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

NHS
CANCER NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

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

Contents

Introduction 3

Buckinghamshire Hospitals NHS Trust 4

Epsom General Hospital 6

Lancashire Teaching Hospitals NHS Foundation Trust 7

Milton Keynes Hospital NHS Foundation Trust 10

North Bristol NHS Trust 12

North West London Cardiac and Stroke Network 16

Royal Devon and Exeter NHS Foundation Trust 18

Surrey and Sussex Healthcare NHS Trust 21

United Lincolnshire Hospitals NHS Trust 23

Stroke resources 25

Further information 27

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

Introduction

The Stroke Improvement Programme 18 atrial fibrillation projects were TOP TIPS
worked with 10 sites from March established in October 2007 and
2009 to test implementing quality completed in April 2009. Working • Clearly define a pathway for
markers 5 and 6 of the National across 15 networks, with PCTs, high and low risk patients,
Stroke Strategy and to contribute to general practices, practice based agreed across primary and
national learning. consortia and acute trusts, they secondary care
piloted a range of approaches to • Streamline the referral route with
single point of contact for high
These markers set some challenging improve detection and optimal
and low risk
goals for health communities to treatment of patients with AF in
• Employ a comprehensive
achieve and required many previously primary care to reduce the risk of
communication strategy
unanswered questions to be solved, stroke. The Stroke Improvement • Establish a sustainable data and
not least what will be the real Programme publications that provide audit system
demand for the service. a summary and overview of the • Tailor the weekend service to
outcomes from this first phase are local needs and demand
Sites commenced work in March listed in the Stroke resources section. • Think differently about how and
2009; during the following 12 where TIA clinics are provided
months they met together on six The suggestions, experiences and
occasions to share ideas and learning. examples provided in this document
are intended to generate ideas, to
All sites were at very different stages show what is possible when teams Contacts for each of the projects are
in the development of their TIA work constructively together and to included. Full details of the service
services and had different aims to guide planning for improvement improvement can be found at:
work towards. Much of the work this activities. Nine of the 10 sites are www.improvement.nhs.uk/stroke
year has concentrated on the front included in this publication.
end of the TIA pathway and work in
the coming year will concentrate on The Stroke Improvement Programme
access to carotid endarterectomy, continuously publishes materials to
follow up and implementing seven help those striving to improve stroke
day services, as well as ongoing work and TIA services. All materials are
on access to imaging. Work in the available on the Stroke Improvement
coming year will also be linked closely Programme web site at:
with the NHS Improvement work on www.improvement.nhs.uk/stroke
atrial fibrillation (AF).

www.improvement.nhs.uk/stroke

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

Buckinghamshire Hospitals TIA Service
Buckinghamshire Hospitals NHS Trust

Aims Actions All of these changes were
To deliver a TIA service to the people The team planned to see high-risk coordinated via the creation of a
of Buckinghamshire in line with the patients on an ad-hoc basis at one of multidisciplinary TIA project group,
recommendations of the National the day hospitals at 9am on the day which met monthly during the main
Stroke Strategy. after the “first contact”. To start development phase, and quarterly
with, one MRI slot was kept free on subsequently.
Issues each site at 10.30am, on the
Buckinghamshire Hospitals NHS Trust understanding that it would be used Outcomes
is a split site trust with two main for an inpatient if no request were The pathway was implemented in
sites, Stoke Mandeville Hospital and received for an outpatient by 10am. July 2009, and has worked very well
Wycombe Hospital, with a combined for patients referred in as per
population of about 500,000. A There was concern that there would protocol. Patients attending the clinic
twice weekly MRI-based TIA clinic be a large number of, possibly at 9am, or shortly after almost
had been running at Stoke inappropriate, referrals or that the always get brain MRI and carotid
Mandeville since 2000, and at service would break down during MRA imaging the same morning,
Wycombe since 2006. While there periods of leave. To tackle this, all and this part of the pathway has
were many good aspects to this patients in the high risk service were proven very reliable.
service, including routine MRI brain seen briefly by the medical on-call
and carotid imaging since the team, partly to filter out Numbers were slightly lower than
inception of the clinics, audits on inappropriate referrals and partly to expected and the radiographers
both sites had shown that the mean check consultant stroke physician dropped the dedicated 10.30am slot
wait to be seen was about two availability the following day. in favour of fitting patients in as
weeks. necessary. The low numbers and very
For low-risk patients the team made few inappropriate referrals meant
One of the challenges locally was that two innovations: the need for review by the on-call
each site has just one stroke • rationalisation of the referral medical teams was rapidly dropped,
physician, and neurology input on process so that all referrals on both making use of middle grade staff
each site restricted by each sites were faxed to stroke service with appropriate supervision during
neurologist being off-site for secretaries periods of consultant leave.
substantial parts of the working • patients not able to be seen on one
week, so it was not practical to offer site within a week were seen on
a daily traditional clinic on each site the other site, if space was
every day of the week. available. The major advantage of
this is around clinic cancellations for
on call duties, annual and study
leave



