Centralising to a 7 day stroke stroke service in Greater Manchester - lessons learnt

Transcription

1 Centralising to a 7 day stroke stroke service in Greater Manchester - lessons learnt Sarah Rickard, Network

2 Partial centralisation of acute care in GM, full centralisation in London Internal review of pathway concludes further change is needed NIHR research demonstrates superiority of full centralisation PAT rationalises stroke services to one site Work to improve community services commences GM implements full centralisation ODN established Macclesfield stroke unit closes Annual review of acute pathway shows improvement GM achieves A acute care for all residents

3 The GM stroke pathway

4 GM stroke providers 3 Hyper Acute Stroke Units 6 District Stroke Centres 16 community rehabilitation teams

5 Pathway strokes Y14/15 Y15/16 Y16/17 SSNAP HASU SSNAP DSC SSNAP GM

6 Performance by CCG Overall score (patient centred) Apr-Jun 14 Jul-Sep 14 Oct- Dec 14 Jan- Apr-Jun Jul-Sep Mar Oct- Jan-Mar Apr-Jul Dec Aug- Nov 16 Dec 16- Mar 17 Apr - Jul 17 Bolton D D X D B B B B A A A A Wigan Borough D D C C B B B B A A A A Trafford D D C D B B B B A A A A Tameside & Glossop D D D D C C B B B A A A Stockport D C C D C B B A B A A A Salford C B C B B A A B A A A A Bury D C C B A A A A A A A A Oldham C C C B A A A A A A A A Heywood, Middleton & Rochdale C C C B A A A A A A A A North Manchester D C C B A A A A A A A Central Manchester D D D C B B B B A A A A South Manchester D D D D C B B B B A A Eastern Cheshire D D D D C C B B B A A A

7 Performance by stroke unit Overall score (team centred) Oct - Dec 2014 Jan - Mar 2015 Apr - Jun 2015 Jul - Sep 2015 Oct - Dec 2015 Jan - Mar 2016 Apr - Jul 2016 Aug- Nov 2016 Dec- Mar 2017 Apr - Jul 2017 Fairfield General Hospital C B A A A A A A A A Salford Royal Hospital B B B A A B A A A A Stepping Hill Hospital C D C B B A B A A A Royal Bolton Hospital X D D D C B B B B B Manchester Royal Infirmary D D A C D C C B B B Trafford General Hospital C D C B C B A A B B Tameside General Hospital E D E E B D C B C D Wythenshawe Hospital D D D D D C B B B C Royal Albert Edward Infirmary D D D C D D A B B B

8 GM vs London vs National National Average (All teams) GM all units trend London all units trend 40

9 SSNAP - SMR ( ) GM DSCs

10 Dr Foster - SMR ( )

11 Dr Foster Crude ( )

12 NIHR HS&DR findings Adjusted before and after analysis of 2015 centralisation: Mortality at 90 days across all stroke types in GM fell by 4.2 percentage points With an estimated 4500 strokes in Greater Manchester each year this represents 189 fewer deaths per year Adjusted before and after analysis of Rest of England (RoE): Mortality at 90 days across all stroke types in RoE fell by 2.6 percentage points Suggests that difference-in-differences might be informative

13 Adjusted between-region difference-in-differences: Across all hospitals in GM there was a borderline significant reduction in mortality at 90 days of 1.3 percentage points Replicated the analysis only for HASUs: Mortality at 90 days across all stroke types in GM fell 1.8 percentage points If there are an estimated 4500 strokes in GM each year and 86% of these go to a HASU then this represents 69 fewer deaths per year (i.e., 4500 x 0.86 x -1.8/100)

14 Impact on LoS Across all stroke types there was a significantly larger decline in risk-adjusted LoS compared with the RoE, by -1.5 days If this reduction was applied to the estimated 4500 patients this would result in 6750 fewer bed-days a year

15 Updated lessons What works at what cost Centralised acute stroke services in urban areas reduce mortality and LOS, and are cost-effective Advantage of models where all eligible for HASU Impact on care and outcomes can be sustained over time Planning, implementation, and sustainability Not a one-off: attend to evidence, consider further change In absence of top-down authority, working across clinical networks and commissioners can drive change Consistent, adaptive leadership facilitates both implementation and sustainability in challenging contexts Independent evidence (audit, research) can help build and maintain stakeholder ownership of changes

16 Network review at 2 years Significant decrease in stroke assessments and admissions at District Stroke Centres 9% increase in proportion of strokes <4hours time of onset at HASUs 94% of stroke patients admitted to a stroke ward Significant reduction in stroke mimics assessed in A&E and admitted to HASU stroke wards in Year 2 Significant increase of directly admitted stroke patients at DSCs treated on non-stroke wards in Year 2

17 Key learning Realistically model changes in patient flow and consider future developments e.g. IAT, ICH pathways Minimise number of stroke units (and community teams) to future proof quality of care and improve efficiency Redesign community services at the same time Measure impacts across whole patient journey

18 Key learning Collaboratively agree SOPs to support pathway Agree at CEO level robust processes to ensure timely repatriation of strokes and mimics Ensure sufficient support to manage increased patient flow at HASUs Improve recognition of stroke to reduce burden of false positives at HASUs Ensure ASUs still able to treat direct admissions appropriately Consider pathway exclusions (e.g. time of onset cut off) and referral pathways (carotid artery etc)

19 Critical success factors Decision to centralise based on robust evidence Collaborative approach built relationships and trust over time Include patient voice Effective use of data to demonstrate impacts Network support for change management

20 Who are we? Established in July 2015; pump primed by SCN and now provider funded (~ 200k/annum) Only Stroke ODN in the country Non-statutory body constituted from all public sector stroke provider organisations across Greater Manchester, including NWAS Providers, in partnership with the Host, are collectively responsible for delivery of the functions of the network

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23 Meet the team Sarah Rickard Manager Chris Ashton Co-ordinator Dr Jane Molloy Hospital Clinical Lead Tracy Walker Community Clinical Lead Supported by Administrator Lisa Chadwick; shared with Neuro Rehab ODN

24 Continuous improvement Stroke unit capacity Mortality Community services Patient information Service developments Regional IAT service TIA services Measuring performance Shared clinical SOPs ICH pathway Sector Forums Audit Patient flow Rehabilitation Life after stroke Vocational rehabilitation Driving Use of assessments Training & Education Competency frameworks Training programme Annual conference Induction training Online training Teaching at universities Secondary prevention SaLT Cardiology services

25 Networks add value Focal point for stroke in GM and increasing our national profile A voice for patients and carers, and involving the voluntary sector Strategic approach to improving local stroke services across the whole care pathway and providing a clear vision for the future Governance structures through which organisations can hold each to account, with mechanisms to identify and address issues and risks Involving a wide range of stakeholders and providing opportunities for networking and peer support, and sharing of best practice Forums for discussion, agreement, implementation and resolution of operational issues and facilitating service improvements

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27 References Morris et al. (2014) Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ;349:g4757 Ramsay et al. (2015) Effects of centralizing acute stroke services on stroke care provision in two large metropolitan areas in England. Stroke;46(8):2244 Turner et al. (2016) Lessons for major system change: centralisation of stroke services in two metropolitan areas of England. J Health Serv Res Policy Jul;21(3): Fulop et al. (2016) Explaining outcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England. Implement Sci. 2016;11(80)