STROKE ANNUAL REPORT 2013/14

Transcription

1 STROKE ANNUAL REPORT 2013/14 FINAL: 10/11/2014 1

2 1. Introduction from the Clinical and Executive Leads for Stroke We are pleased to present our second Stroke Annual Report setting out the progress made during 2013/14 with implementation of our local Stroke Delivery Plan. The Cwm Taf Stroke Delivery Plan was developed by the multi-agency Stroke Delivery Group and approved by Cwm Taf Health Board in We have since reviewed and refreshed this plan to ensure that our strategy and action plan is in line with the needs of our population. Implementation of the Delivery Plan is overseen by the Cwm Taf Stroke Delivery Group, chaired by the Executive Lead for Stroke. This Group received a Cwm Taf Recognition Award for Sustainability and Improvement in May 2014, in recognition of the various stroke service improvements it has driven over recent years. Our Stroke Delivery Plan represents a whole system approach to preventing stroke and improving outcomes for stroke patients. We have already made progress against all elements of the stroke pathway. Our key achievements against the local Stroke Delivery Plan during 2013/14 have been: Preventing stroke Cwm Taf UHB is undertaking an Inverse Law Care Programme in conjunction with Aneurin Bevan Health Board and the Welsh Government, which aims to address the health inequalities in the area. One of the highest priorities to be addressed will be cardiovascular disease, including stroke. The Smoke Free Cwm Taf programme is underway which aims to reduce smoking prevalence to 16% by Training has been provided to frontline health and community workers to help the motivate smokers to quit, and to refer them to smoking cessation services. Local Primary Care QOF data has been analysed, showing significant improvements since 2005 in the achievement of stroke related domains such as the management of hypertension and high LDL cholesterol. Detecting stroke quickly The FAST campaign has been promoted locally by the Stroke Association and stroke teams at local public events, such as the Big Bite in Pontypridd, and Merthyr Tydfil s Global Village; Through the introduction of the ASHICE pre-alert system, handover times of stroke patients from paramedics to A&E have reduced from 45 minutes in Prince Charles Hospital and 21 minutes in Royal Glamorgan Hospital in 2012, to a sustained time of under 9 minutes on both sites during A&E Stroke Nurse Champions have been identified on both sites to ensure the effective co-ordination of care for patients with suspected stroke. During the Spring 2014 we undertook preparations to run an Unscheduled Care Stroke Pilot over the summer with the Welsh and Government and Welsh Ambulance Service, in order to measure the pathway between 999 call and admission to a stroke ward. The results and lessons learned will be reported on in the Autumn/Winter

3 Delivering fast, effective treatment and care Our performance against the Acute Stroke Bundles has improved thanks to the streamlined handover from paramedics to A&E, and the ringfencing of a stroke assessment bed on both acute stroke wards, enabling prompt admission to a stroke bed and to effective stroke care. Our performance against the target to directly admit stroke patients to the stroke ward increased from 62% in October 2013 to 94% in January The Stroke Delivery Group and Finance & Performance Committee take an active role in reviewing performance and any improvement plans. Stroke Thrombolysis rates have increased from 9.2% in 2012 to 12.9% in % of all eligible stroke patients were thrombolysed. Efforts have been made to decrease the door to needle time for stroke thrombolysis in order to maximise the effectiveness of the treatment. In 2012/13 the median door to needle time was 1 hour 31 minutes; in February 2014 this had reduced to 58 minutes at the Royal Glamorgan Hospital, and at Prince Charles Hospital, one patient had a door to needle time of 33 minutes. This will continue to be a topic for improvement during 2014/15. Both of Cwm Taf s stroke consultants are now participating in the Out of Hours Telestroke service and are able to provide specialist advice from home thanks to the installation of home IT equipment and connections. Access to CT scanning has improved with the phased introduction of a radiographer shift system providing 24/7 CT head cover on both sites. Since the outcome of the South Wales Programme was announced, progress with the proposed redesign of stroke services has regained momentum. With the support of the Community Health Council we are now working towards centralisation of acute stroke services on one acute site, and stroke rehab services on one community hospital site, during 2014/15. This is driven by continuous improvement to meet clinical and quality standards. Supporting life after stroke The Life After Stroke project team have mapped current services for stroke survivors, to identify gaps and potential for improvement. This was informed by the views of stroke survivors and carers obtained through focus groups held in May and June A Living Well with Stroke programme has been developed and is being offered to stroke survivors and carers to help them adapt to life after their stroke. The Community Stroke CNS s are now undertaking 6 weekly and 6 monthly reviews of stroke patients. The Stroke Association are reviewing their service model in conjunction with the Life After Stroke team. Improving Information A Stroke Patient Passport has been piloted and launched, providing stroke survivors with accessible and tailored information at each stage of their stroke pathway the acute stage, rehabilitation stage and through to living with stroke. The Passport won a Mediwales Innovation Award in A stroke webpage was launched on the Cwm Taf UHB website in July which provides information 3

4 on stroke, prevention, symptoms, the FAST campaign, local stroke services, our Delivery Plan and links to key documents and associated organisations. Feedback from stroke patients and carers is obtained and regularly analysed through patient questionnaires issued on discharge. Performance information is analysed and reported on a monthly basis. During 2013/14, Cwm Taf UHB, along with all health boards in Wales, made the transition from the intelligent targets to the England and Wales-wide RCP SSNAP database on which clinical information for all stroke patients is entered and reported upon on a quarterly basis. Targeting Research & Development The UHB is participating in 2 research trials (RESTART and FOCUS) and has signed up to others to commence in the coming year. The Therapies team trialled a new Constraint Induced Management Therapy (CIMT) programme, encouraging stroke patients to improve the functionality of stroke affected limbs. The in-house Stroke Awareness programmes have continued to be delivered and evaluate well. A competency matrix has been developed identifying the competency requirements for delivering stroke care, against which staff training and development needs can be identified. This will be particularly helpful in supporting the implementation of the proposed new service model. We should like to thank the members of the Stroke Team and the Stroke Delivery Group for their continued drive and commitment to the ongoing improvement of stroke services across Cwm Taf. Integral to this success has been the input of key partners including the Welsh Ambulance Services Trust, who have helped to improve the pre-hospital pathway for our suspected stroke patients; Stroke Association who provide invaluable support to stroke survivors; our two local authorities who supported the allocation of Intermediate Care Funds to enable development of our Early Supported Discharge service; the Welsh Government s Delivery Unit who keep us on our toes by monitoring our performance and offering improvement advice; and the Community Health Council who have been engaged in, and are supporting our redesign of stroke services which we are implementing during 2014/15. We look forward to an exciting and milestone year ahead which will take us a major step closer to achieving the standards of excellence in stroke care set out by the Royal College of Physicians, thereby providing the people of Cwm Taf with an ever improving prospect of preventing stroke or recovering from its potentially disabling effects. Dr Richard Dewar Consultant Physician Clinical Lead for Stroke Ruth Treharne Director of Planning & Performance Executive Lead for Stroke 4