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

2009 -10 Proportion of high risk patients seen within 24 hours

Q1 33%

Q2 56% - new services started July

Q3 52%

Q4 59%

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

Table 2: Proportion of high risk patients seen as inpatients

2009 -10 Proportion of high risk patients seen as inpatients


Q3 23%

Q4 11%

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

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

2009 -10 Proportion of low risk patients seen within 24 hours

Q1 38%


Q3 70%

Q4 67%

Contact
Dr Matthew Burn
Consultant Stroke Physician
Buckinghamshire Hospitals NHS Trust
matthew.burn@buckshosp.nhs.uk



TIA service development
Epsom General Hospital

Aims Because of this lack of TIA service key departments, such as A&E. A
To establish a comprehensive TIA and stroke specialists, there was referral proforma was drawn up and
service for patients in the Epsom area no data to quantify the need for circulated to key clinicians in the
of Surrey who attend the Epsom improvement, just a very wide gap hospital. A secretary who can book
General Hospital site of Epsom and that all in the trust acknowledged. appointments at short notice was
St Helier NHS Trust. made available to the stroke service.
Actions
Issues A project team was established that Outcomes
Epsom General Hospital only drew together the key clinicians and The team have achieved:
provided one neurovascular clinic run managers required to develop the TIA • one TIA clinic now runs every week,
on alternate weeks by a geriatrician, service, i.e. stroke consultant, stroke on a Tuesday afternoon, for low
far below the standard of service specialist nurse, radiologists, vascular risk TIA patients. Some ad hoc
demanded by the quality standards scientists, service manager, assistant clinics are held on the ward when
for TIA services being developed by medical director, GP, outpatient resources allow (high risk patients
Surrey Heart and Stroke Network department manager, director of continue to be admitted)
(based upon national guidance and operations for planned care, network • good liaison with the vascular
clinical recommendations). data analyst and network service department, that means the entire
improvement manager. TIA clinic can be covered
Consideration for development of TIA • same day scanning is now being
services took into account a A one-stop TIA clinic was immediately provided.
challenging baseline with regards to established to run once per week in • approval by the trust board of a
staffing, imaging, location and the outpatient department. business case to invest in stroke
referral. and TIA services to enable
Immediate difficulties encountered by provision of a Monday to Friday
The stroke consultant to lead this the carotid duplex service were TIA service for high and low risk
project was recruited at the addressed e.g. inappropriate referrals. patients
beginning of 2009 on a part time Longer-term issues such as
basis. Before that, the stroke service inadequate staffing for a daily service, Contact
at Epsom General Hospital was led by were addressed through Janet Putterill
a stroke specialist nurse and general departmental meetings. Consultant Stroke Physician,
physicians. The role of the new Epsom General Hospital
consultant therefore was to embed A TIA pathway was developed by the janet.putterill@epsom-sthelier.nhs.uk
best practice into the care of patients project team and agreed with other
presenting with stroke or TIA.



TIA service improvement project
Lancashire Teaching Hospitals NHS Foundation Trust

Aims Table 4: Working towards a high quality, accessible and effective TIA service
To achieve a high-quality, accessible
and effective TIA service through joint
input from the medicine, Where we are now Where we want to be
neuroscience and radiology • Conventional model • Daily one-stop-shop
directorates to ensure urgent • Four weekly clinics between • High risk patients seen within
assessment and treatment of patients Preston and Chorley 24 hours
with TIA, in line with quality markers • Mix of high/low risk • Lower risk patients seen within
5 and 6 of the National Stroke • Various referral routes one week
Strategy. • Timing of intervention variable • Unified referral pathway
• GP supervised secondary • Carotid intervention (high risk)
Issues prevention seen within 48 hours
In January 2009, Lancashire Teaching • TIA nurse supervision of
Hospitals NHS Trust were nearing secondary prevention
delivery of a daily emergency ‘one-
stop shop’ TIA service for high risk
patients, led jointly by a stroke
physician and a stroke neurologist.
Further substantial work was required Figure 1: Patient pathway - original referral -
to achieve the service envisaged (see procedure performed March 2008 - Jan 2009
table 4).
Numbers of date pairs used to calculate average delays

A conventional TIA service was in
44 U/SScan
place at commencement of the to CTDel

project. There had been a recent 286 OrigRef 687 U/SRef 44 CTDel 25 CTScan 10 MDT1
to U/SRef to U/SScan to CTScan to MDT1 to Clin Rev
move to a rapid access TIA clinic with 4 Clin Rev
a view to TIA patients being assessed Average to Proc Perf

Delay, 10 13 2 2 8 9 6
more quickly. Little hard data was Days
available for the baseline position but Range 0-185 0-49 0-89 0-35 Range
an imaging directorate audit, 0-261 days
0-20
3-11 days

summarised in figure 1, suggests an
0 10 20 30 40 50 60
average 50 day interval between
original patient referral and carotid OrigRef - U/SRef U/SRef - U/SScan U/SScan - CTDel CTDel - CTScan

