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What has happened, where are we now – and where are we going? Stroke Services in Southend

What has happened, where are we now – and where are we going? Stroke Services in Southend. What is a Stroke?. In the beginning…..(pre-2004). 26 bed “Stroke rehabilitation” unit - 6 th floor! 16 consultants No protocols 40% Catheter, 40% mortality. 2004-2007…. Dr Tony O’Brien

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What has happened, where are we now – and where are we going? Stroke Services in Southend

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  1. What has happened, where are we now – and where are we going? Stroke Services in Southend

  2. What is a Stroke?

  3. In the beginning…..(pre-2004) 26 bed “Stroke rehabilitation” unit - 6th floor! 16 consultants No protocols 40% Catheter, 40% mortality

  4. 2004-2007…. Dr Tony O’Brien 2004 : took over Stroke Rehabilitation

  5. 2005 Weekly TIA Clinic 2006 Move to Ground floor 14 bed ASU, Gym, new Consultant: £ 800,000 Strokebusters Charity appeal 2007-2009

  6. Progress: 2007- date 2007 May - 2 Consultants 2007 July - ASU opened, Daily TIA clinic Monday-friday 2007 9-5 thrombolysis weekdays 2008 24 hr thrombolysis 7/7 (1:2 on call) 2009-10 4 stroke consultants (1:4 on call) 2012 7 day Patient-centred TIA service

  7. What do you want if you have a stroke?

  8. What do you want if you have a stroke? RAPID treatment by stroke Specialists: SAVE MY BRAIN!

  9. Immediate pre-alert and stroke team review of all patients Consultant-delivered care 24/7 Rapid imaging directed for that patient Acute stroke nurses 24/7 Single point of contact for hospital/GP Integrated working: Individual patient goals Weekly multidisciplinary team meetings, family conferences Discharge planning begins on admission It’s all about the patient: 2 million brain cells/second

  10. The only hospital in Essex to have 24/7 BASP accredited stroke specialist consultant-led and delivered service including in hospital weekend working Patient-specific imaging decision 24/7: the only hospital to have stroke MRI availability 7 days a week Hyperacute service

  11. The right scan at the right time As soon as urgent imaging is requested • Range – 1 to 15 minutes • Median – 6 minutes • IN hours – median 6 minutes • OUT hours – median 5 minutes Source: Request to scan time (Recurrent Door To Needle Audit 2012)

  12. Intravenous thrombolysis • First in the region to implement the service • Over 500 patients treated since 2007 with highest experience with proven safety in delivery (SITS database) • One of the highest percentages of intravenous thrombolysis nationally (SINAP) • 100% of eligible patients receive the treatment (SINAP)

  13. Stroke beds ring-fenced Consistently the highest performance for >90% stay on stroke unit across the East of England Bed occupancy year to date: Acute stroke unit: 78% Rehabilitation stroke unit: 88% First in the region for rehabilitation 7 day working Acute services

  14. What do you want if you have a TIA?

  15. What do you want if you have a TIA? Rapid investigation and treatment. Risk of Early Recurrent Stroke: 12% with 7 days (most within 24-24 hours)

  16. TIA service • Innovation – systems built around the needs of patients • 7 day clinic • MRI service with ‘walk-in’ protocol • 3 doctors trained in carotid ultrasound which can take place on the stroke unit • Single point of contact for telephone referral • Electronic referral system / TIA HOT referral system • Rapid Carotid surgery assessments • Medication taken before leaving!

  17. What do you want if you have a blocked artery?

  18. What do you want if you have a blocked artery? SAFELY OPERATE to prevent a stroke ASAP!

  19. Collaboration with vascular surgery National Carotid Audit Round 4 (June 2012)

  20. Collaboration with vascular surgery National Carotid Audit Round 5 : formal public report will be October 2013 June 2011-2012 Time from Initial symptoms to carotid surgery

  21. Research • 7 original research articles and 38 posters since 2008 • Collaborative research • NIHR Portfolio research – 10 studies • Only centre in Essex recruiting to commercial studies • Monthly teleconference collaboration with all Essex trusts • Consultant Interventional Radiologist for stroke / Research appointed

