Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

NHS
CANCER NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

Stroke Improvement Programme
Implementing best practice in acute care:
case studies from the Stroke Improvement
Programme projects

Contents

Introduction 3

Milton Keynes Hospital NHS Foundation Trust 4

Nottingham University Hospitals NHS Trust 6

Poole Hospitals NHS Foundation Trust 8

Queens Hospital NHS Foundation Trust 10

Royal United Hospital, Bath 12

Sandwell and West Birmingham Hospitals NHS Trust 13

Surrey and Sussex Healthcare NHS Trust 15

Worcestershire Acute Hospitals NHS Trust 17

Yeovil District Hospital NHS Foundation Trust 19

Resources 21

Further information 23

Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects | 3

Introduction

Since March 2009, ten projects TOP TIPS
worked with the Stoke Improvement
Programme to explore how to • Protect stroke unit beds
improve the care they provide for • Actively cooperate with the rest
their patients. Their experience has of the hospital
led to the identification of the some • Develop a flexible, stroke skilled
key actions. workforce
• Work with stroke survivors and
carers
The suggestions, experiences and
• Build an active partnership with
examples provided in this document
A&E
are intended to generate ideas, to • Work with the ambulance
show what is possible when teams service
work constructively together and to • Move to six days a week
guide planning for improvement working for therapy services
activities. Nine out of the 10 sites
are included in this publication.

The Stroke Improvement Programme
continuously publishes materials to
help those striving to improve stroke
and TIA services. All materials are
available on the Stroke Improvement
Programme web site at:
www.improvement.nhs.uk/stroke

Contacts for each of the projects are
included. Full details of the service
improvement can be found at:


4 | Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

Sustainable acute stroke and TIA
management programme
Milton Keynes Hospital NHS Foundation Trust

Aims Actions wider patient journey, and increased
The project in Milton Keynes aimed The need for ‘fast track’ bed was awareness of the importance of
to achieve a patient-centred pathway agreed with acute stroke unit stroke as a specialism.
for stroke, and worked across several clinicians, the bed management team
areas of their stroke and TIA service. and divisional manager. Use of the A ‘productive board’ listing all
The main aims for the acute stroke bed is monitored and reported patients, and key information on their
portion of this work were to improve weekly, and it is kept solely for use by status and care, was installed to
access and quality of care through: stroke patients to enable timely improve ward organisation. This
• ensuring all patients with acute transfer from A&E and the clinical enabled staff to better plan patient
stroke were admitted directly to an decision unit. care, enable safe discharge, and
acute stroke unit equipped and improve communication amongst all
staffed to be able to deliver high To ensure stroke patients identified in those involved in a patients care.
quality care A&E or clinical decision unit do not
• providing timely access to transfer to another ward, a bed Outcomes
diagnostics both within and out management protocol was put in By the end of the project, all stroke
of hours place and shared around the trust to patients received brain imaging
• ensuring seamless transfer of care ensure members of staff across all within 24 hours of arrival at hospital.
from acute stroke rehabilitation to levels identify the urgency of The proportion of stroke patients
the community based rehabilitation transferring a patient to the acute spending at least 90% of their time
stroke unit. in hospital on a stroke unit increased
Issues from 50% to 70% and continues to
At the start of the project, there was Multiple workshops were held with improve (see figure 1).
a high proportion of stroke outliers acute and community staff involved
on other medical wards. The in stroke patient care to map the
proportion of stroke patients pathway a patient has access to,
spending at least 90% of their stay identify current constraints in hospital
on a stroke unit was, on average, and the community, involve staff on
45%, and 20% of patients were not the ground in suggesting
receiving brain imaging within 24 improvements, and develop transfer
hours. of information across teams. This
helped healthcare professionals put
into perspective their role in the



Figure 1: Patients spending 90% of their time in an
acute stroke unit in Milton Keynes

80
Blip due to
70 winter bed pressures
April 2009
60 40%

50
Percentage

March 2009
40 75%

30

20

10

0
Apr May Jun Jun Aug Sep Oct Nov Dec Jan Feb Mar
2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010
Months

Communication around the hospital
has been improved and there is much
greater awareness and recognition of
stroke within the trust.

