Cardiff and Vale University Health Board Stroke Delivery ...€¦ · - In Public Health - Smoking cessation - Implementation of the Healthy Weight Framework - Alcohol consumption

1 Cardiff and Vale University Health Board Progress Report September 2017

Cardiff and Vale University Health Board

Stroke Delivery Plan / Progress Report

September 2017

1. Overview

Cardiff and Vale University Health Board (CaV UHB) has made progress during the

past year in the following areas:

- Thrombolysis – improvement both in the number of eligible patients

thrombolysed and the door to needle thrombolysis times.

- Overall SSNAP score has improved from 16 in Q3 of 2013 to 79 in Q4 of 2016

giving a B-rating.

- Percentage of Stroke Patients who spend up to 90% of their stay on Acute

Stroke Unit has increased.

- Provision of CT scan within 12 hours and within 1hour (target 95% and 50%

respectively) has remained consistently above target.

- Atrial Fibrillation project supported by Welsh Government has excelled and

will be rolled out across Wales and has been shortlisted for a National Award

(Oct 2017).

- 30 – day Hospital survival has improved.

- Participation in two research trials :

PROMIS – to look at the best method for delivering a 6 month review

for post-stroke patients and a trial looking at specific cognitive deficits

occurring with thalamic strokes.

RESTART - a study to look at REstart or STop Antithrombotics

Randomised Trial - In Public Health

- Smoking cessation

- Implementation of the Healthy Weight Framework - Alcohol consumption


The overall activity of emergency stroke admissions to University Hospital of Wales

has increased year on year over the past 8 years

Emergency stroke admissions to University Hospital of Wales have increased year

on year over the past 8 years (apart of 2015/16, which saw a small drop)

The average yearly stroke admissions to UHW was 508 during the first 4 year period

illustrated compared with 664 in the most recent 4 year period.

2. Key Achievements in 2016-17

Progress with National Priorities

The number of emergency admissions for stroke within CaV UHB has remained

consistent with that expected of its population with a total of 808 admissions during

2016-17 (range 39-54 per month).

Thrombolysis:

Eligibility

Other than one month (May 2016) 100% of eligible patients were thrombolysed,

this has continued into 2017 with 100% during April – August 2017.

The CaV UHB thrombolysis average (mean) rate is 18.8% compared to the Welsh

average of 12.5%; as can be seen in the table below:

Percentage of All Strokes Thrombolysed Apr 16- Mar 17

C&VUHB Wales

Apr-16 23.6% 12.6%

May-16 18.2% 13.2%

Jun-16 10.4% 10.6%

Jul-16 18.5% 12.7%

Aug-16 23.3% 14.9%

Sep-16 10.9% 10.1%

Oct-16 24.4% 14.7%

Nov-16 13.0% 11.1%

Dec-16 28.6% 13.4%

0%

20%

40%

60%

80%

100%

Percentage of eligible patients thrombolsyed, 2016-17

Health Board Wales


Jan-17 17.0% 13.1%

Feb-17 20.8% 11.4%

Mar-17 16.7% 12.4%

MEAN 18.8% 12.5%

The highest achieving period of thrombolysing eligible patients was Dec 2016 at

28.6% compared to 15% for Wales in August and October 2016.

It is believed that Cardiff and Vale UHB performance has had a positive impact on

the All Wales average.

The % of pts thrombolysed within 1hour has increased year on year with 2016-17.

Swallow Screen within 4-hours

Since Jan 2016 the % of patients receiving swallow screen within 4hours has

increased from 50% to 80% in Sept 2017, with a peak of 82.9% in April 2017. The

improvement is attributed to ongoing training within the Emergency and Assessment

Unit nursing staff and improvement in admitting to the acute stroke unit within

4hours. It is anticipated that improvement will continue with the introduction of 7-day

therapy and ongoing training programme.

0%

10%

20%

30%

40%

Percentage of all strokes thrombolsyed, 2016-17

Health Board Wales


CT scan

The percentage of patients receiving CT scan within 12hours is consistently 97.7-

100% (score A)

% of patients receiving CT scan within 12hour of arrival April 2014 to August 2017

Patients receiving CT scan within 1hour consistently and significantly exceed the

aspirational target of 50%.

% of patients receiving CT scan within 1hour of arrival April 2014 to August 2017

0%

10%

20%

30%

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% of Patients who had CT Scan within 12 Hours of Admission


SSNAP score – during the period Dec 2016 to March 2017 the overall score was ‘B’

rating.

