Joining up prevention: case studies from the Stroke Improvement Programme projects

Stroke Improvement Programme

NHSNHS Improvement

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Joining up prevention:case studies from the Stroke ImprovementProgramme projects

Introduction

Buckinghamshire Hospitals NHS Trust

Epsom General Hospital

Lancashire Teaching Hospitals NHS Foundation Trust

Milton Keynes Hospital NHS Foundation Trust

North Bristol NHS Trust

North West London Cardiac and Stroke Network

Royal Devon and Exeter NHS Foundation Trust

Surrey and Sussex Healthcare NHS Trust

United Lincolnshire Hospitals NHS Trust

Stroke resources

Further information

Contents

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Joining up prevention: case studies from the Stroke Improvement Programme projects | 3

Introduction

The Stroke Improvement Programmeworked with 10 sites from March2009 to test implementing qualitymarkers 5 and 6 of the NationalStroke Strategy and to contribute tonational learning.

These markers set some challenginggoals for health communities toachieve and required many previouslyunanswered questions to be solved,not least what will be the realdemand for the service.

Sites commenced work in March2009; during the following 12months they met together on sixoccasions to share ideas and learning.

All sites were at very different stagesin the development of their TIAservices and had different aims towork towards. Much of the work thisyear has concentrated on the frontend of the TIA pathway and work inthe coming year will concentrate onaccess to carotid endarterectomy,follow up and implementing sevenday services, as well as ongoing workon access to imaging. Work in thecoming year will also be linked closelywith the NHS Improvement work onatrial fibrillation (AF).

18 atrial fibrillation projects wereestablished in October 2007 andcompleted in April 2009. Workingacross 15 networks, with PCTs,general practices, practice basedconsortia and acute trusts, theypiloted a range of approaches toimprove detection and optimaltreatment of patients with AF inprimary care to reduce the risk ofstroke. The Stroke ImprovementProgramme publications that providea summary and overview of theoutcomes from this first phase arelisted in the Stroke resources section.

The suggestions, experiences andexamples provided in this documentare intended to generate ideas, toshow what is possible when teamswork constructively together and toguide planning for improvementactivities. Nine of the 10 sites areincluded in this publication.

The Stroke Improvement Programmecontinuously publishes materials tohelp those striving to improve strokeand TIA services. All materials areavailable on the Stroke ImprovementProgramme web site at:www.improvement.nhs.uk/stroke

www.improvement.nhs.uk/stroke

• Clearly define a pathway forhigh and low risk patients,agreed across primary andsecondary care

• Streamline the referral route withsingle point of contact for highand low risk

• Employ a comprehensivecommunication strategy

• Establish a sustainable data andaudit system

• Tailor the weekend service tolocal needs and demand

• Think differently about how andwhere TIA clinics are provided

TOP TIPS

Contacts for each of the projects areincluded. Full details of the serviceimprovement can be found at:www.improvement.nhs.uk/stroke

4 | Joining up prevention: case studies from the Stroke Improvement Programme projects

AimsTo deliver a TIA service to the peopleof Buckinghamshire in line with therecommendations of the NationalStroke Strategy.

IssuesBuckinghamshire Hospitals NHS Trustis a split site trust with two mainsites, Stoke Mandeville Hospital andWycombe Hospital, with a combinedpopulation of about 500,000. Atwice weekly MRI-based TIA clinichad been running at StokeMandeville since 2000, and atWycombe since 2006. While therewere many good aspects to thisservice, including routine MRI brainand carotid imaging since theinception of the clinics, audits onboth sites had shown that the meanwait to be seen was about twoweeks.

One of the challenges locally was thateach site has just one strokephysician, and neurology input oneach site restricted by eachneurologist being off-site forsubstantial parts of the workingweek, so it was not practical to offera daily traditional clinic on each siteevery day of the week.

ActionsThe team planned to see high-riskpatients on an ad-hoc basis at one ofthe day hospitals at 9am on the dayafter the “first contact”. To startwith, one MRI slot was kept free oneach site at 10.30am, on theunderstanding that it would be usedfor an inpatient if no request werereceived for an outpatient by 10am.

There was concern that there wouldbe a large number of, possiblyinappropriate, referrals or that theservice would break down duringperiods of leave. To tackle this, allpatients in the high risk service wereseen briefly by the medical on-callteam, partly to filter outinappropriate referrals and partly tocheck consultant stroke physicianavailability the following day.

For low-risk patients the team madetwo innovations:• rationalisation of the referralprocess so that all referrals on bothsites were faxed to stroke servicesecretaries

• patients not able to be seen on onesite within a week were seen onthe other site, if space wasavailable. The major advantage ofthis is around clinic cancellations foron call duties, annual and studyleave


All of these changes werecoordinated via the creation of amultidisciplinary TIA project group,which met monthly during the maindevelopment phase, and quarterlysubsequently.

OutcomesThe pathway was implemented inJuly 2009, and has worked very wellfor patients referred in as perprotocol. Patients attending the clinicat 9am, or shortly after almostalways get brain MRI and carotidMRA imaging the same morning,and this part of the pathway hasproven very reliable.

Numbers were slightly lower thanexpected and the radiographersdropped the dedicated 10.30am slotin favour of fitting patients in asnecessary. The low numbers and veryfew inappropriate referrals meantthe need for review by the on-callmedical teams was rapidly dropped,making use of middle grade staffwith appropriate supervision duringperiods of consultant leave.