intervention. CTScan - MDT1 MDT1 - Clin Rev Clin Rev - Proc Perf



Actions • created a unified single point of Outcomes
The development of the service has access, with initial telephone call to By establishing ongoing monitoring
been at a time of substantial efforts the acute stroke unit for high and and audit, the team are able to
to improve stroke services and to lower risk TIA patients, triage, and understand their service. Figures 2 to
promote awareness and education by subsequent electronic patient 7 show the outcome of an audit of
the acute trust and in partnership booking and confirmation of 58 patients between May and
with other organisations including appointment time October 2009. The original pathway
the Central Lancashire PCT and the • set up monitoring and audit of the had an emphasis on referral from
Stroke Network in Lancashire and service on an ongoing basis A&E. Following the audit showing a
Cumbria. The Stroke 90:10 project is • established a potential role for a longer referral time from GPs, the
also under way in the North West. specialist TIA nurse to supervise single point of access was introduced
The team: continued adherence to secondary in October 2009.
• convened a multidisciplinary group prevention, as a strategy to
comprising clinicians and the maintaining long-term stroke risk
relevant general managers, in order reduction
to develop a daily emergency clinic • developed a business case to
for high risk TIA patients sustain and develop the service
• launched a daily emergency TIA further
clinic in May 2009, with two (three • hosted educational events
if necessary) daily slots and promoting developments in stroke
immediate access to carotid and TIA
imaging if appropriate, Monday
to Friday

Figure 2: Referral source by interval from first Figure 3: Referral source of all
contact to clinic appointment patients

7%
20
Number of patients

10%
15
42%
10

5
41%
0
<24 hrs 24-48 hrs 2-7 days 1-2 weeks 2-4 weeks >4 weeks
Interval from first contact to clinic appointment
A&E MAU GP Other
A&E MAU GP Other

Figure 4: Interval from first contact to clinic Figure 5: Diagnosis amongst
appointment by final diagnosis patients seen within 24 hours

1
20
Number of patients

15
6
10

5 7
0
<24 hrs 24-48 hrs 2-7 days 1-2 weeks 2-4 weeks >4 weeks
Interval from first contact to clinic appointment by final diagnosis
High risk TIA Low risk TIA Non TIA
High risk TIA Low risk TIA Non TIA



Figure 6: Interval from first contact Figure 7: Interval from first contact
to carotid imaging amongst all high to carotid imaging amongst high
risk TIA patients risk TIA patients assessed in clinic
with 24 hours
8% 13%

17%

20% 33%

21%

21% 67%

<24 hours 24-48 hours 2-7 days

1-2 weeks 2-4 weeks >4 weeks <24 hours 24-48 hours

Table 5: Clinic performance

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

Assessed within 24 hrs of symptom onset 64% (9)

24 – 48 hrs 29% (4)

2-7 days 7% (1)

This demonstrated: ‘The opportunity to exchange ideas with other teams in
• the shortest interval between first
contact and clinic assessment other parts of the UK was one of the most valuable
occurred in patients referred aspects of the project. In particular, perhaps our
directly from A&E, whereas longer
intervals were seen when patients preparedness to adapt quickly based on ideas shared at
initially presented to their GP
• a high non-TIA rate exists amongst
the peer support days (for instance, single point of
patients seen within 24 hours, referral) helped to influence our own service
which has implications for planning
carotid and brain imaging capacity development whilst it was ‘a work in progress’.
• a rapid improvement in key
Lancashire Teaching Hospitals NHS Foundation Trust
measures can be achieved with
such a model – % high risk patients
seen within 24 hours and % high 23 patients attending the emergency Contact
risk patients having carotid imaging clinic between May and July 2009 Dr Hedley Emsley
within 24 hours (already 100% completed a questionnaire Consultant Neurologist
within 48 hours) encompassing a range of issues Lancashire Teaching Hospitals
relating to their experience of the NHS Foundation Trust
Sustaining improvements will depend clinic. Patients were also asked to hedley.emsley@lthtr.nhs.uk
on continued effective interaction provide an overall rating of the
between all the relevant specialties. service, from poor (one) to excellent
(five). Nineteen (83%) gave a rating
of five, the remaining four (17%)
giving a rating of four.



Sustainable acute stroke and TIA
management programme
Milton Keynes Hospital NHS Foundation Trust

Aims attending to identify waiting times to
Seamless GP and A&E referral for being seen in clinic, whether the
patients suspected of having had a patient is low or high risk, whether
TIA, with access to treatment, investigations are required and
including timely access to diagnostics whether they are confirmed TIA.
both within and out of hours.
Implementation of five day a
Issues week TIA clinics. Recognising the
There was no assessment of patients lack of coverage across the week,
by referrer to determine high or low clinic slots were changed to occur five
risk TIA. TIA clinics were held once a days a week using the same three
week. Waiting times were up to three consultants, with the addition of a
weeks for a patient to be seen by a general medicine consultant
stroke specialist and up to two weeks providing TIA clinic slots in his clinic.
for carotid imaging following TIA
clinic. Same day carotid imaging. The
waiting time for a carotid doppler
Actions scan was a bottleneck in patients
Standard TIA pro-forma and receiving urgent outpatient
referral process. The team created assessment and treatment for TIA. A
a standard referral pro-forma for all same day referral process means TIA
referrals sent to TIA clinic, used by is now considered urgent and
A&E, GP surgeries, CDU, patients receive a scan the same day
ophthalmology etc. This ensures as their outpatient appointment.
patients are risk assessed using
national clinical ABCD2 assessment to Outcomes
identify whether they are high or low • same day carotid imaging in place –
risk TIA. removed waiting time
• reduction in patient waiting times
Data reporting mechanism in to be seen by specialist, average
place. The team created a data waiting time reduced by three days
collection form for consultants to
complete in clinic for all patients