During the period Q1-Q3 2016 Cardiff and Vale UHB’s SSNAP score increased from

50 to 79, this can be attributed directly to 7-day working (consultant and therapists)

and Code Stroke being fully implemented

However, with the cessation of the 7-day therapy pilot, performance dipped in Q 4 of

2016/17.

Achieving score A in Domains 1, 9 and 10:

- Domain 1 Scanning: % scanned within 1 hour, % within 12 hours and median

time to scan

0%

10%

20%

30%

40%

50%

60%

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80%

90%

100%

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% of Patients who had CT Scan within 1 Hour of Admission

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14

SSNAP score: C&VQ3 2013 to Period 16 inclusive

C&V


- Domain 9 Standards by Discharge: % screened for nutrition NAD seen by

dietitian by discharge, % have continence plan in place within 3/52, %

assessed for mood and cognition

- Domain 10 Discharge Process: % receiving joint health and social care plan,

% discharged with stroke skilled ESD, % in AF discharged on warfarin or with

a plan to start warfarin. % discharged with a named contact.During the period

Dec 2016 – March 2017 (SSNAP report) Cardiff and Vale UHB is the only

Health Board in Wales achieving score A in this domain (47%)

Achieved level B in Domain 6, Physiotherapy: % requiring PT. Median minutes per

day when PT received, median % of days PT received. Compliance (45 minutes for

5/7 days for 85% of patients)

Therapy assessment within 24 and 72 hours

A successful pilot was completed where all Therapies participated in 7 day working

on the Acute Stroke Unit over a period of 20 consecutive weekends from June to

October 2016. There was then a limited extension providing 6-day working through

to early January 2017. During the pilot the therapy team provided 769 additional

contacts; 262 (34%) of these were new assessments. All SSNAP targets were

achieved at 100% by October 2016. The number of minutes of therapy provided

over the course of the project increased by 18% for PT, 21% for OT and 23% for

SLT. All patients with a nasogastric feeding tube were assessed by a dietician within

1 day of its insertion. The average length of stay for stroke patients on the ASU

reduced by 2.5 days to 5.1 days. Patient and carer satisfaction was high, with

positive feedback received about availability of therapists at weekends, and the

commencement of rehabilitation without delay. Staff satisfaction was high with all

focus group attendees and questionnaire respondents favouring the 7-day model for

service delivery.

There was also improved therapy performance against 24 hours Therapies

assessment and 72 hour individual profession specific (during 7 day working project-

2016 plus early 2017-6 day).

The Percentage of Stroke Patients who spend up to 90% of their stay on an

acute stroke unit has increased from 42% in April 2012 to 83.2% in Feb 2017

(peaked at 90.2% in November 2016 at the time when the 7-day working was

piloted)


30 – day Hospital survival

During the past 10 years, the 30-day Hospital survival rate has increased from 73%

in 2007-08 to 80.2% in 2016-17 with a peak of 84.2% in 2014-15:

30 Day Hospital Survival Rates - Age Group 75+ Years

Source: PEDW Notes: Stroke cases included where primary diagnosis = I61, I63 or I64

Year Wales C&VUHB

2007-08 72.0% 73.0%

2008-09 72.9% 71.7%

2009-10 74.0% 78.4%

2010-11 75.6% 77.7%

2011-12 75.1% 73.9%

2012-13 77.1% 74.8%

2013-14 77.9% 76.3%

2014-15 78.5% 84.2%

2015-16 78.9% 82.6%

2016-17 79.8% 80.2%

Stroke survivors help others with life after a stroke

People who have experienced a stroke now have access to support through a new

book, following its development by a team of psychologists and a group of stroke

survivors and carers.

‘Rebuilding Your Life After Stroke’ was developed with stroke survivors in

partnership with psychologists from Cardiff and Vale and Cwm Taf University Health

Boards and supported by Cardiff University.

0%

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Feb

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17

Percentage of Stroke Patients who spend up to 90% of their stay on ASU,

2012-13 to 2016-17

Health Board Wales


The book and its accompanying materials aim to normalise the psychological effects

of stroke, providing advice and support for people following a stroke while also

providing tips and strategies to make life easier.

With insight from many people who have experienced a stroke, this book focuses on

what stroke survivors can do, rather than what they cannot. Using exercises to help

move towards an acceptance of the long-term side effects, this book delivers a

positive message to help survivors of strokes live a better and happier life.

This book and its accompanying resources have been in production for 18 months

and is now available in both Welsh and English.