Buckinghamshire Hospitals TIA ServiceBuckinghamshire Hospitals NHS Trust


These figures include patients seen as inpatients, but this proportion has beendeclining steadily over the year. It is still the policy of the trust to admit patientsover weekends when there is no outpatient service, and patients still get MRIbrain and carotid MRA at weekends.


ContactDr Matthew BurnConsultant Stroke PhysicianBuckinghamshire Hospitals NHS [email protected]

Table 1: Proportion of high risk patients seen within 24 hours

Proportion of high risk patients seen within 24 hours2009 -10

Q1

Q2

Q3

Q4

33%

56% - new services started July

52%

59%

Table 2: Proportion of high risk patients seen as inpatients

Proportion of high risk patients seen as inpatients2009 -10

Q2

Q3

Q4


23%

11%

Performance on the vital sign has been less good, with some patients recordedas not having had blood tests or an ECG, or not having been started on allnecessary medication with the 24 hour time period. It is possible some of thisreflects the complexities of the data acquisition and transfer.

Table 3: Proportion of low risk patients seen within seven days

Proportion of low risk patients seen within 24 hours2009 -10

Q1

Q2

Q3

Q4

38%


70%

67%



TIA service developmentEpsom General Hospital

AimsTo establish a comprehensive TIAservice for patients in the Epsom areaof Surrey who attend the EpsomGeneral Hospital site of Epsom andSt Helier NHS Trust.

IssuesEpsom General Hospital onlyprovided one neurovascular clinic runon alternate weeks by a geriatrician,far below the standard of servicedemanded by the quality standardsfor TIA services being developed bySurrey Heart and Stroke Network(based upon national guidance andclinical recommendations).

Consideration for development of TIAservices took into account achallenging baseline with regards tostaffing, imaging, location andreferral.

The stroke consultant to lead thisproject was recruited at thebeginning of 2009 on a part timebasis. Before that, the stroke serviceat Epsom General Hospital was led bya stroke specialist nurse and generalphysicians. The role of the newconsultant therefore was to embedbest practice into the care of patientspresenting with stroke or TIA.

Because of this lack of TIA serviceand stroke specialists, there wasno data to quantify the need forimprovement, just a very wide gapthat all in the trust acknowledged.

ActionsA project team was established thatdrew together the key clinicians andmanagers required to develop the TIAservice, i.e. stroke consultant, strokespecialist nurse, radiologists, vascularscientists, service manager, assistantmedical director, GP, outpatientdepartment manager, director ofoperations for planned care, networkdata analyst and network serviceimprovement manager.

A one-stop TIA clinic was immediatelyestablished to run once per week inthe outpatient department.

Immediate difficulties encountered bythe carotid duplex service wereaddressed e.g. inappropriate referrals.Longer-term issues such asinadequate staffing for a daily service,were addressed throughdepartmental meetings.

A TIA pathway was developed by theproject team and agreed with other

key departments, such as A&E. Areferral proforma was drawn up andcirculated to key clinicians in thehospital. A secretary who can bookappointments at short notice wasmade available to the stroke service.

OutcomesThe team have achieved:• one TIA clinic now runs every week,on a Tuesday afternoon, for lowrisk TIA patients. Some ad hocclinics are held on the ward whenresources allow (high risk patientscontinue to be admitted)

• good liaison with the vasculardepartment, that means the entireTIA clinic can be covered

• same day scanning is now beingprovided.

• approval by the trust board of abusiness case to invest in strokeand TIA services to enableprovision of a Monday to FridayTIA service for high and low riskpatients

ContactJanet PutterillConsultant Stroke Physician,Epsom General [email protected]



TIA service improvement projectLancashire Teaching Hospitals NHS Foundation Trust

AimsTo achieve a high-quality, accessibleand effective TIA service through jointinput from the medicine,neuroscience and radiologydirectorates to ensure urgentassessment and treatment of patientswith TIA, in line with quality markers5 and 6 of the National StrokeStrategy.

IssuesIn January 2009, Lancashire TeachingHospitals NHS Trust were nearingdelivery of a daily emergency ‘one-stop shop’ TIA service for high riskpatients, led jointly by a strokephysician and a stroke neurologist.Further substantial work was requiredto achieve the service envisaged (seetable 4).

A conventional TIA service was inplace at commencement of theproject. There had been a recentmove to a rapid access TIA clinic witha view to TIA patients being assessedmore quickly. Little hard data wasavailable for the baseline position butan imaging directorate audit,summarised in figure 1, suggests anaverage 50 day interval betweenoriginal patient referral and carotidintervention.

Table 4: Working towards a high quality, accessible and effective TIA service

Where we are now• Conventional model• Four weekly clinics betweenPreston and Chorley

• Mix of high/low risk• Various referral routes• Timing of intervention variable• GP supervised secondaryprevention

Where we want to be• Daily one-stop-shop• High risk patients seen within24 hours

• Lower risk patients seen withinone week

• Unified referral pathway• Carotid intervention (high risk)seen within 48 hours

• TIA nurse supervision ofsecondary prevention

0 10 20 30 40 50 60

AverageDelay,Days

10 13 22 8 9 6

Numbers of date pairs used to calculate average delays

286 OrigRefto U/SRef

687 U/SRefto U/SScan

44 CTDelto CTScan

25 CTScanto MDT1

10 MDT1to Clin Rev

Range0-261 days

Range3-11 days

0-185 0-49 0-89 0-35

0-20

44 U/SScanto CTDel

4 Clin Revto Proc Perf

OrigRef - U/SRef U/SRef - U/SScan U/SScan - CTDel CTDel - CTScan

CTScan - MDT1 MDT1 - Clin Rev Clin Rev - Proc Perf

Figure 1: Patient pathway - original referral -procedure performed March 2008 - Jan 2009



