Acute Stroke Care Policy. Document Author: Head of Clinical Effectiveness and Governance

Transcription

1 Acute Stroke Care Policy Document Author: Head of Clinical Effectiveness and Governance Date Approved: May 2018

2 Document Reference PO-Acute Stroke Care Policy February 2018 Version V3.0 Responsible Committee Responsible Director (title) Clinical Governance Group Executive Medical Director Document Author (title) Approved By Head of Clinical Effectiveness and Governance Trust Management Group Date Approved May 2018 Review Date May 2020 Equality Impact Assessed (EIA) Protective Marking Yes Not protectively marked 1

3 Document Control Information Version Date Author Status Description of Change (A/D) First draft of first 11/10 Jacqui Crossley A Final approved by CG version will be 0.1 V1.1 01/13 Jacqui Crossley D Revised to reflect current practice and reformat in 2013 policy template. Included NHSLA level one matrix to CGG in January 2013 V1.2 04/13 Jacqui Crossley D Revised to reflect the inclusion of 111 V1.3 4/13 Dr David Macklin D Minor modifications V1.4 12/15 Jacqui Crossley D Minor changes and update following CGG review to reflect network changes V2.0 02/16 Jacqui Crossley A Approved TMG V2.1 02/18 Katrina Dixon D Revised/rewritten to reflect current practice V /18 Jacqui Crossley D Amendment post CGG to add TIA refreshed template V /18 Risk Team A Approved at TMG A = Approved D = Draft Document Author = [J Crossley Head of Clinical Effectiveness and Governance] Associated Documentation: Insert names of associated Policies or Procedures here Statutory & Mandatory Training Policy & Procedure V %20Statutory%20and%20Mandatory%20Training%20Policy%20- %20June% pdf Ambulance Quality Indicators Yorkshire Regional Stroke Pathway 2

4 Section Contents Page No. Staff Summary 4 1 Introduction Purpose/Scope 5 3 Process Development and maintenance of stroke care pathway Hyper-acute Stroke Pathway (operational) Clinical decision making at point of call (ARP within EOC) Stakeholder engagement Training Expectations for Staff Implementation Plan 7 6 Monitoring compliance with this Policy 7 7 Roles & Responsibilities References 9 9 Definitions

5 Staff Summary This policy covers the Role of Yorkshire Ambulance Service in improving outcomes from acute stroke Up- to- date national information on acute stroke patient management Partnership working to deliver high quality stroke care delivered across Yorkshire Ambulance Service Hyper-acute Stroke Pathway Ambulance Response Programme Responsibilities and assurance from Yorkshire Ambulance Service New Stroke treatments- Thrombectomy 1.0 Introduction 1.1 Yorkshire Ambulance Service (YAS) believes that it is beneficial to patients, health community partners, and YAS workforce that, working together to deliver an effective stroke care service optimises clinical outcomes for this group of patients Stroke is a major health problem in the UK. The Stroke Association s report, State of the Nation highlighted that stroke accounted for around 40,000 deaths in the UK in 2015, which represents 7% of all deaths. Each year there are approximately 152,000 cases of stroke in the UK, of which about 25-33% are recurrent strokes. Most people survive a first stroke, but often have significant morbidity. About 1.2 million people in the UK live with the effects of stroke, and over a third of these are dependent on other people. (NICE Quality standard 2010 updated 2016) Over the last few years there has been an increasing demand on the ambulance services related to Stroke symptoms. This may be attributed to public health messaging as symptoms are better understood by the public. In 2014/15 18,232 patients called the Yorkshire Ambulance Service with symptoms of Stroke all were received an ambulance response, with 14,988 patients conveyed to hospital. In 2016/17 a total of 16,171 patients called the Yorkshire Ambulance Service with symptoms of Stroke. Of these, 15,413 were categorised as requiring an ambulance response with 13,196 patients conveyed to a hospital In November 2015, the 23 Clinical Commissioning Groups (CCGs) across Yorkshire & the Humber approved the development of a Yorkshire & the Humber blueprint for Hyper Acute Stroke Services that would provide a high level overview of potentially safe/sustainable services and ensure the best quality of access for the populations served. Three sub regional programs for the reconfiguration of Hyper Acute Stroke services within the acute trusts. 4