Research by the Care Quality Commission in 2011 highlighted that services to

support psychological issues after stroke were often inadequate while the Stroke

Association in 2013 reported that survivors and carers can feel abandoned after

leaving hospital.

The group of authors joined forces with stroke survivors and carers to develop the

self help book which gives an insight into the psychological difficulties after stroke,

for both survivors, and their families. The book was funded by the Stroke

Implementation Group which is a Welsh Government and NHS Wales funded body.

Progress with Local Priorities

Thrombolysis within 1 hour – Cardiff and Vale UHB has increased its percentage

of patient thrombolysed within 1 hour year on year from 19.4% in 2013-14 to 44.5%

in 2016-17 which is a 25.1% improvement; the Welsh average increased 14.1%

(from 25.7% to 40.8%).

There has been a positive reduction of 25.1% in the number of patients receiving

thrombolysis in over one hour from 80.6% in 2013/14 to 55.5% in 2016/17; the All

Wales figure reduced by 15.1% from 74.3% in 2013/14 to 59.2% in 2016/17.


This achievement is attributed to the embedding of the Code Stroke model with

senior clinical presence at the front door.

As can be seen in the table below, during the period Jun 2017 – Aug 2017 Cardiff

and Vale UHB has achieved a median time of 50mins 30secs, the All Wales median

for the same period is 1hr 11mins:

The Business case for 7-day working was approved earlier this year (2017) and will

deliver a sustainable 7-day working model with the weekend Consultant provision

already in place and 7-day therapy provision being phased in from Oct-Nov 2017. It

is anticipated that the improved performance demonstrated during the pilot will be

recovered upon full 7-day implementation.

Atrial Fibrillation (AF)

The percentage of patients with atrial fibrillation in whom stroke risk has been

assessed using the CHA2DS2-VASc score risk stratification scoring system in the

preceding 3 years (excluding those patients with a previous CHADS2 or CHA2DS2-

VASc score of 2 or more) is 98.6% which together with Hywel Dda UHB is the

highest in Wales.

Wales 97.7%

ABMUHB 98.1%

ABUHB 96.1%

0%

20%

40%

60%

80%

100%

2013-14 2014-15 2015-16 2016-17

Percentage of all patients thrombolysed within 1 hour, 2013-14 to 2016-17

Health Board thrombolysed <1hr Health Board thrombolysed >1hr Wales <1hr Wales >1hr


BCUHB 97.4%

C&VUHB 98.6%

CTUHB 95.9%

HDUHB 98.6%

PtHB 97.5%

Of those patients identified with atrial fibrillation with a record of a CHA2DS2-VASc

score of 2 or more, the percentage of patients who are currently treated with anti-

coagulation is 84.0%.

28% of patients in AF in the community are either not anti-coagulated or are

receiving anti-platelet agent. These patients fall into the category of ‘exceptional

reporting’ within Primary Care, the CaV Stop a Stroke project has seen an increase

in anti-coagulation in this group of patients by 83%. This is a significant achievement,

the work has been supported by the Welsh Government Stroke Improvement Group

and the work is now being rolled out across all Health Boards in Wales.

The Cardiff and Vale Atrial Fibrillation project has been shortlisted for the

Anticoagulation Achievement Awards (Centre best able to demonstrate adherence to

NICE Quality Standards for atrial fibrillation). Presentations will be made in the

House of Commons on 11 October 2017.

Multidisciplinary working - CaV UHB received support from the Delivery Unit

during 2016 to undertake an Accelerated Redesign of the stroke pathway/services.

One of the key areas that came out of the event was the desire to work very

differently and in a more integrated way on the SRC, work is ongoing to achieve this

and is outlined in the actions for 2017/18.

Development of self management philosophy using the Bridges Self-

management Training Programme:

Bridges is an innovative and evidenced based programme where self management

support is integrated within every interaction an individual has. It has the potential to

impact on the patient’s experiences and satisfaction and lead to better utilisation of

health and social care resources.

80 health practitioners from stroke and neurological services in Cardiff and

Vale UHB have been trained in the Bridges approach to self management

support.

Wales 86.5%

ABMUHB 83.2%

ABUHB 84.0%

BCUHB 85.7%

C&VUHB 84.0%

CTUHB 86.9%

HDUHB 88.2%

PtHB 89.8%


Staff from all grades and professions across the stroke pathway received the

training and have been empowered to support self management and shared

decision making.

Bridges champions have been identified to ensure the approach is sustained.

9 champions attended a Bridges Master Class in January 2017

Further Bridges training is planned for November 2017

The approach is being incorporated in the ‘How can we help you’ project

underway on the SRC at UHL.

