive outcome in order to move the service forward.

Closing remarks

Staff members have made valuable contributions over the year to maintaining the service, frequently under difficult conditions. Good will has been stretched to the limit.

The vision for the service this year must be to achieve quality patient intervention.

This will require some difficult prioritisation decisions and management strategies on my part to ensure that limited resources are directed where they will be of maximum benefit to patient recovery and staff education,

Linda Greenwood, Clinical Specialist Stroke

Physiotherapy – Acute

The Physiotherapy service in the acute trust has worked hard this year to provide an equitable, efficient and effective service to the stroke patients on ward 110,ward 2 and out lying stroke patients at Castle Hill Hospital. We have also assisted in facilitating the transfer of these patients in to the stroke service for their rehabilitation when appropriate. We aim to see stroke patients daily but not at the expense of the effectiveness and quality of the intervention which is audited against the Chartered Society of Physiotherapy (CSP) Standards for stroke rehabilitation.

Evidence Based Practise

We ensure that our practise is current and underpinned by the evidence available. This is done by dissemination from the clinical specialist who is committed to continual professional development and has completed 2 significant courses this year (Advanced Bobath and Movement Science MSc Module) This is done through a structured in-service teaching program, formal supervision and support of Senior and junior staff to add to the evidence base through their own learning. This year the physiotherapists working in stroke across secondary and primary care have produced a guideline for upper limb management and are currently writing one for positioning. We have also worked with the community physiotherapists to support the stroke foundation course.

Service Development

This year the focus of service development has been around the moving and handling of neurological patients (this was planned as a multidisciplinary project but unfortunately other professions were unable to contribute so it remains uni-professional). We have completed a guideline for therapeutic moving and handling in neurological rehabilitation (UMN lesion); 16 protocols for "high risk" activities as identified by the CSP and a training pack which is being used to teach physiotherapists working with stroke patients This training is to be extended to link nurses on wards 110 and 2 and is also open to other members of the MDT. Our Clinical practise on ward 2 has also been risk assessed by the safety department and a recommendation has been made for overhead tracking for the hoisting, standing/walking of early stroke patients in line with the evidence, to be situated in the rehabilitation gym. Funding has just been agreed for this.

Audit

The physiotherapy service in the acute trust is audited against the CSP standards for stroke as well as physiotherapy department standards of practise Physiotherapists on ward 2 and 110 have also contributed to the development and audit of local levels of rehabilitation. This has identified that 27% of the patients are medically unwell but the characteristics of the other 73% and the reason for their admission to ward2 is unclear. The characteristics and discharge destinations of patients discharged from ward 110 is to be audited next year. This will inform the different rehabilitation centres about the "types" of stroke patient they predominantly see and help them evaluate the best treatment approach to use, their training needs etc.

For the last 2 years the physiotherapists on 110 have audited length of stay on the unit and discharge destination. This will add to the data already collected by physiotherapists on ward2 and give a better understanding of the service and in particular patient flow.   

Measuring Outcome

The physiotherapists with in the acute trust continue to use Teler as an outcome measure and also the shortened Sodring Scale. But we have become increasingly aware in the last year of the difficulty in evaluating our practise in terms of the long term out come of our patients and also the impact of our practise on their continuing rehabilitation in the community To this end we are about to survey the community physiotherapists working in stroke and use this information to inform our practise and provide more cohesive rehabilitation for our patients. This will be followed up by a feedback session and hopefully lead to the establishment of a quarterly meeting of all the physiotherapists working within the stroke service.

Practise Development

In conjunction with our colleagues working in neurology and neurosurgery we are exploring the effectiveness of innovative treatment approaches eg treadmill training, FES, constraint induced therapy etc as described in 4.4 of the national guidelines for stroke. We are a waiting funding for a treadmill at this moment in time.

Closing Remarks

The physiotherapists in the acute stroke service will continue to strive for excellence in their rehabilitation of stroke patients and are committed to ongoing evaluation and development of our selves and the service to this end. We are also committed to team working, as we believe an integrated approach is the most efficient and effective way to deliver rehabilitation. To achieve this we will continue to work hard to strengthen links between our multidisciplinary and community colleagues.     

Jenny Furniss ,Team leader and Clinical Specialist Physiotherapist Stroke

April 2005

INPATIENT COMMUNITY STROKE SERVICE

2003

This year there were 225 admissions to community based rehabilitation services in the City Centre and Community Hospitals.   Average length of stay was 6.7 weeks with over 60% of patients being discharged to their own homes.

Data: January – December 2004

2004

Further developments within the community rehabilitation services include the Rossmore Rehabilitation Day Unit which now provides an excellent facility for stroke patients transferring to Rossmore Nursing Home to focus on their rehabilitation in a therapeutic environment.  Further proposals have been put forward to replicate similar facilities at St Marys Nursing Home.

The success of Nurse and Therapy led rehabilitation at Beverley Westwood Hospital together with contracted medical support has again, enabled a significant number of stroke patients to benefit from rehabilitation at Beverley (this year 28 patients).  The East Yorkshire and Yorkshire Wolds & Coast Primary Care Trusts are currently looking to focus on strengthening rehabilitation facilities at Withernsea and Driffield Community Hospitals to support the current demand.                  

TRAINING & EDUCATION

To date 8 Stroke Foundation courses have been delivered with a total of 205 attendees;

25% of which were Nursing/Residential home staff and 7.4% from Social Services. Further funding from the Workforce Development Confederation has enabled another full year of the Stroke Foundation Course to be run and this continues to be extremely well attended.  The course is set to run through 2005/06, 3 times a year.

Collaboration with York St Johns University has enabled planning to take place for delivery of a Multidisciplinary Stroke Module at level 3 which will be accessible across the disciplines and this is set to run in September 2005 at the Institute of Rehabilitation and has been well supported by the local Stroke Physicians, Therapists and Nursing.

HULL & EAST RIDING STROKE SERVICE

STRATEGIC OBJECTIVES FOR 2005/06

�                   Strengthen current resources for nursing care on Ward 110, Hull Royal Infirmary and Ward 2, Castle Hill Hospital to reflect the workload and nursing needs of this client group and the staffing requirements to introduce a Thrombolysis service.

�                   Develop Acute and Community Stroke Co-ordinating team to support patients throughout the Stroke Care Pathway, which facilitates early discharge from the acute hospital setting.

�                   Strengthen existing rehabilitation facilities in the East Riding including Withernsea and Driffield Community Hospitals.

�                   Secure funding to support access of Clinical Psychology to stroke patients.

�                   Agree plans and protocols for a Thrombolysis service

�                   Establish Degree level Multidisciplinary Stroke Care Module in Hull.

�                   Make recommendations for developing day rehabilitation services to provide top-up/ongoing rehabilitation programmes for stroke survivors and strengthen long term support for this client group, working jointly with Social Services.

�                   Establish the required infrastructure for Hull & East Riding Stroke Services to contribute to stroke research