20

15

10

5

0<24 hrs

Interval from first contact to clinic appointment

Num

bero

fpat

ient

s

24-48 hrs 2-7 days 2-4 weeks >4 weeks1-2 weeks

A&E MAU GP Other

Figure 2: Referral source by interval from firstcontact to clinic appointment

20

15

10

5

0<24 hrs

Interval from first contact to clinic appointment by final diagnosis

Num

bero

fpat

ient

s

24-48 hrs 2-7 days 2-4 weeks >4 weeks1-2 weeks

High risk TIA Low risk TIA Non TIA

Figure 4: Interval from first contact to clinicappointment by final diagnosis

A&E MAU GP Other

42%

41%

10%

7%

Figure 3: Referral source of allpatients

6

7

1

High risk TIA Low risk TIA Non TIA

Figure 5: Diagnosis amongstpatients seen within 24 hours

ActionsThe development of the service hasbeen at a time of substantial effortsto improve stroke services and topromote awareness and education bythe acute trust and in partnershipwith other organisations includingthe Central Lancashire PCT and theStroke Network in Lancashire andCumbria. The Stroke 90:10 project isalso under way in the North West.The team:• convened a multidisciplinary groupcomprising clinicians and therelevant general managers, in orderto develop a daily emergency clinicfor high risk TIA patients

• launched a daily emergency TIAclinic in May 2009, with two (threeif necessary) daily slots andimmediate access to carotidimaging if appropriate, Mondayto Friday

• created a unified single point ofaccess, with initial telephone call tothe acute stroke unit for high andlower risk TIA patients, triage, andsubsequent electronic patientbooking and confirmation ofappointment time

• set up monitoring and audit of theservice on an ongoing basis

• established a potential role for aspecialist TIA nurse to supervisecontinued adherence to secondaryprevention, as a strategy tomaintaining long-term stroke riskreduction

• developed a business case tosustain and develop the servicefurther

• hosted educational eventspromoting developments in strokeand TIA

OutcomesBy establishing ongoing monitoringand audit, the team are able tounderstand their service. Figures 2 to7 show the outcome of an audit of58 patients between May andOctober 2009. The original pathwayhad an emphasis on referral fromA&E. Following the audit showing alonger referral time from GPs, thesingle point of access was introducedin October 2009.



<24 hours 24-48 hours 2-7 days

1-2 weeks 2-4 weeks >4 weeks

13%

21%

17%

8%

20%

21%

Figure 6: Interval from first contactto carotid imaging amongst all highrisk TIA patients

<24 hours 24-48 hours

33%

67%

Figure 7: Interval from first contactto carotid imaging amongst highrisk TIA patients assessed in clinicwith 24 hours

Table 5: Clinic performance

Patients seen in clinic within 24 hours of ‘first contact’ vital sign definition

Assessed within 24 hrs of symptom onset

24 – 48 hrs

2-7 days

64% (9)

29% (4)

7% (1)

This demonstrated:• the shortest interval between firstcontact and clinic assessmentoccurred in patients referreddirectly from A&E, whereas longerintervals were seen when patientsinitially presented to their GP

• a high non-TIA rate exists amongstpatients seen within 24 hours,which has implications for planningcarotid and brain imaging capacity

• a rapid improvement in keymeasures can be achieved withsuch a model – % high risk patientsseen within 24 hours and % highrisk patients having carotid imagingwithin 24 hours (already 100%within 48 hours)

Sustaining improvements will dependon continued effective interactionbetween all the relevant specialties.

‘The opportunity to exchange ideas with other teams inother parts of the UK was one of the most valuableaspects of the project. In particular, perhaps ourpreparedness to adapt quickly based on ideas shared atthe peer support days (for instance, single point ofreferral) helped to influence our own servicedevelopment whilst it was ‘a work in progress’.

Lancashire Teaching Hospitals NHS Foundation Trust

23 patients attending the emergencyclinic between May and July 2009completed a questionnaireencompassing a range of issuesrelating to their experience of theclinic. Patients were also asked toprovide an overall rating of theservice, from poor (one) to excellent(five). Nineteen (83%) gave a ratingof five, the remaining four (17%)giving a rating of four.

ContactDr Hedley EmsleyConsultant NeurologistLancashire Teaching HospitalsNHS Foundation [email protected]



AimsSeamless GP and A&E referral forpatients suspected of having had aTIA, with access to treatment,including timely access to diagnosticsboth within and out of hours.

IssuesThere was no assessment of patientsby referrer to determine high or lowrisk TIA. TIA clinics were held once aweek. Waiting times were up to threeweeks for a patient to be seen by astroke specialist and up to two weeksfor carotid imaging following TIAclinic.

ActionsStandard TIA pro-forma andreferral process. The team createda standard referral pro-forma for allreferrals sent to TIA clinic, used byA&E, GP surgeries, CDU,ophthalmology etc. This ensurespatients are risk assessed usingnational clinical ABCD2 assessment toidentify whether they are high or lowrisk TIA.

Data reporting mechanism inplace. The team created a datacollection form for consultants tocomplete in clinic for all patients

attending to identify waiting times tobeing seen in clinic, whether thepatient is low or high risk, whetherinvestigations are required andwhether they are confirmed TIA.

Implementation of five day aweek TIA clinics. Recognising thelack of coverage across the week,clinic slots were changed to occur fivedays a week using the same threeconsultants, with the addition of ageneral medicine consultantproviding TIA clinic slots in his clinic.

