Number of admissions to Ward 110 (Acute Stroke Unit
2001, 668
2002, 638
2003, 566

Number of patients transferred to Ward 2 CHH
2001, 93
2002, 80
2003, 76

Number of patients discharged directly home from Ward 110 2001, 283
2002, Approx 230
2003, 220

The overall number of patients admitted both to Ward 110 and Ward 2 has reduced from activity levels of the previous 2 years.

There are still approximately 1/3 of stroke patients going directly home from the Acute Stroke Unit. The average length of stay on Ward 110 is estimated at approximately 17 days. The Community Services need to be more supportive / responsive in order to free up Acute Stroke beds.

STROKE REGISTER

Locally, we cannot meet the April 2004 NSF milestone to achieve this.

An accurate database to enable the service to know exactly how many patients are admitted to the Acute hospital with a stroke has not yet been set up, but foundation work to enable this to happen for 2004 has been taking place.

The service estimates that we are receiving approximately 700 admissions a year with stroke and in addition to that, there will be patients who suffer stroke post admission (mainly post surgery or MI). A database for a stroke register has been agreed by the Stroke Physicians and has been set up by the I.T department at the Hull Royal Infirmary. The service is currently seeking approval through the Acute Trust to collate this data ain the form of a register.

It is recognised that the infrastructure to do this is still not resourced and it may be impossible to record accurate data without an additional data input clerk.

OUTREACH SERVICE

The Nurse Consultant together with the Senior Nurses in the Acute Hospital Trust have run a pilot project supporting stroke patients not getting to the Stroke Unit. This has contributed significantly to supporting the clinical management and co-ordination of stroke patients who are not transferred directly to the stroke unit and also in helping to prioritise patients into the unit. This service is extremely limited due to existing work commitments of the team.

It is hoped that a Stroke Nurse Co-ordinator post will be funded imminently and this will contributed significantly to the improved use of the Acute Stroke unit and transfers to Community Rehabilitation facilities without delay. As well as supporting the ongoing care of patients transferring into Community Settings.

FURTHER DEVELOPMENTS

Appointment of a Specialist Occupational Therapist and Physiotherapist for the Stroke services within the Acute Hospital has been welcomed as has the appointment of a Senior Neuro Speech & Language Therapist to the Acute Trust.

The workload of therapists, particularly on Ward 2, has caused some significant difficulty in relation to ongoing daily therapy on this rehabilitation ward. This has been raised by the Head of Physiotherapy services.

Annual Report for 2003; Occupational Therapy Services (Acute Trust)

Current situation

This report aims to document the current situation, achievements, challenges, and gaps in the acute Trust occupational therapy service.

Since the appointment of a clinical specialist in April 2003, the last nine months have provided a valuable opportunity to reflect on an inherited situation.

Two wards provide a specialist stroke service within the acute hospital Trust. These are Ward 110 at Hull Royal Infirmary (HRI) and Ward 2 at Castle Hill Hospital (CHH), comprising 40 beds in total. There is no specialist occupational therapy service to outlying patients on either site, a situation not in line with current guidelines.

The Acute Trust is the gateway to the stroke service, and will be the first therapeutic point of contact a patient will encounter in their rehabilitation journey. Occupational therapists are required to offer a diversity of treatment to these patients at all stages of their recovery.

The priority on Ward 110 is on early assessment to essentially three groups of patient (data only available for the latter six months of the year):

1. The high functioning patient who has the ability to be discharged from the ward, usually home (n 114, of which only 15 needed a home visit)


2. The patient who will require ongoing rehabilitation, either on Ward 2 for those who need a medical setting (n 43), or a rehabilitation bed in the community for those who are medically stable (n 43)


3. The patient who requires early management to prevent complications.

Practice on Ward 2 is influenced by the large number of patients who still require a medical setting, and who have complex rehabilitation needs. Statistics show there is an increased percentage of patients who require hoisting (from 55% in 2002 to 64% in 2003) which means that there are more who need two members of staff to move and treat in order for the patient to have a therapeutic learning experience. In addition 51% of patients remain on the ward in the month following that of their admission, as opposed to 49% who are discharged within the month of their admission (only 15 went home).

There is a requirement for occupational therapists in the acute Trust to treat patients across a continuum of therapeutic needs. Not only in functional task independence, early management strategies, cognitive assessment and discharge planning, but there is frequently also a need for more than one member of the occupational therapy team to treat a single patient. This situation was not fully understood or identified at the time of resource allocation at the inception of the stroke service.

Present staffing levels comprise:

1. 1 Clinical Specialist occupational therapist


2. 1 Senior I occupational therapist (vacant; discontinuously covered by locums)


3. 2 Senior II (rotational) occupational therapists

In addition there are 3.8 whole-time equivalent therapy assistants across both wards, shared by four therapies.