5 1. Stroke Incidence, Mortality and Survival in Cwm Taf Overview The Welsh Government are using three outcome indicators to measure and track how well stroke services are doing over time. These are: Stroke incidence rate Stroke mortality rate 30 day hospital survival rate Outcome One Stroke incidence rate Stroke incidence measures how many people have had a stroke or suffered symptoms of stroke. It provides a feel for how well we are doing at preventing stroke in Wales. If we are achieving our objectives, we would expect to see over time: A slower rise in the rate of increase. A reduced gap between the most and least deprived areas of Wales. Incidence rates comparable with the best in Europe. Figure 1 shows the number of emergency hospital admissions for stroke since Figure 1: Numbers of emergency admissions for stroke Source: Public Health Wales Observatory, using PEDW (NWIS), June / / / /13 Cwm Taf Wales

6 Outcome Two Stroke mortality rate This tells us how many people die from stroke each year 1. If we are successful, over time we would expect to see: A continued fall in the rate of deaths from stroke. A reduced gap between the most and least deprived areas of Wales. Mortality rates comparable with the best in Europe. Deaths from stroke have been steadily falling over the last decade, due to increased awareness of the need to treat stroke as a medical emergency, and improved quality of specialist acute stroke service provision. Figure 2 shows how mortality rates have been reducing in Wales since 2002, and that since 2008 mortality rates in Cwm Taf have been in line with the Wales average: Figure 2: Deaths from stroke - Age standardised mortality rates per 100,000 population Source: NWIS - European age-standardised mortality rate per 100,000 from stroke (all cerebrovascular diseases - underlying cause of death: ICD10 codes I60-I69) Period: 3 year average from up to (date extracted 29 April 2014) 02/04 03/05 04/06 05/07 06/08 07/09 08/10 09/11 10/12 Cwm Taf Wales Mortality indices are important objective indicators but, they are not reliable measures alone with which to assess the overall quality and safety of care provided. They prompt us to consider areas of variance, which require further scrutiny and 1 Expressed as an age standardised rate to allow comparisons between years and countries 6

7 investigation to establish whether there are failings in service delivery and/or quality improvements that can be made. To supplement this mortality data, in April 2013 Cwm Taf Health Board introduced a process of case-note mortality review for every inpatient dying at the Royal Glamorgan or Prince Charles Hospitals, and from April 2014 this has been extended to our community hospitals. This review process has provided a far more meaningful picture of the safety and quality of healthcare provided to patients who are admitted to our hospitals and has resulted in various quality improvements. Outcome Three 30 day hospital survival rates This measure shows us how many people are alive 30 days after they have been admitted to hospital with a stroke. It is an indicator of the overall effectiveness of treatment as well as the general health of the population. If successful, over time, we would expect to see: An increase in 30 day hospital survival rates. A reduced gap between the most and least deprived areas of Wales. Figure 3 shows that survival rates for stroke patients under the age of 75 years have tended to be marginally lower than the Wales average, until 2013/14 when our survival rate exceeded the Wales average by 0.9%: Figure 3: 30 day hospital survival rates for stroke - under 75 years Source: PEDW (23/6/14) Stroke cases included where primary diagnosis = 161, 163 or /07 % 07/08 % 08/09 % 09/10 % 10/11 % 11/12 % 12/13 % 13/14 % Cwm Taf Wales As the likelihood of stroke mortality increases with age, the survival rate is lower in those aged over 75 years. Figure 4 shows that the 30 day survival rate for the over 7

8 75s is lower in Cwm Taf than the Wales average. However, there has been an upward trend in survival since 2006 : Figure 4: 30 day hospital survival rates for stroke Over 75 years 06/07 % 07/08 % 08/09 % 09/10 % 10/11 % 11/12 % 12/13 % 13/14 % Cwm Taf Wales Our Approach to Tackling Stroke In March 2013, we published our local Stroke Delivery Plan. We have since reviewed and refreshed this plan to ensure that our strategy and action plan is in line with the needs of our population. The Plan is designed to enable us to deliver on our responsibility to meet the needs of people at risk of stroke or affected by stroke. It sets out: The population outcomes expected The outcomes from treatment and support to return to health and independence we expect expected How success will be measured and the level of performance we expect. Themes for action by the health board, together with its partners. Reflecting the themes within the Welsh Government s Together for Health Stroke Delivery Plan, our priorities are: Preventing stroke - people live a healthy lifestyle, make healthy choices and minimise risk of stroke. Our priority actions for were: 8

9 To continue to work with partners to implement key actions in the priority areas of: o Smoking o Obesity o Physical activity o Alcohol To promote active management of the risk factors in primary care including maximisation of the QOF scores for CHD, stroke and atrial fibrillation (AF), and participation in the 1000 Lives + AF programme Detecting stroke quickly stroke is detected quickly where it does occur or recur. Our priority actions for were: To continue to raise public awareness through press articles and participation at public events of the signs and symptoms of potential stroke and the need to treat it as a medical emergency. To identify where improved awareness raising amongst health professionals is needed, (eg. GPs, A&E, other hospital wards) and to target this accordingly. Raise awareness of TIA as a warning sign of potential stroke, and ensure timely referral and assessment services are in place. Delivering fast, effective care - people receive fast, effective treatment and care so they have the best chance of living a long and healthy life. Our priority actions for were: To reduce door to needle time for stroke thrombolysis; To establish the out of hours on-call telestroke service on a sustainable footing; To improve timeliness of admission to the acute stroke wards. To consult on and implement the proposed redesign of stroke services. Supporting life after stroke - people are placed at the centre of stroke care with their individual needs identified and met so they feel well supported and informed, and able to manage the effects of stroke. Our priority actions for were: Develop an Early Supported Discharge service for stroke patients; Participating in the 1000 Lives + Life After Stroke Collaborative to ensure improved service provision and co-ordination, including development of a Patient Passport ; Supporting the Stroke Association with their proposed redesign of local services; Secondary prevention of stroke and TIA, through advice and referral to support services: Improving Information - patients and carers have timely access to information about their condition, treatment, care and support available; and stroke services manage information effectively to monitor performance and inform service change. Our priority actions for were: Implementing the Communication Strategy to ensure staff and stakeholders are informed of developments and any service changes arising from local stroke services redesign; 9