  22. Patient Outcomes …what actually matters!

  23. Dr Foster Stroke Mortality Aug-11 / Jul-12 National PAH 119.9 BTUH 106 MEHT 101.6 CHUFT 92.3 SUHFT 78.4

  24. Estimates done as part of the stroke review: • If number of deaths from stroke cut by 30% in Essex: • 422 deaths/year saved • If more modest reduction to the 100 baseline (Relative risk of 1) • 104 deaths/year saved • Most London HASUs are below 80 (RR 0.8) – even greater benefit

  25. Outcome for all stroke patients at Southend Source:Southend stroke database

  26. 1st April 2011- 31st March 2012 Source – Network Stroke Database SUHFT 13 Days

  27. Stroke patient satisfaction survey 2013 What was your overall impression of your care and the support you received from the stroke multidisciplinary team?

  28. Awards and recognition • Awards for quality of stroke unit care • Health and Social Care Awards(2009) • WINNERS: East of England • RUNNERS-UP: National finals • Transforming Services Award: • ‘Strokebusting’ - a comprehensive neurovascular service, saving lives and • preventing disability • Health Service Journal Awards(2009) • WINNERS: ‘Delivering Quality and Value with NICE Guidance’ • Research awards • TSRN – Top Recruitment to RCTs 2009-2010 • TSRN – Top Recruitment to RCTs 2010-2011 • TSRN – For Essex and Herts Award for highest recruitment to RCTs by CLRN 2011-2012 • TSRN – Highest Recruitment to Commercial Studies 2011-2012   • UK Stroke Forum award (2009): Highest IST-3 trial recruitment 2009 in the UK

  29. Hyperacute Stroke unit: what is it? HASU for South Essex ….Full circle • Recommended clinicalreconfiguration decision following the completion of the Essex stroke options appraisal: • 3 HASUs: • One for South Essex • HASU - Southend; ASU - Basildon • It’s worked before and it will work again

  30. Service provision effectively manages population flows into and out of the area • Before Basildon Hospital started thrombolysis - we delivered this service • The EoE ambulance service has delivered patients from Basildon, Harlow, Chelmsford AND Colchester – all who received thrombolysis within 3 hours – before their services started • Patients have been airlifted in to provide a thrombolysis • Basildon’s CT scanner broke recently; we were able to accept patients both in and out of hours and some were repatriated • We have never refused a patient from anywhere

  31. Sustainability of outcomes as a HASU Mortality rate reduced over time

  32. Scope for improving the door to needle time: SINAP data

  33. WHERE DO WE GO NEXT? WHAT DO WE NEED? A COMPLETE PATIENT-CENTERED SERVICE As easy as 1-2-3!

  34. 15 February 2013 Ms Jacqueline Totterdell Chief Executive Southend University Hospital NHS Foundation Trust Dear Ms Totterdell RE: MIDLANDS AND EAST REVIEW OF STROKE SERVICES: ESSEX HASU/ASU CLINICAL RECONFIGURATION DECISION I am writing to you following my letter dated 4 February 2012. On behalf of the Essex stroke commissioner group I am now able to share with you the recommended clinicalreconfiguration decision following the completion of the Essex stroke options appraisal....... 3 centre HASU model with HASUs at: • Mid Essex Hospitals • Colchester Hospital University NHS Foundation Trust • Southend University Hospital NHS Foundation Trust There will be an ASU at all DGHs including Princess Alexandra Hospital and Basildon and Thurrock University Hospital.

  35. I must emphasise that this recommendation is a clinical reconfiguration recommendation only. Before an ultimate decision can be made the following must be concluded: 1. A full financial sustainability evaluation of the whole stroke pathway, your finance leads are currently working with Stephanie Watson who has been seconded from the SHA to work with the Essex Stroke commissioners and Dawn Scrafield, finance lead for the Essex local area office to assess financial viability of the suggested reconfiguration. Further work is also required to assess ambulance interference costs and PTS transport costs. 2. CCG agreement to the proposed financial impact of the new service model for stroke services 3. Further patient flow analysis work taking into consideration suggested reconfigurations across the whole of Midlands and East. 4. Public consultation.