Same day carotid imaging. Thewaiting time for a carotid dopplerscan was a bottleneck in patientsreceiving urgent outpatientassessment and treatment for TIA. Asame day referral process means TIAis now considered urgent andpatients receive a scan the same dayas their outpatient appointment.

Outcomes• same day carotid imaging in place –removed waiting time

• reduction in patient waiting timesto be seen by specialist, averagewaiting time reduced by three days

Sustainable acute stroke and TIAmanagement programmeMilton Keynes Hospital NHS Foundation Trust



ContactNicola EvansProject ManagerMilton Keynes Hospital NHSFoundation [email protected]

Best we did was 8 days - Target was 24 hours

Data from Q3 2009 - 2010

First contact Referral to clinic TIA clinic Referral for cartoid imaging Cartoid imaging

First contact Referral to clinic TIA clinic Referral for cartoid imaging Cartoid imaging

All cases within 1 day All cases same day Two cases within one dayTook at least five days in all cases

Best we did was 3 days - (Result after first month)

Data from March to April 2010

All cases within 1 day All cases same day Same day was bestTook at least three days in all cases

Figure 8: Milton Keynes TIA pathway analysis

‘Research other organisations to understand lessonslearnt - don’t reinvent the wheel, the chances ofsomeone having implemented the same change as youis highly likely’.



AimsThe team at North Bristol NHS Trust,supported by the Avon,Gloucestershire, Wiltshire andSomerset Cardiac and StrokeNetwork, had a clear vision for theservice they wished to provide andaimed to:• provide a seven day, one stop TIAservice with full diagnostic imagingthat patients can access within 24hours of onset of symptoms, toinclude same day brain and carotidimaging and next day cardiacdiagnostics

• have a single point of referral• ensure universal use of ABCD2

score and stratification of patientswith a score above and below 4,with patients ≥ 4 assessed andtreated within 24 hours andpatients < 4 assessed and treatedin less than seven days

• ensure prompt referral andtreatment for all patients requiringvascular surgery

• ensure patients are dischargedfrom outpatient clinic with a copyof the discharge summary

IssuesIn March 2009, one stop TIA clinicswere held three times a week, with avariable waiting time. There was onestroke physician and one registrar.

ActionsThe weekday service was developedand strengthened and the pathwaywas redesigned for the weekendservice, with the development ofclose links with A&E.

The team developed a standard TIAnetwork-wide referral form for allGPs and appointed a TIA coordinatoras single point of referral.

The following staffing changes weremade:• increased number of strokeconsultant sessions

• a stroke co-ordinator assessmentof patients as part of the weekdayservice

• nurse staffing on the acute strokeunit changed to accommodateweekend service

• an on call physician rota forweekend service

• a weekly neuro-vascular meetingto ensure prompt referral andtreatment and to review all criticalcarotid imaging

Providing a seven day, one stop, TIAservice at North Bristol NHS TrustNorth Bristol NHS Trust

Imaging needed to be available:• negotiated one stop services withradiology to provide head CTs andcarotid doppler scans

• training of ultrasonographers tocarry out doppler to increasestaffing in response to demand

• diffusion weighted imaging (DWI)available for weekday servicesinstead of CT if required

• MRI imaging for weekend TIAservices including DWI and MRangiography

The University of West Englanddeveloped a online training modulefor ABCD2 assessment for all GPs andGreat Western Ambulance Servicestaff.

Pre-packs of medication for patientsto take away from TIA outpatientattendances were made available.Patient information packs weredeveloped for all TIA patients.



OutcomesThe following outcomes have beennoted:• five day service is embedded andrunning well, a seven day one stopservice commenced in April 2010

• there is a good relationship withclinical support and vascularservices

• the appointment of a TIAco-ordinator ensures timely andefficient booking of patientsaccording to ABCD2 prioritisation

• there is a commitment withinstroke team to develop services

• the mean waiting time for patientsseen in clinic went from 7.78 daysto 1.76 days as the frequency ofclinics was increased

• there is an indication of reductionin admissions for high risk patientsduring weekdays as frequency ofclinics has increased

Reduction in admissions will beexplored further. There is thepotential to reduce weekendadmissions but this needs furtherwork as the trust provides the out ofhours service for the whole of Bristol.

Figure 9: Clinics running three times a weeek



Figure 10: Clinics increased from three to five a week in November



Figure 11: Six day a week clinics tested from December 2009Figure 12 shows high levels ofpatient satisfaction:• the majority of patients felt thatthey were fully informed of thevarious parts of their outpatientattendance (diagnosis, tests,results etc)

• all patients received informationand the majority found this to behelpful

• two patients (out of a total of 10respondents) commented that theyhad not received informationregarding not driving prior to theirattendance

ContactDr Neil BaldwinConsultant Stroke PhysicianNorth Bristol NHS [email protected]

100

90

80

70

60

50

40

30

20

10

0Explanation

given forattending

clinic

Purposeof tests

understood

Adequatetime with

staff

Understandingof final

diagnosis

Wereleafletshelpful

Understandingwhich teststo receive

Test resultsexplained

Ease offinding scanning

departments

Informationleafletsreceived

Adequateinformation

given

%po

sitiv

ere

spon

ses

Figure 12: Patient satisfaction



AimsThe aim of the project was theprompt assessment and treatment ofhigh and low risk TIA patients andthe communication of relevantinformation to key stakeholdersacross north west London. This is amulti-site project coordinated by theNorth West London Cardiac andStroke Network, involving thefollowing organisations:• North West London Cardiac andStroke Network

• Imperial College HealthcareNHS Trust

• TIA clinics and A&E departments atthe following hospital sites:Northwick Park, West Middlesex,Charing Cross, St. Mary’s,Hillingdon, Chelsea andWestminster

• GP surgeries across north westLondon

IssuesGPs were demonstrating aninconsistent approach to TIAdiagnosis and referral. Awareness ofTIA and stroke also needed to beimproved. There are over 600 GPsacross eight PCTs within the northwest London region who needed tobe informed of pathways and

supplied with referral forms. TheseGPs also needed to be encouraged tocomplete these forms accurately andincrease their knowledge andunderstanding of TIA. There were noprocedures in place to collect data.