10 Increasing participation in patient surveys to inform service improvements, to be summarised in an annual Patient Experience report; To actively contribute to the transition to SSNAP data collection, ensuring the effectiveness of information management is maintained and maximised; Create a web page on the health board s internet site on which to publish regular information about stroke services and performance. Targeting Research & Development - foster a strong culture of research to support ongoing improvements in patient outcomes. Our priority actions for were: To maximise opportunities for involvement in other stroke related research; Address the training and development needs of stroke staff to deliver the proposed new stroke model This second annual report sets out the progress we have made against each of our priorities in 2013/14 and sets out a baseline for future years against which progress can be monitored. 3.0 Preventing Stroke Overall, health in Wales is improving and our population is getting older. However, improvements in health have not been achieved equally for all people, and there is certainly evidence of health inequalities in the more deprived areas of Cwm Taf. Life expectancy for the most deprived fifth of the population has risen more slowly than for other groups; the Cwm Taf area has the lowest life expectancy for both males and females of any of the health boards in Wales. Many of the causes of poor health are deep-rooted and difficult to tackle. Obesity is widespread in Wales and rates of smoking, drinking and substance misuse continue to cause concern. These root causes of poor health contribute directly to the risk of having a stroke Progress against our Preventing Stroke Priorities Lifestyle Change - Our priority for was to continue to work with partners to implement key actions in the priority areas of: o Smoking o Obesity o Physical activity o Alcohol Over the past 12 months we have undertaken a range of measures to address lifestyle risk factors and to encourage behavioural change: Smoking The Welsh Government has set a target to achieve a smoking prevalence rate of 16% by 2020, and has set a Tier 1 target to increase the number of smokers who make a quit attempt. Key priorities identified within the Tobacco Control Action Plan for Wales are included as actions within the Cwm Taf Smoke Free Strategic Action 10

11 Plan, Health Board Environmental Tobacco Plan, the emerging Respiratory Action Plan, and other partner strategies and action plans. Recognising that smoking cessation is a key treatment for all smokers, the health board has developed a policy statement requesting that all health professionals should take every opportunity to Ask, Advise, Act : Colleagues from the Public Health Team have worked with primary and secondary care colleagues to embed the Ask, Advise, Act approach and increase referrals to smoking cessation services. This has included: 1. Developing a dedicated intranet site to communicate the policy statement to all staff 2. Building clear understanding of the referral pathways 3. Staff training and support. Community pharmacies play a key role, with 39 pharmacies currently offering smoking cessation services across Cwm Taf, with an increase in a further 20 planned for this year. Targeting pharmacy services in our areas of greatest deprivation reaches our population where smoking prevalence is highest and addresses inequalities. 11

12 The 2013 Welsh Health survey results show that smoking rates in Cwm Taf have continued to reduce to 24% of the adult population, compared to 26% in Merthyr has seen a significant drop in smoking rates from 31% to 23% of the population and the rates in Rhondda Cynon Taf have steadily declined from 28% to 25%. For her 2013 Annual Report, Counting the Cost of Tobacco: Who Really Pays?, Cwm Taf s Director of Public Health has chosen to highlight the breadth of work that is taking place across Cwm Taf in relation to tobacco control. Obesity The Welsh Health Survey 2013 showed that the proportion of the population classified as obese (BMI 30+) has risen consistently since 2005/7 and, at 26%, Cwm Taf is statistically significantly higher than the Wales average (23%) and is the highest among health boards in Wales. However, the latest WHS shows a 1% improvement in the obesity figure for Merthyr Tydfil. The figure for RCT has remained static at 25% since 2009/10 (Figure 6). 12

13 Obesity partly results from modifiable lifestyle behaviours around nutrition and physical activity. The 2013 Welsh Health Survey showed that the proportion of people living in the Cwm Taf area who eat healthily has reduced further since 2011, and is still lower than in the rest of Wales. Cwm Taf has the lowest proportion of people reporting consumption of 5 fruit and vegetables a day in Wales, and at 28% this is statistically significantly lower than the Wales average (33%). Regular physical activity helps lower blood pressure, creates a healthier balance of blood fats and improves the body s ability to handle insulin, the hormone that is lacking or ineffective in diabetes. The percentage of adults who reported being physically active on 5 or more days in the past week was higher in Merthyr Tydfil than the Wales average, but significantly lower in Rhondda Cynon Taff, which brings the Cwm Taf average down to below 26% which is the lowest rate in Wales average. The causes of obesity are, however, not simply due to individuals food and physical activity choices. They are more complex than this, and relate to a wide variety of societal, environmental and behavioural factors. Action to address obesity often requires multi agency partnership working. A weight management resource and support toolkit has been developed for use in communities. To date, 21 community weight management groups have been established in Cwm Taf. A good practice scheme is being developed to support the groups. A community based, Joint Care Programme (JCP) pilot was successfully completed as a partnership between Public Health, the Health Board and Local Authorities. The JCP pilot was a 16 week programme for patients with a BMI of 30 or above who have chronic hip or knee pain to receive support with weight loss and increase activity in order to manage their condition more effectively. The Health Board is currently considering the feasibility of implementing this programme on a permanent basis. Maximising the opportunities for walking and cycling has been identified as Regional Collaboration Board priority. An Active Travel Steering Group has been 13