Technology

The use of iPads by therapy teams using ‘apps’ to support therapy interventions/

rehabilitation and self management. Also environmental images/video to provide

information on access visits/home assessment which improves efficiency (e.g.

reduces some visits to community setting) which in turn supports complex discharge

planning.

One issue to arise from the Community Neurosciences review was lack of robust

governance relating to the use of technology. It was therefore decided to convene a

Therapies Technology Forum which has scoped current and future opportunities for

technology usage as well as develop a governance framework to ensure the safety

and security of information of users. The best practice guideline for use of

technology within Therapy is planned for launch in October 2017 with training plan to

follow.

Community Neurological Rehabilitation Service (CNRS)

In 2016 – 2017 a project was undertaken to scope community rehabilitation services

(including stroke) available to people living with a neurological condition in Cardiff

and the Vale of Glamorgan.

A new service model has been developed that integrated the current condition based

and uniprofessional services within a framework that offered a stepped approach to

providing needs led rather than condition based rehabilitation. The aim of this

approach is to begin to address the inequalities and gaps in service provision

identified in the scoping exercise.


This stepped model of rehabilitation has 4 levels:

Level 1 Level 2 Level 3 Level 4

Empowering

living well with a

neurological

condition

through co-

produced

education and

support.

Group

programmes that

are not condition

based.

Group

rehabilitation

programmes that

address specific

rehabilitation

needs but are not

condition based.

E.g. upper limb

activity group and

conversation

groups

Specialized group

rehabilitation

programmes & 1:1

programmes that

are delivered by

trained support

staff.

These may be

specific to a

condition.

Interventions &

programmes

delivered 1:1 by

specialist staff and

teams

E.g. Early

supported

discharge team for

stroke

The project funding has been utilised to provide clinical leadership for the integrated

service and to implement Level 1 and Level 2 programmes. The new programmes

will widen availability to services and will support people to step down from

specialized Level 3 and 4 services such as ESD. The newly appointed CNRS clinical

lead post will start in post in October 2017. This role will initially provide clinical

leadership to ESD for Stroke alongside developing Level 1 and 2 programmes. The

role will evolve and aim to move the other community / outpatient neurological

rehabilitation services into its remit once the programmes are established. It is

anticipated that outcomes from these initial developments will include:

1) Improvements in the ESD pathway - referral process / capacity management 2) Impact of Level 1 and 2 programmes – PROMs / links with organisations

outside of UHB/ service user involvement / pathway management for specialist neuro rehab teams

A rehabilitation technician has also been appointed to support the Level 1 &2

programmes and some administrative support.

Research and Development

Recruitment into R&D studies has been challenging over the last few years with

limited success.


However, there has been some improvement this year with plans in place as follows:

Following the move to double the national recruitment of stroke patients in to

research trials within Wales, CaV UHB has engaged with the Welsh stroke research

lead to identify stroke research leads within the UHB. The decision was made in CaV

UHB to allocate two leads, Claire Butterworth and Benjamin Jelley; a clinical

specialist physiotherapist and consultant stroke physician respectively. The purpose

of this is to increase research capacity and activity across the Allied Health

Professionals’ teams as well as the medical teams.

As a result of this there have been 2 additional portfolio trials adopted by CaV UHB;

PROMIS which will look at the best method for delivering a 6 month review

for post-stroke patients and a trial looking at specific cognitive deficits

occurring with thalamic strokes. The former trial is targeted to recruit 100-200

patients and the latter is aiming to recruit 15 patients. The thalamic stroke trial

will have shared funding credit with psychology but is also our second trial to

build links with the The Cardiff University Brain Research Imaging

Centre (CUBRIC). The recruitment for both of these trials commences

September 2017.

Agreement has been secured to extend the first trial being run through

CUBRIC looking at neurofeedback in moderate upper limb functional deficit

which has also been accepted on to the research portfolio.

One of our consultants had been engaged with Health Care Research Wales (HCRW) to run the Paramedic Acute Stroke Treatment Assessment trial (PASTA) and the UHB was the highest recruiting site involved, but unfortunately HCRW support had to be terminated recently. However, trial recruitment is continuing with two of our stroke consultants having taken on this direct recruitment themselves.

The commencement of REstart or STop Antithrombotics Randomised Trial

(RESTART) in the UHB is being finalised, this is a trial that aims to answer an

0

10

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30

40

50

2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Recruitment to Stroke CRP studies, 2010-11 to 2016-17


important clinical question about the continued use of blood thinning agents

after a primary intracerebral bleed.