Figure 8: Milton Keynes TIA pathway analysis
Data from Q3 2009 - 2010
Best we did was 8 days - Target was 24 hours

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

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

Data from March to April 2010
Best we did was 3 days - (Result after first month)

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

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

Contact ‘Research other organisations to understand lessons
Nicola Evans
Project Manager learnt - don’t reinvent the wheel, the chances of
Milton Keynes Hospital NHS
Foundation Trust
someone having implemented the same change as you
nicola.evans@mkhospital.nhs.uk is highly likely’.



Providing a seven day, one stop, TIA
service at North Bristol NHS Trust
North Bristol NHS Trust

Aims Issues Imaging needed to be available:
The team at North Bristol NHS Trust, In March 2009, one stop TIA clinics • negotiated one stop services with
supported by the Avon, were held three times a week, with a radiology to provide head CTs and
Gloucestershire, Wiltshire and variable waiting time. There was one carotid doppler scans
Somerset Cardiac and Stroke stroke physician and one registrar. • training of ultrasonographers to
Network, had a clear vision for the carry out doppler to increase
service they wished to provide and Actions staffing in response to demand
aimed to: The weekday service was developed • diffusion weighted imaging (DWI)
• provide a seven day, one stop TIA and strengthened and the pathway available for weekday services
service with full diagnostic imaging was redesigned for the weekend instead of CT if required
that patients can access within 24 service, with the development of • MRI imaging for weekend TIA
hours of onset of symptoms, to close links with A&E. services including DWI and MR
include same day brain and carotid angiography
imaging and next day cardiac The team developed a standard TIA
diagnostics network-wide referral form for all The University of West England
• have a single point of referral GPs and appointed a TIA coordinator developed a online training module
• ensure universal use of ABCD2 as single point of referral. for ABCD2 assessment for all GPs and
score and stratification of patients Great Western Ambulance Service
with a score above and below 4, The following staffing changes were staff.
with patients ≥ 4 assessed and made:
treated within 24 hours and • increased number of stroke Pre-packs of medication for patients
patients < 4 assessed and treated consultant sessions to take away from TIA outpatient
in less than seven days • a stroke co-ordinator assessment attendances were made available.
• ensure prompt referral and of patients as part of the weekday Patient information packs were
treatment for all patients requiring service developed for all TIA patients.
vascular surgery • nurse staffing on the acute stroke
• ensure patients are discharged unit changed to accommodate
from outpatient clinic with a copy weekend service
of the discharge summary • an on call physician rota for
weekend service
• a weekly neuro-vascular meeting
to ensure prompt referral and
treatment and to review all critical
carotid imaging



Outcomes
The following outcomes have been Figure 9: Clinics running three times a weeek
noted:
• five day service is embedded and
running well, a seven day one stop
service commenced in April 2010
• there is a good relationship with
clinical support and vascular
services
• the appointment of a TIA
co-ordinator ensures timely and
efficient booking of patients
according to ABCD2 prioritisation
• there is a commitment within
stroke team to develop services
• the mean waiting time for patients
seen in clinic went from 7.78 days
to 1.76 days as the frequency of
clinics was increased
• there is an indication of reduction
in admissions for high risk patients
during weekdays as frequency of
clinics has increased

Reduction in admissions will be
explored further. There is the
potential to reduce weekend
admissions but this needs further
work as the trust provides the out of
hours service for the whole of Bristol.



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



Figure 12 shows high levels of
Figure 11: Six day a week clinics tested from December 2009 patient satisfaction:
• the majority of patients felt that
they were fully informed of the
various parts of their outpatient
attendance (diagnosis, tests,
results etc)
• all patients received information
and the majority found this to be
helpful
• two patients (out of a total of 10
respondents) commented that they
had not received information
regarding not driving prior to their
attendance

Contact
Dr Neil Baldwin
Consultant Stroke Physician
North Bristol NHS Trust
neil.baldwin@nbt.nhs.uk

Figure 12: Patient satisfaction

100
90
80
% positive responses

70
60
50
40
30
20
10
0
Explanation Purpose Adequate Understanding Were
given for of tests time with of final leaflets
attending understood staff diagnosis helpful
clinic
Understanding Test results Ease of Information Adequate
which tests explained finding scanning leaflets information
to receive departments received given



Improving the TIA pathway for high and low
risk patients across north west London
North West London Cardiac and Stroke Network