14 established to take forward the implementation of the Active Travel Act and Open Space Strategy through partnership working. Alcohol Drinking too much alcohol raises blood pressure which causes arteries to fur up and puts extra strain on the blood vessels. The 2013 Welsh Health Survey showed a slight reduction in the rate of people who report drinking alcohol above the recommended guidelines, from 45% in 2011 to 43% in There is quite a variation across Cwm Taf, with Merthyr at 39% which is below the Wales average, and Rhondda Cynon Taff at 44% which is the second highest rate in Wales. The rate of binge drinking has also decreased from 30 to 29%, but this is the highest rate in Wales. Alcohol Brief Intervention Training has been rolled out, led by Public Health Wales. In 2013/14, 29 training sessions were delivered across Cwm Taf with 290 individuals trained. The training has been promoted to a range of community partners, including those working with young people. Over 50s Health Checks The Add to Your Life programme aims to make a positive contribution towards improving health and wellbeing for people aged over 50 in Wales by providing quality information and advice, helping people to get easy access to the right public health services. All the Communities First clusters in Cwm Taf have worked with Public Health Wales and Age Cymru to encourage participation in this online health check. The Stroke Association is also active in our local communities, promoting awareness of stroke and stroke risks at public events and offering blood pressure testing. 14

15 Managing known clinical risk factors Our priority for 2013/14 was to promote active management of the risk factors in primary care including maximisation of the QOF scores for CHD, stroke and atrial fibrillation (AF), and participation in the 1000 Lives + AF programme. The main clinical risk factors for cardiovascular disease, including stroke, are hypertension, atrial fibrillation, high LDL cholesterol and diabetes. People with these known risk factors should be appropriately managed, with a view to preventing a primary or secondary stroke. In the Outcomes Framework which accompanies the Stroke Delivery Plan, Welsh Government set three Assurance Measures relating to the prevention of stroke. These are: Assurance Measure 1 - % of the population with cardiovascular risk conditions managed appropriately Assurance Measure 2 - % of people with atrial fibrillation who are treated with anti-coagulation drug therapy or anti-platelet therapy Assurance Measure 3 - % of patients with hypertension who have had their blood pressure checked in the past 9 months The following graphs below (figures 9-11) show that performance against each of these Assurance Measures in Cwm Taf is above the Wales average: Assurance Measure 1 The percentage of population with cardiovascular risk conditions managed: Figure 9: % of population with cardiovascular risk conditions managed Source: StatsWales - QOF Database June 2014 Cited: CM Web data as at 30 /6/ Cwm 82.1 % 84.5% 84.7% Taf Wales 83.8% 83.4% 84.2% UK 82.3% 81.9% 83.5% The UHB has launched a major programme aimed at managing and reducing the risk of cardiovascular disease. The comprehensive Inverse Care Law Programme is focused on disease prevention and early intervention through primary care and community services, which will realise benefits across the whole pathway. 15

16 Focussing initially on cardiovascular disease, the plan will detail specific interventions to be undertaken in primary care to assess vascular risk and ensure optimal treatment of patients. It is proposed that investment upstream in primary care and the community will in time realise reduced demand on services in secondary and tertiary care. The programme has a number of priority commitments as follows: To focus on premature mortality from cardiovascular disease (approx 40 fewer deaths per annum in adults under 75 yrs across Cwm Taf); To be implemented across Cwm Taf University Health Board targeting the six GP Cluster areas with the highest level of deprivation. The approach will be determined by the needs and maturity of the locality; To prioritise actions that should be able to demonstrate outcomes within 5 years; To focus on systematic and population scale implementation of evidencebased interventions; In the initial phase, the programme will focus on the determinants of inequalities in health that are within the control and influence of primary care and the wider locality networks. Assurance Measure 2 The percentage of patients with hypertension who have had their blood pressure checked in the past 9 months Figure 10: % of patients with hypertension who have had their blood pressure checked in the past 9 months Source: StatsWales - QOF Database June 2014 Cited: CM Web data as at 30/6/ Cwm 92.9% 92.9% 93.5% Taf Wales 92.5% 92.1% 92% UK 91.8% 91.3% 91.4% High blood pressure is an important risk factor for stroke, contributing to about 50% of all strokes and it has been estimated that 53% of men and 41% of women with high blood pressure are not receiving treatment. Of those who are being treated, 16

17 around half still have high blood pressure. 2 Ensuring those at risk have regular blood pressure checks is a key aim for our health board. The QOF data illustrated in figure 10 shows that Cwm Taf is above the Wales and UK average for the percentage of patients with hypertension who have had their blood pressure checked in the past 9 months. Data just issued from QOF shows encouraging improvements in achievement in Stroke Domain data. There are fewer patients with blood pressure readings above the 150/90 target valuesand there are only nine practices whose stroke and cholesterol target achievement data is in the poor achievement quadrant. There are some concerns about the reliability of the data, however it is helpful to prompt discussion about variation at cluster level. The focus for Cwm Taf will be on minimising missing data, minimising variation and developing and implementing a Quality Improvement Work Plan In May 2013, all community pharmacies in Wales ran a Stroke: Lower Your Risk Campaign which aimed to help patients understand the link between hypertension and stroke and how they could help lower their own risk of stroke. 2 Coronary heart disease statistics 2010 edition. British Heart Foundation. 17

18 Assurance Measure 3 The percentage of people with atrial fibrillation who are treated with anti-coagulation drug therapy or anti-platelet therapy Figure 11: % of people with atrial fibrillation who are treated with anticoagulation drug therapy or anti-platelet therapy Source: StatsWales - QOF Database June 2014 Cited: CM Web data as at 30 June Cwm 94.7% 94.7% 96% Taf Wales 93.9% 93.8% 95.1% UK 93.7% 93.8% 95.2% Again the QOF data shows that Cwm Taf performs better than the Wales and UK average against this indicator. The all Wales Stroke Implementation Group has identified Atrial Fibrillation as a key national priority and Cwm Taf (Dr Dewar) is leading the national work to help improve the identification and effective management of people with AF. The stroke prevention priorities in our updated Stroke Local Delivery Plan for are: To continue to work with partners to implement key actions in the priority areas of: o Smoking o Obesity o Physical activity o Alcohol To ensure links between the Inverse Care Law programme and stroke risk reduction. To promote active management of the key cardiovascular risk factors in primary care, particularly hypertension, high cholesterol, Atrial Fibrillation and diabetes. 18