Contact
Nicola Evans
Project Manager
Milton Keynes Hospital NHS
Foundation Trust
nicola.evans@mkhospital.nhs.uk



Direct access into the stroke
hyper acute unit (DASH)
Nottingham University Hospitals NHS Trust

Aims Actions
The central aim of the Nottingham As many stakeholders as possible
project was that individuals who had were involved to gain commitment,
a stroke had rapid and equitable including the support and
access to the stroke hyper-acute sponsorship of the chief executive,
service. This would include admission along with clinical and medical
directly to the stroke unit when directors.
arriving at the hospital, as opposed to
admission through A&E. Patients The existing pathway was ‘process
should be admitted, assessed and, mapped’ to identify what worked
where appropriate, treated with well and the gaps in service.
thrombolysis within three hours of Communication and monitoring work
onset of symptoms. was systematically undertaken. This
included contacting the ambulance
Issues service to ensure they had the
At the start of the project there were pathway information and supported
patients being admitted directly onto the project, and collecting
the stroke unit, but lower in number information weekly on stroke
than compared with those being admissions to A&E to enable
transferred from the A&E situated on challenge of the ambulance service to
a campus five miles across the city, explore why patients were not
and from the emergency admissions admitted directly into the stroke unit. management to produce bulletins
unit which was on the same site as Common themes that arose were containing the direct access policy,
the stroke unit. that crews were unaware of and more importantly, the direct
admission protocol, unsure of time phone number for the telephone on
Patients began to arrive on the stroke for admission, and there was the stroke unit, known as ‘the bat
unit from A&E without a call being confusion around thrombolysis. phone’.
made to the stroke unit to advise
them in advance. Telephone calls and To ensure that the ambulance crews To help distinguish the ‘bat phone’
triage of the calls were not reliably were fully informed of changes which from the several other phones on the
recorded. would affect the patients pathway, unit, a new ring tone and flashing
work was undertaken with East light was installed to alert the team
Midlands Ambulance Service to the emergency response required.



This new phone and number alerts Outcomes Contact
staff on the ward immediately when The project has successfully produced Heather McCormack
a patient is going to be transferred, a direct access route into the hyper- Service Development Manager
giving them the opportunity to triage, acute stroke unit. All suspected East Midlands Cardiac
and then give advice to the crew on stroke patients are now referred and Stroke Network
where to take the patient. directly to the stroke unit via the ‘bat heather.mccormack@nhs.net
phone’.
Information was sent to all GPs
asking them to contact the stroke The ‘bat phone’ changed the
unit if they assessed a patient with pathway for the patient almost
stroke symptoms. A further request immediately, with everyone
was sent with a reminder that the call concerned fully aware of what was
to East Midlands Ambulance Service happening, where the patient was to
should include the instructions for an be sent and what would happen
emergency ambulance, and not a next. There was a reduction in delays
routine admission. The vehicle to be in transfer, and a decrease in the
sent must also be a four wheel number of patients being admitted
vehicle with a two manned crew. via A&E. FAST-negative patients later
confirmed as a stroke are then sent
‘Walking the patient pathway’ was directly to the stroke unit from A&E.
carried out by both clinical and non-
clinical members of the team, and All ambulance crews now assess
highlighted a number of problems patients at site and report their
that could be easily and rapidly findings to the triage nurse, who
addressed, such as the A&E not records all relevant information on
having the ‘bat phone’ number new documentation in readiness for
displayed, even though the ‘bat the arrival of the patient. The unit
phone’ number had been included on now has new signs identifying where
the stroke emergency department they are located, which helps with
pathway poster. directions for both ambulance crews
and relatives.



Improving acute stroke care in Poole
Poole Hospitals NHS Foundation Trust

Aims Actions A ‘Patient Group Directive’ was
The team from the Integrated Stroke After raising stroke higher on the established for aspirin to assist
Unit at Poole Hospital aimed to trust agenda through widespread delivery to appropriate patients
improve direct admissions to the unit, communication and process mapping within 24 hours of admission.
and increase the percentage of (including bed managers and high Extending the developments to stroke
patients spending more than 90% of dependency unit staff). A new patient patients who were not suitable for
their hospital stay there. As part of pathway was agreed, focusing thrombolysis, they created an
this they wanted to consolidate the specifically on the part of the ‘assessment trolley’ on the acute
hyper-acute service experience for all pathway from arrival at hospital to stroke unit to speed their assessment
stroke admissions and improve their completion of the multi-disciplinary and admission process. Local
thrombolysis service. team assessment. This would agreements with a neighbouring
minimise unnecessary delays for trust enabled 24 hour thrombolysis to
Issues patients being admitted and ensure commence in November 2009,
A lot of work had been done across a safe but speedy pathway for supported by a range of publicity and
the stroke network to improve the thrombolysis patients both in and visits from the team to local GPs.
urgent response by ambulance teams out of hours.
to stroke in the area and develop Outcomes
provision of 24 hour thrombolysis, The team put in place an ambulance Stroke patients are now more likely to
but the number of patients pre-alert system to ensure A&E, the be thrombolysed, to be admitted
thrombolysed at Poole remained low. stroke team and other key staff were directly to acute stroke unit, to have
The team had tried a number of aware of any potential thrombolysis timely swallow screening and brain
initiatives over the years to improve patient en route to the hospital to scanning and to be commenced on
the quality of service, but were not speed up the response time on antiplatelet therapy within 24 hours.
achieving the standards around arrival. They established training in
assessment and treatment of stroke thrombolysis and telemedicine for all
for every patient, and only 37% of relevant staff, from ambulance crews
stroke patients were admitted to the through to radiology. Additional
unit within four hours. nursing staff for the acute stroke unit
to support thrombolysed patients
were secured, protocols agreed for
the senior nurse practitioner to
request CT scans, and all registered
nurses and medical staff undertook
training in safe swallow screening.