6 Humber and North Yorkshire West Yorkshire South Yorkshire & Bassetlaw Adults presenting at an accident and emergency (A&E) department with suspected stroke are scanned within an hour for confirmation of type of stroke or other conditions; thrombolysis for those with a stroke caused by a thrombus; and admission to a hyper-acute stroke unit (HASU) within 4 hours of arrival. (2010, updated 2016) This policy aims to provide an overview for the procedure YAS employ with other healthcare organisations from which pathways for acute stroke services are developed, delivered and monitored. 2.0 Purpose/Scope 2.1 This policy aims to set out how high quality stroke care is delivered, monitored and developed across the trust. It is aimed at all YAS clinicians involved in the development of and/or the delivery of, care and advice to patients with acute stroke or TIA. The policy highlights the roles and responsibilities of YAS clinicians in the management of patients with symptoms of acute stroke This policy will aim to ensure that care delivered by YAS is reflecting best practice within the following: National Stroke Strategy Dec 2007; National Institute for Health and Clinical Excellence (NICE) clinical guideline published 2010 updated 2016, and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK Clinical Practice Guidelines This policy reflects how YAS interacts with partner organisations to enable the timely assessment and treatments of patients with acute stroke. YAS provide strategic support and direction across the patient population area, to inform changes in service redesign, or to deliver service improvements across the whole health community for stroke. 3.0 Process 3.1 Development and maintenance of stroke care pathway The nominated stroke clinical lead will review current and proposed, referral pathway for stroke from, the call for help to the arrival at the designated unit. They will highlight any changes and map the need for new clinical skills or assessment tools to optimise the care of the patient across the whole pathway. This will be reflected in changes or modifications to pathways, guidelines or clinical quality measures Hyper-acute Stroke Pathway (operational) A single regional pathway operates across Yorkshire and Humber (appendix 1); 5

7 developed with NHS North of England and the three CVD network clinical leads. The pathway reflects the inclusion criteria, and the minimum assessment, and referral to the regions hyper-acute stroke units (HASU). The assessment tool employed is FAST any patient with new onset symptoms are deemed as having an acute neurological event and will be referred to the nearest HASU hospital Trans ischemic attack TIA is not a diagnosis made in the pre-hospital environment and all patients with resolved /resoling symptoms will be managed as per the stroke pathway. The agreed pathway is integral to the stroke service validation process for each trust offering hyper-acute care Sign-off of the single pathway was agreed August 2012 through all the Network boards, YAS Clinical Governance Group and issued to YAS clinical staff. Some HASU now have direct to scan whereby when YAS activate the stroke team they go direct to the CT scanner and handover to the stroke team there this reducing call to needle time Clinical decision making at point of call (ARP within EOC) Within the call assessment process those with symptoms of stroke are assessed using FAST. Priority categorisation is nationally agreed those with symptom onset within three and half hours receiving a Category 2 response Stakeholder engagement CVD networks are tasked by NHS England primarily with coordinating all health and social care services to focus the delivery of the National Stroke Strategy. Networks are made up of senior clinicians, CCG representatives with responsibility for stroke service development, and have sign-off responsibility for their organisation. YAS clinical lead is a board member providing links to neighboring networks where cross border care is required. There is now one network stroke working group (the three main networks in the Yorkshire and Humber region were dissolved over 2015) they were:- West Yorkshire Stroke Network WYSN North East Humber Clinical Alliance CVD NEYHCA CVDMG North Trent Network of Cardiac Care NTNCC The 23 Clinical Commissioning Groups (CCGs) agreed the development of a Yorkshire & Humber blueprint as the mechanism to assure the clinical senate, and other stakeholders, that a Yorkshire and Humber wide view is available to inform and align any reconfigurations of Hyper Acute Stroke services across the region. They have also approved the development of a managed clinical network for stroke in the South Yorkshire region with this being replicated in West Yorkshire Consultation Process This policy has been reviewed and reflects the changes to practice and pathways made following consultation with the CVD or managed clinical network networks which are comprised of other health care providers and their patient 6