Despite the difficulties with PASTA progress has been made in building strong links

with HCRW over the last 12 months and as a result of the study Delivery of Patient

Reported Health Status Questions in Stroke (previously known as PROMIS), links

with the Clinical Research Facility in UHW are being strengthened with positive

indications about further trial involvement focusing on stroke patients.

Various posters (2017): showcased at Stroke Conference: e.g.

How You Can Help Me (PT/Cons)

Hydration of Patients on a Busy Stroke Unit-MDT (Dietetic Lead/Cons)

Public Health Key achievements in 2016-17

Tobacco

The percentage of adults reporting being a current smoker or using e-cigarettes has reduced to 15% for Cardiff and Vale of Glamorgan (Cardiff 12% and vale of Glamorgan 13%). This is a decrease from 18% for 2014-2015. Cardiff and Vale UHB have achieved the Welsh Government smoking prevalence target of 16% by 2020

Whilst numbers of smokers accessing smoking cessation services and setting a firm quit date (“Treated Smokers”) have reduced from 2015-2016, the percentage of those quitting smoking at 4 weeks (CO validated) has increased to 56% from 46% (2015-2016) achieving Welsh Government’s Tier 1 target of 40% (4 week CO rate)

All 3 specialist smoking cessation services in Cardiff and Vale of Glamorgan (Stop Smoking Wales, Cardiff and Vale University Health Board (UHB) Smoking Cessation Service and Level 3 Smoking Cessation Enhanced Service Community Pharmacies) achieved over 50% 4 week CO validated quit rates with the UHB’s in-house service achieving 63% and the Level 3 Pharmacy scheme achieving 71%

20 Community Pharmacies in areas of high deprivation now offer a Level 3 Smoking Cessation Service across the UHB (an increase from 15 in 2015-2016)

80% of community based smoking cessation groups run in venues of high deprivation – the majority of which, are based at GP Practices

Over 80% of all new referrals to SSW (2016-2017) are via GP Practices with 66% having a direct e-referral pathway

The numbers of smokers challenged by the UHB’s No Smoking Enforcement Officer at UHW have decreased during 2016-2017 to 3,300 from over 5,000 during 2015-2016. Visitors continue to be the highest percentage of smokers (60%)

A study carried out by Cardiff Metropolitan University on behalf of the UHB into behavioural Insights of Young People and Smoking (November, 2016) showed that the most important factor in influencing a young person to try


smoking, is whether the mother smokes. The most important factor relating to the use of e-cigarettes by young people is whether a sibling or peer is using e-cigarettes. The study showed that young people that had never smoked were using e-cigarettes

7 Primary Schools in Cardiff and Vale of Glamorgan launched a ‘Smoke Free School Gates’ initiative during 2016-2017 with TV and radio coverage during March 2017

Healthy weight

Implementation of the Healthy Weight Framework

Cardiff and Vale Eating Well Plan 2015-2018 developed and agreed with key partners, implemented with a focus on providing nutritional information and providing advice and training within community settings

Hospital restaurant food standards implemented and audited to ensure a 75-25% split in favour of healthy options in all UHB restaurants and food retail outlets.

Lowest levels of obesity (17%) and overweight/obesity (54%) in Wales

Continued roll out of adult Level 3 obesity service (84 new patients referred in 2016/17)

Level 2 Obesity service saw 525 new patients in group sessions in 2016/17, of which 57% completed the course

Physical activity plan on track for Year 2 delivery during 2016/17

Alcohol

196 people attended Alcohol Brief Intervention training in 17 training sessions.

Alcohol consumption levels in Cardiff & Vale have generally been falling, but this is not the case amongst all population groups, with older groups either drinking the same or increasing consumption, and younger groups decreasing consumption

30 participants from organisations working with older people took part in training around older people and alcohol, focusing on developing skills and confidence to have a conversation and deliver a brief intervention with this population group

3. The Challenge for Cardiff and Vale UHB Stroke Delivery Group

Thrombolysis

We will aim to further reduce the mean door-to-needle time to improve compliance

against the 45minute indicator. We aim to review current processes through process

mapping and applying service improvement methodology.

4 hours admit

47.3% in April 2016 and 47.6 in March 2017 with a peak of 67.6% in November

2016; analysis of this performance show that the 4hour breaches are in the main due

to availability of beds or bed of the correct gender mix.