Data shows that thrombolysis rates
have improved from 1.4% at the
start of the project to 5.6% by March
2010, and mean door-to-needle time
had reduced steadily from 120
minutes in January to 96 minutes by
March 2010. The percentage of
patients receiving aspirin within 24
hours of admission has risen by 40%
and brain scanning within 24 hours
by 16%. The percentage of patients
admitted to the acute stroke unit
within four hours of arrival has risen
from 50% to 76%.

Contact
Dr Suzanne Ragab
Stroke Consultant
Poole Hospitals NHS Foundation Trust
suzanne.ragab@poole.nhs.uk



Improving access to the acute stroke unit
Queens Hospital NHS Foundation Trust

Aims Actions A stroke unit admission protocol
The team from Queens Hospital The TIA service was completely was written and agreed and a
aimed to increase the numbers of redesigned to include a five day a competency based in-house training
patients that access the acute stroke week drop in clinic, with a single programme put in place on the acute
unit) through direct admission point of referral and dedicated stroke unit. Developments on the
protocols from A&E. They also carotid ultrasound slots. All referrals stroke unit were linked in with
wanted to enhance the stroke and carotid requests were screened hospital emergency pathway redesign
pathway from A&E to the acute by a stroke coordinator, and a direct to make sure acute stroke was
stroke unit and include TIA referral pathway for those patients included in daily operations meetings
admissions, provide 24 hour needing vascular surgery was and bed allocation was used
admission to support stroke established. appropriately.
thrombolysis and to develop the
acute stroke unit staff to support A&E The thrombolysis service was Outcomes
in managing stroke patients and extended to 9am to 8pm weekdays TIA patients are now managed on an
facilitating transfer. using on call registrars to manage outpatient basis, avoiding admission,
calls and provision of an in-house and most are now seen within 24
Issues radiographer until 8pm. An out of hours.
Initially, most stroke patients were hours pathway was developed to
admitted to the emergency support staff. Developments included The acute stroke unit now runs much
admissions unit for at least 24 hours daily provision of an admission bed more smoothly. Patients are identified
and transferred to the stroke unit on the stroke unit to support by bed management earlier and are
later. No protection of stroke unit thrombolysis. allocated to the stroke unit quicker.
beds meant the six beds in the stroke Communication between clinicians
unit were often used for care of the An agreement was put in place with and capacity management is much
elderly and medical admissions. the imaging department to routinely improved. The proportion of patients
scan all stroke patients over spending 90% of their stay on the
All high risk TIA patients were weekends and bank holidays. This stroke unit has increased from 71%
admitted and managed as inpatients, included provision for tele-radiology to 89%. Now 96% of stroke
and the thrombolysis service only ran so radiologists could read scans at patients are scanned within 24 hours,
9am to 5pm on weekdays. home. compared to 70% at the start of the
project.



A&E now recognise the importance
of the stroke pathway and the
benefits of thrombolysis. More
patients are being assessed for
suitability and the stroke service has
joined the IST-3 research trial.1

Two members of the stroke team
received the trusts service
improvement award this year.