Achievements

1. The appointment of a clinical specialist occupational therapist in April 2003, which has provided leadership and support.


2. Evidencing practice (Mini-Mental state examination, Rey Osterrith copy test, and Hand Swelling post stroke).


3. Full recruitment to therapy assistant posts.


4. Implementation of weekend working on Ward 110 (group multi-disciplinary therapy).
   
5. Occupational therapy presentations at local, regional and national levels.

1. Recruitment and retention of occupational therapists.


2. Demands relating to the diversity of practice


3. Constant induction and training of rotating staff, and locums, often with limited neurological background.


4. Consolidation of the occupational therapy team across two sites, balancing the skill mix, and implementing more flexible working.

Gaps in the service

The current number of occupational therapists is a cause for concern. The College of Occupational Therapists recommends a ratio of one occupational therapist to five patients within an acute rehabilitation setting. To meet the guidelines, four more occupational therapists are needed to offer the frequency and duration of treatment that patients need to develop foundation skills from which to progress their rehabilitation in the community. Present staffing levels do not enable this level of intervention, and the service provision remains inadequate without this.

There is a need for a weekend service at CHH, involving both qualified and support staff, to extend rehabilitation across seven days, and to speed the discharge process.

There is presently no clerical support, which results in trained clinical staff being diverted to essential clerical duties relating to discharge paperwork. This is not best use of their time.

Action plan for the occupational therapy service; stroke

1. Advertise the Senior I post internally as a career development opportunity.


2. Seek funding for one additional, whole time equivalent, static Senior II whose primary responsibility would be to lead the established weekend service on Ward 110, and the proposed weekend service on Ward 2. An additional 0.5 whole time equivalent weekend Therapy Assistant time would also be required (.Ward 2) These posts would involve flexible working to complement and expand services beyond traditional working hours


3. Seek funding for 0.5 whole time equivalent Clerical Assistant to support occupational therapy across both sites.

Community Occupational Therapy Annual Report Statistics

Service has dealt with 112 inpatients and 27 outpatients (by 2 staff)

33 in-patients were not seen for a variety of reasons but mainly due to staff shortages and patients being discharged to long term care.

84 have been discharged having reached their full potential

15 have been discharged for other reasons (i.e. RIP)

40 are currently receiving occupational therapy

Figures are currently unobtainable across the rest of the Trust. However, in the first half of the year 22 patients were seen in Beverley by 1 Occupational Therapist.

AUDIT

Nursing and Dietetic staff carried out a joint audit on the nutritional management of patients who go onto to require percutaneous endoscopic tube feeding. This audit supports the current development within the Gastroenterology services to provide a more responsive PEG insertion service. It is also highlighted practice issues for nursing staff in relation to Nasogastric feeding skills and dysphagia management skills.

DYSPHAGIA MANAGEMENT

The Nurse Consultant, together with the support from the Speech and Language Therapy teams across the Acute and Community Service, has instigated a Dysphagia Screening Training with a period of clinical supervision. This has been well received by the Nursing staff and has improved skills within the service to identify patients with dyphagia problems.

There are further plans to expand the training and support of nursing staff within the Stroke Service over the coming year.

Destination	Alderson	St Marys	Rossmore
Number of Patients	58 (6still in)	52 (6still in)	46 (7still in)
Transfer home	52 (89.6%)	27 (52%)	22 (48%)
Trans to Nurs/Resi Homes	6 (10.4%)	21 (40%)	17 (37%)
Return to Acute	0	2 (4%)	5 (11%)
RIP	0	2 (4%)	2 (4%)
Length of Stay
Average Number days	52.7	39.5	55
Average Number Weeks	7.5	5.6	7.8

Number of admissions to Community Rehabilitation
2001 = 143
2002 = 203
2003 = 211

211 patients were transferred to a Community based rehabilitation setting in 2003. 66% of those patients, despite many of whom have significant disability manage to get home.

An increase of resource to Physiotherapy and Occupational Therapy will enable the rehabilitation teams to be more responsive to patients transferred to the Community Rehabilitation Units and reduce the current length of stay. This will, in turn, support the Acute Stroke Unit in freeing up beds more readily to enable more stroke patients to access this facility.

The appointment of a Speech & Language Therapist to the three Community Stroke Rehabilitation Units has been welcomed and is now in place.

The development of more nurse and therapy led rehabilitation at the Westwood Hospital in Beverley has resulted in a significant increase in the number of patients receiving stroke rehabilitation at Beverley. It is hoped that this will be able to continue in 2004.

Recruitment to a Neurophysiotherapist post in West Hull has improved the follow up support of stroke patients living in the West Hull PCT area.