Swallow Screen

A review of the Swallow screen tool in ED is currently underway with a comparison

between HEADS and the Yale tools; this work is being led by the Dysphagia lead in

conjunction with Stroke physicians and nursing leadership

24 hours

The assessment by consultant and nurse has continued to improve. The

assessment by one of OT, PT or SLT performed well during the period of the 7-day

pilot in 2016. It is anticipated that the drop in performance since then will improve

from Oct/Nov 2017 onwards as the sustainable arrangements are put in place for

7-day therapy services in acute stroke.

72 hrs

0%

20%

40%

60%

80%

100%

<4-hours care performance indicator, 2016-17

Health Board Wales

0%

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20%

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40%

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80%

90%

100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

<24-hours care performance indicator, 2016-17

Health Board Wales


There was an improvement in the performance during the period of the pilot. In

addition the Speech and Language Therapy service had received some additional

investment as well as changing their model of assessment.

Oct 2016 - 100%

Nov 2016 - 97.8% - this being during the 7-day pilot

March 2017 - 83.3%

Following the completion of the pilot a successful case was made for investment to

provide the service on a substantive basis with changes to therapist job plans to

deliver 7 day working. Staff consultation has been completed and implementation will

progress during Sept-Nov 2017.

The sustainability of the 72 hour standard in the interim has been challenging

particularly SLT. Added to which there have been vacancies and new appointments

in SLT which has impacted on their capacity to deliver within the required standard.

The SLT service is now entering a period of stability where they have additional

dysphagia trained staff.

The challenge will be to recruit the required staff in some of the smaller professions

to operationalise the 7-day working on a sustainable basis.

Patient Flow

Patient flow through the pathway is dependent on their being good processes in

place within the acute, rehabilitation and community components of the pathway.

Much work has been undertaken to focus on A6South which is the acute admitting

ward for stroke. The UHB has seen an improvement in flow from A6S but this

continues to be a challenge for the Stroke Rehabilitation Centre at University

Hospital Llandough. A focussed piece of work has been undertaken reviewing the

0%

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100%

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

<72hours care performance indicator, 2016-17

Health Board Wales


delayed transfers of care and reasons for delays. In addition focused work on

predicted dates of discharge has commenced. The average length of stay (ALOS)

has decreased during recent months as a result of this work.

o June 2016 – March 2017 ALOS range 56.9 – 125.4days

o April 2017 - August 2017 ALOS range 48 – 75.5 days

It has been identified that the use of a standardised predicted length of stay of 42

days did not suit the needs of the SRC. There were frequent breaches and patients

identified as DTOCs which was unhelpful for planning discharge and predicting flow.

The team undertook an audit of patients and compared LOS with the categories

utilised by the Orpington predictive tool for mild/moderate and severe. In addition the

PDD uses the descriptor of ‘Medically fit for discharge’ which again is unhelpful in a

rehabilitation setting as it fails to capture those patients still on an active

rehabilitation pathway.

Using the evidence from this audit the team have developed a new descriptor called

‘clinically expected length of stay’ (CELOS)

o Clinically expected length of stay (CELOS) has been developed onto the

existing WCWS and replaces Planned Date of Discharge (PDD), this is

currently a pilot within our stroke pathway from point of entry through to

discharge. The CELOS is generated following an assessment of physical

functionality and stratifies them according to mild/moderate/severe stroke

differentiating patient who are medically fit but still require therapy

intervention.

o The Ward Clinical Workstation (WCWS) has the functionality to record

discharge delays but relies on the manual selection in an optional field which

is often not completed.

Staffing and recruitment

There continue to be challenges in relation to recruitment across a number of

professions including medicine, nursing and some therapies. Strategies are in place

to address these and there has been some improvement particularly in nursing.

Stroke Association Post Stroke Review Update

A six month pilot has been implemented by the Stroke Association; the project is

supported by the Stroke Improvement Group to provide 6 month follow up for post

stroke patients. The project has, to date, completed just over 60 post stroke reviews.

The pilot will run to the end of December 2017 following which a full evaluation will

be published.

4. Areas for Improvement The UHB continues to work on refining the acute stroke pathway in UHW including;

- Door to needle time – process map

- 4 hour admit - continue with breach analysis


- Review code stroke out of hours and 24/7 – how it is working?

In addition further work is required to strengthen the pathway from acute to

rehabilitation and community. The Delivery Unit facilitated an accelerated redesign

workshop during September 2016.

A review of the action plan has been undertaken and a number of the actions

identified by staff across the pathway remain outstanding. There has been a

significant change in the structure of the nurse leadership structure and one of the

priorities over the last year has been to stabilise the current nursing workforce

establishment. The leadership structure is now well embedded.