Contact
Peter Tari
Stroke Co-ordinator
Queens Hospital NHS
Foundation Trust
peter.tari@burtonh-tr.wmids.nhs.uk

1The Third International Stroke Trial (IST-3) of thrombolysis for acute ischaemic stroke: an
international multi-centre, randomised, controlled trial to investigate the safety and efficacy of
treatment with intravenous recombinant tissue plasminogen activator (rt-PA) within six hours of
onset of acute ischaemic stroke. For further information, see www.controlled-trials.com



Royal United Hospital, Bath, Stroke 2010
Royal United Hospital, Bath

Aims Actions Outcomes
The team from the acute stroke unit Systematic modelling showed that As there is now, for the first time, an
at Royal United Hospital, Bath aimed bed numbers were inadequate for entire ward clearly signposted ‘Acute
to improve access to the unit and demand on the unit. In addition, Stroke Unit’, the service’s profile
develop the services provided there. existing beds were integrated on a within the trust has been raised,
The existing stroke services would be 28 bed ward shared with neurology, morale for staff much improved and
expanded to include a hyper-acute which resulted in a lack of clear a clear mandate given to gear the
unit and to provide thrombolysis 24 identify for the acute stroke unit. ward around providing the best
hours a day. These improvements Calculations showed that 26 acute stroke care.
would be evident through measures stroke unit beds were needed to
on speed of access to the unit, time ensure all stroke patients could be Patients are now admitted directly
spent on the unit and scanning directly admitted from A&E, even at from A&E to the acute stroke unit,
promptness. times of peak stroke admissions. bypassing the medical admissions
unit and other wards. By the third
Issues Board level sign up to improving stroke week of direct admissions, length of
The biggest problem was getting all services was obtained to make this a stay had reduced from 18 to 5.5
stroke patients in the trust onto the priority within the trust. Stroke and days. Staff throughout the hospital,
acute stroke unit. Despite proactively neurology services were separated into from infection control to bed
tracking stroke patients within the two ward areas to give each specialty management, commented on the
hospital and managing beds closely, its own clear identity. This left a 28 bed dramatic change in the unit.
in the 2008 National Sentinel Audit, ward, including one six bed area that
only 36% of patients spent 90% of was converted into a hyper-acute Twenty eight patients have already
their stay on a stroke unit. In stroke unit and reduced to four beds. been thrombolysed in the last year
addition, only 2% were admitted to compared to 12 the year before.
a stroke unit within four hours of Support for bed availability was The service has been significantly
admission to hospital. provided by agreeing equity of the improved with no extra money, and
acute stroke unit with the coronary the reduced length of stay has
Patient focus groups, run with the care unit within the trust in terms of resulted in cost savings to the trust.
help of The Stroke Association, bed and site management. Every day
highlighted how bad acute stroke at the site meeting, the availability of Contact
patients’ experiences were when on a stroke bed is checked in the same Dr Louise Shaw
the medical assessment unit for way as a cardiac bed. As soon as a Consultant Stroke Physician
several days. stroke patient is admitted to acute Royal United Hospital, Bath
stroke unit, bed management louise.Shaw@ruh-bath.swest.nhs.uk
prioritise clearing another bed.



Fast access to stroke care pathway
Sandwell and West Birmingham Hospitals NHS Trust

Aims Actions An audit clerk has been recruited and
The core aim of the team in Sandwell Two initial consultation exercises were the information department have
was to develop a direct admission held with all staff and also patients developed a monitoring system that
pathway and protocol for all stroke and carers. This lead to a plan of highlights patients that do not spend
patients. This would improve care areas to be reviewed and developed 90% of their time on a stroke unit.
and result in patients being and had management support and This allows the pathway to be
transferred directly to an acute stroke engagement. An initial review of the continuously checked and data to be
unit from A&E within four hours, pathway confirmed that there were validated easily. There is a weekly
spending at least 90% of their often long delays in admission to the review of the patient’s pathway and a
hospital stay on a stroke unit, and stroke unit. monthly stroke action group
receiving timely swallow assessment (including representation from all
and brain scanning. A process of meetings and departments) which provides support
discussions were held over a period for development of the wider stroke
Issues of time with the acute on-call teams, service.
At the start of the project, the stroke A&E, the stroke unit and radiology
pathway meant patients went teams. The agreed path was to Outcomes
through the emergency assessment admit patients directly from A&E, A staff and patient and carer
unit before going to the stroke unit. following a medical review there with engagement process, called ‘listening
There could be a delay of a day or the co-operation of the on call teams, in action’, was successful in raising
more before the patients were and patients should receive their CT awareness of stroke and engaging all
admitted to the stroke unit; those head scans before transfer to the key stakeholders.
who had minor strokes could be stroke unit, all within 24 hours.
discharged home without reaching Stroke has become recognised as an
the stroke unit at all. However, everyday pressures meant emergency and it is acknowledged
that the new pathway required widely that ‘time is brain’. Scans are
Although there was a clear pathway continuously reinforcing, monitoring done faster and suspected stroke
established, the thrombolysis service and reviewing. There was agreement patients are transferred directly from
was from 9am to 5pm weekdays from management, bed management A&E to the stroke unit. There has
only. and the stroke unit that there would been a significant increase in patients
always be a bed available on the being scanned in a timely manner,
stroke unit. Any delays in A&E were and there is always a bed available on
escalated up to the on call manager. the stroke unit.