19 4.0 Detecting stroke quickly Rapid diagnosis and treatment not only improve survival but also the quality of life of survivors. In Cwm Taf we have been focussing on raising awareness of the symptoms of stroke / TIA, and how to ensure prompt diagnosis and treatment when stroke strikes. In 2013/14 our priorities for detecting stroke quickly were: To continue to raise public awareness through press articles and participation at public events of the signs and symptoms of potential stroke and the need to treat it as a medical emergency. To identify where improved awareness raising amongst health professionals is needed and to target this accordingly. Raise awareness of TIA as a warning sign of potential stroke, and ensure timely referral and assessment services are in place. FAST Campaign Through promotion of the national FAST campaign, the health board and partners have been raising awareness of stroke symptoms and the need to treat stroke as a medical emergency. The stroke awareness campaign run by all community pharmacies in Cwm Taf in May 2013 included promotion of the FAST test as a way of recognising and responding to the symptoms of a potential stroke. This awareness raising has been further reinforced through the public presentations by Dr Dewar, and by the Stroke Association who regularly attend local public events such as the Big Bite in Pontypridd and Merthyr s Global Village. The September 2013 edition of Cwm Taf s Your Healthcare magazine also raised awareness of the FAST test, which is promoted on the UHB s website. Pre-hospital pathway Most stroke patients are brought into hospital by the Welsh Ambulance Services NHS Trust (WAST). Between 1 st August 2013 and 31 st August 2014, WAST conveyed 471 category A suspected stroke patients to the Royal Glamorgan Hospital, and 473 to Prince Charles Hospital. WAST are required to comply with the WAST Stroke Care Bundle which comprises three key observations: blood pressure, blood glucose and the FAST test. WAST are currently reporting on their performance on a national level only: compliance across all three bundles has improved from 77.5% in June 2013 to 94.7% in June Through the introduction of the ASHICE pre-alert system, handover times of stroke patients from ambulance technicians to A&E have reduced from 45 minutes in PCH and 21 minutes in RGH in 2012, to under 10 minutes on both sites during 2013, and 8.5 minutes or under in 2014 Handover Time at Hospital Hospital May 2012 May 2013 August 2014 Prince Charles Hospital mins 9.9 mins 8.2 mins Royal Glamorgan Hospital mins 7.5 mins 8.5 mins 19

20 Transient ischaemic attack (TIA) TIAs (or mini strokes) serve as an early warning sign of stroke and require immediate medical attention. The window of opportunity to do this effectively is small and requires such patients to have a specialist assessment as early as possible following the event. Patients with suspected TIA are assessed in Primary Care or in A&E using the ABCD2 test. In line with the TIA Care Bundles, those considered low risk are referred to the outpatient TIA clinic within 7 days, and high risk patients within 24 hours. At weekends, appropriate treatment for high- risk TIA patients is initiated within 24 hours by the acute physicians and they are then seen at the next available TIA clinic. One potential symptom of TIA is amaurosis fugax, a transient loss of vision in one or both eyes. As an embolic event and a symptom of carotid artery disease, amaurosis fugax signals that the patient is at risk of stroke. Discussions have been held with the Cwm Taf Eye Health Group to raise awareness of the associated stroke risk and the need to refer the patient to TIA clinic for assessment including the potential need for treatment such as carotid endarterectomy surgery. Arrangements are being made to enable direct referral by optometrists to the TIA clinic, thereby avoiding delays associated with referring via GPs or other specialists. The priorities for detecting stroke quickly in the updated Stroke Local Delivery Plan for are: To continue to raise public awareness through press articles and participation at public events of the signs and symptoms of potential stroke and the need to treat it as a medical emergency. To continue to work with the Welsh Ambulance Service in improving the prehospital pathway and efficient communication over / handover of suspected stroke patients. To pilot the Unscheduled Care performance measures for stroke from time of 999 call to admission to acute stroke unit. To raise awareness of TIA as a warning sign of potential stroke, and ensure timely referral and assessment services are in place. 5.0 Delivering fast, effective care Stroke services within Cwm Taf deliver effective evidence-based care through multidisciplinary teams comprising stroke physicians, nurses, therapists and a psychologist. Care is provided in line with national standards and guidelines, such as those produced by NICE and the Royal College of Physicians. We participate in all relevant National Clinical Audits and Clinical Outcome reviews, set out in the Welsh Government s National Annual Audit Programme, and act on the findings. Our priorities for delivering fast, effective care in for were: To reduce door to needle time for stroke thrombolysis; To establish the out of hours on-call telestroke service on a sustainable footing; 20

21 To improve timeliness of admission to the acute stroke wards. To consult on and implement the proposed redesign of stroke services. Sentinel Stroke National Audit Programme - SSNAP Audit From July 2013, all health boards in Wales commenced participation in the Royal College of Physicians SSNAP Audit. SSNAP is the single source of stroke data for NHS stroke services in England, Wales and Northern Ireland. It prospectively collects a minimum dataset for every stroke patient covering their acute care, rehabilitation, therapy and 6 month follow-up assessment. Every quarter, the RCP publishes reports detailing every stroke unit s performance against a set of key quality indicators. Various versions of these quarterly reports are published, including an Easy Access version for stroke survivors and their families. For each indicator and for overall performance, the RCP s quarterly reports assign an achievement level of A (high) to E (low). The maps below show how Cwm Taf s acute stroke units compared to others across Wales, England and N.Ireland: 21

22 In the January to March 2014 audit, Prince Charles Hospital achieved an overall level D, and the Royal Glamorgan Hospital achieved a level E. Although this may sound disappointing, it is worth noting that the majority (approx 65%) of stroke units across England, Wales and N.Ireland only achieved a level of D or E. The SSNAP standards are hailed by the RCP as more stringent than anywhere else in the world, and they advise that the report should be read in this context. This is of particular relevance to Wales where SSNAP participation started 6 months later than in England, and the SSNAP standards are generally more challenging than the Intelligent Target care bundles to which we have been working in Wales to date. The scores for the January to March 2014 SSNAP Audit are as follows: Figure 12 SSNAP January to March 2014 summary Prince Charles Hospital Royal Glamorgan Hospital Areas where Cwm Taf performed well in comparison to other units include:: Brain Scanning both units scored a level B for brain scanning: Figure 13 SSNAP January to March 2014 scores for brain scanning Prince Charles Hospital Royal Glamorgan Hospital 22

23 Urgent cases, including patients who could be eligible for thrombolysis, should be scanned within one hour. Figure 14 shows how both of our hospitals have improved the percentage of patients who are scanned within one hour: Figure 14 CT scanning within one hour Prince Charles Hospital Royal Glamorgan Hospital The median times to scanning have also reduced, particularly at Prince Charles Hospital where access to scanning is quicker than the national average : Figure 15 median times to scanning Prince Charles Hospital Royal Glamorgan Hospital These improvements to CT scanning times have been achieved through the phased introduction of a 24/7 radiographer shift system which is ensuring round the clock onsite radiographer presence, coupled with a health board wide focus on treating stroke as a medical emergency. 23