Aims supplied with referral forms. These • who to?
The aim of the project was the GPs also needed to be encouraged to • how do we do this?
prompt assessment and treatment of complete these forms accurately and • what products do we need to
high and low risk TIA patients and increase their knowledge and acquire or produce?
the communication of relevant understanding of TIA. There were no • what resources do we need?
information to key stakeholders procedures in place to collect data. • roles and responsibilities
across north west London. This is a • timescales
multi-site project coordinated by the The project commenced in November • how do we need to consider
North West London Cardiac and 2009 following the publication of the additional stakeholders?
Stroke Network, involving the Stroke Strategy for London.1 • how do we measure success?
following organisations:
• North West London Cardiac and Actions New referral forms were launched on
Stroke Network The team created new referral forms 7 December 2009:
• Imperial College Healthcare outlining the approved protocols and • emails were sent to all GPs across
NHS Trust out of hours service for TIA referral: north west London explaining the
• TIA clinics and A&E departments at • gained consensus from clinical new referral forms
the following hospital sites: teams in each hospital • the clinical contracts lead for each
Northwick Park, West Middlesex, • produced separate forms for GPs PCT assisted by forwarding emails
Charing Cross, St. Mary’s, and A&E departments to GPs to save the lengthy process
Hillingdon, Chelsea and • forms included an aid to diagnosis of creating a database
Westminster (including ABCD2 score) and • GPs mailshot included a link to
• GP surgeries across north west contact details for TIA clinics, both dedicated webpages on the
London weekdays and out of hours network website
• produced forms in every format • dedicated webpages included
Issues likely to be used by GPs (EMIS, downloadable versions of all forms
GPs were demonstrating an Vision, Word) and information regarding aids to
inconsistent approach to TIA diagnosis and use of referral forms
diagnosis and referral. Awareness of Alongside this, the project created a • stroke consultants at each trust
TIA and stroke also needed to be communications plan to launch the trained their local A&E departments
improved. There are over 600 GPs new forms to GPs, A&E departments on use of forms
across eight PCTs within the north and all interested parties which
west London region who needed to included:
be informed of pathways and • what information do we need to
communicate? 1Stroke Strategy for London, Healthcare

for London, November 2008.



Ongoing engagement of GP practices Outcomes
continued: The team have achieved:
• additional emailshot to GPs • a well defined TIA service has been
encouraging them to access the created within north west London,
website to download the forms and with provision of TIA services in six
for information on how to fill them hospitals, with clear protocols and
out correctly one referral form
• hard copy mailshot with forms sent • a clear pathway for both high and
to every practice manager, low risk patients with suspected
enclosing pens with the website TIA
address of the dedicated TIA • an out of hours, 24 hour TIA
webpage to further publicise the service for high risk referrals based
site at the hyper-acute centres
• stroke consultants write to every • dedicated webpages have
GP who has referred a TIA patient provided a new reference point to
using the old form and sends a offer everything that a GP needs to
copy of the new form know about the new forms and
pathways
Additional GP and A&E aids to • A&E departments and London
encourage timely assessment of Ambulance Service use the new
patients: pathways
• urgent TIA assessment referral card
created for A&E departments to Baseline data is in the process of
give to patients to encourage them being collected and collated and data
to attend TIA clinics and reduce regarding referral patterns and vital
levels of DNAs signs and subsequent improvement
• appointment card reproduced on of service should be available soon.
the dedicated webpages in a
downloadable form for GPs to give Early indications show the following:
to patients with suspected TIA • use of new referral forms in A&E
who present at the surgery departments is now in excess of
80%
The team created a data template for • use of new referral forms by GP is
use within TIA clinics to collect variable but is increasing month by
baseline data, assess the use of month and has reached 60% in
referral forms and measure referring one unit
patterns and vital signs: • hits on the network website
• data was accepted in hard or soft increased by 20% after the launch
copy .
• assistance was offered by the Contact
network to facilitate collection Marcia Reid
Interim Senior Project Manager
Data was collected for the: North West London Cardiac and
• use of new referral forms by GPs Stroke Network
and A&E departments (measured marciareid@nhs.net
in TIA clinics)
• number of TIA referrals (total and
% of mimics)
• vital signs for high and low risk
patients
• GP awareness (through survey
monkey, evaluation forms and one
to one interviews)



Improving access to TIA assessment
Royal Devon and Exeter NHS Foundation Trust
and Peninsula Heart and Stroke Network

Aims defined by the ABCD2 score) The role of the stroke nurse
To develop an equitable and remained at two days. The main practitioners includes:
responsive TIA assessment service, reason was that referrals received on • assessment of all new acute stroke
with improved out of hours access, Friday, Saturday or Sunday, could not admissions in A&E and the
through the use of risk stratification, be assessed until the next working medical triage unit, using ROSIER.
based upon carotid ultrasound day. If positive, the stroke nurse
screening undertaken by stroke nurse practitioners are able to request CT
practitioners. Actions imaging and arrange admission to
Rather than replicate a ‘traditional’ the acute stroke unit within four
The project was initiated to improve face-to-face outpatient clinic service hours of hospital arrival
the responsiveness of the TIA service at weekends, the project team are • initial point of referral for TIA
for patients presenting at weekends investigating an innovative model of patients assessed in A&E. Referrals
and bank holidays, achieve the vital providing specialist assessment and are risk stratified and allocated to
signs target of TIA cases with a addressing the issue of appropriate the next available daily stroke clinic
higher risk of stroke who are treated urgent imaging and screening (i.e. slot. On weekdays, a TIA clinic slot
within 24 hours, and assist in carotid ultrasound) during weekend is often available later the same day
working towards the 48 hour and bank holiday periods. • thrombolysis assessment and liaison
window for urgent carotid surgery. with the on-call stroke team and
Carotid ultrasound scan results for a provision of 1:1 care in the period
Issues 12 month period have been collated following thrombolysis
The daily TIA/stroke clinic at the Royal to establish a ‘baseline’ percentage of • dysphagia screening
Devon and Exeter NHS Foundation ‘normal’ and ‘abnormal’ scans.
Trust serves a population of 350,000 The stroke nurse practitioners are
and receives approximately 1,000 The results shown in table 6 provided currently being trained to perform
new referrals per year (60% of these a broad indication of the percentage carotid ultrasound screening to
referrals are diagnosed as either TIA of ‘abnormal’ screening results which enable improved access to TIA
or minor stroke). will be identified by the stroke nurse assessment during weekends and
practitioners. bank holidays.
Since the clinic was established in
2006, access times from referral to Three stroke nurse practitioners at
assessment have improved the Royal Devon and Exeter work
dramatically. However, the median seven days a week, from 7.30am to
referral to assessment time, for both 8pm.
high risk and lower risk patients (as