The most significant change is the
recognition of stroke and team
development across a wide range of
departments from the ambulance
service, A&E, bed management,
radiology, the acute stroke unit and
general management.

There is now a 24 hour thrombolysis
service including a comprehensive
pathway and a structured education
programme for both doctors and
nurses.

Contact
Jackie Wilkinson
Stroke Co-ordinator
Sandwell and West Birmingham
Hospitals NHS Trust
jackie.wilkinson@swbh.nhs.uk



Acute stroke care: ‘building teams,
building stroke services’
Surrey and Sussex Healthcare NHS Trust

Aims Having had a long period of time Many initial difficulties within the
The project aimed to develop an with different clinical leadership and service stemmed from the lack of a
effective stroke team, which would styles, morale on the ward was low. unified vision of its future amongst
drive their stroke service forward and the team. The project was used to set
to develop comprehensive Actions objectives with timeframes in which
interdisciplinary working. This would Two key actions have facilitated to map the changes, and establish
support wider aspirations around improved bed management and flow: working groups to achieve them.
improving the acute stroke service, 1. the introduction of a fast-track
including establishing an acute bed for patients who can be Senior team members organised
pathway for direct access to specialist moved off the acute stroke unit, training for junior members as well as
stroke services, introducing a and a daily bed status form to ensuring core competencies were
thrombolysis service, improved access highlight delays to discharge is met, and specific training on goal
to brain imaging and patients presented at the daily 9am bed planning was given to therapy and
spending more of their stay on the meeting nursing staff. As a result, working
stroke unit. 2. a 24 hour stroke outreach team practices have gradually developed,
now identifies and tracks stroke delivering a more cohesive approach.
Issues patients within the hospital, with a This includes interprofessional
The acute stroke unit comprised 21 supernumery bleep holder during support for the daily ward rounds to
beds, but lacked a formal bed policy the day, a senior acute stroke unit enable status updates, effective
or stroke pathway. The service had nurse at night and other outreach discharge planning and a predicted
been led by successive locum nurses who proactively seek stroke date of discharge for each patient.
consultants for two years, and patients from the wards
selection of patients for the acute A new whiteboard has become the
stroke unit was made by on call Through engagement with radiology, centre of the teams’ activities,
medical staff, resulting in an ad hoc a dedicated bleep is held by a duty allowing rapid knowledge of the
approach. CT was accessed via the radiographer for 24 hours and acute current status of each patient,
‘next day early bird slot’ system. The stroke patients are automatically including their predicted discharge
trust did not have a thrombolysis added to the urgent protocol for next date and destination. This allows the
service for eligible patients and so CT scan slot. weekly interdisciplinary team
FAST positive patients were diverted meetings to focus on patient centred,
to other trusts. Only 7% of patients specific goals and trialling different
were directly admitted from the A&E outcome tools.
and 56% of stroke patients did not
spend any time on acute stroke unit.



Two experienced stroke consultant and become clearer, encapsulating
physicians have been in post since status and goals, and a simple
January 2010, bringing new summary sheet for better
leadership and direction to the communication with patients and
service, with new ideas for relatives. Average length of stay has
development and productivity. The steadily reduced from 20.4 to 13.7
new stroke pathway commenced in days.
January 2010, and an 8am to 10pm
thrombolysis service was launched A recent staff feedback exercise
with four consultant physicians showed positive attitudes and
working the rota, supported by off- examples of considerably improved
site CT viewing. mutual professional regard and
understanding. A key learning point
Outcomes has been that the team is more
Significant improvements have been powerful as a whole than the sum of
made to access to the acute stroke its parts, and that forward
services and compliance with vital progression need not rely on any one
signs targets is better. Direct individual. With mutual respect and
admissions peaked at 60% in an understanding of each others roles
February 2010, with 67% of patients a team can work effectively without a
achieving 90% stays on the acute single leader. When a team is
stroke unit, and 86% of patients motivated and empowered, it has
spending some of their hospital stay direct effects on patient care and
on the acute stroke unit. By March outcome measurements.
2010, 66% of patients had CT scans
within three hours. Contact
Dr Natalie Powell
The team feels that much Specialist Registrar in Stroke
improvement is due to the Surrey and Sussex Healthcare
development of the outreach service, NHS Trust
crucially incorporating a dedicated East Surrey Hospital
bleep holder, presence in A&E and natalie.powell@sash.nhs.uk
proactive approach. This has been
further enhanced by staff
enthusiasm, positive PR for the stroke
service and improved relations with
radiology.

