Acute Stroke Care
Stroke Improvement Programme National Project 2009-10
Quality Markers 7, 8 and 9
The Acute Stroke Care project focused on quality markers seven, eight and nine which look at urgent
response, assessment and treatment. The National Stroke Strategy states:
‘People with suspected stroke should be immediately transferred to a hospital providing hyperacute services throughout the day and night – this includes a clinical assessment, rapid imaging and the ability to deliver intravenous thrombolysis. They should receive early multidisciplinary assessment, including swallow screening, and have prompt access to a high quality stroke unit.’
Project objectives
The Acute Stroke Care national project was more than just about thrombolysis. It was about urgent response, assessment and the treatment of stroke. It focused on improving and streamlining the first-line response and acute phase of care of the patient pathway on an acute (or hyper-acute) stroke unit.
• To establish protocols between ambulance service and receiving hospitals for a rapid response for
stroke patients, using agreed local pathways of care.
• To improve first line assessment and access to imaging for stroke patients.
• To improve performance in acute stroke services on sentinel audit data.
• To improve performance of the vital sign relevant to acute stroke.
• To demonstrate local improvement against the National Stroke Strategy quality markers seven, eight and nine.
Local aims and objectives
• Establish and agree acute care stroke pathways and guidelines/protocols
• Improve engagement with acute care key stakeholders
• Patients spend >90% of their stay on an ASU
• Direct admissions to ASU from A&E
• Develop 27/7 thrombolysis service (as appropriate)
• Aim for all patients to receive a brain scan within 24 hours
• ASUs staffed at ‘critical care’ levels provided with on-going training
• Physiotherapy, occupational therapy and SALT assessment times are improved
• Pathway knowledge and data management is improved
• Improve bed management and ‘culture’ of ASUs
• Improve patients experience and overall quality of acute care – in line with national guidance
• Reduce patient discharge delays and improve overall LOS times.
Project sites
Launched in March 2009, there were 10 project teams involved in piloting innovative work and testing solutions for national dissemination and learning.
• Queens Hospital NHS Foundation Trust
• Milton Keynes Hospital NHS Foundation Trust
• North West London Hospitals NHS Trust
• Nottingham University Hospital NHS Trust
• Poole Hospitals NHS Foundation Trust
• Royal United Hospital, Bath
• Sandwell and West Birmingham Hospitals NHS Trust
• Surrey and Sussex Healthcare NHS Trust
• Worcestershire Acute Hospitals NHS Trust
• Yeovil District Hospital NHS Foundation Trust
Measures/anticipated outcomes
Specific project measures include:
• Percentage of eligible patients receiving initial FAST test prehospital
• Time from call for help (or first professional contact) to arrival at A&E
• Time from arrival at A&E to CT scan
• Percentage of eligible patients that receive thrombolysis
• Percentage of patients treated for 90% of stay in a stroke unit
• Percentage of patients admitted directly to the acute stroke unit from A&E
• Percentage of patients admitted within four hours of arrival to hospital to an acute stroke unit
• Percentage of patients that are admitted to the acute stroke unit on the day of their stroke
• Percentage of eligible patients receiving a brain scan within 60 minutes of arrival to hospital (NICE recommendations)
• Percentage of eligible patients receiving a brain scan within 24 hours of arrival to hospital
• Percentage of patients that receive a swallow assessment within 24 hours of admission
• Percentage of patients that receive a physiotherapy assessment within the first 72 hours of admission
• Length of stay on acute stroke unit
• Overall hospital length of stay (including rehabilitation)
• Time from decision to discharge to actual discharge date.
National policy/strategy
Imaging - Meeting the imaging requirements of the National Stroke Strategy is a significant challenge for
many organisations. The NHS Improvement Diagnostics team are working with the Stroke Improvement team and are available to support imaging departments in finding solutions to deliver the imaging for acute stroke care. The National Imaging Board are kept informed of key issues enabling them to give guidance where appropriate.
Tariff - Throughout the year the Stroke Improvement Programme have been facilitating discussion between clinical teams and the PbR best practice tariff team for stroke, linking them with teams that have
been doing detailed work on tariff and seeking views on the proposals for a best practice tariff for acute
stroke.
National audit - Working with the Department of Health and the Royal College of Physicians’ sentinel audit team to support the development of a real time national audit of the first 72 hours of care (SINAP)
Learning from the projects
• Going up a gear: practical steps to improve stroke care publication, June 10
• Project case studies
• Presentations and posters from the Accelerating Progress in Stroke Care event, 22 June 10
Contact details
Ian Golton, Director
NHS Stroke Improvement Programme
Email: ian.golton@improvement.nhs.uk
Tel: 07810 836304
Resources
Stroke and TIA Vital Signs Frequently Asked Questions
The final version of the Stroke and TIA Vital Signs frequently asked questions (FAQ) can now be downloaded. A number of different clinical and pathway scenarios, and individual points of clarity have now been addressed to aid in the interpretation of the vital signs monitoring return guidance. However, several guiding principles have also been established based on the feedback that has been given to date:
• The FAQ does not deal with clinical issues (e.g. what is the definition of a stroke unit? or what blood tests should patients be given?) Those questions are addressed in the relevant guidance such as the RCP's National Clinical Guideline for Stroke (third edition) and The National Stroke Strategy.
• A revised version of the full Vital Signs Monitoring Return guidance for stroke has been published. If you are in doubt about whether you are using the latest version, please download it again. Among other changes, the revised version contains clearer information about TIA clinics.
• Patients should always be cared for in the most appropriate clinical setting irrespective of the requirements of the stroke vital signs.
• This guidance, like The Stroke Strategy itself, applies and refers to adult patients only.
Stroke and TIA Assessment Training (STAT)
National Stroke Strategy Quality Marker 7, 8 and 9
Northumbria Healthcare NHS Trust identified a lack of formal training for nursing and junior medical staff in the recognition, assessment and initial management of patients presenting with acute stroke and TIA. Working with the North of England Cardiovascular Network, Northumbria Healthcare NHS Trust set up a teaching day for stroke and TIA assessment. To find out more about this, please click here.
Useful links
• Diagnostics Improvement
• Department of Health (DH)
• National Institute for Clinical Excellence (NICE)
• The Royal College of Physicians (RCP)
• The Stroke Association
• Different Strokes
• Connect
• Crossroads Care
• Care Quality Commission (CQC)
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