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

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

No Visible Disease 32%

Minimal (Detectable but < 30%) 31%

Mild (30 – 49%) 28%

Moderate (50 – 69%) 5%

Severe (70 – 99%) 4%

Occluded (100%) <1%

Training is provided ‘in house’ by the Outcomes
chief clinical technologist. Two Between 1 April 2009 and 31 March
stages of training were initially 2010, 36 TIA patients were admitted
identified: during weekends and bank holidays.
1. ability to locate and identify the The carotid ultrasound results for
common carotid artery and the these patients were examined to
carotid branches provide an indication of whether the
2. ability to record velocities and patients would have been admitted if
assess velocity shifts using a the carotid screening service had
spectral doppler, and produce been in place.
B-mode colour images
It is envisaged that the cut-off for
The training includes a period of ‘dual admission will be >50% stenosis.
scanning’. A clinical technologist Using this figure, analysis of the
validates the results. 36 weekend and bank holiday
admissions in 2009/10, (see table 7)
All patients presenting during shows:
weekend and bank holiday periods
will have a carotid ultrasound Table 7: Analysis of the 36 weekend and bank holiday admissions in 2009/10
screening investigation. Those
patients considered as ‘normal’ will
be discharged home with an < 50% or no detectable disease - Potential ‘avoided’ admission 16
appointment to attend the clinic the < 50% but difficult scan 2
next working day. Patients whose
screening results suggest an >50% 4
abnormal result (as defined by an No Scan requested during admission 16
agreed protocol, which includes key
measurements, defined ‘normal’
results and tolerance levels) will be
admitted. Prior to this project, all
patients presenting during weekends
and bank holiday periods with TIA
would be admitted.



This provides a prospective indication Training will continue, to enable the
of the impact of the new service, and stroke nurse practitioners to become
indicates that 44% of TIA admissions proficient in carotid ultrasound
during the weekends and bank screening. It is anticipated that the
holidays of 2009/10 could potentially stroke nurse practitioners training
have been avoided if the stroke nurse and sign-off of competencies will be
practitioners service was in place. It completed by September 2010. It is
will also be necessary to establish the intention of the project team to
whether any other factors, such as co produce a project report, including
morbidities, determined the costs, training information and
requirement for admission. competencies, to support future
commissioning decisions with regard
It is anticipated that this model will to development of TIA assessment
be a cost effective solution for services.
increasing access to, and
enhancement of, TIA assessment at Contact
weekends and bank holidays. Carol Massey
Service Improvement Manager
The stroke nurse practitioners and Peninsula Heart and Stroke Network
clinical measurements department carol.massey@plymouth.nhs.uk
have approached the project
enthusiastically. A collaborative and
open approach has enabled
specialties and disciplines to work
together and understand roles within
the project.



Acute medicine TIA service
Surrey and Sussex Healthcare NHS Trust

Aims A pathway was created to ensure To improve awareness across the
To create a sustainable, effective one- that fasting blood tests, CT brain health economy the team:
stop TIA service to meet the vital sign scans and doppler of the carotids • produced standardised forms for
requirement for high risk and low risk were all performed as early as GPs and other referral areas
TIA. possible, as needed, usually the same • taught GPs and other clinicians
morning ahead of the consultant • worked with the Surrey Heart and
Issues review, results discussion and Stroke Network on training days
At baseline in, 2008 Surrey and treatment prescription from the clinic • rolled out a newly empowered
Sussex NHS Trust offered a TIA service in the afternoon. This was broadly stroke team across the trust
based on two clinics per week that based on the EXPRESS2 study. • created a single bleep holder to
was unable to offer assessment, take all calls
investigation and treatment within 24 In the early days this relied on one
hours. Since the retirement of the consultant and the challenge became The team also worked closely with
substantive consultant physician in how to make the service sustainable. radiology to access CT and doppler
2008 the stroke service had been led In order to do this the trust: slots on a needs related basis and
by successive locum consultant • appointed a trust doctor created an electronic audit tool to
clinicians throughout 2009. Clinicians • appointed two stroke consultants standardise note-keeping, letters to
were clear that a system-wide change with job plans including TIA review GPs and gather audit data that was
of practice was needed. • embedded the service within the reliable and easy to analyse.
ever-open acute medical unit
Actions environment
A TIA service was created based on • included more junior staff from
the acute medical unit, operating the stroke and acute medical unit
each day, Monday to Friday, for all services
patients referred the previous day • created pathways and proformas to
with TIA (including low and high risk standardise care delivery
patients).