The Stroke Rehabilitation Centre at UHL have also reviewed the composition and

constitution of their improvement group and identified a number of projects from the

accelerated redesign report to focus on to give the maximum amount of benefit.

The following priorities have been identified;

Joint working; further work is required to develop an integrated workforce.

Establishment of the Key worker role, Improve patient involvement and

engagement

Effective and efficient communication; Streamlining the number of meetings

and improving the effectiveness across the MDT

Comprehensive pathway; Stratification of patients according to need.

Appropriate rehabilitation in the community; this is addressed within the

CNRS model incorporates stroke services and the appointment of the Clinical

lead will progress this work to next steps as outlined earlier in the report.

Provision of a sustainable 6 month review service

Delivering an Integrated education and training model for all professions.

5. Priorities for 2017-18

National Priorities

HASU development –following the publication of A new Hyperacute stroke

service for Wales (Dec 2016) the UHB is considering the work ahead within its

Stroke Strategy Improvement Group

Repatriation (incoming and outgoing) – ensuring all residents can return to their

own Health Board in a timely manner to purse ongoing stroke care, this will be

particularly important where HASU exist to facilitate flow and appropriate

utilisation of hyper acute services.

Thrombectomy service / interventional radiology; the mechanical thrombectomy

service continues to be uncommissioned by WHSSC. The UHB is currently

working with other Health Boards across Wales and WHSSC to establish if this

service can be commissioned on a sustainable basis. In the meantime the UHB

has developed a pathway to provide a service to Cardiff and the Vale of

Glamorgan residents only until a sustainable service is in place.


Patient related outcome measures and patient reported experience measures

(PROMS & PREMS); – There is a national project underway and the National

Stroke Improvement Group is considering rolling this out to include stroke. The

UHB is awaiting confirmation of the preferred approach to be adopted but already

has key personnel in place within informatics to support. It is anticipated that

learning from the pilot in intermediate care will be utilised.

Early Supported Discharge: The UHB is progressing this work within the

framework of the new Community Neurorehabilitation Model in conjunction with

Community Resource Teams. The Clinical lead has now been appointed and will

be developing an action plan which will focus on ESD in the first instance.

Local Priorities

4 hour admit: we will continue to analyse all 4hour breaches to monitor and develop

appropriate actions to reduce the number of breaches, this will include continually

ensuring acute beds are available.

Mechanical thrombectomy for acute ischaemic stroke (Section 3.5 RCP 5th Edtn

2016) the mechanical thrombectomy service continues to be uncommissioned by

WHSSC. The UHB is currently working with other Health Boards across Wales and

WHSSC to establish this service on a sustainable basis. In the meantime the UHB

has developed a pathway to provide a service to Cardiff and the Vale of Glamorgan

residents only until a sustainable service is in place.

Swallow screen: there has been a significant recruitment in nursing workforce in the

Emergency department which has resulted in a large number of nursing staff who

will require training in swallow screening. The training schedule and the screening

tool are currently under review with a plan to deliver anticipated by end of November

2017. A review of the assessment tool will also be undertaken.

Consultant review: the majority of patient are now receiving consultant review

within 24 hours and with the continued 7-days working this should be achievable.

Ffurther work to be undertaken to ensure inpatient stroke pathway is activated

immediately upon stroke being suspected

7 day therapy: Following a period of consultation through the organisational change

policy the delivery of a sustainable model of 7 day therapies is expected to be fully

implemented by November 2017. Physiotherapy has already recommenced the

service using voluntary overtime in anticipation of the recruitment of staff.

Thrombolysis times: Delivering sustainable improvement in door to needle times

as well as onset to needle times.

Hyper Acute Stroke Unit: The UHB is awaiting the final report and

recommendations from SIG in relation to the HASU model for Wales. In the

meantime it will be undertaking a review of the requirements to deliver a hyper acute

stroke unit for the residents of Cardiff and Vale. Following this an options appraisal

will be submitted to the Management Executive for consideration and decision.


Community Neuro-rehabilitation service: establish and consolidate the leadership

role for the community neuro-rehabilitation services, ensure the delivery Level 1 and

Level 2 programmes and evaluate their efficacy in particular the ability to support

step down from specialised Level 3 and 4 services such as ESD.

The clinical lead role will continue to evolve and look at the feasibility of including

other community / outpatient neurological rehabilitation services within its remit.

SLT: Dysphagia training: a new dysphagia lead has been appointed in SLT and is

currently reviewing the capacity of the dysphagia trained staff. A training needs and

resource gap analysis will then be developed.