24 Standards by Discharge Both hospitals performed particularly well on this indicator, which includes screening for nutritional needs, for mood and cognition, and having a continence plan drawn up if required within 3 weeks of admission. Both hospitals scored an A for this: Figure 16 Standards by Discharge Prince Charles Hospital Royal Glamorgan Hospital Thrombolysis Prince Charles Hospital scored a level C for thrombolysis, however Royal Glamorgan scored D. Stroke thrombolysis rates have increased from 9.2% in 2012 to 12.9% in Prince Charles Hospital Figure 17 Thrombolysis rates Royal Glamorgan Hospital Thrombolysis is also one the Welsh Government s Assurance Measures for the Stroke Delivery Plan. 24

25 Assurance Measure 4 The percentage of eligible stroke patients who receive thrombolysis and the percentage of those receiving thrombolysis within the optimum time. Figure 18 shows that in Cwm Taf, 100% of all eligible stroke patients were thrombolysed: Figure 18 Assurance measure 4a) eligible patients who receive thrombolysis Figure 19 shows that the percentage of patients thrombolysed within an hour is in line with the Wales average: Figure 19 Assurance measure 4b) time taken to thrombolyse Efforts have been made to decrease the door to needle time for stroke thrombolysis in order to maximise the effectiveness of the treatment. In 2012/13 the median door to needle time was 1 hour 31 minutes; in February 2014 this had reduced to 58 minutes at the Royal Glamorgan Hospital, and at Prince Charles Hospital, one patient had a door to needle time of 33 minutes. This will continue to be a topic for improvement during 2014/15. 25

26 Both of Cwm Taf s stroke consultants are now participating in the Out of Hours Telestroke service and are able to provide specialist advice from home thanks to the installation of home IT equipment and connections. Another of the Assurance Measures monitored by Welsh Government in relation to the Stroke Delivery Plan is the percentage of stroke patients who spend more than 90% of their time on an Acute Stroke Ward. Evidence shows that the specialist care provided on an acute stroke ward helps to improve patient recovery and outcomes. In 2012/13, 50.6% of Cwm Taf stroke patients spent more than 90% of their time on the Acute Stroke Ward. Thanks to the success of the ring-fenced bed on each of our stroke wards in December 2013, our performance improved to 87% in March This compared to the Wales average of 55% and is therefore a significant achievement:: Figure 20 Assurance measure 5 patients who spend more than 90% of their time on the acute stroke ward Section 3 of this Annual Report detailed Cwm Taf s performance against key outcome measures including mortality and survival rates. This theme is also reflected in Assurance Measure 6 - Mortality within 30 days of admission: Figure 21 - Assurance Measure 6 admission - Mortality within 30 days of 26

27 Acute Stroke Bundles Performance against the four acute stroke care bundles is Assurance Measure 7 included by Welsh Government in the Outcomes Framework for the Stroke Delivery Plan. Our performance is reported for both acute hospitals on a monthly basis to Welsh Government via the Delivery Unit. The information is also reviewed by the Cwm Taf Stroke Steering Group, the Finance & Performance Committee, Executive Board and full Board, who all take an active role in monitoring our performance levels and any remedial actions planned and implemented. The requirement to report performance against the care bundles has undoubtedly led to significantly improved compliance since their inception in As the care bundles are evidence based, improved compliance implies improved outcomes for patients. Cwm Taf s performance from April 2012 to March 2014, and comparison with the Wales average, is shown in the following graphs: Care Bundle 1 within first 3 hours: Rapid diagnosis using a recognised tool, eg ROSIER (Recognition Of Stroke In the Emergency Room) Diagnosis confirmed by an experienced clinician Figure 22: % compliance with bundle 1 Care Bundle 2 within first 24 hours: CT scan Direct admission to acute stroke unit bed Swallow screen Nutritional screen Aspirin prescribed (if eligible) This has been the most challenging bundle to achieve in Cwm Taf and across Wales. In December 2013, following a period of disappointing performance, we introduced a new acute pathway incorporating a fast-track stroke trolley in A&E, and a ring-fenced stroke bed on each stroke unit, to which stroke patients were to be directly admitted without firstly going to an assessment ward. This led to a significant improvement in our performance as can be seen in figure 23 below: 27

28 Figure 23: % compliance with bundle 2 Our ability to ring-fence the stroke beds was enabled by our NHS Wales Award winning Focus on Flow initiative, which improved patient flow across the organisation through providing alternatives to admission and ensuring care is provided in the right place at the right time. Our success in ensuring direct admission to the stroke wards has had a corresponding impact on the percentage of patients who spend more than 90% of their time on an acute stroke ward: figure 24 illustrates the sharp improvement from December 2013 when the ring-fenced beds were introduced: Figure 24: % of stroke patients who spend more than 90% of their time on an Acute Stroke Ward Care Bundle 3 within first 72 hours: Physiological monitoring Manual handling assessment Specialist medical review Physiotherapy assessment Patient mobilised / got out of bed 28

29 Compliance rates with this bundle highlight our current reliance on single-handed stroke professionals and our lack of 7 day working; when the consultant or physiotherapist is not in work, this has a significant impact on compliance rates. Overall compliance with bundle 3 is as follows: Figure 25: % compliance with bundle 3 Care bundle 4 within 7 days: Occupational Therapy assessment Full screening and assessment of residual impairments Multi-disciplinary goals set Information shared with patients and carers Estimated discharge dates discussed with patients and carers Compliance with this bundle has been fairly consistent with any dips again largely coinciding with single-handed specialists (stroke Occupational Therapists) being on leave. Overall compliance with this bundle is as follows: Figure 26: % compliance with bundle 4 The acute stroke bundles continue to be reported to Welsh Government as a tier 1 target for 2014/15. Meanwhile, a new more challenging set of care bundles is being developed, consistent with the Royal College of Physicians SSNAP targets. The UHB and Welsh Government have commenced shadow monitoring of these targets which are likely to be introduced from 2015/16. 29