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



Outcomes
Creating a patient-centred service, Figure 13: TIA bed days per month
accessible at the point of need, was
very well received by patients and 180
clinicians alike. GPs are very happy 160
with the bleep holder for stroke; they
140
told the team that this sort of access
120
is exactly what they want. The profile
of TIA and stroke has been raised Days 100

dramatically internally and externally. 80
60
The team are waiting for validation of 40
an outcome audit of strokes at 90
20
days.
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

There is no waiting list at all for TIA Month April 2007 to May 2010
patients and there is consistently
good performance against the vital
sign. The percentage of high risk
patients with TIA seen and treated in TIA patients are no longer admitted
24 hours is 66% currently (baseline to the trust other than in exceptional
data is not available, but anecdotally circumstances. Data in table 8 shows
assumed to be 0%). a reduction of 88% in required bed
days for TIA. Assuming £255 a night,
this represents a potential saving to
the trust of over £100,000 per year.

Table 8: Total Q4 TIA bed days

2007/08 124

2009/10 15

Contact
Dr Ben Mearns
Consultant Physician,
Surrey and Sussex Healthcare
NHS Trust
ben.mearns@sash.nhs.uk



Improving TIA services in Lincolnshire
United Lincolnshire Hospitals NHS Trust

Aims Table 9: Stroke physician capacity and frequency of TIA clinics
The objectives for this project were
to:
Site WTE Stroke Physicians Number of TIA Clinics
• develop sustainable TIA services
that are available five days per Lincoln County 1.00 2 per week
week, with plans to progress the
Pilgrim 0.8 5 per week
service to cover weekends during
2010/11 Grantham and District 0.2 2 per month
• implement a rapid access TIA
pathway for high risk patients
• develop the workforce to ensure Patients were referred to the hospital Actions
all TIA patients receive care from via traditional referral letters and The project team ran a service
staff with the appropriate level of were appointed to the next available scoping day with all those involved
expertise clinic slot. The information included to review current service provision,
in the referral letter varied greatly and identify gaps, and explore options
Issues the inclusion of the ABCD2 score was for service redesign. The preferred
United Lincolnshire Hospitals NHS minimal. It was therefore difficult to model for service delivery agreed
Trust has three acute hospital sites, grade referrals based on a was an extension of current
Lincoln County Hospital, Grantham standardised risk stratification system. outpatient based service, with
and District Hospital and Pilgrim High and low risk patients were increased capacity and frequency to
Hospital Boston. At commencement referred to any site. meet demand and access to same
of this project, the configuration of day diagnostics.
TIA service provision varied across the At the commencement of the project
sites (see table 9). there was no baseline data or a A TIA referral form was designed
mechanism for data collection. The and piloted which could be used by
timeframes for access to diagnostics all healthcare professionals to refer
varied across the sites. into the TIA clinics. The purpose of
the form was to:
• collect set information about each
patient to allow for accurate
grading of referrals, so the team
could appoint patients into clinic
slots based on high or low risk
ABCD2 scores



• educate referrers about the referral The business case was approved for
process, the importance of the recruitment of a new stroke
providing the information required physician at Lincoln County and
on the form, advice on initiation of Pilgrim Hospital. This will enable
treatment and prompts to provide additional clinics to be set up with
essential information to patients enough capacity to ensure access to
specialist assessment five days a week
The referral pathway advised referrers for high risk patients.
to fax all high risk referrals to either
Lincoln County or Pilgrim Hospitals as Contact
the frequency of clinics at Grantham Louise Pearson
did not serve the requirements of Clinical Services Manager –
high risk patients. Grantham Stroke and TIA
continued to receive referrals for low United Lincolnshire Hospitals
risk patients. Work took place with NHS Trust
the A&E and emergency assessment louise.pearson@ulh.nhs.uk
unit teams to highlight the
importance of urgent telephone
referrals directly to the stroke
physicians for patients presenting
with symptoms of TIA and a
dedicated fax line was established so
referral went directly to the stroke
physicians.

Outcomes
The biggest improvement made was
to the streamline the referral process
for TIA patients into the clinics by
encouraging the use of the ABCD2
score at point of referral and ensuring
that appointments for high risk
patients could be prioritised.

Implementation of the standardised
referral form allowed collection of
baseline data and the ability to
continually monitor demand for TIA
clinics. This will enable capacity to be
tailored to the need for rapid access
clinics for high risk patients.