The project commenced in November2009 following the publication of theStroke Strategy for London.1

ActionsThe team created new referral formsoutlining the approved protocols andout of hours service for TIA referral:• gained consensus from clinicalteams in each hospital

• produced separate forms for GPsand A&E departments

• forms included an aid to diagnosis(including ABCD2 score) andcontact details for TIA clinics, bothweekdays and out of hours

• produced forms in every formatlikely to be used by GPs (EMIS,Vision, Word)

Alongside this, the project created acommunications plan to launch thenew forms to GPs, A&E departmentsand all interested parties whichincluded:• what information do we need tocommunicate?

Improving the TIA pathway for high and lowrisk patients across north west LondonNorth West London Cardiac and Stroke Network

• who to?• how do we do this?• what products do we need toacquire or produce?

• what resources do we need?• roles and responsibilities• timescales• how do we need to consideradditional stakeholders?

• how do we measure success?

New referral forms were launched on7 December 2009:• emails were sent to all GPs acrossnorth west London explaining thenew referral forms

• the clinical contracts lead for eachPCT assisted by forwarding emailsto GPs to save the lengthy processof creating a database

• GPs mailshot included a link todedicated webpages on thenetwork website

• dedicated webpages includeddownloadable versions of all formsand information regarding aids todiagnosis and use of referral forms

• stroke consultants at each trusttrained their local A&E departmentson use of forms

1Stroke Strategy for London, Healthcarefor London, November 2008.



Ongoing engagement of GP practicescontinued:• additional emailshot to GPsencouraging them to access thewebsite to download the forms andfor information on how to fill themout correctly

• hard copy mailshot with forms sentto every practice manager,enclosing pens with the websiteaddress of the dedicated TIAwebpage to further publicise thesite

• stroke consultants write to everyGP who has referred a TIA patientusing the old form and sends acopy of the new form

Additional GP and A&E aids toencourage timely assessment ofpatients:• urgent TIA assessment referral cardcreated for A&E departments togive to patients to encourage themto attend TIA clinics and reducelevels of DNAs

• appointment card reproduced onthe dedicated webpages in adownloadable form for GPs to giveto patients with suspected TIAwho present at the surgery

The team created a data template foruse within TIA clinics to collectbaseline data, assess the use ofreferral forms and measure referringpatterns and vital signs:• data was accepted in hard or softcopy

• assistance was offered by thenetwork to facilitate collection

Data was collected for the:• use of new referral forms by GPsand A&E departments (measuredin TIA clinics)

• number of TIA referrals (total and% of mimics)

• vital signs for high and low riskpatients

• GP awareness (through surveymonkey, evaluation forms and oneto one interviews)

OutcomesThe team have achieved:• a well defined TIA service has beencreated within north west London,with provision of TIA services in sixhospitals, with clear protocols andone referral form

• a clear pathway for both high andlow risk patients with suspectedTIA

• an out of hours, 24 hour TIAservice for high risk referrals basedat the hyper-acute centres

• dedicated webpages haveprovided a new reference point tooffer everything that a GP needs toknow about the new forms andpathways

• A&E departments and LondonAmbulance Service use the newpathways

Baseline data is in the process ofbeing collected and collated and dataregarding referral patterns and vitalsigns and subsequent improvementof service should be available soon.

Early indications show the following:• use of new referral forms in A&Edepartments is now in excess of80%

• use of new referral forms by GP isvariable but is increasing month bymonth and has reached 60% inone unit

• hits on the network websiteincreased by 20% after the launch

.ContactMarcia ReidInterim Senior Project ManagerNorth West London Cardiac andStroke [email protected]



Improving access to TIA assessmentRoyal Devon and Exeter NHS Foundation Trustand Peninsula Heart and Stroke Network

AimsTo develop an equitable andresponsive TIA assessment service,with improved out of hours access,through the use of risk stratification,based upon carotid ultrasoundscreening undertaken by stroke nursepractitioners.

The project was initiated to improvethe responsiveness of the TIA servicefor patients presenting at weekendsand bank holidays, achieve the vitalsigns target of TIA cases with ahigher risk of stroke who are treatedwithin 24 hours, and assist inworking towards the 48 hourwindow for urgent carotid surgery.

IssuesThe daily TIA/stroke clinic at the RoyalDevon and Exeter NHS FoundationTrust serves a population of 350,000and receives approximately 1,000new referrals per year (60% of thesereferrals are diagnosed as either TIAor minor stroke).

Since the clinic was established in2006, access times from referral toassessment have improveddramatically. However, the medianreferral to assessment time, for bothhigh risk and lower risk patients (as

defined by the ABCD2 score)remained at two days. The mainreason was that referrals received onFriday, Saturday or Sunday, could notbe assessed until the next workingday.