The bed status sheet has been
invaluable in highlighting where
problems are encountered on a daily
basis and has given the team
permission to actively manage their
own beds. Documentation of the
interdisciplinary team has improved



EASY (early admission to stroke
unit your brain heals quicker)
Worcestershire Acute Hospitals NHS Trust

Aims
The team aimed to improve patient Figure 2: Worcestershire Acute Hospitals NHS Trust process map
access to the acute stroke unit, and
ensure those transferred to other
wards are identified and moved to
acute stroke unit promptly. This was
coupled with specific aims to speed
up physiotherapy assessment,
improve discharge processes and
develop staff education and training.

Issues
Initially, only 20% of patients were
directly transferred to the acute
stroke unit from A&E and/or the
medical admissions unit. There were
daily issues with patients with stroke
on other wards and stroke beds filled
with non-stroke patients.

Process mapping showed the
pathway for stroke patients was
complicated and confused (see figure
2). There was no formal programme A key step in the project was to A capacity mapping exercise was
of education for staff, rehabilitation promote the stroke service status as undertaken to look at the number of
was bed-based and only one an urgent specialist service, similar to acute stroke beds and the number
consultant physician was undertaking cardiology. This raised the profile of needed. An agreement was made to
thrombolysis. improving the quality of stroke ring-fence beds on the acute stroke
management and care within the units countywide, and three
Actions trust by prioritising stroke patients, additional acute stroke beds opened
The service improvement lead for the and ensured stroke was considered at in August 2009. Two new
trust ran a pathway exercise with a bed meetings three times a day. appointments of stroke specialist
group from the trust and the PCT to
plot the current pathway and design
a better one.



nurses enabled an overview of where Outcomes appointment of a family and carer
all patients are, and helped to work Access to the stroke unit and the support worker from The Stroke
closely with the bed manager to proportion of time spent on the unit Association offers inpatient and post-
transfer patients appropriately. has been increasing month by month, discharge follow up. The stroke
with an increase in direct admissions rehabilitation ward has been
The team set up a formal programme from A&E or the medical admission upgraded in line with privacy and
of education and training for staff unit. Physiotherapy assessment has dignity guidelines and further clinic
working in stroke units, including improved, and the Commissioning for slots opened for high-risk TIA patients
thrombolysis training days, and Quality and Innovation (CQUIN) for to avoid admission.
undertook a workforce mapping the service achieved.2
exercise. There was increased A successful ‘stroke school’ has been
awareness of how fundamental it is There are now daily multidisciplinary established, and further sessions are
to manage the ‘back door’, i.e. team meetings on the acute stroke being delivered, giving staff greater
improving rehabilitation and speeding unit and all stroke patients are insight into their work and the work
up discharge. Although delays still discussed at all bed meetings three of other members of the team. A
occur with social services discharging times a day. The acute stroke unit on cardiovascular disease degree module
patients, close liaison with the the Worcester site has been at Worcester University has also been
community stroke team has enabled reconfigured to have its own staff set up.
improved patients flows. (who are not rotated), and the
Contact
Elaine Stratford
Stroke Specialist Nurse
Figure 3: Percentage of stroke patients spending
at least 90% of their time on a stroke ward Worcestershire Acute
Hospitals NHS Trust
50 elaine.stratford@worcsacute.nhs.uk
45
40
35
Percentages

30
25
20
15
10
5
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2008/09 2008/09 2008/09 2008/09 2009/10 2009/10 2009/10 2009/10

Further information on CQUIN can be found on the
2

Department of Health website at: www.dh.gov.uk



One call does all: smoothing the transfer from
the emergency room to the acute stroke unit
Yeovil District Hospital NHS Foundation Trust