30 Stroke Services Redesign Engagement with stakeholders has been ongoing since 2012 over the proposed redesign of our stroke services, driven by continuous improvement to meet clinical and quality standards. The outcome of the South Wales Programme, which included emergency medical services, was awaited to inform the final redesign proposal. Plans have now been developed for the centralisation of acute stroke services on one acute site (Prince Charles Hospital), stroke rehab services on one community hospital site (Ysbyty Cwm Rhondda), and the development of an Early Supported Discharge Service, which are being implemented during 2014/15. This will enable us to pool our specialist stroke resources and offer more consistent access to high quality stroke treatment and care in specialist centres and in people s own homes. Evidence shows that this will improve outcomes and quality of life for stroke survivors and their families. Cwm Taf Community Health Council have been engaged in the redesign process since the onset, providing invaluable and impartial advice, and in acknowledgment of the extensive engagement undertaken have given approval to proceed without formal public consultation. 6.0 Supporting Life after Stroke Stroke can have a significant and long term impact on the individual and on their families and relationships. Stroke survivors may experience a range of complex physical, psychological and social needs and require ongoing support and advice to meet the challenges of adapting to life after their stroke, and re-integrating into community life. The Health Board is working across secondary, community and primary care, and with social services and the third sector, to develop integrated care and support to enable the safe discharge of stroke patients and longer term follow up as required. Our priorities for Supporting Life After Stroke were: Develop an Early Supported Discharge service for stroke patients; Participating in the 1000 Lives + Life After Stroke Collaborative to ensure improved service provision; Supporting the Stroke Association with their proposed redesign of local services. Secondary prevention of stroke and TIA, through advice and referral to support services: Early Supported Discharge The Health Board has secured funding from the integrated Intermediate Care Fund for the pump-priming of a stroke specialist Early Supported Discharge (ESD) service which will become operational during November The ESD will comprise Physiotherapists, Occupational Therapists, a Speech & Language Therapist, Psychology Assistant and Therapy Support Worker who will work closely with the existing community based stroke nurses. 30

31 Provision of ESD services is recommended by the Royal College of Physicians as evidence shows that such services can help to improve patient outcomes in terms of their ability to undertake activities of daily living, and can increase patient and carer satisfaction levels. The core function of the Service is to: Maximise rehabilitation and recovery following stroke. Minimise premature dependence on long term institutional care and long term community services. Promote independence and prevent inappropriate hospital stays. Enable eligible stroke patients to be discharged early and receive rehabilitation in their own home at an appropriate level of intensity, thereby enabling more patients to recover and rehabilitate at home. Initially the service will be offered to stroke patients with mild to moderate disability and for a period of up to 6 weeks. Intervention will be individually goal oriented, incorporated into a personalised Patient Stroke Passport that allows the patient to take ownership of their rehabilitation. Upon completion of this scheme patients may, if required, be offered ongoing community services via re-ablement or outpatient clinics according to the specific service required, and patients will also be signposted to other support services available within the community including those provided by the third sector, in particular the Stroke Association. Stroke Association The Stroke Association are commissioned by the Health Board to provide a Keep in Touch service, Communication Support service and Day service for stroke survivors: Stroke Keep In Touch Service Information, advice & emotional support Secondary prevention of stroke Home visiting and telephone contact service Understanding Stroke Course & Living Well with Stroke working closely with Statutory bodies Communication Support Service Opportunity to practice communication and gain confidence Working with Speech & Language Therapists Provision of support in a group setting via staff / trained volunteers Peer Support for stroke survivors, carers and family members Day Service Support to return to the community Exercise and education programmes Provision of support in a group setting via staff / trained volunteers Peer Support for stroke survivors, carers and family members All of the above services refer or signpost stroke survivors to other organisations, such as the local authority services, Citizen s Advice Bureau and other third sector bodies, according to the individual s needs. 31

32 Current Cwm Taf Services Stroke Keep in Touch Service (whole of Cwm Taf) Communication Support Service Stroke Day Service (inc Comm Support in Merthyr Tydfil) Total of five groups Church Village Mountain Ash Tonypandy Trehafod Merthyr Tydfil Communication Support Stroke Helpline stroke.org.uk Health promotion and stroke prevention is also an important element of the Stroke Association s role and they regularly attend public events and meetings to provide general information and blood pressure checks and advice. A recent survey of service users helped confirm what they felt most valuable about the service: What our Service Users Tell Us The communication group has been invaluable to my recovery and progress. I know that there are financial constraints but I would like the opportunity to meet more often during the week. We need new members (referrals). Physio support. Occupational therapy. I am happy with the help I get. I have been surprised at what is available. I found the follow up of stroke services invaluable. Really enjoy the group support. Relaxed, friendly atmosphere. Activities, quizzes and educational courses. Arts, crafts and exercise class. Verbal support from each other and co-ordination. I am grateful for our stroke group meetings, as this has enabled me to chat / communicate with other people in the same position as myself.. Stroke Helpline stroke.org.uk 32

33 The feedback from service users is being used to inform the work being undertaken by the Stroke Association in conjunction with health board and local authority colleagues, to review their current service provision and identify how they can best support Life After Stroke services in Cwm Taf in the future. 6 month reviews As part of the 1000 Lives + Life After Stroke Programme, stroke survivors are now offered a comprehensive review 6 months after admission, by the community stroke nurses. This enables a formal discussion with the individual around their progress with achieving goals, and any ongoing issues and needs for which further support and advice is required. The review is recorded on the SSNAP database and covers where the patient is living, their mood and any psychological follow up, modified rankin score which identifies how they are functioning now and will give an indication of their disabilities. The review asks if they have Atrial Fibrillation and if so covers the medication that they are taking and if there are further hospitalisations. The review will also establish how they are managing, if the carers are happy or may need further support, how they are managing their risk factors e.g. they may have given up smoking and they are asked how they are coping with this. They will be asked if they are managing their medication, if they are having their blood pressure checked by their GP s, if they have returned to driving, hobbies, work etc. Any problems generated by the contact will be addressed and the patient supported. The nurses can also be contacted by the patient prior to this review for support and advice if required. Living Well With Stroke An education programme for stroke survivors and carers, Living Well With Stroke has been running since This programme covers the following topics, allowing for group discussion of the issues and individuals experiences: What is a stroke, risk factors, prevention and physical effects including communication. Psychological, emotional, family, cognitive, behavioural effects Support available after stroke - benefits, Stroke Association etc. 7.0 Targeting research Since being granted University Health Board status in 2013, we in Cwm Taf have been working with our academic partners to develop a Memorandum of Understanding and collective Vision, to enable us to maximise the opportunities afforded. It is acknowledged that a step change in culture is required if we are to maximise the opportunities for shared research and learning. In terms of stroke our priorities for Targeting Research in were: To progress the proposed low risk TIA direct referral trial with the Wales Ambulance Service; (NB WAST chose not to pursue this as a research trial) To maximise opportunities for involvement in other stroke related research; Address the training and development needs of stroke staff to deliver the proposed new stroke model 33