8 representation. Pathway procedures are tested for clarity and ambiguity by operational staff, through clinical advisory groups, random tested at road show events. This engagement provides feedback from the operational setting prior to issue Approval Process This policy is reviewed by Clinical Governance Group and recommended for acceptance by TMG 4.0 Training expectations for staff 4.1 Training is delivered as specified within the Trust Training Needs Analysis (TNA). Stroke training requirements are identified in the training needs analysis which can be found in the Statutory and Mandatory Training Policy & Procedure, along with the process for following up those who fail to attend. The areas covered in the Training Needs Analysis (TNA), meet with the minimum stroke care training requirements of the current JRCALC guidelines YAS 24/7 e-learning environment has a stroke specific interactive module supported by patient stories with practical assessment scenarios updated with latest evidence relative to stroke care. This offers clinicians open access to CPD sessions focusing on stroke care with downloaded YAS approved certificates for inclusion within their clinical portfolio. 5.0 Implementation Plan 5.1 The Acute Stroke Clinical pathways are available on YAS Pulse in the Acute Referral Pathways section under Clinical Pathways. These are current with archived material available via the library. This system is monitored via the online team at YAS. They can be contacted at online@yas.nhs.uk version control is maintained through the online team and the document author The latest approved version of this Policy will be posted on the Trust Intranet site for all members of staff to view. New members of staff will be signposted to how to find and access this guidance during Trust Induction Changes are communicated by the Stroke lead through, Corporate Communications and via clinical managers, team leaders and operational leads. The stroke pathway and policy information is also available through the clinical hub. 6.0 Monitoring compliance with this Policy 6.1 Organisational Participation with Managed Clinical Networks 7

9 Attendance and participation at clinical network meetings and updates on changes and progress is monitored via Associate Medical Director at 1.1 and PDR for the stroke lead Standards for training YAS staff are familiarised in the use of Face, Arm, Speech, Telephone, FAST as part of core training, Statutory & Mandatory Training Policy & Procedure 7.0, this also describes the assurance provided through records within Organisational and Learning Department as per this policy. The location and use of the stroke pathways as well as the inclusion criteria, and how Minimum standards for stroke care Clinical care bundles for stroke are measured through the National Ambulance Clinical Quality Indicators. Ambulance Clinical Quality Indicators for Stroke provide performance monitoring with local reports at CBU level. The ACQI feed action plans which reflect the need for improvement these are developed by the Clinical Managers and are supported by the locality Directors for Operations. 7.0 Roles & Responsibilities 7.1 Clinical Governance Group (CGG) CGG will have responsibility for this policy and will ensure that all new process changes for the delivery and monitoring of acute stroke care are reviewed and approved prior to implementation. The Terms of Reference for the CGG can be found on the YAS Intranet Medical Director Or a named representative, currently the YAS Head of Clinical Effectiveness and Governance, will attend strategic development and operational stroke groups. These provide the means by which service delivery for stroke care is strategically developed on behalf of CGG s. Bordering groups are linked through annual attendance and direct contact where required by the YAS stroke clinical lead Stroke Clinical Lead Is responsible for developing and producing clear and concise stroke care pathways, that are, unambiguous for staff to refer patients. They are responsible for the review of NICE and other relevant guidance to ensure practice is current and changes to clinical skills requirements are communicated through workforce and education. The named lead (Head of Clinical Effectiveness and Governance) is the trust representative on stroke and will be involved in the decision making effecting the strategic arrangements of care for acute stroke patients through the network boards. They provide expert advice to the organisation on the clinical care and strategic focus on the management and health promotion on stroke. 8