ActionsRather than replicate a ‘traditional’face-to-face outpatient clinic serviceat weekends, the project team areinvestigating an innovative model ofproviding specialist assessment andaddressing the issue of appropriateurgent imaging and screening (i.e.carotid ultrasound) during weekendand bank holiday periods.

Carotid ultrasound scan results for a12 month period have been collatedto establish a ‘baseline’ percentage of‘normal’ and ‘abnormal’ scans.

The results shown in table 6 provideda broad indication of the percentageof ‘abnormal’ screening results whichwill be identified by the stroke nursepractitioners.

Three stroke nurse practitioners atthe Royal Devon and Exeter workseven days a week, from 7.30am to8pm.

The role of the stroke nursepractitioners includes:• assessment of all new acute strokeadmissions in A&E and themedical triage unit, using ROSIER.If positive, the stroke nursepractitioners are able to request CTimaging and arrange admission tothe acute stroke unit within fourhours of hospital arrival

• initial point of referral for TIApatients assessed in A&E. Referralsare risk stratified and allocated tothe next available daily stroke clinicslot. On weekdays, a TIA clinic slotis often available later the same day

• thrombolysis assessment and liaisonwith the on-call stroke team andprovision of 1:1 care in the periodfollowing thrombolysis

• dysphagia screening

The stroke nurse practitioners arecurrently being trained to performcarotid ultrasound screening toenable improved access to TIAassessment during weekends andbank holidays.



Table 6: Data from the Royal Devon and Exeter TIA clinic - 14 May 2008 to 13 May 2009

Percentage of patients affectedDegree of Stenosis within the Common Carotid Artery (CCA), Internal CarotidArtery (ICA), Carotid Bulb and Carotid Bifurcation

No Visible Disease

Minimal (Detectable but < 30%)

Mild (30 – 49%)

Moderate (50 – 69%)

Severe (70 – 99%)

Occluded (100%)

32%

31%

28%

5%

4%

<1%

Training is provided ‘in house’ by thechief clinical technologist. Twostages of training were initiallyidentified:1. ability to locate and identify thecommon carotid artery and thecarotid branches

2. ability to record velocities andassess velocity shifts using aspectral doppler, and produceB-mode colour images

The training includes a period of ‘dualscanning’. A clinical technologistvalidates the results.

All patients presenting duringweekend and bank holiday periodswill have a carotid ultrasoundscreening investigation. Thosepatients considered as ‘normal’ willbe discharged home with anappointment to attend the clinic thenext working day. Patients whosescreening results suggest anabnormal result (as defined by anagreed protocol, which includes keymeasurements, defined ‘normal’results and tolerance levels) will beadmitted. Prior to this project, allpatients presenting during weekendsand bank holiday periods with TIAwould be admitted.

OutcomesBetween 1 April 2009 and 31 March2010, 36 TIA patients were admittedduring weekends and bank holidays.The carotid ultrasound results forthese patients were examined toprovide an indication of whether thepatients would have been admitted ifthe carotid screening service hadbeen in place.

It is envisaged that the cut-off foradmission will be >50% stenosis.Using this figure, analysis of the36 weekend and bank holidayadmissions in 2009/10, (see table 7)shows:

Table 7: Analysis of the 36 weekend and bank holiday admissions in 2009/10

< 50% or no detectable disease - Potential ‘avoided’ admission

< 50% but difficult scan

>50%

No Scan requested during admission

16

2

4

16



This provides a prospective indicationof the impact of the new service, andindicates that 44% of TIA admissionsduring the weekends and bankholidays of 2009/10 could potentiallyhave been avoided if the stroke nursepractitioners service was in place. Itwill also be necessary to establishwhether any other factors, such as comorbidities, determined therequirement for admission.

It is anticipated that this model willbe a cost effective solution forincreasing access to, andenhancement of, TIA assessment atweekends and bank holidays.

The stroke nurse practitioners andclinical measurements departmenthave approached the projectenthusiastically. A collaborative andopen approach has enabledspecialties and disciplines to worktogether and understand roles withinthe project.

Training will continue, to enable thestroke nurse practitioners to becomeproficient in carotid ultrasoundscreening. It is anticipated that thestroke nurse practitioners trainingand sign-off of competencies will becompleted by September 2010. It isthe intention of the project team toproduce a project report, includingcosts, training information andcompetencies, to support futurecommissioning decisions with regardto development of TIA assessmentservices.

ContactCarol MasseyService Improvement ManagerPeninsula Heart and Stroke [email protected]



Acute medicine TIA serviceSurrey and Sussex Healthcare NHS Trust

AimsTo create a sustainable, effective one-stop TIA service to meet the vital signrequirement for high risk and low riskTIA.

IssuesAt baseline in, 2008 Surrey andSussex NHS Trust offered a TIA servicebased on two clinics per week thatwas unable to offer assessment,investigation and treatment within 24hours. Since the retirement of thesubstantive consultant physician in2008 the stroke service had been ledby successive locum consultantclinicians throughout 2009. Clinicianswere clear that a system-wide changeof practice was needed.

ActionsA TIA service was created based onthe acute medical unit, operatingeach day, Monday to Friday, for allpatients referred the previous daywith TIA (including low and high riskpatients).

A pathway was created to ensurethat fasting blood tests, CT brainscans and doppler of the carotidswere all performed as early aspossible, as needed, usually the samemorning ahead of the consultantreview, results discussion andtreatment prescription from the clinicin the afternoon. This was broadlybased on the EXPRESS2 study.