SUB GROUP UPDATE

Documentation and Guidelines

The Hull and East Riding Stroke Service now has 20 local guidelines which have been circulated within the service and to all PCTs. Work is continuing in this group to look at further local guidelines which are needed including guidelines for the pathway and care management of younger stroke patients, and guidelines for the management for hand and shoulder care.

The guidelines sub group will continue to review local guidelines in relation to the recommendation of the Royal College of Physicians National Guidelines.

Audit and Outcome measures

We now have an agreed data collection tool for an Acute Stroke Register and this has been set up on a template. We are unable to meet the NSF milestone of having a stroke register set up by April 2004. The appointment of a Stroke Nurse Co-ordinator will help with the collection of the data for an accurate stroke register, but additional support to process the data is needed.

The Stroke Association has agreed new ways of working within the Family Support Service; this will enable a six month review mechanism to be initiated during 2004 and will provide much more accurate post stroke data with which to plan and build the service locally.

User and Carer Sub Group

During 2003, 6 User and Carer workshops were held across Hull & East Riding and a report compiled. Many of the aspects of evaluation brought out in these workshops have already been addressed, including:
· consolidating verbal information with written information in a Personal Health and Information Record.
· Strokewatch's publication of a leaflet on how to access benefits and services after stroke.
· Early attempts to co-ordinate the care of stroke patients not getting to the Stroke Unit via the Outreach service project
· Continuing education and training for the staff.

In addition to this Strokewatch, together with professionals within the service have collated a 'Life after Stroke' directory, which will be available for all stroke survivors and carers, giving them clearer direction on activities, educational opportunities and support services.

Strokewatch continue to support the training and education of staff on the Stroke Foundation Programme and in fund raising to support the purchasing of equipment for many of the stroke rehabilitation units across the patch.

Training and Education

The Stroke Foundation Programme has been hugely successful over 2003. Four three day programmes have now run with a continued high interest from Health and Social Care workers across all areas in the Acute and Community Services. The programme has been extremely well supported by professionals working within the Stroke Service and we have now received funding from the Education Consortium for the next year to continue to run these courses free of charge.

Quarterly Training and Education Forums have also continued to run during 2003 with the support of Boehringer Ingelheim. Again, this has been extremely well received and allows an opportunity for professionals working in the service, across all disciplines and areas to meet up and benefit from discussions and presentations on many different aspects of stroke care. Boehringer has confirmed that they will continue to support these forums during 2004.

Primary and Secondary Prevention and Long Term Care Sub Group

There are two main focuses around this aspect of developing our stroke service at present. Firstly, to implement a six month review mechanism (work in progress), secondly to support Primary Care Health Professionals with the implementation of chronic disease management and support for stroke patients in line with the new GP contract.

Two dates have been circulated to District and Practice nurses to offer a full days training and update on stroke management and how to access the service locally. Boehringer Ingelheim have also offered to support this financially.

The Nurse Consultant is currently updating the Stroke Service Information leaflet which will be re-circulated in 2004 to all Practice Nurses, GPs and District Nurses. The booklet will include some of our Local Guidelines and information on how to access the service.

TIA/Minor Stroke Clinic

This clinic is held on a Monday and Friday morning and a Wednesday afternoon with a total of 17 patients being seen in one week. This shows an increase of 6 appointment slots within the last 12 months.

The TIA Nurse spends 30-40 minutes with each patient and any investigations needed are then ordered and an appointment is made on that day to see the appropriate, usually within 4-6 weeks of seeing the TIA nurse.

TIA Rapid Assessment Clinic

Whilst all GP referrals are triaged by the Consultant Physician, inpatient referrals are dealt with directly by the TIA nurse and if appropriate, referred onto the nurse led clinic and it is the aim of the service to see all referrals within 14 days.

The Consultant Physician reviews all patients seen by the TIA nurse within 4-6 weeks, provided all investigations have been completed and results are available; the appropriate course of action for the patients care is then decided by the Consultant Physician.

Number of patients seen by TIA Nurse and Consultant Physician in 2003

JANUARY	78
FEBRUARY	57
MARCH	50
APRIL	59
MAY	45
JUNE	36
JULY	51
AUGUST	62
SEPTEMBER	43
OCTOBER	42
NOVEMBER	32
DECEMBER	67
Total	622

HULL & EAST RIDING STROKE SERVICE AREAS OF FOCUS FOR 2004

1  Improve the co-ordination of care and flow of patients through the Acute Stroke Unit and into Community Services.
2  Recruitment to therapy services to support the much needed throughput of patients and level of therapy input to stroke patients.
3  Establish a Stroke Register in the Acute Trust.
4  Reduce the length of stay of patients in the Community Rehabilitation Units in order to free up beds in the Acute Stroke Unit.
5  Gain funding for the recruitment of Clinical Psychology expertise into the service.