Aims The issue of outlying stroke patients All the newly developed
The team wanted to improve the was highlighted to senior staff by documentation, protocols, and
process for all acute stroke patients creating a daily list. This meant that training information for stroke was
being admitted and make the service the process of transfer onto the transferred onto the trust intranet,
less dependent on individual staff. It stroke unit became less dependant for use as the key resource and for
was envisaged that this would on the knowledge of any one the stroke team collectively to keep it
increase the likelihood of success of professional and reduced the number up to date.
expanding the thrombolysis service of duplicate phone calls.
into evenings and the weekend. Outcomes
To tackle challenges around transfer Stroke patients are being triaged
Issues out of the unit, work with community more quickly in A&E. Initially, data
There was agreement within the teams reduced the paperwork trail collection showed no significant
team on perceived key issues, but an and streamlined the process where improvement in either initial
absence of readily available data to possible. As there were three PCTs, diagnosis or direct admissions, but
support this. Firstly, challenges each with different referral processes, this may been due to the recent
around early assessment for stroke this was a complex task. To resolve extension of the thrombolysis service
patients in A&E, and secondly, this, at each multidisciplinary team to 8am to 11pm Monday to Friday,
insufficient capacity on the stroke meeting, the stroke unit team would which had meant additional training
unit because of difficulties with timely code each patient red (medically of medical and nursing staff. As
transfer to the community. unfit) amber (ready for transfer within with other teams, local factors, such
72 hours) or green (fit for transfer), as ward closures and peaks in
Actions and then share this with the admissions, may have skewed the
The team held monthly meetings appropriate PCT link team. The picture for direct admissions,
with time divided between the two community team now anticipate although there is now a confidence
key issues to help them remain clear patients that will be ready for that a change in thinking has been
and progress with both aspects. discharge in the next few weeks, and embedded, and that all staff are
Money released by a reduction of take the necessary actions locally. working collectively to ensure access
clinical hours of the consultant nurse to the stroke unit from A&E.
was transferred into two posts for
stroke within A&E, thereby
smoothing the process of training
and developing protocols in stroke
amongst A&E staff.



Despite problems created by ward
closures for infection control creating Figure 4: 90% stay on a stroke unit
‘bumps in the road’, progress
100
continues towards the aspiration for
90
‘90% stay on a stroke unit’.
80
70
The length of stay for Somerset
Percentages
60
patients in the last three months has
50
reduced from 18 days to 13 days; 40
whilst the only change in practice has 30
been the smooth, consistent, transfer 20
of information from the acute trust to 10
the PCT on a weekly basis. 0
Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

The team feel that the appointment % of total stroke admissions spending 90% of time on stroke unit PCT target
of a stroke link within A&E has
resulted in a greater than expected
improvement in knowledge and
stroke care, which is evidenced by
increased attendance of A&E staff at
stroke study days. Data collection will
continue, as it has helped quantify
‘gut feelings’ and demonstrate
improvements, however small. The
service is now viewed less as a
Monday to Friday service across all
parts of the organisation, with more
recognition being given to the
importance of timely intervention,
particularly in relation to brain
scanning and direct admissions.

Contact
Caroline Lawson
Consultant Nurse – Stroke
Yeovil District Hospital NHS
Foundation Trust
caroline.lawson@ydh.nhs.uk



Stroke Resources

Stroke Improvement Programme website Trainer’s Resource Pack – An Introduction to Service
The Stroke Improvement Programme website offers Improvement, NHS Improvement
information and resources on improving stroke and TIA The Trainer's Resource Pack - An Introduction to Service
services, including: Improvement, is a collection of tried and tested training
• information on topical issues affecting stroke and modules for service redesign tools and techniques, and
TIA services change management skills.
• presentations from events and meetings www.heart.nhs.uk/trainers_resource_pack.htm
• examples of successful redesign and stroke
improvement in stroke and TIA services Guidance on Risk Assessment and Stroke Prevention
• information on measures for Atrial Fibrillation (GRASP-AF) Tool
www.improvement.nhs.uk/stroke This tool should be used as part of a systematic approach
to the identification, diagnosis and optimal management
Sustainability Checklist, NHS Cancer of patients with AF to reduce their risk of stroke.
Improvement Programme Developed collaboratively and piloted by the West
A checklist containing key questions to ask about your Yorkshire Cardiovascular Network, the Leeds Arrhythmia
project or service to ensure plans are in place to sustain team and PRIMIS+, as part of the AF in primary care
the improvement. projects, made available nationally through NHS
www.improvement.nhs.uk/cancer/documents/inpatients/ Improvement.
Sustainability_Checklist.pdf www.improvement.nhs.uk/graspaf

The Sustainability Toolkit, NHS Heart Atrial Fibrillation documents, NHS Improvement
Improvement Programme The following documents are available to download from
Although focused on improving cardiac pathways, The the Stroke Improvement website
Sustainability Toolkit provides useful information and www.improvement.nhs.uk/stroke
examples on how to sustain improvements. It also
contains resources on capturing data, measurement Atrial fibrillation in primary care: making an impact
and analysis. on stroke prevention, October 2009
www.improvement.nhs.uk/heart/sustainability This document aims to capture the final summary of their
individual approach, lessons learned, improvements to
practice and quality outcomes, also sharing tools and
resources developed to enable other health communities
to drive this agenda forward.