In the early days this relied on oneconsultant and the challenge becamehow to make the service sustainable.In order to do this the trust:• appointed a trust doctor• appointed two stroke consultantswith job plans including TIA review

• embedded the service within theever-open acute medical unitenvironment

• included more junior staff fromthe stroke and acute medical unitservices

• created pathways and proformas tostandardise care delivery

To improve awareness across thehealth economy the team:• produced standardised forms forGPs and other referral areas

• taught GPs and other clinicians• worked with the Surrey Heart andStroke Network on training days

• rolled out a newly empoweredstroke team across the trust

• created a single bleep holder totake all calls

The team also worked closely withradiology to access CT and dopplerslots on a needs related basis andcreated an electronic audit tool tostandardise note-keeping, letters toGPs and gather audit data that wasreliable and easy to analyse.

2Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JNE, Lovelock CE,Binney LE, Bull LM, Cuthbertson FC, Welch SJV, Bosch S, Carasco-Alexander F, Silver LE, GutnikovSA, Mehta Z, on behalf of the Early use of Existing Preventive Strategies for Stroke (EXPRESS)Study. Major reduction in risk of early recurrent stroke by urgent treatment of TIA and minorstroke: EXPRESS Study. Lancet 2007; 370: 1432-42



OutcomesCreating a patient-centred service,accessible at the point of need, wasvery well received by patients andclinicians alike. GPs are very happywith the bleep holder for stroke; theytold the team that this sort of accessis exactly what they want. The profileof TIA and stroke has been raiseddramatically internally and externally.

The team are waiting for validation ofan outcome audit of strokes at 90days.

There is no waiting list at all for TIApatients and there is consistentlygood performance against the vitalsign. The percentage of high riskpatients with TIA seen and treated in24 hours is 66% currently (baselinedata is not available, but anecdotallyassumed to be 0%).

180

160

140

120

100

80

60

40

20

01 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Day

s

Month April 2007 to May 2010

Figure 13: TIA bed days per month

Table 8: Total Q4 TIA bed days

2007/08

2009/10

124

15

TIA patients are no longer admittedto the trust other than in exceptionalcircumstances. Data in table 8 showsa reduction of 88% in required beddays for TIA. Assuming £255 a night,this represents a potential saving tothe trust of over £100,000 per year.

ContactDr Ben MearnsConsultant Physician,Surrey and Sussex HealthcareNHS [email protected]



AimsThe objectives for this project wereto:• develop sustainable TIA servicesthat are available five days perweek, with plans to progress theservice to cover weekends during2010/11

• implement a rapid access TIApathway for high risk patients

• develop the workforce to ensureall TIA patients receive care fromstaff with the appropriate level ofexpertise

IssuesUnited Lincolnshire Hospitals NHSTrust has three acute hospital sites,Lincoln County Hospital, Granthamand District Hospital and PilgrimHospital Boston. At commencementof this project, the configuration ofTIA service provision varied across thesites (see table 9).

Patients were referred to the hospitalvia traditional referral letters andwere appointed to the next availableclinic slot. The information includedin the referral letter varied greatly andthe inclusion of the ABCD2 score wasminimal. It was therefore difficult tograde referrals based on astandardised risk stratification system.High and low risk patients werereferred to any site.

At the commencement of the projectthere was no baseline data or amechanism for data collection. Thetimeframes for access to diagnosticsvaried across the sites.

ActionsThe project team ran a servicescoping day with all those involvedto review current service provision,identify gaps, and explore optionsfor service redesign. The preferredmodel for service delivery agreedwas an extension of currentoutpatient based service, withincreased capacity and frequency tomeet demand and access to sameday diagnostics.

A TIA referral form was designedand piloted which could be used byall healthcare professionals to referinto the TIA clinics. The purpose ofthe form was to:• collect set information about eachpatient to allow for accurategrading of referrals, so the teamcould appoint patients into clinicslots based on high or low riskABCD2 scores

Improving TIA services in LincolnshireUnited Lincolnshire Hospitals NHS Trust

Table 9: Stroke physician capacity and frequency of TIA clinics

Site

Lincoln County

Pilgrim

Grantham and District

WTE Stroke Physicians

1.00

0.8

0.2

Number of TIA Clinics

2 per week

5 per week

2 per month



• educate referrers about the referralprocess, the importance ofproviding the information requiredon the form, advice on initiation oftreatment and prompts to provideessential information to patients

The referral pathway advised referrersto fax all high risk referrals to eitherLincoln County or Pilgrim Hospitals asthe frequency of clinics at Granthamdid not serve the requirements ofhigh risk patients. Granthamcontinued to receive referrals for lowrisk patients. Work took place withthe A&E and emergency assessmentunit teams to highlight theimportance of urgent telephonereferrals directly to the strokephysicians for patients presentingwith symptoms of TIA and adedicated fax line was established soreferral went directly to the strokephysicians.

OutcomesThe biggest improvement made wasto the streamline the referral processfor TIA patients into the clinics byencouraging the use of the ABCD2

score at point of referral and ensuringthat appointments for high riskpatients could be prioritised.

Implementation of the standardisedreferral form allowed collection ofbaseline data and the ability tocontinually monitor demand for TIAclinics. This will enable capacity to betailored to the need for rapid accessclinics for high risk patients.

The business case was approved forthe recruitment of a new strokephysician at Lincoln County andPilgrim Hospital. This will enableadditional clinics to be set up withenough capacity to ensure access tospecialist assessment five days a weekfor high risk patients.

