The Stroke Service has now been up and running for two years. During that time we are averaging to receive approximately 650 patients per year through Ward 110. Approximately eighty of those patients have transferred to Ward 2 for continuing rehabilitation in the Acute Hospital setting and 203 patients have benefited from continuing rehabilitation in a Community Rehabilitation Unit.
We now have a much stronger infrastructure to provide longer periods of rehabilitation to those stroke patients who need this. The break-down of admissions to Ward 110, Ward 2 and Community rehabilitation facilities are as follows:
Ward 110, Hull Royal 638
Ward 2, Castle Hill 80
Community Rehab 203
ORGANISATION OF CARE WITHIN THE ACUTE HOSPITAL The organisation of care for the acute management of stroke patients still requires considerable focus. Whilst we are confident that 60 – 70% of patients admitted to the hospital with a primary diagnosis stroke are reviewed by the Specialist Stroke Team, either on Ward 110 or perapatetically, we do not yet have a fail safe infrastructure to ensure that all stroke survivors are reviewed by the stroke team.
There are difficulties on Ward 110 in freeing up the Acute Stroke Unit beds, particularly with those patients who are not fit to engage in a rehabilitation programme but need long term care. The net result of this is that not all stroke patients get to access the Acute Stroke Unit and this, therefore, should be a real focus for 2003. The Acute Stroke Unit has managed to deliver the service despite significant constraints with available Therapy support.
OUTREACH FOR THE ACUTE SERVICE
Some attempts to support stroke patients via an Outreach Service have been made with Dr Abdul Hamid receiving referrals from other clinicians, and the Nurse Consultant supports the transfer of some of these patients to the Community Rehabilitation Unit. A focus needs to be made in the Acute hospital in relation to the organisation of care, both for outreach support to stroke patients on outlying wards, and in agreeing how best to ‘free up’ beds on Ward 110. This may require a rearrangement of current practice where beds are blocked for some considerable time with patients who are unable to partake in an active rehabilitation programme and require long term care.
THE T.I.A RAPID ASSESSMENT SERVICE
There has been no further expansion of this service provision over 2002. Patients are seen by the T.I.A nurse within approximately 2 weeks and the Consultant Physician within approximately 2 months. There is a fast track service for those patients who present with more urgent symptoms. Underpinning support to this clinic is essential for it’s maintenance before any further developments can be considered.
COMMUNITY REHABILITATION
The inner city Community Rehabilitation Units are now well established and all provide therapeutic environments which enable stroke survivors to maximise their potential. We are now at the stage where beds are always full and we are unable to support the flow of patients from the Acute hospital as promptly as we would wish.
Rehabilitation in the Community Hospitals has been varied. This year we have been unable to transfer any stroke patients to Hornsea because there has been no Occupational Therapy support at Hornsea Cottage Hospital. This has reduced the impact of training and education and development in stroke rehabilitation in Hornsea Cottage Hospital.
Rehabilitation of stroke patients at the Driffield hospital has developed well with 2 senior nurses linking in strongly with the stroke service developments. The transfer of stroke patients to the Driffield hospital remains varied; some Driffield patients are transferred to the Bridlington hospital for acute management rather than the Hull Royal Infirmary, and concerns relating to acute management of these patients have been raised.
We have received a significant increase in stroke rehabilitation patients at the Beverley Westwood hospital this year, and some patients have been transferred under the care of the nursing and therapy team where GPs have not supported transfer to a rehabilitation bed. Nurse and Therapy led rehabilitation is developing gradually at Beverley.
STRATEGIC DEVELOPMENTS IN THE STROKE SERVICE
Over the past 18 months, staff across the organisations and disciplines within the service have worked together to develop a multi disciplinary document. This underpins the standards and guidelines for the carers/patients and is now in the piloting stage.
There has been tremendous and continuing support from Strokewatch, the local stroke survivors network. A system enabling carers and stroke patients to send comments directly to Strokewatch is now well established and this enables professionals within the service to take action, often during the rehabilitation process, where concerns are raised.
Strokewatch are also facilitating ‘Roadshows’ across Hull & East Yorkshire. The purpose of these events is to enable stroke survivors and carers to come together, have an update on the service delivery and also comment back to professionals in the service, about their experience of it. This provides a live Action Research approach with which to build and shape the service in direct response to users and carers experience.
The first User & Carer workshop took place in November 2002, and 60 stroke survivors and carers attended. An action plan is now being drawn up to address the key points which were made. Workshops in Goole and Holderness are planned for 2003.
Strokewatch, together with the Stroke Association, have also helped professionals within the service develop a Patient Information & Personal Health Record. These will be introduced over 2003 and will support information and explanation given to patients during their rehabilitation. Stroke patients will have ownership of their type of stroke, their risk factors for stroke and what the plan of action is to help prevent further stroke occurring. Professionals will be encouraged to write in the Health Record for the stroke patient and carer regarding their treatment and rehabilitation plans.
The Hull & East Riding Stroke Service were short listed as one of the top three finalists in the Northern & Yorkshire Modernisation Awards for developing the service with users & carers.
DATA AND INFORMATION ABOUT THE SERVICE
The Audit Sub Group have identified the current mechanism for collating information about the number of stroke patients admitted to the Acute Hospital Trust. This information remains very unreliable as it totally reliant on the correct coding systems being processed.
We know that 638 patients were admitted to Ward 110 during 2002 but the data available does not reflect that and we cannot yet clearly identify the number of patients who do not access the Acute Stroke Unit due to lack of bed availability.
PRIMARY AND SECONDARY PREVENTION
Work is currently underway to identify the most suitable mechanism for initiating 6 month reviews of all stroke patients. This is a requirement outlined in the National Service Framework for Older People, which needs to be met by 2004. Negotiations and discussions are currently underway with the Stroke Association who provide the Family Support Service locally. It is hoped that by the end of 2003, we will have a robust mechanism in place for 6 month reviews that will also enable an increased focus to the monitoring of individuals risk factors for stroke.
Identification of additional resource for continuing secondary prevention support through Community nurses has been put forward in the Business Planning process. A proposal by the Eastern Hull PCT to carry out a pilot study and look at the benefits related to general screening of the local population, age range between 55-75. This screening would include risk factors for stroke and a pilot such as this (to include 2000 people) would provide very strong information in terms of the health gain for such practice.
The Stroke Association have also been supporting secondary prevention projects locally, and currently provide a service to the people of Hull who need support in managing their risk factors and lifestyle following a TIA and following a stroke. They are hoping to expand this service further to compliment the local primary and secondary plan for stroke.
TRAINING AND EDUCATION
A multi disciplinary training and education programme is now being set up and is a three day training programme which will run 4 times a year. Delivery of this training has been supported across the professions, which will enable a very comprehensive in house training programme to take place.
Training places will be available and accessible to professionals across the Acute and Community Trusts, Social Services, and Private Sector Nursing Homes who are involved in stroke care.
Quarterly educational forums have been set up and are well attended by professionals across all the disciplines. These are supported by Boeringer Ingelheim and outside speakers with expertise in stroke are invited to give presentations.
SUMMARY
The organisational model for stroke care, which included community rehabilitation facilities at the outset, has provided a very strong framework for professionals across all disciplines and organisations to work together in pursuit of developing an excellent service. This philosophy has carried on throughout 2002 and many improvements to patient care have been implemented as a result. The service continues to work under significant pressure and recognition for expanding existing infrastructures and resources have been made through the stroke business planning process. It is necessary to provide a focus for service development and achievements for 2003.