10 7.1.3 Organisational Development (Training) Ensure adequate training is delivered incorporating the current guidance on assessment and management of patients with Stroke as per JRCALC. The minimum standard of assessment for stroke is Face Arm Speech assessment FAST with symptom onset time as part of the history. In addition all staff should be made aware as part of the patient assessment process to consider a stroke when a patient presents with other less common symptoms including unilateral weakness of upper and lower limb, Vision changes or loss of vision, acute severe headache with unknown cause, acute dizziness/syncope or altered gait, Sudden confusion, difficulty in speaking or understanding others YAS staff Ambulance clinicians, Emergency Medical Dispatchers, NHS111 Call handlers and clinical advisors, Patient Transport Services, and Community First Responders are all trained in FAST assessment. All staff will apply appropriate requests for emergency support for patients assessed with acute stroke, whilst managing the patient with a time critical condition. YAS clinicians are responsible for providing acute stroke assessments appropriate to their skill level. This will be demonstrated through the reporting of the national stroke Ambulance Clinical Quality Indicators (ACQI). Staff and clinicians have a duty of care to their patients, which includes adherence to local pathways, referring patients appropriately to hyper-acute stroke services. Integral to this is legible completion of Patient Care Record (PCR) as per the documentation policy, ensuring all key history and treatment elements are included on the PCR including time of onset of symptoms Clinical Managers The clinical managers are responsible for undertaking analysis and action plan development in both the ACQI for stroke and the trending of learning from Clinical Case Reviews CCR. These recommendations are shared with the operational managers and included as actions for improvement in local Clinical Business Units CBU. 8.0 References 8.1 Joint Royal Colleges Ambulance Liaison Committee (JRCALC) 2013 UK Ambulance Clinical Practice Guideline The National Stroke Strategy (DH Dec 2007) available at Stroke Association. (2012). Suspect a Stroke Act FA ST. London: Stroke Association. Available at: The National Audit office (2010) How the NHS manages acute stroke Department 9

11 of Health NHS England revolutionary new treatment NHS England 11/4/ NICE Guidance February Recommendations Hyper Acute Stroke Services Yorkshire & the Humber Clinical Commissioning Groups June NICE Quality Statement updated Definitions 9.1 Stroke A stroke occurs when blood flow to part of the brain is interrupted, causing damage to the brain tissue. The two main causes of stroke are blood clots, blocking arteries (ischemic 85% of all strokes) and arteries rupturing (haemorrhagic 15% of strokes). The diagnosis and type of stroke is confirmed using a CT image of the brain Transient Ischaemic Attack (TIA) TIA is like a stroke but the symptoms resolve within 24 hrs. There are high and low risk groups identified through focused assessment tools, these patient groups are managed differently by specialists. High risk TIA is referred to hospital for early investigation and treatment to reduce the risk of the developing a full stroke. YAS clinicians refer all patients with any sign of stroke to an acute stroke service to ensure all patients receive a timely assessment and specialist treatment Stroke Thrombolysis Thrombolysis (clot busting) is a treatment that has proven to be effective in treating a stroke caused by a clot, if given within four and a half hours of onset of symptoms. Using this drug early makes it more likely that patients will make a good recovery from their stroke. The drug called rt-pa is given through a drip over one hour and works by dissolving the clot that has blocked the artery and stopped the supply of blood to part of the brain Stroke Thrombectomy An estimated 8,000 stroke patients a year are set to benefit from an advanced emergency treatment which can significantly decrease the risk of long-term disability. Mechanical clot retrieval for treating acute ischemic stroke aims to remove the obstructing blood clot or other material from arteries within the brain, restoring blood flow to the brain and minimizing brain tissue damage. A delivery catheter is inserted usually through the femoral artery in the groin, and advanced into the occluded 10

12 artery using X-ray. Many patients will also have had initial treatment with intravenous thrombolysis Face Arm Speech Time to call 999 (FAST) The FASt test is the nationally accepted test used to identify those patients with a potential stroke as an emergency. Used by the both the public and health professionals it aims to rapidly identify patients with a sudden onset of any one the neurological symptoms, and transport to a centre with hyper-acute stroke care facilities. Both EOC and all YAS frontline clinicians use in addition to FASt include those with sudden weakness in a lower limb as a potential sign of stroke. 11