ContactLouise PearsonClinical Services Manager –Stroke and TIAUnited Lincolnshire HospitalsNHS [email protected]



Stroke Improvement Programme websiteThe Stroke Improvement Programme website offersinformation and resources on improving stroke and TIAservices, including:• information on topical issues affecting stroke andTIA services

• presentations from events and meetings• examples of successful redesign and strokeimprovement in stroke and TIA services

• information on measureswww.improvement.nhs.uk/stroke

Sustainability Checklist, NHS CancerImprovement ProgrammeA checklist containing key questions to ask about yourproject or service to ensure plans are in place to sustainthe improvement.www.improvement.nhs.uk/cancer/documents/inpatients/Sustainability_Checklist.pdf

The Sustainability Toolkit, NHS HeartImprovement ProgrammeAlthough focused on improving cardiac pathways, TheSustainability Toolkit provides useful information andexamples on how to sustain improvements. It alsocontains resources on capturing data, measurementand analysis.www.improvement.nhs.uk/heart/sustainability

Trainer’s Resource Pack – An Introduction to ServiceImprovement, NHS ImprovementThe Trainer's Resource Pack - An Introduction to ServiceImprovement, is a collection of tried and tested trainingmodules for service redesign tools and techniques, andchange management skills.www.heart.nhs.uk/trainers_resource_pack.htm

Guidance on Risk Assessment and Stroke Preventionfor Atrial Fibrillation (GRASP-AF) ToolThis tool should be used as part of a systematic approachto the identification, diagnosis and optimal managementof patients with AF to reduce their risk of stroke.Developed collaboratively and piloted by the WestYorkshire Cardiovascular Network, the Leeds Arrhythmiateam and PRIMIS+, as part of the AF in primary careprojects, made available nationally through NHSImprovement.www.improvement.nhs.uk/graspaf

Stroke Improvement Programme e-bulletinContaining updates, news and information for anyoneinterested in developing stroke services, the StrokeImprovement Programme e-bulletin is essential foranyone working in stroke and TIA services.

The Stroke Improvement Programme e-bulletin ispublished every two weeks and the latest edition isavailable on the Stroke Improvement websitewww.improvement.nhs.uk/stroke. If you would like tosubscribe to the Stroke Improvement e-bulletin, pleaseemail [email protected].

Stroke Resources



Atrial Fibrillation documents, NHS ImprovementThe following documents are available to download fromthe Stroke Improvement websitewww.improvement.nhs.uk/stroke

Atrial fibrillation in primary care: making an impacton stroke prevention, October 2009This document aims to capture the final summary of theirindividual approach, lessons learned, improvements topractice and quality outcomes, also sharing tools andresources developed to enable other health communitiesto drive this agenda forward.Commissioning for Stroke Prevention in PrimaryCare - The Role of Atrial Fibrillation, June 2009Developed following a national consensus meeting ofopinion leaders in the field, this document is to developa concerted strategy towards the management of AF inprimary care, in particular anticoagulant managementand its significance in relation to reduction in the risk ofstroke.

Atrial Fibrillation in Primary Care National PriorityProject, April 2008A summary document produced in April 2008 includingdescriptions, supporting information and key learningfrom the local projects that were part of the AtrialFibrillation in Primary Care national priority project.

Atrial Fibrillation in Primary Care Resources andLearning, April 2008This online resource is a tool produced in April 2008 thatcaptured the learning from the local project sites thatworked on the Atrial Fibrillation in Primary Care nationalpriority project. The resource provides documents,guidelines, presentations, proformas and algorithmsdeveloped and used by the local priority projects.

NHS Improvement SystemThe NHS Improvement System is a free, comprehensiveonline resource supporting quality improvement in NHSservices, offering a range of service improvement tools,case studies and resources.

The Improvement System gives NHS staff the capability torecord, track and report on projects, share improvementstories and documents, access Statistical Process Control(SPC) software, Demand and Capacity tools and a PatientPathway Analyser, all within a secure environment.www.improvement.nhs.uk/improvementsystemEmail: [email protected]

Sustainability Model, NHS Institute of Innovationand ImprovementThe Sustainability Model is a diagnostic tool that is usedto predict the likelihood of sustainability for yourimprovement project and provides practical advice onhow you might increase the likelihood of sustainability foryour improvement initiative.www.institute.nhs.uk/sustainability_model/general/welcome_to_sustainability.html

Improvement Leaders’ Guides, NHS Institute forInnovation and ImprovementA series of service improvement guides, including a guideto sustainability and how it can be used in improvementwork. The NHS Institute for Innovation and Improvementwebsite also contains worksheets for measuringimprovement.www.institute.nhs.uk/index.php?option=com_content&task=view&id=134&Itemid=351

StrokEngine-AssessThis website provides evidence to support strokerehabilitation assessment tools.www.medicine.mcgill.ca/strokengine-assess

Spreading good practice documents andinformation, Sarah Fraser & Associates LtdSarah Fraser is an independent consultant who workswith NHS organisations on how good practice spreadsand how improvements can be made. The websitecontains a number of free resources on spreading goodpractice and improvements.www.sfassociates.biz/sitebody/MultiMedia/Documents.php

Stroke Improvement ProgrammeNational TeamNHS Improvement - StrokeImprovement Programme3rd Floor, St John's House,East Street, Leicester LE1 6NB

Tel: 0116 222 5184Fax: 0116 222 5101www.improvement.nhs.uk/strokeEmail: [email protected]

Further information

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101


NHS Improvement

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

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

Delivering tomorrow’simprovement agendafor the NHS

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Joining up prevention: case studies from the Stroke Improvement Programme projects