  36. What do we need: 1. Firm decisions regarding the Stroke Hyperacute Stroke Units (HASUs) Since this letter: 7 months Unable to plan services & staffing until decisions made Similarly, a decision required regarding Vascular Surgery services In South Essex

  37. Stroke rehabilitationLong-term rehabilitation after strokeIssued: June 2013NICE clinical guideline 162 The core multidisciplinary stroke team A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation: consultant physicians nurses physiotherapists occupational therapists speech and language therapists clinical psychologists rehabilitation assistants social workers.

  38. Stroke Association: ‘Feeling overwhelmed’ 2012 :UK survey to understand the emotional impact of stroke on survivors, carers and their families. Aimed at stroke survivors and their carers The total sample size is 2,711

  39. Survey responses from stroke survivors My emotional needs are not looked after as much as my physical needs(62.8%) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 3.8% 9.6% 23.7% 41.4% 21.4% Health and social care services provide good emotional support(18.0%) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 20.0% 30.9% 31.2% 13.7% 4.3% Survey responses from carers My emotional needs were not supported(66.7%) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 6.6% 8.8% 18.9% 37.4% 28.3%

  40. What do we need: 2. Work quickly to ensure that Stroke Psychology services continue after January 2014.

  41. Andrew Marr's wife hits out at stroke carehttp://www.bbc.co.uk/news/health-23530168 THE WIFE OF THE BBC JOURNALIST ANDREW MARR HAS CRITICISED THE LEVEL OF CARE AVAILABLE TO PEOPLE WHO HAVE HAD A STROKE, ONCE THEY LEAVE HOSPITAL SHE SAID THE INTENSIVE DAILY CARE IN HOSPITAL WAS REPLACED BY - AT BEST - WEEKLY APPOINTMENTS. CAMPAIGNERS SAID MANY SURVIVORS FELT "ABANDONED" WHEN THEY RETURNED HOME. SHE SAID THE NHS HAD BEEN "WONDERFUL, WONDERFUL, WONDERFUL". SHE ADDED: "THE INFLEXIBILITY OF THE SYSTEM IS STAGGERING. "I'VE BEEN CONTACTED BY MANY, MANY STROKE VICTIMS AND THE GENERAL VIEW IS THAT HOSPITAL CARE IS EXCELLENT, BUT THERE'S VERY LITTLE SUPPORT AFTER THAT.

  42. Flexible Working between hospital and community …. For the Patient, not the system Within the hospital • Stroke support worker – works with patients and carers • Multidisciplinary: including vascular, radiology and cardiology teams • End of life • Information sharing • Seamless transfer of care of every stroke patient into the community……

  43. Community stroke ……seamless transfer of care of every stroke patient into the community Stroke support worker – works with patients and carers Community stroke team Early supported discharge Psychology End of life Patient and carer groups: local stroke clubs, Carers Association Flexible Working between hospital and community …. For the Patient, not the system

  44. What do we need: 3. A complete patient-centred single streamlined service from admission to discharge – across primary care and the community ‘flex’ services across hospital and community: will need a change in the way we work The teams we have do a great job – but the system is inflexible: need to put the patient first Can’t plan properly until HASU decision: depends on beds and staffing

  45. We are a centre of excellence which delivers excellence and continually strives to deliver quality

  46. Scope for improving the door to needle time: SINAP data

  47. From: Jeffries Candy (NHS ENGLAND) Sent: 14 August 2013 08:46 To: Guyler, Subject: RE: psychology Dear Paul, There is no doubt that psychology provision at all levels and at all stages of the pathway, is valuable to patients and carers, shortens length of stay and improves goal attainment and outcomes. The network supports having psychology available and it is in the service specification. It is certainly best practice, but many acute trusts and CCGs are treating it as a luxury item rather than a core part of the service and, as such, it is not commissioned in all parts of the pathway, and in some areas, not commissioned anywhere at all. I am happy to try and support your fight for continued funding, but, as I don't have any budget to support services, all we can do to support you is to lend our weight behind your request for ongoing funding. Do let me know if that would be any help, BW Candy Jeffries Cardiovascular SCN Manager (East of England) NHS England CPC1 | Capital Business Park | Fulbourn | Cambridge | CB21 5XE

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