Commissioning for Stroke Prevention in Primary Sustainability Model, NHS Institute of Innovation
Care - The Role of Atrial Fibrillation, June 2009 and Improvement
Developed following a national consensus meeting of The Sustainability Model is a diagnostic tool that is used
opinion leaders in the field, this document is to develop to predict the likelihood of sustainability for your
a concerted strategy towards the management of AF in improvement project and provides practical advice on
primary care, in particular anticoagulant management how you might increase the likelihood of sustainability for
and its significance in relation to reduction in the risk of your improvement initiative.
stroke. www.institute.nhs.uk/sustainability_model/general/
welcome_to_sustainability.html
Atrial Fibrillation in Primary Care National Priority
Project, April 2008 Improvement Leaders’ Guides, NHS Institute for
A summary document produced in April 2008 including Innovation and Improvement
descriptions, supporting information and key learning A series of service improvement guides, including a guide
from the local projects that were part of the Atrial to sustainability and how it can be used in improvement
Fibrillation in Primary Care national priority project. work. The NHS Institute for Innovation and Improvement
website also contains worksheets for measuring
Atrial Fibrillation in Primary Care Resources and improvement.
Learning, April 2008 www.institute.nhs.uk/index.php?option=com_content&ta
This online resource is a tool produced in April 2008 that sk=view&id=134&Itemid=351
captured the learning from the local project sites that
worked on the Atrial Fibrillation in Primary Care national StrokEngine-Assess
priority project. The resource provides documents, This website provides evidence to support stroke
guidelines, presentations, proformas and algorithms rehabilitation assessment tools.
developed and used by the local priority projects. www.medicine.mcgill.ca/strokengine-assess

Stroke Improvement Programme e-bulletin Spreading good practice documents and
Containing updates, news and information for anyone information, Sarah Fraser & Associates Ltd
interested in developing stroke services, the Stroke Sarah Fraser is an independent consultant who works
Improvement Programme e-bulletin is essential for with NHS organisations on how good practice spreads
anyone working in stroke and TIA services. and how improvements can be made. The website
contains a number of free resources on spreading good
The Stroke Improvement Programme e-bulletin is practice and improvements.
published every two weeks and the latest edition is www.sfassociates.biz/sitebody/MultiMedia/Documents.php
available on the Stroke Improvement website
www.improvement.nhs.uk/stroke. If you would like to
subscribe to the Stroke Improvement e-bulletin, please
email anne.coleman@improvement.nhs.uk.

NHS Improvement System
The NHS Improvement System is a free, comprehensive
online resource supporting quality improvement in NHS
services, offering a range of service improvement tools,
case studies and resources.

The Improvement System gives NHS staff the capability to
record, track and report on projects, share improvement
stories and documents, access Statistical Process Control
(SPC) software, Demand and Capacity tools and a Patient
Pathway Analyser, all within a secure environment.
www.improvement.nhs.uk/improvementsystem
Email: support@improvement.nhs.uk


Further information

Stroke Improvement Programme
National Team
NHS Improvement - Stroke
Improvement Programme
3rd Floor, St John's House,
East Street, Leicester LE1 6NB

Tel: 0116 222 5184
Fax: 0116 222 5101
Email: info@improvement.nhs.uk

NHS
CANCER
NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

NHS Improvement

With over ten years practical service improvement experience in cancer,
diagnostics and heart, NHS Improvement aims to achieve sustainable
effective pathways and systems, share improvement resources and
learning, increase impact and ensure value for money to improve the
efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England,
NHS Improvement helps to transform, deliver and build sustainable
improvements across the entire pathway of care in cancer, diagnostics,
heart, lung and stroke services.

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
Telephone: 0116 222 5184 | Fax: 0116 222 5101

©NHS Improvement 2010 | All Rights Reserved | June 2010

Delivering tomorrow’s
improvement agenda
for the NHS

Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects

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Implementing best practice in acute care: case studies from the Stroke Improvement Programme projects