34 The Stroke team are still currently participating in two research trials: RESTART REstart or STop Anti-thrombotics Research Trial for stroke patients with cerebral haemorrhage who were on anti-thrombotic drugs at the time of their stroke. The aim is to determine whether the beneficial effects of antiplatetet drugs on the risk of clotting outweigh any risks of a repeat cerebral haemorrhage. FOCUS Fluoxetene Or Control Under Supervision to consider the effect(s) of routine administration of Fluoxetine in patients with a recent stroke. The study hypothesis is that routine administration of fluoxetine (20mg daily) for 6 months after an acute stroke will improve patients functional outcome. The Occupational Therapy service has also registered and been accepted for the Study of Prisms and Therapy in Attention Loss after stroke (SPATIAL) trial with Manchester University, and is in the process of applying for funding. There is a strong and proactive culture within Cwm Taf Stroke services of innovation and service improvement. One such example of this is the CIMT project: Constraint induced movement therapy (CIMT) CIMT is an innovative approach in stroke rehabilitation. It encourages patients to use their stroke affected limb by constraining use of their non-affected limb. Through ongoing practice and perseverance, patients are able to improve the functionality of their affected limb. Although CIMT is endorsed in the RCP Stroke Guidelines and has a strong evidence base, it is not widely used in the UK due to resource limitations, lack of training and the need for a cultural shift in practice. The Cwm Taf stroke therapists overcame these barriers through arranging a one day training programme for OTs and physiotherapists and securing funding for a small scale trial with a group of 5 patients. The results of the trial were very positive: all 5 patients experienced improved function in their affected limb which they were all using more frequently. Despite the frustrations experienced by the participants when trying to use their affected limb, all felt more motivated by seeing the improvements they were able to make. Following the success of the trial, further group CIMT sessions are now being held enabling other stroke patients to benefit from this innovative therapy. Patient - 65 year old lady with new diagnosis of stroke, presenting with a right sided weakness. Lived at home with husband. Previously completely independent and working in a school kitchen. CIMT Programme - programme set up at home to comply with the following: Intense 2 week programme of wearing mitt every day. 90% of her waking day was going to include constraint mitt. 3 hours of prescribed exercises for 5 out of 7 days. Outcome - significant objective results in function including being able to do her own hair, peel potatoes and lock and unlock back door. Patient very pleased with results and outcomes. Discharged from service without a package of care or without any further indication for therapy. 34

35 Education and Development To ensure that all staff of Cwm Taf Health Board who care for stroke patients and their carers are trained and competent to do so, a competency matrix has been developed identifying the competency requirements for delivering stroke care, against which staff training and development needs can be identified. This will be particularly helpful in supporting the implementation of the proposed new service model. There is an expectation that all will be supported to undertake the following training available to them: STARS - the on-line Stroke Training & Awareness Resources (STARS) training, available on: Understanding Stroke - to supplement the STARS training, an Agored Cymru accredited 2 day Understanding Stroke Care programme was developed and has been delivered by the Cwm Taf stroke team for the past few years. All staff who care for stroke patients are expected to attend, and complete the work books on this 2 day course, receiving an accredited qualification and certificate on successful completion. Further information on this course can be found on the link below: HH12CY002 Person Centred Goal Planning designed and delivered by our Consultant Neurospychologist. Acute Stroke Dysphagia Awareness and ScreeningTraining designed and delivered by Speech & Language Therapists, to enable staff to undertake an initial swallow screen and refer for swallow assessment. Brief Intervention Training - designed and delivered by the Cwm Taf Public Health Team to encourage healthcare staff to engage with patients on the issues of smoking cessation and alcohol reduction. Our Stroke Education sub group has also developed a stroke training portfolio and online training record system to enable training records to be audited. 8.0 Improving Information Information is used in a variety of ways to support patients and carers with recovery from and prevention of stroke, and to inform service and performance improvement. Our priorities for Improving Information for were: Implementing the Communication Strategy to ensure staff and stakeholders are informed of developments and any service changes arising from local stroke services redesign; Create a web page on the health board s internet site on which to publish regular information about stroke services and performance; Increasing participation in patient surveys to inform service improvements, to be summarised in an annual Patient Experience report; To actively contribute to the transition to SSNAP data collection, ensuring the effectiveness of information management is maintained and maximised. 35

36 Information for Stroke Survivors & Carers Patients are placed at the centre of their care and provided with appropriate information about their condition, treatment, secondary prevention and support available. The new Patient Passport demonstrates our commitment to ensuring we provide useful information in an accessible format to aid patient and carer understanding about stroke and to empower them to adapt to life after stroke. The Patient Passport was developed and piloted in 2013 to provide accessible information and a joint goal planning tool for stroke survivors and carers. The Passport is held and owned by the patient, providing personalised information from acute hospital stroke care through active rehabilitation to living with the long term effects of stroke. The Passport won a Mediwales Innovation Award in

37 Feedback from stroke survivors, carers and staff has shown that they welcome the Stroke Patient Passport, as: Easy to read and the simple language, colour, symbols and pictures are helpful to aid understanding for patients with typical stroke symptoms Also made available in Welsh language The three standalone booklets mean patients receive information as they need it, rather than having information overload It is helpful to have written information that reinforces information given verbally, which can be difficult to take in after a stroke As the Passport is patient-held it promotes self-management and active engagement in the recovery process It provides a personalised record of the individual s care plan and their recovery journey, which can help remind the patient how far they have come It is a useful and comprehensive source of information about local support services Information for the Public In July 2013 the Health Board launched a Stroke page on our website which provides information on stroke, prevention, symptoms, the FAST campaign, local stroke services, our Delivery Plan and links to key documents and signposts to associated websites and organisations. Feedback from Patients & Carers A Patient Questionnaire is routinely issued to all patients on discharge to obtain feedback on the acute stroke care they received. During 2013 the questionnaire was revised and is now in an aphasia friendly format reflecting the Stroke Patient Passport. Stroke Performance Information From July 2013 all health boards in Wales were required to commence entering details of all stroke patients onto SSNAP, the Royal of Physicians stroke database 37