Stroke Resources

Stroke Improvement Programme website Trainer’s Resource Pack – An Introduction to Service
The Stroke Improvement Programme website offers Improvement, NHS Improvement
information and resources on improving stroke and TIA The Trainer's Resource Pack - An Introduction to Service
services, including: Improvement, is a collection of tried and tested training
• information on topical issues affecting stroke and modules for service redesign tools and techniques, and
TIA services change management skills.
• presentations from events and meetings www.heart.nhs.uk/trainers_resource_pack.htm
• examples of successful redesign and stroke
improvement in stroke and TIA services Guidance on Risk Assessment and Stroke Prevention
• information on measures for Atrial Fibrillation (GRASP-AF) Tool
www.improvement.nhs.uk/stroke This tool should be used as part of a systematic approach
to the identification, diagnosis and optimal management
Sustainability Checklist, NHS Cancer of patients with AF to reduce their risk of stroke.
Improvement Programme Developed collaboratively and piloted by the West
A checklist containing key questions to ask about your Yorkshire Cardiovascular Network, the Leeds Arrhythmia
project or service to ensure plans are in place to sustain team and PRIMIS+, as part of the AF in primary care
the improvement. projects, made available nationally through NHS
www.improvement.nhs.uk/cancer/documents/inpatients/ Improvement.
Sustainability_Checklist.pdf www.improvement.nhs.uk/graspaf

The Sustainability Toolkit, NHS Heart Stroke Improvement Programme e-bulletin
Improvement Programme Containing updates, news and information for anyone
Although focused on improving cardiac pathways, The interested in developing stroke services, the Stroke
Sustainability Toolkit provides useful information and Improvement Programme e-bulletin is essential for
examples on how to sustain improvements. It also anyone working in stroke and TIA services.
contains resources on capturing data, measurement
and analysis. The Stroke Improvement Programme e-bulletin is
www.improvement.nhs.uk/heart/sustainability published every two weeks and the latest edition is
available on the Stroke Improvement website
www.improvement.nhs.uk/stroke. If you would like to
subscribe to the Stroke Improvement e-bulletin, please
email anne.coleman@improvement.nhs.uk.



Atrial Fibrillation documents, NHS Improvement Sustainability Model, NHS Institute of Innovation
The following documents are available to download from and Improvement
the Stroke Improvement website The Sustainability Model is a diagnostic tool that is used
www.improvement.nhs.uk/stroke to predict the likelihood of sustainability for your
improvement project and provides practical advice on
Atrial fibrillation in primary care: making an impact how you might increase the likelihood of sustainability for
on stroke prevention, October 2009 your improvement initiative.
This document aims to capture the final summary of their www.institute.nhs.uk/sustainability_model/general/
individual approach, lessons learned, improvements to welcome_to_sustainability.html
practice and quality outcomes, also sharing tools and
resources developed to enable other health communities Improvement Leaders’ Guides, NHS Institute for
to drive this agenda forward. Innovation and Improvement
Commissioning for Stroke Prevention in Primary A series of service improvement guides, including a guide
Care - The Role of Atrial Fibrillation, June 2009 to sustainability and how it can be used in improvement
Developed following a national consensus meeting of work. The NHS Institute for Innovation and Improvement
opinion leaders in the field, this document is to develop website also contains worksheets for measuring
a concerted strategy towards the management of AF in improvement.
primary care, in particular anticoagulant management www.institute.nhs.uk/index.php?option=com_content&
and its significance in relation to reduction in the risk of task=view&id=134&Itemid=351
stroke.
StrokEngine-Assess
Atrial Fibrillation in Primary Care National Priority This website provides evidence to support stroke
Project, April 2008 rehabilitation assessment tools.
A summary document produced in April 2008 including www.medicine.mcgill.ca/strokengine-assess
descriptions, supporting information and key learning
from the local projects that were part of the Atrial Spreading good practice documents and
Fibrillation in Primary Care national priority project. information, Sarah Fraser & Associates Ltd
Sarah Fraser is an independent consultant who works
Atrial Fibrillation in Primary Care Resources and with NHS organisations on how good practice spreads
Learning, April 2008 and how improvements can be made. The website
This online resource is a tool produced in April 2008 that contains a number of free resources on spreading good
captured the learning from the local project sites that practice and improvements.
worked on the Atrial Fibrillation in Primary Care national www.sfassociates.biz/sitebody/MultiMedia/Documents.php
priority project. The resource provides documents,
guidelines, presentations, proformas and algorithms
developed and used by the local priority projects.

NHS Improvement System
The NHS Improvement System is a free, comprehensive
online resource supporting quality improvement in NHS
services, offering a range of service improvement tools,
case studies and resources.

The Improvement System gives NHS staff the capability to
record, track and report on projects, share improvement
stories and documents, access Statistical Process Control
(SPC) software, Demand and Capacity tools and a Patient
Pathway Analyser, all within a secure environment.
www.improvement.nhs.uk/improvementsystem
Email: support@improvement.nhs.uk


Further information

Stroke Improvement Programme
National Team
NHS Improvement - Stroke
Improvement Programme
3rd Floor, St John's House,
East Street, Leicester LE1 6NB

Tel: 0116 222 5184
Fax: 0116 222 5101
Email: info@improvement.nhs.uk

NHS
CANCER
NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

NHS Improvement

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

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

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
Telephone: 0116 222 5184 | Fax: 0116 222 5101

©NHS Improvement 2010 | All Rights Reserved | June 2010

Delivering tomorrow’s
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Joining up prevention: case studies from the Stroke Improvement Programme projects

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