Incorporation of clinical psychology/clinical neuropsychology, dietetics and

Orthoptics expertise into the multidisciplinary stroke rehabilitation team:

The lack of dedicated dietetic resource in ESD to facilitate discharges with NGT’s

means a small number of patients remain in hospital purely because of swallow

impairment and they are then transferred to SRC or remain on the acute ward until

their swallow improves or a PEG becomes more suitable. It is anticipated this will be

addressed within the CNRS plan and financial envelope. There is already a well

established dedicated psychology resource within the stroke service. Links with

orthotics will be reviewed to identify if there are any gaps in the pathway.

Stroke Rehabilitation Centre:

Joint working; further work is required to develop an integrated workforce.

Establishment of the Key worker role, all staff are now acting as key workers

Improve patient involvement and engagement by implementing the ‘How can

we help you’ project incorporating the Bridges philosophy

Effective and efficient communication; The SRC are currently undertaking a short test of change to the MDT/Medical ward round structure to reduce the number of meetings that the team have to attend and streamline/simplify the communication process. Further development of the integrated record developed on the acute unit and needs to be rolled out in SRC.

Comprehensive pathway; Stratification of patients according to need and development of the CELOS model which transfers with the patient throughout the pathway

Appropriate rehabilitation in the community; this is addressed within the

CNRS model incorporates stroke services and the appointment of the Clinical

lead will progress this work to next steps as outlined earlier in the report.

Provision of a sustainable 6 month review service subject to the evaluation of

the pilot currently underway with the Stroke Association.

Integrated education and training model for all professions.

Development of a research delivery plan to increase the level of research activity

and increase the number of patients recruited into research trials. Work is already

underway by the R&D leads and Health Care Research Wales (HCRW) to identify

resources to support the recruitment into the Restart trial


6month follow up – evaluation of the current project led by the Stroke Association

Stroke survivors help others with life after a stroke - further evaluation of the

resource ‘Rebuilding Your Life After Stroke’ which was developed with stroke

survivors in partnership with psychologists from Cardiff and Vale and Cwm Taf

University Health Boards and supported by Cardiff University.

Public Health Key priorities for 2017-18 and 2018-19

Tobacco

The role of the GP in supporting smokers to quit smoking and referring to a specialist support service is a key promotion priority. As such, a key action is to increase the number of GP Practices with e-referral pathways to the ‘Help me Quit’ call centre. A mapping exercise has been completed to identify those without formal log-in referrals and GP Practices in areas of high deprivation are being prioritised to set this service up

To increase the number of Community Pharmacies in areas of high deprivation offering a Level 3 Enhanced Service for Smoking Cessation

To remove the exemption that allows mental health in-patients to smoke (outside, in enclosed gardens) from the UHB’s No Smoking and Smoke Free Environment Policy

To increase the number of primary schools offering a ‘Smoke Free School Gates Policy’

Healthy weight

Continue with implementation of the Cardiff & Vale Eating Well Plan

Further develop the UHB restaurant standards to include external outlets and trolley services for wards

Development of three year food and physical activity plans

Continued expansion of adult level 3 obesity service (2017/18 and 2018/19)

Finalise and implement the Cardiff Planning & Well-being Supplementary Planning Guidance

Implement and evaluate the promotion of physical activity within the primary care setting

Develop commissioning intentions for child level 2/3 obesity service (2017/18 and 2018/19)

Continued development and integration of the level 2 and level 3 adult obesity services (2017/18 and 2018/19)

Implementation of compact nutrition training for midwives to support healthy weight in pregnancy (2017/18 and 2018/19)

Alcohol

Prioritise targeting older segments of the population, through continued training of service providers, a pilot initiative with Taith (substance misuse service) who are working with older people in GP practices to help reduce


their alcohol consumption, and continuing to offer ABI training (particularly in primary care) as this is the intervention with the strongest evidence base.

6. Priorities for 2018-19

National Priorities

The focus will be on the development of sustainable HASU model and implementation of a commissioned mechanical thrombectomy service if agreed by WHSSC.

Local Priorities

The focus will be on the HASU and Mechanical thrombectomy model.

In addition the completion of the Cardiff and Vale AF Stroke project will be completed

in 2018 and the focus will be embedding a sustainable service.

Documents

Cardiff and Vale University Health Board Stroke Delivery ...€¦ · - In Public Health - Smoking cessation - Implementation of the Healthy Weight Framework - Alcohol consumption